CSX Fatalities Probable Cause, Ivy City, DC

[AnthonyV]

The following is a link to the preliminary report.  It's only two pages, but it shows a photo of the CSX train involved that night.  I hadn't seen this photo before,  It's incredible to me how tight the layout is, something that doesn't quite come across in the NTSB accident brief (at least to me anyway).

https://www.ntsb.gov/investigations/AccidentReports/Reports/DCA17MR010-prelim.pdf

 

[Euclid]

charlie hebdo

Where in the report does it say the 175 engineer was required to apply emergency brakes as soon as the CSX crew were seen (was that ~15seconds prior to impact)?  Where does it say that would have saved their lives? 

 

 

Nobody can know that it would have saved their lives.  But it is a fact that it could have saved their lives.  Nobody can say what the odds of saving their lives would have been had an emergency application been made as early as possible.  What would be a good reason not to take that chance?   

[charlie hebdo]

Where in the report does it say the 175 engineer was required to apply emergency brakes as soon as the CSX crew were seen (was that ~15seconds prior to impact)?  Where does it say that would have saved their lives? 

[243129]

Murphy Siding

 

 

243129

. 

 

 

 

      I think we all kind of understand how you feel about Amtrak's training ("Poor vetting ,poor training , poor supervision, and lack of common sense coupled with inexperience and bad decisions on the parts of the CSX crew and Amtrak 175  engineer") etc.

      Can you walk us through this event? If you are the engineer in this situation, what is the sequence of events and what should an engineer who had 'all the right stuff' have done?

-Thanks

 

 

Two people walking on my track with their backs to me with a train on one side and an oncoming on the other signals disaster to me. Instantaneous emergency brake application and all the noise that I can possibly make.

[Euclid]

tree68

 

Euclid

I think it is fair to conclude that the fact that they did not move into the clear is proof that they were not aware of 175, and therefore, they never looked back during that period. 

 

 

Therefore, they were not expecting a train, at any time, in any direction.  Add to that the fact that they were fouling the track with their back to oncoming flow of traffic.

Trying to discern if, and when, they looked back is a moot point.  They didn't see the oncoming 175.  They were not aware of their surroundings.  

 

Well, you did not think it was moot when you brought it up as an issue in the second post from the top of this page.  

[tree68]

Euclid

I think it is fair to conclude that the fact that they did not move into the clear is proof that they were not aware of 175, and therefore, they never looked back during that period. 

Therefore, they were not expecting a train, at any time, in any direction.  Add to that the fact that they were fouling the track with their back to oncoming flow of traffic.

Trying to discern if, and when, they looked back is a moot point.  They didn't see the oncoming 175.  They were not aware of their surroundings.  

[Murphy Siding]

243129

. 

      I think we all kind of understand how you feel about Amtrak's training ("Poor vetting ,poor training , poor supervision, and lack of common sense coupled with inexperience and bad decisions on the parts of the CSX crew and Amtrak 175  engineer") etc.

      Can you walk us through this event? If you are the engineer in this situation, what is the sequence of events and what should an engineer who had 'all the right stuff' have done?

-Thanks

[Euclid]

tree68

 

Euclid

I assume he did look back, and probably frequently.  

 

 

Was not at least one of the engineers quoted in the report as saying the crewmembers did not look back?

 

I am referring to the entire time they were fouling the Amtrak track, when I say I assume they did look back frequently.  It is just an assumption, but it is one I make because any reasonbly competent person would check back at some intervals. 

You are referring to the interval where they were in sight of the engineer of 175 during the 15 or so seconds of the approach.  I agree that they did not look back during that period.  I think it is fair to conclude that the fact that they did not move into the clear is proof that they were not aware of 175, and therefore, they never looked back during that period. 

But I do not think it is accurate to say they never looked back in a way that you are speaking of their entire time on the track. 

In any case, if they had looked back at times prior to the arrival of 175, I can see how the arrival of 66 would have drawn all their attention, making it likely that they simply forgot about what might be happening behind them.  Clearly they broke the rule requiring them to alert for trains, but nevertheless, there is an explanation as to why they broke the rule. 

This accident actually has some parallel elements with the ATSF incident at Robbinson, NM in which the engineer of a passenger train in the hole was using the horn and lights to warn the fireman on the ground at the switch.  He apparently became so distracted by what he thought the engineer was trying to tell him that he dashed to the switch which was lined correctly and he lined it wrong right in face of an approaching passenger train. 

What brought this odd sequence on was that the fireman had intially approached that switch, and unlocked and released the locking treddle, thus making the engineer worry that he may have thrown the switch, which would have lined it into the siding.  As the tension of the approaching passenger train rose, the doubt between the two men cascaded into runaway thought process that propelled the fireman into making the wrong decision. 

[243129]

tree68

Was not at least one of the engineers quoted in the report as saying the crewmembers did not look back?

All the more reason for 175's engineer to apply the brake in emergency. No "yadda,yadda, yadda".

[tree68]

Euclid

I assume he did look back, and probably frequently.  

Was not at least one of the engineers quoted in the report as saying the crewmembers did not look back?

[Euclid]

Thanks Overmod.  I found that section about the 4 ft. zone.  But just to be clear, this did not apply to the victims of the Ivy City accident, right?  But you are looking for ways to accomplish that.

Let’s say the foul zone is within 4 ft. of the outer edge of the base of the nearest rail.  Or maybe it would be simpler to say the center of the nearest rail.  Or maybe the gage side would be more appropriate.  In any case, the precise fouling boundary will never be exactly known for practical purposes, so the nominal maximum boundary should have a safety factor added to it.  I would think at least a one foot safety factor would be prudent, but if the zone gets too wide, it might interfere with operations on adjacent tracks. 

But once that is all decided, the question becomes this:  when you decide you need protection within a portion of this zone, how do you go about acquiring a guarantee that no trains will operate in that area?  And how could you for instance ride the side of a car moving though that zone of protection where no trains or equipment is supposed to be?  Or what if you wanted to pull a pin on a cut of standing cars?  Would you still need protection to get within 4 ft. of the rail?  If so, what would it be protecting you from? 

Yard trackage is not governed by signals, so how do you convey an order to all operations to stay out of a protected area? 

[BaltACD]

tree68

The "rule of thumb" I've heard is that if the tips of your fingers, extended arms-length toward the rail, are over the rail, you are in the "kill zone."  

I'd revise that to 'if the tips of your fingers are over the ends of the ties' you are in the kill zone.  At that distance you are going to be where you can be struck - if not killed then severely injured.

[tree68]

Overmod

(I am still looking for where the 4' comes from -- it might be a 'long metre' in conversion.  

It may just be a practical measurement.  Most railcars widths are in the 10' 6" to 10' 8" range.  The rails are 4' 8.5", leaving three feet of overhang on each side.  Add a one foot "cushion" for safety's sake.

Dangling material (chains, straps, overwidth cargo) can take up that foot in no time.  You don't want to get hit by steel strapping flapping off the side of a freight doing 50.  The outcome will not be good.  And you can't discount swaying cars.

The "rule of thumb" I've heard is that if the tips of your fingers, extended arms-length toward the rail, are over the rail, you are in the "kill zone."  

[Overmod]

Euclid

... what I am wondering about is your mention of ES23 requiring employees to ensure protection if more than 4’ from a rail.  Can you provide the full statement about that requirement as it appears in ES23 or in GS10?

See if you can get someone to provide you a current copy of the CSXT Safe Way.  The copy I have is from 2012, and a PDF copy can be downloaded here.

My notes indicated that the requirement to ensure protection inside 4' (in other words, less than rather than more than four feet from a rail) was in ES23 (Section 2, "Engineering Department Safety Rules", page 6 of 6).  These are MOW-centric rules, as you might expect.  I recall the note about the 4' from rail being (a), "Ensure On-Track Worker Protection is in place when working within four feet of the nearest rail of any track", right ahead of "When observing passing trains or equipment always look in the direction from which the train or equipment is coming".

What this suggests as an approach to 'patch' CSX procedures might include:

1) Formalize the methods used to invoke 'On-Track Worker Protection' so they can be used by any worker, at any time, not just 'engineering' or MOW people;

2) Put this language about a 4' approach into GS as well as ES safety regulations and training, so that all workers understand they have a 'right' to protection when within 4' of any rail -- CSX, Amtrak, or other -- and their railroad's procedure is a 'gateway' to get that protection and then be able to check on or receive updates about it without "confusion".

(I am still looking for where the 4' comes from -- it might be a 'long metre' in conversion.  The same 4' is specifically mentioned for arc flash and 480V exposure elsewhere in the Safe Way regulations.)

Of course this is contingent on what changes might have been made to Safe Way or associated training after Hunter's accession in 2017 and perhaps yet again more recently.  I am looking forward with some interest (albeit with popcorn ready to hand) to see what NTSB recommmendations filtered through the lens of CSX policy-making actually produce as new Safe Way rule changes.

[Euclid]

Overmod

Except that ES23 required them to 'ensure protection' if more than 4' from a rail ... and that's any rail.  It also requires them to KEEP looking in the direction a train could be expected to come from, and I don't think either train was running 'wrong main' at the point of impact.  The general equivalent to NS rule 21(a) (which is like the old Southern Rule M) and 21(c)(6) which calls for vigilant lookout at ALL times, is in GS10 (the language includes 'be alert for and keep clear of', which they manifestly did not, did not, did not do, and no 'confusion' excused them from doing so)

 

Overmod,

I understand your point about ES23 requiring what is stated in CSX rule GS10 about the requirement to be alert for trains.  But what I am wondering about is your mention of ES23 requiring employees to ensure protection if more than 4’ from a rail.  Can you provide the full statement about that requirement as it appears in ES23 or in GS10?  I don’t recall seeing anything like that in CSX Rule GS10, but I might have missed it. 

[Overmod]

ES 23 is one of the CSX 'safety' rules.

Every railroad has a provision in its rules like the old Southern rule M:  "Expect a train on any track at any time".  There is no exception for distraction, or weather, or orders of protection.  ANY time.  (Training that isn't going to be done by adding rules enforced with 'brownie' discipline, and finding effective ways is going to be a large part of proper response to this accident and some others like it.)

[Euclid]

Overmod

 

Euclid

So what to do?  Their decision does not seem that irresponsible to me.  They were not required to have protection to foul the Amtrak track.  Their engineer said he did not how to acquire protection if they desired.  They were not prohibited from walking on the Amtrak track by rule or trespassing law...

 

 

Except that ES23 required them to 'ensure protection' if more than 4' from a rail ... and that's any rail.  It also requires them to KEEP looking in the direction a train could be expected to come from, and I don't think either train was running 'wrong main' at the point of impact.  The general equivalent to NS rule 21(a) (which is like the old Southern Rule M) and 21(c)(6) which calls for vigilant lookout at ALL times, is in GS10 (the language includes 'be alert for and keep clear of', which they manifestly did not, did not, did not do, and no 'confusion' excused them from doing so)

 

 

Overmod,

What is ES23, and how would it have applied to this accident? 

I am not excusing the victims for not paying attention.  I am exploring the reasons why they did not pay attention.  I see a particular pattern scenario in which employees are unusually prone to forgetting to pay attention.  You cannot pay attention if you are not aware of the fact that you are not paying attention.  But of course, if there is a rule that requires paying attention, and a person forgets to pay attention, that person has violated the rule with no excuses possible. 

But I am just interested in analyzing a scenario in which employees are unusually prone to forgetting to pay attention.  I think it is an extremely dangerous anomaly rooted in a certain set of circumstances, and the mechanics are mostly unrecognized.  I am referring to the danger of two trains converging and their simultaneous warnings sounding like one train instead of two.

I have never seen a railroad rule or other form of regulation that specifically recognizes this unique danger.  Instead, they cover it obliquely by saying something like, “Always be alert to danger.” This is adequate if the objective is to blame the correct person for the error.  But a more useful objective would be to train people in how to avoid this type of error.  If there is an obvious rule violation that seems to often occur almost as a trap with resulting death or injury, it is time to ask why.  "Always be alert to danger" is easy.  It goes without saying.  Who doesn't think they are always alert to danger?

The closest that the industry gets to recognizing this unique danger is their recognition of the fact that drivers are often inclined to driving onto a grade crossing after a train clears, and then driving directly into the path of a second train on a parallel track.   There is a thought process that the train has cleared and it is safe.  They see the lights still flashing but, they dismiss that as just a leftover remnant of the operation.  It is the clearing of the train that they “take to the bank” as assurance that the crossing is clear.  They were waiting for one train and it has passed.  The last thing they expect is another train right then and there.  They are caught off guard.  But while it is common to warn of this scenario of danger, I have never heard mention of the convergence of two trains on a person on the ground.

When people are properly wary of the possibility of an approaching train, they naturally think of one train.  Thus, the next train to arrive validates and fulfills the need to be wary.  So they naturally let their guard down.  Also, the approach of the first train absorbs their attention.  So together they suddenly have less sense of a need for caution and less attention to devote to caution.  Then to make matters worse, the sudden loss of these protective faculties can also go completely unnoticed.   Inherently, a person who is not paying attention is not aware of that fact. 

[243129]

Euclid

 

 

AnthonyV

What is the responsibility of an engineer once he/she realizes impact with a vehicle, person, or another train is unavoidable?

Can he/she decide to not take emergency action based on their conclusion that it would not make any difference?

 

 

 

 

If it is a vehicle or person, the engineer will never know if impact is unavoidable unless the train is so close that impact is almost certain.  In that case, there is no choice to make regarding when to make an emergency application because impact is only a second away. 

Based on free will, an engineer can decide to not make an emergency application based on a conclusion that it would not make any difference.  However, the engineer has no logical way to arrive at the conclusion that an emergency application would make no difference.  Experts would never advise that it is okay to assume that an emergency application may be withheld because of a belief that it will not make any difference.

 

I can receive but not reply to your PM. However I will take your counsel under consideration.

[243129]

243129

 

 

charlie hebdo

It seems that's what the report says. To hoist some blame or responsibility on anyone else seems motivated by another agenda. The obsessive hair splitting over words and attacks on the engineer have driven this thread into the ditch.

 

 

So you advocate not activating the emergency brake because this situation was hopeless?

175's engineer showed poor judgement and that fact will be borne out in the ensuing lawsuits. Her convoluted and sometimes indecipherable testimony coupled with her lack of experience will attest to that fact. As I stated previously a 'perfect storm' of events led to this tragedy.

 

So charlie,again I ask/confront you with a question and again you run/ ignore as is your M.O.

Are you just content to snipe from the sidelines because you have nothing of substance to offer on the subject matter?

That being said, do you condone not activating the emergency brake because this situation was hopeless?

[tree68]

Bucky is once again trying to get a black and white answer to a question that has no black and white answer.  

If this, then that.

There are dozens of variables at play here, too many to list, but many already mentioned.  Each has an effect on the final decision.  Second guessing is all we can do as we were not there at the moment the incident occurred.  

 

[charlie hebdo]

Electroliner 1935

 

 

charlie hebdo

It seems that's what the report says.  To hoist some blame or responsibility on anyone else seems motivated by another agenda.  The obsessive hair splitting over words and attacks on the engineer have driven this thread into the ditch. 

 

 

Amen. It seems that some like dogs, enjoy chasing thier tails. Quit.

 

Or like a dog returning to its vomit.  A nasty bunch,  especially attacking a fellow engineer.  Very bad,  especially since lawsuits (which he welcomes maybe)  are likely. 

[charlie hebdo]

You two may find yourselves tied up in some civil legal proceedings.  Good luck with that.  

[243129]

Euclid

However, the engineer has no logical way to arrive at the conclusion that an emergeny application would make no difference. Experts would never advise that it is okay to assume that an emergeny application may be withheld because of a belief that it will not make any difference.

Precisely.

[Euclid]

AnthonyV

What is the responsibility of an engineer once he/she realizes impact with a vehicle, person, or another train is unavoidable?

Can he/she decide to not take emergency action based on their conclusion that it would not make any difference?

 

If it is a vehicle or person, the engineer will never know if impact is unavoidable unless the train is so close that impact is almost certain.  In that case, there is no choice to make regarding when to make an emergency application because impact is only a second away. 

Based on free will, an engineer can decide to not make an emergency application based on a conclusion that it would not make any difference.  However, the engineer has no logical way to arrive at the conclusion that an emergency application would make no difference.  Experts would never advise that it is okay to assume that an emergency application may be withheld because of a belief that it will not make any difference.

[243129]

charlie hebdo

It seems that's what the report says. To hoist some blame or responsibility on anyone else seems motivated by another agenda. The obsessive hair splitting over words and attacks on the engineer have driven this thread into the ditch.

So you advocate not activating the emergency brake because this situation was hopeless?

175's engineer showed poor judgement and that fact will be borne out in the ensuing lawsuits. Her convoluted and sometimes indecipherable testimony coupled with her lack of experience will attest to that fact. As I stated previously a 'perfect storm' of events led to this tragedy.

[Electroliner 1935]

charlie hebdo

It seems that's what the report says.  To hoist some blame or responsibility on anyone else seems motivated by another agenda.  The obsessive hair splitting over words and attacks on the engineer have driven this thread into the ditch. 

Amen. It seems that some like dogs, enjoy chasing thier tails. Quit.

[charlie hebdo]

BaltACD

The CSX Employees demonstrated lack of situational awareness was responsible for their deaths.  Nothing else.

 

It seems that's what the report says.  To hoist some blame or responsibility on anyone else seems motivated by another agenda.  The obsessive hair splitting over words and attacks on the engineer have driven this thread into the ditch. 

[BaltACD]

The CSX Employees demonstrated lack of situational awareness was responsible for their deaths.  Nothing else.

[Euclid]

tree68

 

Euclid

So what benefit would withholding the emergency application have that would outweigh the benefit making the emergency application, if in doing so, there was a chance of saving two lives? 

 

 

Given the circumstances - withholding the emergency application would have had the same effect as making the emergency application.

As I noted (and as reported in the incident report), the two CSX crew members never looked back.  Had they at least maintained sufficient situational awareness, then perhaps a second or three might have given them a fighting chance.  

But they weren't paying attention.  Even if the train had slowed to 45 MPH at the point of impact, it may well have killed them, or at least seriously injured them.  And they still wouldn't have known what hit them.

So, the answer to your question is (and you must include both parts of this answer): There was no benefit to withholding the emergency application in this incident.  Nor was there any benefit to making an emergency application in this incident.   

By all indications, the two crew members never knew what hit them.  No action by the engineer of 175, other than figuring out how to stop the train in a quarter mile or less, would have changed the outcome.

 

 

In the second post from the top of this page, you said this:

“I am also saying that in this particular circumstance, making an emergency application would likely have made no difference in the outcome.”

Now you say this:

“Given the circumstances - withholding the emergency application would have had the same effect as making the emergency application.”

 

Which way is it?  In the first statement, you used the phrase, “likely made no difference.”

In the second statement, you changed that to, “would have had the same effect…” 

Your two statements have two different meanings. 

Regarding the second statement:  A couple posts up, you suggested that I gather all the technical information to determine if how much longer (if any longer) the approach to impact would have been had the engineer made the emergency application upon first seeing the men on the track.   Neither one of us have that technical information, so how can you say that making the emergency application earlier would have made no difference in the length of the approach to impact?

Regarding the second statement:  A couple posts up, you suggested that I gather all the technical information to determine if how much longer (if any longer) the approach to impact would have been had the engineer made the emergency application upon first seeing the men on the track.   Neither one of us have that technical information, so how can you say that making the emergency application earlier would have made no difference in the length of the approach to impact?

Or are you concluding that even if the early application yielded more time, it would not have made any difference?  It sounds like you are concluding that to have been the case based on your comment that the two victims “never looked back.”  By that, you seem to imply that they would not have looked back even with more time because they never looked back during their entire walk. 

Of course, you have no way of knowing that.  All we know is they never looked back during the final approach to impact.  If they had walked 40 miles across the desert without ever looking back, then it might be reasonable to assume they would not look back during the last 15 seconds of their walk.  But for all you know they looked back 20 times during their entire walk, and then forgot to look back as their attention was drawn to #66 coming at them.  In that circumstance, they could have easily remembered to look back any moment during that final 15 seconds.  So I don’t see how you can rule out that possibility.  You have no evidence for that contention. 

[Deggesty]

zardoz

 

 

AnthonyV

What is the responsibility of an engineer once he/she realizes impact with a vehicle, person, or another train is unavoidable? 

 

 

 

If on passenger, then just dump the air (less distance for the crew to walk back);if on freight, then bring the train to a stop as quickly as safe train-handling will permit.

 

 

 

AnthonyV

Can he/she decide to not take emergency action based on their conclusion that it would not make any difference?

 

 

From a practical standpoint, yes, especially on freight; however, from a legal standpoint, then no. Someone with railroad experience will understand, most others would not ("Surely there must have been SOMETHING you could have done!!!").

 

Once the situation has passed the point of no return, the best action to take is whatever action will prevent the lawyers from nipping at your heels.

 

Zardoz, I appreciate your response.