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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by tree68 on Thursday, June 13, 2019 6:39 PM

Overmod
There may be some Progress documentation about why they build and tune their horns that way.

I'm pretty sure all locomotive manufacturers buy their horns "off the shelf."  

There is some discussion of design specs on Ed Kapriski's horn site: http://www.dieselairhorns.com/collection.html

Listening to a site like the Deshler diamond on YouTube will introduce one to the wide variety of horn sounds that result from time and lack of maintenance.

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Posted by BaltACD on Thursday, June 13, 2019 6:49 PM

tree68
 
Overmod
There may be some Progress documentation about why they build and tune their horns that way. 

I'm pretty sure all locomotive manufacturers buy their horns "off the shelf."  

There is some discussion of design specs on Ed Kapriski's horn site: http://www.dieselairhorns.com/collection.html

Listening to a site like the Deshler diamond on YouTube will introduce one to the wide variety of horn sounds that result from time and lack of maintenance.

Least we forget - SOUND is greatly influenced by the wind.

If the wind is blowing from the origin of the sound - it will sound like it is right on top of you.  If it is blowing away from the orign of the sound - you may not even hear it.  If the wind is blowing hard enough, you may only hear the wind no matter where the warning sound originates.

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Posted by Euclid on Thursday, June 13, 2019 7:40 PM

Overmod
Charlie - do you have thoughts on a correct methodology to design alert sounds for the particular situation posed by the Ivy City tragedy?

I don't see a connection in preventing the Ivy City accident with louder horns.  The conductors were not struck because they failed to hear the horn.  They heard the horns of both trains, but they thought they were only hearing the horn of #66. 

The Amtrak horns were plenty loud enough to cut through the background noise.  You can make the horns ten times louder, but if two trains blow them at the same time, bystanders are still likely to think they are hearing just one train as they get runover by the second one.

What is needed in a situation like at Ivy City would be a way for the engineer of #175 to turn off the horn of #66.  That would have undoubtedly prevented the accident. 

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Posted by blue streak 1 on Thursday, June 13, 2019 8:01 PM

What about the sound of european emergency vehicles?  The 2 two note up and down is completely different than present horns.  Might just take a single bell horn only activated alternately with the regular horn.  Still does not solve the problem of two trains at once.  

Any thoughts from our CHI people? 

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Posted by tree68 on Thursday, June 13, 2019 8:31 PM

Euclid
They heard the horns of both trains, but it appears they thought they were only hearing the horn of #66.

A slight correction, based on the official report.  

In the end, they didn't have their heads on a swivel, as they should have.  A primary rule of railroading:  Always expect a train.  They apparently didn't, and we all know the result.

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Posted by MMLDelete on Thursday, June 13, 2019 9:25 PM

It seems to me there should be a large red or orange “hot button” which activates a sound very much unlike any other (and expected) sound. I like the above suggestion of the European police siren.

But here is my wrinkle. The button is switchable, and it can produce two very different unexpected noise. From my experience, trains on a line always have a “direction.” Despite the actual directions in a given spot, a line will have, for example, northbound and southbound trains.

Each time an engineer goes on duty, he/she is required by rule to set the hot button for either NB or SB duty, and record/report that this was done. This way, the two Amtrak trains at Ivy City would have been making TWO VERY DIFFERENT unusual noises. A person would be much more likely to discern that two different trains are approaching.

Considering the cost of a locomotive, this feature would be a tiny drop in the bucket.

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Posted by Euclid on Thursday, June 13, 2019 11:33 PM

tree68
 
Euclid
They heard the horns of both trains, but it appears they thought they were only hearing the horn of #66.

 

A slight correction, based on the official report.  

In the end, they didn't have their heads on a swivel, as they should have.  A primary rule of railroading:  Always expect a train.  They apparently didn't, and we all know the result.

 

What correction?  What you quoted from me is true.

I don’t think it is as simple as failing to expect trains.  It may not have been that at all.  Back on page 1, Balt seemed to say he assumed the conductors never looked back, and he could not understand why.  I mentioned to him that I assume they did look back.  But apparently they did not look back during the approach of #175.    They may not have looked back often enough.  How often should a person look back? It would have to be often enough to not exceed the time interval between a train coming into view and reaching the employees at whatever speed the train was moving.  Having your head on a swivel sounds nice, but what does it really mean?  What is really needed is eyes in the back of your head and in front.

I told Balt that I thought a reasonable swivel routine would be to look back for one second at 5-second intervals.  Is that a head on a swivel? I think the two conductors were competent and responsible.  Maybe they broke a rule, but certainly, they encountered a set of unusual circumstances that totally absorbed all their attention, making them oblivious to the danger approaching from behind.  This probably happened without their conscious realization that their attention had been partly lost. 

They were expecting trains and they probably believed the one they saw approaching was one they were expecting. They saw the front approaching train (#66) and heard its loud horn warning.  They knew they were in the clear of it. They were not expecting a train from the rear because they had been checking periodically and were hearing full time without detecting a train.  When they heard the loud horn, they assumed it was only #66, and they did not know it was also #175 with the two horn sounds merged.  As their attention became riveted on #66, they assumed their hearing was still protecting them from behind, so they were not expecting #175 coming up behind them.       

I would not jump on their case for causing their demise by breaking a rule requiring people to always expect trains.  Rule 10 requires employees to look both ways before walking across a live track.  When you cross a live track you look both ways to see if it is clear.  If clear, you foul the track as you cross.  During that crossing, you are not expecting a train because you know it is clear.  If you were actually expecting a train as the rule requires, you would not cross.  So, “always expect a train” allows some discretion to know whether there is a reason to expect a train.

So an employee walks down a track and occasionally looks back to make sure a train is not approaching.  An employee also knows they have the sense of hearing and trains make some noise.  The employee knows whether train noise will be prominent or muffled by wind, fallen snow, etc., and they allow for that.  Like making a crossing, an employee walking down the track between looks-back is not expecting a train.  He can’t be expecting a train if he is on the track.

Rule 10 requires employees to look both ways before walking across a live track.  It says nothing about how to maintain such a precaution when walking along a track.  It says nothing about having your head on a swivel or how often to look back.

Given these circumstances, I would not conclude that the employees broke any rules.  I don’t believe that getting struck by a train proves that the victims failed to expect trains.  By far, the more egregious offense in this case was the CSX sending employees into tight quarters bordering on the foul zone of 125 mph trains without protection.

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Posted by mudchicken on Friday, June 14, 2019 7:26 AM

LO: TAWS didn't work / won't work...In the end, the senior conductor (actually both) broke more than one cardinal rule and paid the consequences. The dimestore lawyers can continue to argue, but sad case - closed.

Mudchicken Nothing is worth taking the risk of losing a life over. Come home tonight in the same condition that you left home this morning in. Safety begins with ME.... cinscocom-west
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Posted by Overmod on Friday, June 14, 2019 11:25 AM

Euclid
I would not jump on their case for causing their demise by breaking a rule requiring people to always expect trains.  [...]  So, “always expect a train” allows some discretion to know whether there is a reason to expect a train.

The problem with this whackjob kind of rationalization is that it completely ignores either the actual premise or the actual purpose of the rule.

Let's look at the exact analogue of this rule for firearms, the one that in the NRA rhyme begins "Sonny, never let your gun/Pointed be at anyone."

You'd be saying there's no reason to use care not to point a loaded gun at paths because you don't think there would be people there that time of day.  And perhaps at least some of the time, you'd be right -- but you can no more know that than, let's say, you can know whether prompt emergency braking would provide just the right additional 1/4 second of reaction time.  Your 'advice' there is just as applicable here:

You never relax vigilance for a moment if you're even close to fouling a track.  Any time.  Any where.  And you observe that as a rule, even if 'common sense' tells you there isn't a 'predominance of evidence' that you "need" to.  The whole point of the rule being to assure 100% effective vigilance as a habitual reflex.

That evidently wasn't 'trained' (or, to troll a little, wasn't 'vetted for') adequately for the conductor and trainee in question.  Had the simple rule of 'expect a train in any direction, at any time' been the habit it must be on the railroad, there is no question at all they wouldn't have died as they did.

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Posted by Overmod on Friday, June 14, 2019 11:32 AM

NDG
However, I was On Duty when a Trainman reached in to open the knuckle and align the drawbar as the rest of his train was backing down to make the joint.

Can you explain to me how frequent it is that you'd try to move a drawbar toward alignment from the 'danger zone' by grasping the knuckle or pushing the 'inside' of the engagement zone?  Does it save that much time when 'both' the knuckle is closed and the drawbar misaligned over?

Because that's likely what happened there: him reaching in from the side to pull the knuckle, then shifting to pull or push the drawbar as a continuation -- not to be cruel but you could probably tell which it was by the amount of 'above the wrist' that was left unsquashed.

Makes me wonder, again, if there is some kind of modern analogue to a Bishop coupling knife that would let you do both opening a knuckle and pushing/pulling a drawbar to alignment conveniently from completely outside the 'engagement zone'

Not to mention the likely bloodstain ... and worse ... under the dusting of new snow.

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Posted by charlie hebdo on Friday, June 14, 2019 12:12 PM

Overmod

 

 
Euclid
I would not jump on their case for causing their demise by breaking a rule requiring people to always expect trains.  [...]  So, “always expect a train” allows some discretion to know whether there is a reason to expect a train.

 

The problem with this whackjob kind of rationalization is that it completely ignores either the actual premise or the actual purpose of the rule.

Let's look at the exact analogue of this rule for firearms, the one that in the NRA rhyme begins "Sonny, never let your gun/Pointed be at anyone."

You'd be saying there's no reason to use care not to point a loaded gun at paths because you don't think there would be people there that time of day.  And perhaps at least some of the time, you'd be right -- but you can no more know that than, let's say, you can know whether prompt emergency braking would provide just the right additional 1/4 second of reaction time.  Your 'advice' there is just as applicable here:

You never relax vigilance for a moment if you're even close to fouling a track.  Any time.  Any where.  And you observe that as a rule, even if 'common sense' tells you there isn't a 'predominance of evidence' that you "need" to.  The whole point of the rule being to assure 100% effective vigilance as a habitual reflex.

That evidently wasn't 'trained' (or, to troll a little, wasn't 'vetted for') adequately for the conductor and trainee in question.  Had the simple rule of 'expect a train in any direction, at any time' been the habit it must be on the railroad, there is no question at all they wouldn't have died as they did.

 

In support of your analogy, there is another,  tighter one most of us learn when young.  If walking down a road with no sidewalk, walk on the side facing traffic.  Don't walk with the flow because you might not notice a vehicle approaching from behind until it's too late. 

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Posted by Overmod on Friday, June 14, 2019 12:24 PM

charlie hebdo
Don't walk with the flow because you might not notice a vehicle approaching from behind until it's too late. 

There is a somewhat darker further affirmation of this principle: if you're walking with the flow, you might not notice malicious drivers intent on 'near missing' or actually hitting you, including 'getting you with the door', throwing garbage at you, 'rolling coal' and other pathetic once-probably-more-common-than-they-should-have-been practices.

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Posted by Miningman on Friday, June 14, 2019 12:35 PM

Single file

Indian style

Facing traffic all the while 

We sang that in grade school .. perhaps politically incorrect these days.

 

 

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Posted by Euclid on Friday, June 14, 2019 1:06 PM

The rule saying “always expect a train…” means one must know that a train could arrive at any time.  Anybody that works for a railroad knows this fact.  It is a fallacy to conclude that every railroader who is struck by a train did not know this fact.  Of course they knew that trains can arrive at any time.  They just didn’t realize one was arriving when it struck them.  

That realization requires sensory input, which can necessarily be somewhat sporadic and therefore take some time.  If an arriving train happens to be missed by the sensory input.  So is there also a rule requiring employees to always see any danger that exists?  

Also notice that the NTSB report does not say that the victims failed to expect a train.  It says the cause of the accident was their decision to walk on the track.  And yet, they also say there was no prohibition against walking on the track.  The way I see it, the NTSB did not want to prejudice the case by directly finding that CSX caused the accident, but they left the door wide open for that case to be made if anyone chooses to make it.  That is why the cause that they did find seems so nebulous.

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Posted by Flintlock76 on Friday, June 14, 2019 1:11 PM

I remember that rhyme myself, just a appropriate today as it was fifty-plus years ago.

I took it a step further.  If I was riding my bike on a road with a less-than-generous shoulder I rode facing the traffic.

I know you're supposed  to ride with the traffic, but if there was a two-ton mass of machinery coming at me I wanted to know about it!  

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Posted by Deggesty on Friday, June 14, 2019 1:24 PM

As to adjusting a drawbar or knuckle while making a joint, I do not recall if there is a rule that says the movement must be stopped before making any such adjustment.

Johnny

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Posted by Overmod on Friday, June 14, 2019 3:54 PM

Deggesty

As to adjusting a drawbar or knuckle while making a joint, I do not recall if there is a rule that says the movement must be stopped before making any such adjustment

Johnny, doesn't this belong over in String Lining where we're discussing a different 'attention deficit' bad-judgment accident?

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Posted by Deggesty on Friday, June 14, 2019 4:43 PM

Overmod

 

 
Deggesty

As to adjusting a drawbar or knuckle while making a joint, I do not recall if there is a rule that says the movement must be stopped before making any such adjustment

 

 

Johnny, doesn't this belong over in String Lining where we're discussing a different 'attention deficit' bad-judgment accident?

 

Yes, it would fit there.

Johnny

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Posted by tree68 on Friday, June 14, 2019 5:22 PM

Euclid
What correction?  What you quoted from me is true.

I quoted you, but I added (in bold type) two very important words.

You have no way of knowing what they heard or were thinking.

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Posted by zugmann on Friday, June 14, 2019 5:54 PM

Overmod
Makes me wonder, again, if there is some kind of modern analogue to a Bishop coupling knife that would let you do both opening a knuckle and pushing/pulling a drawbar to alignment conveniently from completely outside the 'engagement zone'

Brakestick for the knuckle.  Drawbars, depends how freely they move.  Some need some might, others you can breathe on them and they slide the whole way over.

It's been fun.  But it isn't much fun anymore.   Signing off for now. 


  

The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.t fun any

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Posted by Euclid on Friday, June 14, 2019 7:05 PM

tree68
 
Euclid
What correction?  What you quoted from me is true.

 

I quoted you, but I added (in bold type) two very important words.

You have no way of knowing what they heard or were thinking.

 

Okay, I see.  Yes I assume they thought they were only hearing the horn of #66.  I also assume they did hear both horns, and that they would have gotten clear had they realized that one of the horns was #66 behind them.  But those are only assumptions because I don't know what they were actually experiencing. 

As for the rule to always expect a train, I think we have no way of knowing whether they were doing that or not.  I do not believe that it logically follows that everyone struck by a train is automatically guilty of not expecting a train.  So I do not assume that they failed to expect a train.  I tried to explain this a little above.        

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Posted by Euclid on Sunday, June 16, 2019 6:47 PM

What is needed is a new rule:

 

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group.

 

Adhering to this rule would have prevented this Ivy City tragedy and perhaps several hundred similar ones in that past, plus all in the future.  This would surely be one of those rules written in blood. 

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Posted by BaltACD on Sunday, June 16, 2019 7:01 PM

Euclid
What is needed is a new rule: 

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group. 

Adhering to this rule would have prevented this Ivy City tragedy and perhaps several hundred similar ones in that past, plus all in the future.  This would surely be one of those rules written in blood. 

CSX has such a rule for MofW personnel.  Whenever a train passes on an adjacent track they are to stop work and dismount their machines until the train passes.  There is a Employee in Charge as stated in Train Messages that the train much establish contact with to obtain permission to pass through the designated Work Zone and the speed that the train is permitted to operae is also specified by the Employee in Charge.  The Employee in Charge must also know that the members of the MofW Work Zone have placed themselves in a place of safety before issuing the permission for the train to pass through the Work Zone.

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Posted by 243129 on Monday, June 17, 2019 4:43 PM

This from the 'locked' thread:

The CSX train had both CSX main tracks 2 & 1 occupied as they were making a crossover move. Why the conductor and trainee were inspecting the train from a live track when they could have done so from the CSX main #1 side smacks of poor judgement due to inexperience and inadequate training.

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Posted by Euclid on Monday, June 17, 2019 5:55 PM

Euclid

What is needed is a new rule:

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group.

Adhering to this rule would have prevented this Ivy City tragedy and perhaps several hundred similar ones in that past, plus all in the future.  This would surely be one of those rules written in blood. 

I am not sure how unusual it is for employees to walk on the track, but in the course of thinking about this new rule, something occurred to me.  I do find it very strange that the two conductors chose to remain walking on that track as a passenger train sped by on the other adjacent track.  Most people would tend to step back off of that track and get further back for more clearance from the moving train.  The two conductors continued walking where they would only be about 13 feet from #66 as it passed by them.  Standing this close to #66 seems much more imprudent than merely walking on the track with no trains approaching.

Not only is standing too close to the path of an approaching train dangerous, but it also is somewhat of a red flag to the train crew who probably think it is unusual and it makes them a bit nervous wondering why a person is standing so close.

Had the two conductors instinctively followed the basic premise of giving #66 a little more room, they would have stepped off the track and into the clear of #175 despite the fact that they were unaware of it coming up behind them. 

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Posted by BaltACD on Monday, June 17, 2019 6:11 PM

243129
This from the 'locked' thread:

The CSX train had both CSX main tracks 2 & 1 occupied as they were making a crossover move. Why the conductor and trainee were inspecting the train from a live track when they could have done so from the CSX main #1 side smacks of poor judgement due to inexperience and inadequate training.

Remember - CSX Rules for inspecting trains for defects identified by Defect Detectors - REQUIRE BOTH sides of the train be inspected.  In which order which side of the train is inspected is not specified by the rules.  I did not notice in the report of this incident, which side the Conductor and Trainee inspected first.  I doubt that being on the 'Amtrak' side of the train indicates that it had been previously inspected.

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Posted by 243129 on Monday, June 17, 2019 6:29 PM

BaltACD

 

 
243129
This from the 'locked' thread:

The CSX train had both CSX main tracks 2 & 1 occupied as they were making a crossover move. Why the conductor and trainee were inspecting the train from a live track when they could have done so from the CSX main #1 side smacks of poor judgement due to inexperience and inadequate training.

 

Remember - CSX Rules for inspecting trains for defects identified by Defect Detectors - REQUIRE BOTH sides of the train be inspected.  In which order which side of the train is inspected is not specified by the rules.  I did not notice in the report of this incident, which side the Conductor and Trainee inspected first.  I doubt that being on the 'Amtrak' side of the train indicates that it had been previously inspected.

 

That being the case they should have contacted the Amtrak dispatcher and requested protection on the adjacent track.

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Posted by Miningman on Monday, June 17, 2019 7:01 PM

Now THAT is the first thing stated here that's makes any sense. Surely this is standard operating procedure. An eight year old can see that.

How on earth could it not be? 

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Posted by Convicted One on Monday, June 17, 2019 7:22 PM

BaltACD
Remember - CSX Rules for inspecting trains for defects identified by Defect Detectors - REQUIRE BOTH sides of the train be inspected.  In which order which side of the train is inspected is not specified by the rules.  I did not notice in the report of this incident, which side the Conductor and Trainee inspected first.  I doubt that being on the 'Amtrak' side of the train indicates that it had been previously inspected.

The way I read the report, the conductor trainee got off the train on the north side, while the conductor got off on the south side. And the CSX train was not occupying the cross over at that time .   While they were inspecting and releasing set handbrakes, the  dispatcher decided the cars needed to be set out on main #2 and the CSX locomotive advanced through the crossover to accomplish this.  But a mechanical dept employee subsequently determined that the cars did NOT need to be set out.

So the train  that was only occupying one main when the conductors began their inspection, had moved to where it was occupying the crossover and both mains...creating a set of circumstances that were new to the conductors since their inspection had begun.

Correct me if I'm wrong, but the CSX train couldn't simply "back up" to where it was again occupying  only main #1, unless one of the conductors was first willing to walk all the way back to the rear end of the train, to "protect" that movement, could it?. 

If this is so,   then it was likely a choice of convenience  by the conductors to use the Amtrak main #3 to walk around the front portion of the CSX train  now stopped on CSX  main #2, as an alternative to  having to walk all the way back to the rear end of their train to allow a backup movement?

At least that is the way it appears to me.

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Posted by 243129 on Monday, June 17, 2019 7:28 PM

Miningman

Now THAT is the first thing stated here that's makes any sense. Surely this is standard operating procedure. An eight year old can see that.

How on earth could it not be? 

 

Poor vetting, poor training, poor supervision.

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