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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by Euclid on Thursday, July 25, 2019 7:33 AM

Another point to consider:

If making an emergency application prior to impact poses too much risk for derailing the train or injuring passengers, why make an emergency application after impact when it is no longer needed?  After impact, an emergency application does no good, but it still poses the alleged risk of derailment and passenger injury. 

In this accident, the engineer of #175 did not make an emergency application prior to impact where it might have saved lives, but did make an emergency application immediately after impact. 

The engineer of #66 also believed he was involved in the accident, and yet he did not make an emergency application after impact.  Instead, he stopped with a service application.

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Posted by Euclid on Thursday, July 25, 2019 7:13 AM

AnthonyV

Serious question:  Why do trains have emergency brakes at all?  Apparently they aren't very effective in slowing the train and it's not worth going into emergency because of the derailment risk.  I seems it is safe and effective to go into emergency after impact though.

Note: These comments are not directed specifically at Ms. Reece, but to the commentary I have read on this forum about emergency braking.  I must admit as a layman, I scratch my head and say Whaaat?

 

An “emergency application” is the most effective and quickest way of stopping a train.  That is why it is available.  But, takes more time to recover from than does a “service application,” which is for routine stopping.

In previous threads here, we have discussed the question of whether an engineer should make an emergency application and risk derailing the train when a collision seems probable, even though it is not certain.  The reasoning was that if you make an emergency application prior to impact, the person or vehicle might clear in time.  So then you have derailed the train for nothing.  This is an interesting question, so I contacted the FRA and talked to one of their people. The guy I talked to has been in train service as a conductor, and he used to have a role in instructing others in the company.  He sounded very clear and logical.   

He told me that he has heard people say they would not make an emergency application until actual impact occurred.   But he said he did not know if they would actually do that or if it was just something they claimed they would do.  I asked him about the risk of derailing the train because of making the emergency application.  He said he hears that, but the risk of derailing the train is being overblown according to him.  He said the emergency application is there for a reason, and you should not hesitate to use it if there is any hint that it is called for.   He said trains go into emergency all the time and they seldom derail because of that.  He said that the risk of derailment is not an acceptable reason to withhold making an emergency application when a situation calls for it.     

He said that there is another reason to make the emergency application that people might not be aware of.  He said that if you do make the emergency application and someone is killed, you will at least have the peace of mind in knowing that you did everything within your power to prevent the death.  But if you don’t make the emergency application, you will be haunted by the question of whether you failed to take an action that might have prevented the death.  He said, for that reason alone, you should make the emergency application as soon as a collision seems likely.  

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Posted by Overmod on Thursday, July 25, 2019 6:43 AM

AnthonyV
Serious question:  Why do trains have emergency brakes at all?  Apparently they aren't very effective in slowing the train and it's not worth going into emergency because of the derailment risk.  I seems it is safe and effective to go into emergency after impact though.

It may help to look at the technical description of the difference between emergency braking and 'full service' to get an idea of the difference.  Emergency offers both a higher cylinder pressure (and shoe-to-wheel force) and a quicker setup to achieve that pressure: it is intended as a 'quickest way' to get the brakes applied as hard as they can be.  

This is "the most effective" any air brake can be in slowing a train of a given weight.  It isn't very effective in many cases, such as this one, because the kinetic energy is so massive, and the available contact area between wheel and rail that actually accomplishes the braking is so small and relatively slippery by comparison, that a long time is required for the actual stop.  

A good way to understand the mechanical difference is to compare the published statistics for electronically proportional brakes (ECP or EP; the system Sarah at FRA wanted to prioritize here) vs. regular 'quick-action' air in service braking (where there is an enormous difference) vs. emergency braking (where there is only about a 3% difference).

Obviously you don't want to use emergency unless you have to: the risk of skidding wheels, breaking the train in two for various reasons, or causing a derailment is nontrivial, as is the likely effect on passengers if done without warning (which is a highly likely consequence of anything requiring or deserving emergency braking in the first place!)  As noted, the 'practical' effect of going into emergency is not a carlike quick stop -- the problem being that in a case like the Midnight Rider accident, not going into emergency 'because it wouldn't have mattered' -- in fact, apparently not applying the brakes at all until after hitting the bed on the bridge -- will be presented almost as depraved indifference by plaintiff's attorneys... they will ask why a best effort wasn't made, and expert witnesses will not look good to a carefully-selected 'jury of peers' if they cannot substantiate why a situation resulting in death wasn't sufficient 'emergency' to use the 'emergency' brake functionality.

There are effective technologies to stop a freight train in a very short distance, but they don't involve braking the wheels, are more or less disruptive to the track structure, cost even more than EP brakes per car, and pose an enormous risk of causing derailments and other accidents if part of the apparatus fails or falsely engages (or if part of it fails to engage when other parts do).  You wouldn't want to use such a thing on a fast passenger train, as the deceleration rate can easily be in the range causing aortic dissection and similar injuries to passengers who are walking in the aisle or even are unbelted.  As you know or can guess, there are large numbers of people in North America who would press for an 'unfunded mandate' to require such a system, in as short a time as possible, once they think it is possible.  

As I think I said before, I have my own opinion of going to emergency only when 'you know you're going to have to stop' when the reason you know you're going to have to stop is that you've actually hit somebody.  That opinion does not matter here.

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Posted by AnthonyV on Thursday, July 25, 2019 5:58 AM

Serious question:  Why do trains have emergency brakes at all?  Apparently they aren't very effective in slowing the train and it's not worth going into emergency because of the derailment risk.  It seems it is safe and effective to go into emergency after impact though.

Note: These comments are not directed specifically at Ms. Reece, but to the commentary I have read on this forum about emergency braking.  I must admit as a layman, I scratch my head and say Whaaat?

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Posted by 243129 on Wednesday, July 24, 2019 10:07 PM

tree68
Even slamming the brake handle to emergency immediately would have had almost no effect on the forward speed of her train

It could have afforded milleseconds to the victims. Her reaction, or lack of, afforded none.

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Posted by Euclid on Wednesday, July 24, 2019 9:26 PM

243129
 
charlie hebdo
roughly much blame for the outcome can be attached to #175's engineer?

 

None, the CSX and the two employees who were killed are to blame.

Blame for 175's engineer reaction or lack of is a direct result of Amtrak's poor vetting, poor training and poor supervision.

 

1)  If the engineer of #175 had been properly trained by Amtrak to "read" the situation and make the emergency application immediately, as you mentioned earlier; and if her reaction was the same as in this accident scenario; then how much of the blame would you assign to her?

2)  If the engineer had made an emergency application 20 seconds before impact; while traveling at 74 mph; how many seconds would have been added to the 20-second interval preceding impact?

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Posted by charlie hebdo on Wednesday, July 24, 2019 9:04 PM

Duplication 

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Posted by tree68 on Wednesday, July 24, 2019 8:55 PM

charlie hebdo

Serious question: roughly much blame for the outcome can be attached to #175's engineer?  To Amtrak vetting,  training and supervision?

Given the laws of physics, my take would be just about zero.  Even slamming the brake handle to emergency immediately would have had almost no effect on the forward speed of her train.  And the blasting horn would probably have covered the sound of the emergency application propogating through the train.

And I'd opine that no amount of training or experience of either engineer would have changed the ultimate outcome.  As has been mentioned before, it was a perfect storm.

Simply glancing down to check speed, and possibly cab signal indication, would have taken time away from the sighting of the CSX crew members.  

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Posted by 243129 on Wednesday, July 24, 2019 8:54 PM

charlie hebdo
roughly much blame for the outcome can be attached to #175's engineer?

None, the CSX and the two employees who were killed are to blame.

Blame for 175's engineer reaction or lack of is a direct result of Amtrak's poor vetting, poor training and poor supervision.

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Posted by charlie hebdo on Wednesday, July 24, 2019 8:39 PM

Serious question: roughly much blame for the outcome can be attached to #175's engineer?  To Amtrak vetting,  training and supervision?

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Posted by 243129 on Wednesday, July 24, 2019 7:38 PM

Lithonia Operator
I am wondering: How many engineers, traveling at 100 mph, would put their train into emergency IMMEDIATELY upon seeing a person on the track?

In the situation at Ivy City an experienced engineer, which she was not, would have assessed the scenario almost immediately. They are walking away from her, on her track, with a train, theirs on their right, and a train (66) on their left coming toward them and this engineer could not see the dire situation unfolding?

Lithonia Operator
Ms. Reece could not be expected in a few seconds to process the idea that “oh, they are confusing my horn with #66’s horn.”

She certainly should have been expected to react in a few seconds. Amtrak's 'state of the art' training facility in Wilmington has a simulator. If she were vetted and trained properly situations similar to Ivy City, Frankford Jct and Dupont WA could be simulated to assess the candidates acumen.

Lithonia Operator
These guys doomed themselves.

Yes they did but the reaction of 175's engineer exposes Amtrak's inadequate hiring and training procedures

 

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Posted by MMLDelete on Wednesday, July 24, 2019 7:00 PM

I am wondering: How many engineers, traveling at 100 mph, would put their train into emergency IMMEDIATELY upon seeing a person on the track?

You engineers out there, you tell me. It’s an honest question.

I have never been an engineer (only a clerk/operator, but I would think that the initial response would be the horn, not the brakes. One would expect the trespasser(s) to hear and react. Ms. Reece could not be expected in a few seconds to process the idea that “oh, they are confusing my horn with #66’s horn.” The engineer would know there is no way to stop, or significantly slow the train. Yes, I guess she could have done both. But she had so little time to make a decision.

Isn’t there some danger of the train derailing when put into emergency? And what about any standing passengers? They would get injured, perhaps seriously.

Do you think Amtrak (or other) railroads train engineers to go to emergency instantly if someone is on the track? Will Amtrak fire her for not doing so?

Overmod, I did not read the other interview. But what Balt says is definitely true: eyewitness accounts, sincere ones, can differ widely. In any event, I think is academic. They were on the track and had lost situational awareness.

I think Ms. Reece deserves some slack here. These guys doomed themselves.

 

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Posted by BaltACD on Wednesday, July 24, 2019 5:46 PM

I am presuming that the Amtrak locomotives are equipped with forward facing video?  If so, why are we talking about what the engineers 'thought' they saw.

We all know, that at times of stress, they human animal does not always see and remember what actually happened.  I am not saying either engineer don't believe what they are saying - but there is the potential that their memories are not truly accurate.

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Posted by Overmod on Wednesday, July 24, 2019 5:11 PM

Lithonia Operator
I just read the interview with Ms. Reece. She does make it clear that, in fact, the CSX conductors were not between the rails, but rather on the tie ends.

The problem is that the engineer of 66, who is the only one to see the actual impact, is on record as stating they were in the gauge.  While the interviewers were reluctant to ask him for more of the traumatic details, he did make something of a point emphasizing that.

I'm quite certain that the physical evidence of the strike would confirm the actual point of impact, but that's something I don't have enough 'need to know'.

If I remember correctly the event-recorder data provided the speed at impact, corroborated by the emergency application made 'at or just after' that time by Sahara's testimony. 

The "15mph" business doesn't apply to the accident.  She said it was her 'personal preference' (or words to that effect) when passing known railroad people, for example in a civil slow-order area.  It would be uncharitable of me to speculate whether she was 'telling the Inquisition things she thought they'd want to hear'.

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Posted by Euclid on Wednesday, July 24, 2019 4:28 PM

Overmod
 
AnthonyV
Yet, other than braking for the next signal, she did nothing except blow her horn until impact. I'm not an engineer and I wasn't in her shoes, but I hope I would have starting some hard braking once I observed what she said she observed.

 

1) you need to read through the thread, where this is discussed in some detail; it should be noted there was no way, even at full emergency, that 175 could be stopped or even have particular way off the train.  The argument for emergency, other than sentiment, is that it might have provided the few milliseconds of additional time before impact necessary for at least one of the conductors to realize the danger and leap aside enough to avoid impact.

2) you need to carefully read the actual transcript.  Sahara said she did more than 'nothing', in fact said she went to some pains (I thought excessive) to run slowly, more slowly than the requirements for restricted speed, when she knew workers would be present; she had a different conception of what measures to take when surprised by finding people on the track -- the engineer of 66 said in his interview they were not on the ends of the ties but actually walking in the gauge (i.e. not in the limits of the loading gage but actually between the rails).  Even in the fragment Joe quoted, you will note that she started 'inching toward full service' as a separate action from reducing speed for the signal change.

In addition she vastly overestimated the actual time she could possibly have had to see and react to the situation; this too is discussed in the interview record and 'put together' by the NTSB.

 

Overmod,

I agree that the argument calling for making the emergency application at the point where the two conductors were first seen is that it would slightly lengthen the time remaining until impact.  However, while that extra time would be miniscule, so too would be the time needed to realize the danger and get clear.  I would estimate that a person could realize the danger and get clear within ½ second.     

I cannot conclude what the engineer did in terms of braking prior to impact, or whether there was any extra braking related to the two men on the track.  Also, if there was extra braking, I cannot conclude whether the cause was the need to comply with signals; or whether it was in anticipation of the conductors not getting clear in time. 

I do not find any reference what you mention about the engineer going to pains to run slowly while passing the CXS train.   Toward the end of the interview, she describes how she would slow to 15 mph if she knew ahead of time that there would workers on the ground.  She did say that this was her own personal policy and that Amtrak had trained her to make such a policy as an option.  But this had no application during the accident because she had not been notified that people would be on the ground.

You mention that the NTSB discussed that the engineer vastly overestimated the time she had to react before impact.  I don’t recall seeing that, but what conclusions does it lead to?  How would things have been different had she not over estimated her time?

She said she had 15-20 seconds.  I looked at the event recorder data and it looked like it was maybe 10-15 seconds.

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Posted by zugmann on Wednesday, July 24, 2019 4:21 PM

AnthonyV
But, it is Monday morning quarterbacking in situations like these that have led to all the safety improvements we enjoy today.

If we talk about the situation and how to improve it from here going out - not get fixated on the actions of the individuals involved.

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


  

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Posted by AnthonyV on Wednesday, July 24, 2019 4:15 PM

zugmann

 

 
Euclid
What would be a better use of those few seconds than taking a chance that they could save two lives? What was there to lose? What is the emgency application for?

 

Monday morning quarterbacking is so easy. 

 

As I have said before, I am not a railroad engineer and I have no idea what I would have done if I was in her shoes.

But, it is Monday morning quarterbacking in situations like these that have led to all the safety improvements we enjoy today.

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Posted by AnthonyV on Wednesday, July 24, 2019 4:11 PM

zardoz

 

 
AnthonyV
The distance from coming out of the curve to point of impact is in the range of 1,500-1,800 ft.  As a hypothetical, if the engineer placed the train in emergency say 1,500 ft away from the conductors doing 90 mph, what reduction in speed could we expect?

 

90mph=132fps. If we accept your numbers, there was approximately 12-15 seconds from first sighting until impact.

 

An emergency application would take a second or two to propigate, then another second or two for full retardation to begin (so far the train has travelled about 525')--roughly 1/3 the stated distance. That still leaves five+ seconds for the speed to begin to reduce. If they were indeed walking on the outside of the rail, then a split-second might have been all they needed.

However, as I am unfamiliar with the braking characteristics of Amtrak trains, I will reserve speculation regarding whether the braking would have been sufficient to grant them that needed split-second. 

 

Thanks zardoz.

For the record, I estimated the distance using Google Earth.  One point was the impact point and the other point was the end of the curve.  The impact location is indicated in the NTSB report and appears to be somewhat aligned with the right (east?) end of the Amtrak maintenance building.  This distance along the tracks from the impact point to the end of the curve was calculated to be 0.35 miles or 1,848 ft.  I decreased it to 1,500 to 1,800 ft to be conservative.

I just chose the 90 mph as a hypothetical.  I don't know her speed coming out of the curve but I think her train struck the conductors at about 75 mph, so I just assumed it was 90 since she was braking at varying degrees the whole time.

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Posted by BaltACD on Wednesday, July 24, 2019 4:05 PM

zugmann
 
Euclid
What would be a better use of those few seconds than taking a chance that they could save two lives? What was there to lose? What is the emgency application for? 

Monday morning quarterbacking is so easy. 

The horse is still dead and so are the CSX employees who were walking in the foul of Amtrak - any way you look at it.

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Posted by zugmann on Wednesday, July 24, 2019 4:02 PM

Euclid
What would be a better use of those few seconds than taking a chance that they could save two lives? What was there to lose? What is the emgency application for?

Monday morning quarterbacking is so easy. 

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


  

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Posted by zardoz on Wednesday, July 24, 2019 3:29 PM

AnthonyV
The distance from coming out of the curve to point of impact is in the range of 1,500-1,800 ft.  As a hypothetical, if the engineer placed the train in emergency say 1,500 ft away from the conductors doing 90 mph, what reduction in speed could we expect?

90mph=132fps. If we accept your numbers, there was approximately 12-15 seconds from first sighting until impact.

An emergency application would take a second or two to propigate, then another second or two for full retardation to begin (so far the train has travelled about 525')--roughly 1/3 the stated distance. That still leaves five+ seconds for the speed to begin to reduce. If they were indeed walking on the outside of the rail, then a split-second might have been all they needed.

However, as I am unfamiliar with the braking characteristics of Amtrak trains, I will reserve speculation regarding whether the braking would have been sufficient to grant them that needed split-second. 

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Posted by Euclid on Wednesday, July 24, 2019 2:59 PM

Lithonia Operator

I just read the interview with Ms. Reece. She does make it clear that, in fact, the CSX conductors were not between the rails, but rather on the tie ends. But still, I don’t think that anything Ms. Reece could have done in those few seconds would have made any difference. None of this is on her head.

 

What would be a better use of those few seconds than taking a chance that they could save two lives?  What was there to lose?  What is the emgency application for?

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Posted by MMLDelete on Wednesday, July 24, 2019 2:52 PM

I just read the interview with Ms. Reece. She does make it clear that, in fact, the CSX conductors were not between the rails, but rather on the tie ends. But still, I don’t think that anything Ms. Reece could have done in those few seconds would have made any difference. None of this is on her head.

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Posted by 243129 on Wednesday, July 24, 2019 2:50 PM

By putting the train to emergency you afford the victims a chance albeit a very slight chance. By not putting the train in emergency you take away any chance.

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Posted by AnthonyV on Wednesday, July 24, 2019 2:29 PM

Lithonia Operator

Because they were walking between the rails, and because they obviously did not realize that some of the horn noise was from #175, it seems impossible that the delay in impact that would have resulted from putting her train in emergency would have made any difference.

In my view, the blame for this very sad tragedy lies solely on the two CSX conductors. They were acting in an extremely unsafe manner, in contravention of simple common sense.

Sometimes in life there is no one to blame but yourself.

I think of #175’s engineer as a victim in this situation. Fault or not, she will have to relive this for the rest of her life. I feel bad for her.

 

The engineer of #175 had the best view and she claims they were walking outside of the rails on the ends of the ties.

It conceivable to me that because both trains passed the point of impact at about the same time, slowing #175 and delaying its arrival at the eventual point of impact might have allowed the conductors to realize there is train behind them by #175's light and horn.

The distance from coming out of the curve to point of impact is in the range of 1,500-1,800 ft.  As a hypothetical, if the engineer placed the train in emergency say 1,500 ft away from the conductors doing 90 mph, what reduction in speed could we expect?

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Posted by tree68 on Wednesday, July 24, 2019 1:58 PM

Lithonia Operator
In my view, the blame for this very sad tragedy lies solely on the two CSX conductors. They were acting in an extremely unsafe manner, in contravention of simple common sense.

Yep.

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Posted by MMLDelete on Wednesday, July 24, 2019 1:37 PM

Because they were walking between the rails, and because they obviously did not realize that some of the horn noise was from #175, it seems impossible that the delay in impact that would have resulted from putting her train in emergency would have made any difference.

In my view, the blame for this very sad tragedy lies solely on the two CSX conductors. They were acting in an extremely unsafe manner, in contravention of simple common sense.

Sometimes in life there is no one to blame but yourself.

I think of #175’s engineer as a victim in this situation. Fault or not, she will have to relive this for the rest of her life. I feel bad for her.

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Posted by AnthonyV on Wednesday, July 24, 2019 1:31 PM

Thanks Overmod.  I was just sloppy.  I originally took her comments to mean she was braking for the approach limited and inched toward full service as she saw the workers. It is obvious to me now (as you point out) she inched toward full service because she saw the workers, and as she got closer to them.

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Posted by Overmod on Wednesday, July 24, 2019 7:53 AM

AnthonyV
Yet, other than braking for the next signal, she did nothing except blow her horn until impact. I'm not an engineer and I wasn't in her shoes, but I hope I would have starting some hard braking once I observed what she said she observed.

1) you need to read through the thread, where this is discussed in some detail; it should be noted there was no way, even at full emergency, that 175 could be stopped or even have particular way off the train.  The argument for emergency, other than sentiment, is that it might have provided the few milliseconds of additional time before impact necessary for at least one of the conductors to realize the danger and leap aside enough to avoid impact.

2) you need to carefully read the actual transcript.  Sahara said she did more than 'nothing', in fact said she went to some pains (I thought excessive) to run slowly, more slowly than the requirements for restricted speed, when she knew workers would be present; she had a different conception of what measures to take when surprised by finding people on the track -- the engineer of 66 said in his interview they were not on the ends of the ties but actually walking in the gauge (i.e. not in the limits of the loading gage but actually between the rails).  Even in the fragment Joe quoted, you will note that she started 'inching toward full service' as a separate action from reducing speed for the signal change.

In addition she vastly overestimated the actual time she could possibly have had to see and react to the situation; this too is discussed in the interview record and 'put together' by the NTSB.

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Posted by AnthonyV on Wednesday, July 24, 2019 6:04 AM

243129

 

 
Lithonia Operator

 

 
243129

A perfect storm of events created this tragedy. 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. CSX and Amtrak also bear responsibility for this tragedy

 

 

 

What did the engineer of Amtrak #175 do wrong?

 

 

 

Read her testimony here and if you have any operations knowledge her errors will be self evident. If you were not employed in railroad operations I will be happy to explain. Here is a preview:

"When I start seeing them, I start inching to full service.

Q. Okay. I'm just taking some notes here, just what you said. So you said you were in suppression when you saw them. And then you started inching towards full service --

A. Yes. 

Q. -- after seeing them and blowing the horn simultaneously.

A. Yes.

Q. And did you ever place your train in emergency?

A. Yes.

Q. And did -- when did you do that?

A. Once I struck"

The full interview:

https://dms.ntsb.gov/pubdms/search/document.cfm?docID=470819&docketID=62103&mkey=95451

 

The way I read her testimony, she had the workers in sight for 15 or 20 seconds.  She saw that they wore reflective vests so it was unlikely they were ordinary trespassers.  She saw them make no attempt to move out of the way or even turn their heads.  Yet, other than braking for the next signal, she did nothing except blow her horn until impact.

I'm not an engineer and I wasn't in her shoes, but I hope I would have starting some hard braking once I observed what she said she observed.

Yes 243129, I would like to hear what you have to say.

Thanks.

 

 

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