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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by 243129 on Thursday, June 20, 2019 7:22 AM

243129

 

 
BaltACD

 

 
tree68
NORAC already has a rule in place that would apply in this situation:

V. Fouling Tracks Fouling a track may be necessary in the performance of railroad work. Employees must expect the movement of trains, locomotives, or other on-track equipment at any time, on any track, in either direction. Employees must maintain a vigilant lookout for and detect the approach of a train, locomotive or other railroad equipment moving in either direction. Proper safeguards for the job classification needing protection must be in place before fouling any track.

Direct copy and paste from NORAC, 11th Edition.

I have no reason to doubt that CSX has the same, or a very similar, rule.  Amtrak uses NORAC.

In addition, there are specific rules about fouling track:

140. Foul Time Foul Time may be issued only by the Dispatcher.

A. Action Required Prior to Issuance Before issuing or authorizing Foul Time, the Dispatcher must determine that no trains or other on-track equipment have been authorized to occupy the track segment to be fouled. In signaled territory, the Dispatcher must ensure that Stop Signals have been displayed and blocking devices applied to controls of switches and signals leading to the affected track. When trains are to be held at a TBS where blocking devices cannot be applied, the Dispatcher must issue Form D line 13 instructing the Operator to hold trains clear of the affected track.

B. Permission to Foul Permission to foul the track must include the following information:

1. Title and name of employee receiving foul time

2. Track designation

3. Track limits (between/at)

4. Time limits

The receiving employee must repeat this permission and the Dispatcher must then confirm it before the Foul Time becomes effective.

 C. Releasing Foul Time Once protection has been provided, it must be maintained until the employee who was granted the foul time has released the foul time. The employee who was granted Foul Time must not release the Foul Time until they have ensured that all fouling activity under their authority has been cleared. The release must include the employee's title and name, and the track designation and limits being released. This information must be repeated by the Dispatcher, and confirmed by the employee releasing the foul time before blocking devices are removed.

NORAC 11th Edition – February 1, 2018 

 

To my knowledge - those rules are taught to MofW personnel, not T&E personnel.  Not saying that it shouldn't be taught to T&E - just that it is not.

 

 

 

"Just that it is not" seems to indicate that you purport to have knowledge of Amtrak rules. You do not and you have disappointed your cheerleader.

 

You say "those rules" which are in direct reference tree 68's post which contains the NORAC 11th Edition – February 1, 2018 rules and you are now trying to say that you are referring to B&O rules??? Nice try at damage control.

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Posted by 243129 on Thursday, June 20, 2019 7:27 AM

BaltACD

 

 
243129

It is quite obvious that you have no knowledge of what Amtrak teaches and you did claim to have said knowledge as is evidenced in your reply to tree 68 which I shall post below.

 

You are reading things that were never stated - I am stating my experience - experience dating from the B&O in 1965 and the successor corporate identities of the same.  Amtrak has never been a B&O descendent organization, despite haing selected some B&O equipment when they formed and equipped Amtrak.  From Amtrak's accident record it appears that a number of Amtrak employee showed up for their 'Rules Classes' in body only, their mind was somewhere else.

 

"I have no knowledge of what Amtrak teaches - and don't claim to have.  How many CSX Rules classes have you attended?"

For easy reference.

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Posted by 243129 on Thursday, June 20, 2019 7:31 AM

Inexperience, poor vetting, poor training and poorer supervision are the root causes of this avoidable tragedy.

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Posted by Euclid on Thursday, June 20, 2019 7:41 AM

From the rules:

140. Foul Time Foul Time may be issued only by the Dispatcher.

I don't see anything in the rules that says foul time was required.  Without that requirement, the procedure used by the employees was entirely approved and made necessary by CSX. 

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Posted by n012944 on Thursday, June 20, 2019 8:08 AM

BaltACD

 

 
243129
 
BaltACD
To my knowledge - those rules are taught to MofW personnel, not T&E personnel. Not saying that it shouldn't be taught to T&E - just that it is not. 

You are wrong. Those rules are most certainly taught to T&E personnel on Amtrak.

 

 

I have no knowledge of what Amtrak teaches - and don't claim to have.  How many CSX Rules classes have you attended?

 

 

Interesting, but not suprising, that he didn't answer your question.   Using Mr numbers "logic" in another thread, he has never taken a CSX rules class.

An "expensive model collector"

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Posted by MMLDelete on Thursday, June 20, 2019 8:10 AM

They were required to inspect their train. They were not required to walk on Amtrak’s track. And they could have minimized their time on the bad side. If they had returned on the safe side, nothing bad would have happened.

I also don’t understand why they didn’t ask Amtrak what was due by soon. They probably could have determined what was a safe window of time to be on the bad side. 

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Posted by Euclid on Thursday, June 20, 2019 8:30 AM

Lithonia Operator
They were not required to walk on Amtrak’s track.

They were not required not to.  They walked up from a long ways back, and we don't know where they walked or what guided their decisions.  We only know they were on the Amtrak track when then were hit.  The NTSB said people have told them they prefer to walk on track rather than on ballast.  In this case, I wonder why the sloped concrete ties would be preferable to walking on ballast.  I would think the sloped ties would be very annoying to walk on. 

In any case, what ultimately caused their deaths was hearing the horns of #66 and #175 which blended together and sounded like the horn of just one train.  They were watching #66 approaching from their front, and they assumed the horn sound they were hearing was coming only from #66.  So while, they obviously had to hear the horn of #175, they thought it was from #66.  If they had their head on a swivel, as they say, the swivel was facing the wrong direction during the 10 seconds they had to turn and spot #175 behind them. 

It was definitely dangerous.  For this very reason of two trains approaching, a double track is not just twice as dangerous as a single track.  A double track is probably 1000 times more dangerous than a single track.

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Posted by MMLDelete on Thursday, June 20, 2019 9:56 AM

Just because other employees routinely did this same unsafe thing doesn’t make it anything other than unsafe.

Anyone who would make such an unwise decision is not going to be dissuaded by a rule. No one was watching. This is about safety and common sense, not rules compliance.

Sure, they can enact such a rule. And next time this happens they can fire the dead guys ...

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Posted by MMLDelete on Thursday, June 20, 2019 10:10 AM

I don’t see any HARM in such a rule, but I think it would be meaningless.

It is not against the law to go out on I-95 and step into the path of a speeding Mack truck. But most people realize that’s a bad idea.

And understand this. I am not a knee-jerk anti-regulations kind of guy. Politically I am a pretty hard-core liberal. I think a LOT of things ought to be regulated more.

I am not opposed to such a rule. But do I think it would have made a difference in this case? No.

Was lack of said rule a “cause” of the accident? No.

It was a terrible, sad tragedy.

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Posted by Euclid on Thursday, June 20, 2019 12:04 PM

Lithonia Operator
Anyone who would make such an unwise decision is not going to be dissuaded by a rule. No one was watching. This is about safety and common sense, not rules compliance.

It is the rules that define the unwise decision.  Sure rules are often broken, but to conclude that a person will not follow a rule because he basically a bad person is way too judgmental.  Railroads have rules about everything.  The rules define the behavior.  The rules in this case did not prohibit them from walking on the track.  You say it was too dangerous and should have been guided by common sense.  What about walking across a track?  Is that too dangerous?  Common sense would say of course it is.  People get killed all the time when crossing tracks. 

There are rules that govern walking on live track.  The one rule is to always expect a train, look for trains, etc.  I believe those rules have been proven by a lot of past experience to not work in the odd type of distraction that played out in this accident.  So yes, you can say the conductors violated a rule.  But when you have a rule like this that seems to not work in a long pattern of a particular type of accident, it is time to look for a better rule.  The real rule that is needed is the rule requiring formal protection for people working on the ground in close proximity to live track.  That is exactly what the NTSB concluded.    

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Posted by girarddepot on Thursday, June 20, 2019 12:08 PM

If  the Wall St. Jourtnal is tobe believed, there is a serious problem with street drug use among Amtrak employees.  In the case of these fatalities, small amounts of cocaine were found on one and cocaine plus meth on the other--not enough to be high but enough to impair judgement and reaction time.  In any case, it's still a tragedy to have serious injury or loss of life.

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Posted by tree68 on Thursday, June 20, 2019 12:12 PM

Euclid
The real rule that is needed is the rule requiring formal protection for people working on the ground in close proximity to live track. 

That rule already exists.

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Posted by Euclid on Thursday, June 20, 2019 12:25 PM

tree68
 
Euclid
The real rule that is needed is the rule requiring formal protection for people working on the ground in close proximity to live track. 

 

That rule already exists.

 

There is a rule about how protection is granted, but no rule requiring it to be granted.  The use of protection is only an option, and not a mandate. 

It is right there in the NTSB report.  They refer to an existing procedure to provide protection as an option, and the conclude by advising that the exiting procedure be made mandatory.

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Posted by MMLDelete on Thursday, June 20, 2019 12:55 PM

Euclid
but to conclude that a person will not follow a rule because he basically a bad person is way too judgmental

Nowhere did I even remotely suggest that they were bad people. Not only may they have been exemplary human beings, they may also have been extemely safe railroaders ordinarily. But in this case, in one fateful moment, for whatever reason, they (or the conductor, and the trainee went along against his better judgement) made a bad decision.

It's very sad.

If I had fallen between the cars at Atlanta Yard and gotten killed, it would have been solely my own fault. What I did - cutting across moving cuts - was perhaps more dangerous, statistically, than what those guys did. But I made the decision to do so for my own convenience or, even, simple reckless fun.  A rule did not prevent me from doing so when no one was looking (which was usually the case).

Unfortunately, good people make bad decisions every day. Those CSX men may both have been better, smarter people than I am. But their tragic lack of vigilance happened to coincide with a very unlikely set of circumstances. They were victims of really bad luck.

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Posted by tree68 on Thursday, June 20, 2019 1:03 PM

Euclid

It is right there in the NTSB report.  They refer to an existing procedure to provide protection as an option, and the conclude by advising that the exiting procedure be made mandatory.

NTSB Report

Recommendation

As a result of its investigation, the National Transportation Safety Board makes the following new safety recommendation:

To CSX Transportation and the National Railroad Passenger Corporation: Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads. (R-19-006

I see nothing about an exiting procedure.  They say they shouldn't be there in the first place.

And this still would require the employees to notify the dispatcher that they are fouling the adjacent tracks.

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Posted by MMLDelete on Thursday, June 20, 2019 1:18 PM

In many places, two railroads have adjacent tracks.

Honest Question: how often does it occur that one road will order their trains to proceed slowly because a train on the other road is being inspected?

Does that routinely happen? (I am just not sure that this is practical.) I have no idea how often the situation comes up.

Are other (non-CSX) freight railroads routinely getting Amtrak (or other freight roads) to proceed slowly or stop because of train inspections? It's just something I'd never thought about before. I was a clerk/operator for a couple of years. But I never worked in train service, unfortunately; I wanted to, but they weren't hiring for that then.

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Posted by charlie hebdo on Thursday, June 20, 2019 1:33 PM

BaltACD

 

 
243129

It is quite obvious that you have no knowledge of what Amtrak teaches and you did claim to have said knowledge as is evidenced in your reply to tree 68 which I shall post below.

 

You are reading things that were never stated - I am stating my experience - experience dating from the B&O in 1965 and the successor corporate identities of the same.  Amtrak has never been a B&O descendent organization, despite haing selected some B&O equipment when they formed and equipped Amtrak.  From Amtrak's accident record it appears that a number of Amtrak employee showed up for their 'Rules Classes' in body only, their mind was somewhere else.

 

Jeez, to paraphrase a classic film, what a failure in communication we've got!  It's reasonably clear to a person with even average reading comprehension skills (which include contextual meaning) that BaltACD is referring solely to CSX rules and practices, not Amtrak's.

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Posted by Euclid on Thursday, June 20, 2019 2:25 PM

tree68
 
Euclid

It is right there in the NTSB report.  They refer to an existing procedure to provide protection as an option, and the conclude by advising that the exiting procedure be made mandatory.

 

 
NTSB Report

Recommendation

As a result of its investigation, the National Transportation Safety Board makes the following new safety recommendation:

To CSX Transportation and the National Railroad Passenger Corporation: Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads. (R-19-006

 

I see nothing about an exiting procedure.  They say they shouldn't be there in the first place.

And this still would require the employees to notify the dispatcher that they are fouling the adjacent tracks.

 

Look at this part of the report (in blue).  It is on the last page just before their “Recommendation”.  I have broken it up a little and added bold in places.  In the first paragraph, NTSB implies that the crew was not prohibited from walking on the track by saying they believed crews should be prohibited from that.  Earlier, also they did affirm that crews were not prohibited from walking on the track.  

In the second paragraph, they say they would need protection.  This seems inconsistent with what they have said about not being prohibited.  I can only conclude that they mean they would “need” protection to be adequately safe, but not “need” it in terms of needed to satisfy a mandated requirement or rule.   But at this point, it is hard to be sure.  If they are referring to needing to follow an existing rule requiring protection, it seems inconsistent with what they said earlier in the report. 

The third paragraph outlines the protection that is available.  That is the “existing procedure” I referred to.

But, if it were required (under that definition of “need”), why would the last paragraph recommend that CSX and Amtrak prohibit employees from fouling a track without protection?  That fact that they recommend protection clearly means that it is not now required.  So, their overall report conclusion is that protection be changed from an option to a requirement.    From the report

The engineer mentioned that he did not understand why the conductors had stayed on the side of the train closest to the Amtrak tracks. The conductors could have safely crossed over their train and walked well away from the live Amtrak tracks. The NTSB believes that the crew should have been prohibited from walking near the live tracks of the other railroad.

However, there are circumstances when the operating employees cannot safely walk away from the other railroad’s tracks. In these situations, when the crew is fouling the other railroad’s adjacent track, they would need protection.9

A current process is readily available to provide this protection. For example, a train dispatcher will communicate with another train dispatcher from a different railroad if a derailed train has obstructed an adjacent railroad’s track. This derailment would be an emergency and has the possibility of contributing to an additional collision and derailment. The NTSB believes that this same communication could be used to protect employees that find it necessary to occupy the other railroad’s active tracks.

Therefore, to eliminate the hazard of unknown traffic on adjacent tracks of other railroads, the NTSB recommends that CSX and Amtrak prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads.

https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1901.pdf 

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Posted by tree68 on Thursday, June 20, 2019 2:51 PM

I see the problem - you had earlier provided what you thought should be a procedure involving standing well away from the active track.  You then mistyped "exiting" instead of "existing," leading me to link the two.

But that still doesn't change the fact that the only piece missing is coordination between the two railroads if employees of one will foul the track of the other.  

Someone still has to initiate the request for said protection.  And that's got to be the crew.  The dispatcher has no idea if such protection is needed.  And even their own engineer couldn't understand why they were where they were, as noted in the report.

In the end, two people were someplace they should not have been, and were not sufficiently aware of their surroundings.  There is nothing in the report that says anything different.  We'll never know why they took that route, nor why they didn't look both ways.  

 

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Posted by Euclid on Thursday, June 20, 2019 3:16 PM

tree68

But that still doesn't change the fact that the only piece missing is coordination between the two railroads if employees of one will foul the track of the other.  

Someone still has to initiate the request for said protection.  And that's got to be the crew.  The dispatcher has no idea if such protection is needed.  And even their own engineer couldn't understand why they were where they were, as noted in the report.

In the end, two people were someplace they should not have been, and were not sufficiently aware of their surroundings.  There is nothing in the report that says anything different.  We'll never know why they took that route, nor why they didn't look both ways.  

 

 

The main piece missing is the fact that protection is not required.  I am not sure if there are also organizational issues that are missing pieces.  That seems quite unclear in the way the report is written.  I think you are right that it would have to be the crew that asks for the protection if it is to be granted.  But first you need a rule making it mandadory to have protection, and clearly that does not yet exist.  That is why the NTSB recommends it.  I don't think you can conclude that the two people were someplace they should not have been.  The report makes it crystal clear that they were not prohibited from walking on that track. 

The employees did apparently violate the rule to watch for trains during the 10 seconds during the approach of #175.  Yet they were obviously distracted and did not realize it.  If they realized they were distracted, they would have made themselves undistracted.

The only point I question about their behavior is their decision to remain walking on the Amtrak track as #66 passed.  Most people would back off that track and move as close as possible to the CSX train.    

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Posted by tree68 on Thursday, June 20, 2019 4:58 PM

Euclid
I don't think you can conclude that the two people were someplace they should not have been.  The report makes it crystal clear that they were not prohibited from walking on that track. 

You're not prohibited from walking down the middle of a busy highway (unless it's a freeway, in which case it is prohibited) during rush hour, either, but prudence dictates that you not do it.

Regardless of whether it was prohibited by a rule, walking on a high-speed railroad ROW shows a lack of that same prudence.  Hence the conclusion that they should not have been where they were.  

Had they taken the safe course (which is a rule) and stayed off that ROW, we would not be having this discussion.  Not being alert to the possibility of a train in either direction just piles on top of that.

Euclid
Yet they were obviously distracted and did not realize it.

If they were distracted, they should have stepped off the ROW to a safe place, never mind any trains that might be approaching.  

Euclid
The only point I question about their behavior is their decision to remain walking on the Amtrak track as #66 passed.  Most people would back off that track and move as close as possible to the CSX train.

You're right - most people would - and in the process probably would have seen the other train approaching.  

Their deaths are a terrible loss - but if they had abided by existing rules, they'd still be alive.  

The rule requiring protection would probably produce one good result - if a crew was planning to do something that required them to obtain foul time but could get by without having to get it - they wouldn't do it in the first place.

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Posted by Euclid on Thursday, June 20, 2019 5:57 PM

tree68
 

       Euclid

Yet they were obviously distracted and did not realize it.

 

If they were distracted, they should have stepped off the ROW to a safe place, never mind any trains that might be approaching.   

I don't think they realized they were distracted.  That is the nature of distraction.  It is like that guy who tipped over the Amrak train in Philadephia because he lost situational awareness.  If he would have realized he had lost it, with that realization, he would have gained it back. 

These two conductors got caught by something they had never anticipated in this convergence of two trains sounding like one train.  Is that negligence?  I suppose it is if you expect no mistakes.  But everybody makes little mistakes all day long.  It is just that they don't have the monstrous consequences of this little mistake.  But CSX should have known about the monstrous consequences and made protection mandatory just like all the other mandatory rules they have covering every little tidbit about safety.  If a little mistake is known to have such dire consequences, a better form of prevention is needed.  That is common sense.  So I am surprised that anyone would blame the two victims while giving CSX a free pass.   

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Posted by Convicted One on Thursday, June 20, 2019 6:16 PM

Euclid
But CSX should have known about the monstrous consequences and made protection mandatory just like all the other mandatory rules they have covering every little tidbit about safety.

Hey, how about this one "If you are an engineer who has fellow crewmen out on the ground,  and you are stopped next to another railroads main line, then don't go into the bathroom until your crew are safely back on board"?

Seems like an extra pair of eyes might have been useful in this incident (hindsight I'll admit)

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Posted by 243129 on Thursday, June 20, 2019 6:37 PM

243129

 

 
243129

 

 
BaltACD

 

 
tree68
NORAC already has a rule in place that would apply in this situation:

V. Fouling Tracks Fouling a track may be necessary in the performance of railroad work. Employees must expect the movement of trains, locomotives, or other on-track equipment at any time, on any track, in either direction. Employees must maintain a vigilant lookout for and detect the approach of a train, locomotive or other railroad equipment moving in either direction. Proper safeguards for the job classification needing protection must be in place before fouling any track.

Direct copy and paste from NORAC, 11th Edition.

I have no reason to doubt that CSX has the same, or a very similar, rule.  Amtrak uses NORAC.

In addition, there are specific rules about fouling track:

140. Foul Time Foul Time may be issued only by the Dispatcher.

A. Action Required Prior to Issuance Before issuing or authorizing Foul Time, the Dispatcher must determine that no trains or other on-track equipment have been authorized to occupy the track segment to be fouled. In signaled territory, the Dispatcher must ensure that Stop Signals have been displayed and blocking devices applied to controls of switches and signals leading to the affected track. When trains are to be held at a TBS where blocking devices cannot be applied, the Dispatcher must issue Form D line 13 instructing the Operator to hold trains clear of the affected track.

B. Permission to Foul Permission to foul the track must include the following information:

1. Title and name of employee receiving foul time

2. Track designation

3. Track limits (between/at)

4. Time limits

The receiving employee must repeat this permission and the Dispatcher must then confirm it before the Foul Time becomes effective.

 C. Releasing Foul Time Once protection has been provided, it must be maintained until the employee who was granted the foul time has released the foul time. The employee who was granted Foul Time must not release the Foul Time until they have ensured that all fouling activity under their authority has been cleared. The release must include the employee's title and name, and the track designation and limits being released. This information must be repeated by the Dispatcher, and confirmed by the employee releasing the foul time before blocking devices are removed.

NORAC 11th Edition – February 1, 2018 

 

To my knowledge - those rules are taught to MofW personnel, not T&E personnel.  Not saying that it shouldn't be taught to T&E - just that it is not.

 

 

 

"Just that it is not" seems to indicate that you purport to have knowledge of Amtrak rules. You do not and you have disappointed your cheerleader.

 

 

 

You say "those rules" which are in direct reference tree 68's post which contains the NORAC 11th Edition – February 1, 2018 rules and you are now trying to say that you are referring to B&O rules??? Nice try at damage control.

 

Show me where CSX rules are mentioned in tree 68's post that you responded to.

 

What does me attending or having attended CSX rules have to do with anything? I had no reason to and  have not purported to be knowledgeable of them as you did with NORAC.

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Posted by 243129 on Thursday, June 20, 2019 6:42 PM

charlie hebdo
Jeez, to paraphrase a classic film, what a failure in communication we've got! It's reasonably clear to a person with even average reading comprehension skills (which include contextual meaning) that BaltACD is referring solely to CSX rules and practices, not Amtrak's.

OK then show me where he is referring "solely to CSX rules" in BaltACD's response to tree 68's post. See my above post for reference.

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Posted by charlie hebdo on Thursday, June 20, 2019 7:22 PM

243129

 

 
charlie hebdo
Jeez, to paraphrase a classic film, what a failure in communication we've got! It's reasonably clear to a person with even average reading comprehension skills (which include contextual meaning) that BaltACD is referring solely to CSX rules and practices, not Amtrak's.

 

OK then show me where he is referring "solely to CSX rules" in BaltACD's response to tree 68's post.

 

It's clearly  there as I explained.  The inability to infer answers from the context is a form of dyslexia, specifically reading comprehension.  Try reading what he said in several posts. 

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Posted by 243129 on Thursday, June 20, 2019 7:26 PM

charlie hebdo
It's clearly there as I explained. The inability to infer answers from the context is a form of dyslexia, specifically reading comprehension. Try reading what he said in several posts.

So show me exactly where CSX rules are mentioned in Balt's response to tree 68. You cannot that is why you did not.

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Posted by 243129 on Thursday, June 20, 2019 7:28 PM

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Posted by BaltACD on Thursday, June 20, 2019 7:33 PM

243129
 
charlie hebdo
It's clearly there as I explained. The inability to infer answers from the context is a form of dyslexia, specifically reading comprehension. Try reading what he said in several posts. 

So show me exactly where CSX rules are mentioned in Balt's response to tree 68. You cannot that is why you did not.

I have NEVER mentioned Amtrak Rules.  I don't have a Amtrak Rule Book and have never attended a Amtrak Rules Class.  Any assertion that I have intimated Amtrak procedures are totally between 243129's ears from a lack of reading comprehension.

Never too old to have a happy childhood!

              

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Thursday, June 20, 2019 7:39 PM

BaltACD

 

 
243129
 
charlie hebdo
It's clearly there as I explained. The inability to infer answers from the context is a form of dyslexia, specifically reading comprehension. Try reading what he said in several posts. 

So show me exactly where CSX rules are mentioned in Balt's response to tree 68. You cannot that is why you did not.

 

I have NEVER mentioned Amtrak Rules.  I don't have a Amtrak Rule Book and have never attended a Amtrak Rules Class.  Any assertion that I have intimated Amtrak procedures are totally between 243129's ears from a lack of reading comprehension.

 

You responded to tree68's post concerning NORAC did you not?

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