Trains.com

NTSB Railroad accident brief contains contradiction Locked

8697 views
186 replies
1 rating 2 rating 3 rating 4 rating 5 rating
  • Member since
    May 2015
  • 1,836 posts
NTSB Railroad accident brief contains contradiction
Posted by 243129 on Friday, May 3, 2019 8:08 PM

A major contradiction in the NTSB report of June 27, 2017 concerning the deaths of two CSX employees who were hit by an Amtrak train at Ivy City has been reported (by me) over two weeks ago. I spoke directly via telephone  with a railroad accident investigator to apprise the NTSB of the glaring contradiction. No action has yet been taken. I find this disturbing as the contradiction is most critical in the recommendation process which will be compromised if this contradiction is not addressed.

I call your attention to page four, paragraph one, third to the last sentence of NTSB report RAB-1901.

Secondly I call your attention to page six, paragraph six, the last sentence.

There is also a misspelling/misuse of the word gauge on page four.

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

  • Member since
    September 2017
  • 5,636 posts
Posted by charlie hebdo on Friday, May 3, 2019 10:25 PM

243129
I call your attention to page four, paragraph one, third to the last sentence of NTSB report RAB-1901. Secondly I call your attention to page six, paragraph six, the last sentence. There is also a misspelling/misuse of the word gauge on page four.

A comment:
It is more effective not just to cite the paragraph or sentences in question, but rather to indicate specifically what it is you feel is deficient beyond the  typographical error on page four.

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Saturday, May 4, 2019 8:15 AM

 

charlie hebdo

 

 
243129
I call your attention to page four, paragraph one, third to the last sentence of NTSB report RAB-1901. Secondly I call your attention to page six, paragraph six, the last sentence. There is also a misspelling/misuse of the word gauge on page four.

 

A comment:
It is more effective not just to cite the paragraph or sentences in question, but rather to indicate specifically what it is you feel is deficient beyond the  typographical error on page four.

 

An answer:

You cannot see the contradiction? You would like me to point it out for you? How did you determine that the error on page four was typographical not misuse or misspelling?

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Saturday, May 4, 2019 8:59 AM

I typically see poor writing in NTSB accident reports.  Sometimes their writing can be interpreted in two different ways with different meanings.  I have called them in the past on a few occasions and the person who answered could not offer an explanation, but assured me that an investigator could provide the answer and that one would definitely call me back.  None ever called. 

As to the word "gage," that is a legitimate alternate spelling of the word "gauge." I always spell it "gage" because I see no reason to include the "u".  Both forms are widely used.

But regarding this accident, I too have questions about the details, and would be very interested in what contradictions you are referring to in the report.  I think I see one of them which is a reference to the employees walking near the track, but I am not sure if you are referring to that.  I think I have read that report 30-40 times in the course of a recent thread about it in the general forum.  It is a difficult read besides any direct contradictions it may have.  General topic focus is broken up and scattered around rather than being kept together where the information can flow in sequence. 

I think they put a lot of effort in how the writing conveys implication while being oh so careful to say just enough, but not too much.  It feels manipulative. 

I have unaswered questions left over from that last discussion thread, so I am interested in this thread and especially how the NTSB writing affects the report.

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Saturday, May 4, 2019 9:28 AM

Euclid
I typically see poor writing in NTSB accident reports. Sometimes their writing can be interpreted in two different ways with different meanings.

That would lead one to question the credibility of the NTSB would it not?

Euclid
I have called them in the past on a few occasions and the person who answered could not offer an explanation, but assured me that an investigator could provide the answer and that one would definitely call me back. None ever called.

I spoke with a NTSB Railroad Investigator and nothing has been done to address/rectify my observation.

Euclid
As to the word "gage," that is a legitimate alternate spelling of the word "gauge." I always spell it "gage" because I see no reason to include the "u". Both forms are widely used.

Gage is the spelling of an obsolescent word meaning a pledge, a challenge, etc. Gauge is the spelling to use when you measure measurement, estimate, or standard.

Euclid
But regarding this accident, I too have questions about the details, and would be very interested in what contradictions you are referring to in the report. I think I see one of them which is a reference to the employees walking near the track, but I am not sure if you are referring to that. I think I have read that report 30-40 times in the course of a recent thread about it in the general forum. It is a difficult read besides any direct contradictions it may have. General topic focus is broken up and scattered around rather than being kept together where the information can flow in sequence

Page four,paragraph one, second to last sentence states:

After the impact, at 11:18 p.m., the engineer placed the train into emergency braking, announced emergency three times on the radio, and called the Amtrak dispatch center via the radio. After her train came to a complete stop, she called her conductor to come to the head end of the train. The crew inspected their train and waited for officials to arrive.

Page six, paragraph six, last sentence:

According to the event recorder and the engineer interview, the Amtrak engineer responded immediately and applied emergency braking upon seeing the CSX employees walking near the tracks.

  • Member since
    September 2003
  • 21,669 posts
Posted by Overmod on Saturday, May 4, 2019 12:28 PM

Personally, I don't see a major semantic 'smoking gun' here, just a lapse of what might be called 'continuity' in the screenplay sense.

Joe in particular will understand -- perhaps firsthand and more than once -- what is involved when an engineer sees a trespasser that will be unavoidably hit.  In this case, the engineer reported that she put the train in emergency 'before the impact' - this is surely correct.  It would have taken time for the brakes to apply fully, which wouldn't have happened (or registered on the event recorder) until after the impact.  I would expect that the received call of 'Emergency!' didn't occur until afterward, either.  The "latter" timeline is someone relating events in sequence, not the engineer relating experience.

And the use of 'gage' for civil aspects of railroad construction has a long and very well-established history, part of which I think dates back to the simplified-spelling craze so beloved of Theodore Roosevelt.  To this day I still use 'loading gage' to refer to clearance measure to distinguish it from gauges as instruments of measurement, or guages as an egregious misspelling by the ignorant.  (I note also the evolved meanings of "engaged" in the engineering sense, which I think derives from the hand-in-hand etymology, but has to my knowledge never had the 'u' in its spelling)

As an amusing aside, I never use any spelling but 'gauge' for the nominal distance between the rails (as in 'standard gauge' or 'standing in the gauge') but use 'gage' for the measurements out to clearance and plate limits.

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Saturday, May 4, 2019 12:37 PM

That most definitely is a descrepancy.  After impact, the employees were no longer walking near the tracks.  So, seeing them walking near the tracks had to have occurred prior to impact.  So making the emergency application "upon seeing them walking near the tracks" (as the NTSB says) clearly means the emergency application was made prior to impact.  Yet they also say that the emergency application was made after the impact.

So which was it?  And related to that, would either action be considered acceptable? 

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Saturday, May 4, 2019 12:41 PM

 

From Merriam Webster:

 

Gage:

 

less common spelling of gauge

 

1a : a measurement (as of linear dimension) according to some standard or system: such as

(1) : the distance between the rails of a railroad

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Saturday, May 4, 2019 12:48 PM

Overmod
In this case, the engineer reported that she put the train in emergency 'before the impact' - this is surely correct.

Why do you assume that?  This has been discussed at great length before regarding impacts including vehicle impacts.  One school of thought is that the engineer should make an emergency application up seeing that impact may be immenent. 

Another school says that there is no point in making an emergency application prior to immenent impact because the emergency application will not slow the train in that short of a distance, and the fouling person or vehicle may clear at the last second, thus subjecting the train to stopping uncessarily. 

I call ed the FRA and asked them which was the proper course.

  • Member since
    September 2003
  • 21,669 posts
Posted by Overmod on Saturday, May 4, 2019 12:51 PM

Hint to Euclid, who has built whole threads out of this discrepancy or things like it:  What is the difference between 'application' in the sense of 'pulling the little handle' and 'application' in the sense of the shoes setting up on the discs and treads ... after what may be up to several seconds ... to begin physically stopping the train.

Impact happened between those two.

(Note:  does anyone know if the current event recorders measure the signal coming off the locomotive brake-valve handle or just the resulting pressure changes in the physical brake system?)

  • Member since
    September 2003
  • 21,669 posts
Posted by Overmod on Saturday, May 4, 2019 12:59 PM

For the love of God, Montresor -- it was a PASSENGER train.  There is no controversy over prompt emergency with typical Amtrak NEC consists.  If she said she put the lever past full blended into emergency, why should I call her a liar?

I also think that much of the 'reason' for applying the brake in these situations is more 'moral' than actually expected to be effective.  It shows you were attentive and caring of human life, and like 'notching the barograph' in a sailplane it shows on the record that you acted knowledgeably at a time that matters.  The 'large money damages' in the Midnight Rider case were related to the complete lack of brake application.  She reacted appropriately to the perceived danger by applying the brakes, whether it was as ultimately pointless doing so as hitting the emergency button at Cayce was.

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Saturday, May 4, 2019 1:25 PM

Overmod

Hint to Euclid, who has built whole threads out of this discrepancy or things like it:  What is the difference between 'application' in the sense of pulling the little handle' and 'application' in the sense of the shoes setting up on the discs and treads ... after a few seconds ... to physically stop the train.

Impact happened between those two.

 

The difference between pulling the handle and the shoes applying pressure is beside the point.  The point is that NTSB is talking only about the engineer pulling the handle in both statements, and in those two statements, it gives conflicting information as to when the handle was pulled. 

The NTSB has gone to some effort to clarify the actions of the engineer, and has apparently not carefully checked what they have written.  I am not criticizing the engineer, but the point of her actions is critical to the report as the NTSB confirms with their carefully worded statements.  I am criticizing the NTSB. 

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Saturday, May 4, 2019 6:36 PM

Overmod
Personally, I don't see a major semantic 'smoking gun' here, just a lapse of what might be called 'continuity' in the screenplay sense.

Not very professional for a national investigative agency wouldn't you say?

 

 

 

Overmod
It would have taken time for the brakes to apply fully, which wouldn't have happened (or registered on the event recorder) until after the impact.

The emergency application should register instantly.

Overmod
The "latter" timeline is someone relating events in sequence, not the engineer relating experience.

"Latter" timeline:

According to the event recorder and the engineer interview, the Amtrak engineer responded immediately and applied emergency braking upon seeing the CSX employees walking near the tracks

 

"Engineer interview" indicates to me that she did indeed relate her experience.

One of the 'statements' in the engineer interviews is wrong.

  • Member since
    May 2003
  • From: US
  • 25,292 posts
Posted by BaltACD on Saturday, May 4, 2019 8:58 PM

243129
 
Overmod
Personally, I don't see a major semantic 'smoking gun' here, just a lapse of what might be called 'continuity' in the screenplay sense. 

Not very professional for a national investigative agency wouldn't you say?

All forms of governance have not been very professional since January 20, 2017

Never too old to have a happy childhood!

              

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Saturday, May 4, 2019 9:07 PM

BaltACD

 

 
243129
 
Overmod
Personally, I don't see a major semantic 'smoking gun' here, just a lapse of what might be called 'continuity' in the screenplay sense. 

Not very professional for a national investigative agency wouldn't you say?

 

All forms of governance have not been very professional since January 20, 2017

 

You will get no argument from me on that point.

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Saturday, May 4, 2019 9:54 PM

Did the CSX employment status and job duties of the two CSX employees give them the right to be on the property occupied by the Amtrak tracks?

  • Member since
    February 2018
  • From: Flyover Country
  • 5,557 posts
Posted by York1 on Saturday, May 4, 2019 9:59 PM

Deleted by poster

York1 John       

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Sunday, May 5, 2019 8:13 AM

Euclid

Did the CSX employment status and job duties of the two CSX employees give them the right to be on the property occupied by the Amtrak tracks?

 

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.

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Sunday, May 5, 2019 8:30 AM

.

  • Member since
    September 2017
  • 5,636 posts
Posted by charlie hebdo on Sunday, May 5, 2019 9:09 AM

243129
  An answer: You cannot see the contradiction? You would like me to point it out for you? How did you determine that the error on page four was typographical not misuse or misspelling?

1. I was simply pointing out that it is customary when criticizing another's work to not only cite the page and line numbers, but also elucidate what you believe to be wrong, in this case, a contradiction.

2. 'Gage' can be an alternate spelling for 'gauge' (though used more in the UK). It can also be a typo. In either case, your pointing it out is based on error.

  • Member since
    September 2017
  • 5,636 posts
Posted by charlie hebdo on Sunday, May 5, 2019 9:10 AM

243129

 

 
BaltACD

 

 
243129
 
Overmod
Personally, I don't see a major semantic 'smoking gun' here, just a lapse of what might be called 'continuity' in the screenplay sense. 

Not very professional for a national investigative agency wouldn't you say?

 

All forms of governance have not been very professional since January 20, 2017

 

 

 

You will get no argument from me on that point.

 

Nor from me, and it worsens daily.

  • Member since
    June 2002
  • 20,096 posts
Posted by daveklepper on Sunday, May 5, 2019 9:23 AM

I would like to encourage posters to put information into their postings and not just URLs.  Often, it takes no more time to type what the information is than it does to accurately duplicate the URL, and it certainly saves the readers' time.

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Sunday, May 5, 2019 9:53 AM

charlie hebdo

 

 
243129
  An answer: You cannot see the contradiction? You would like me to point it out for you? How did you determine that the error on page four was typographical not misuse or misspelling?

 

1. I was simply pointing out that it is customary when criticizing another's work to not only cite the page and line numbers, but also elucidate what you believe to be wrong, in this case, a contradiction.

2. 'Gage' can be an alternate spelling for 'gauge' (though used more in the UK). It can also be a typo. In either case, your pointing it out is based on error.

 

1. If you follow the instruction what is "wrong" is blatantly obvious.

2. "Gage"? Although technically correct it is rarely used. I go with it being an error that the user got 'lucky' with. I have never seen that form used in any official reports previously.

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Sunday, May 5, 2019 10:01 AM

daveklepper

I would like to encourage posters to put information into their postings and not just URLs.  Often, it takes no more time to type what the information is than it does to accurately duplicate the URL, and it certainly saves the readers' time.

 

You do not have the time to follow these precise instructions?

I call your attention to page four, paragraph one, third to the last sentence of NTSB report RAB-1901.

Secondly I call your attention to page six, paragraph six, the last sentence.

Perhaps I should have typed the full nine pages for your reference and highlighted the contradictions so as to save you some time.

  • Member since
    September 2017
  • 5,636 posts
Posted by charlie hebdo on Sunday, May 5, 2019 10:13 AM

243129

 

 
charlie hebdo

 

 
243129
  An answer: You cannot see the contradiction? You would like me to point it out for you? How did you determine that the error on page four was typographical not misuse or misspelling?

 

1. I was simply pointing out that it is customary when criticizing another's work to not only cite the page and line numbers, but also elucidate what you believe to be wrong, in this case, a contradiction.

2. 'Gage' can be an alternate spelling for 'gauge' (though used more in the UK). It can also be a typo. In either case, your pointing it out is based on error.

 

 

 

1. If you follow the instruction what is "wrong" is blatantly obvious.

2. "Gage"? Although technically correct it is rarely used. I go with it being an error that the user got 'lucky' with. I have never seen that form used in any official reports previously.

 

I was trying to help you. Using standard manners of presentation is as important in certain arenas as proper training and instruction is in your former career.  "When in Rome..." if you want the NTSB to respond. Snippy replies to people (as you just did to Dave) is guaranteed to get you nowhere.  Your choice.

 

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Sunday, May 5, 2019 11:18 AM

charlie hebdo
I was trying to help you. Using standard manners of presentation is as important in certain arenas as proper training and instruction is in your former career.

I feel that my presentation was stated clearly.

charlie hebdo
"When in Rome..." if you want the NTSB to respond.

The NTSB did respond. I spoke wth a railroad accident investigator via telephone.

charlie hebdo
Snippy replies to people (as you just did to Dave) is guaranteed to get you nowhere.

What you refer to as a "snippy"(your slant) reply is merely a response to a niggling request.

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Sunday, May 5, 2019 12:24 PM

.

  • Member since
    September 2017
  • 5,636 posts
Posted by charlie hebdo on Sunday, May 5, 2019 1:15 PM

243129
243129 wrote the following post 1 hours ago: charlie hebdo I was trying to help you. Using standard manners of presentation is as important in certain arenas as proper training and instruction is in your former career. I feel that my presentation was stated clearly.

Self-insulated from a mild suggestion.

charlie hebdo "When in Rome..." if you want the NTSB to respond. The NTSB did respond. I spoke wth a railroad accident investigator via telephone.

"A major contradiction in the NTSB report of June 27, 2017 concerning the deaths of two CSX employees who were hit by an Amtrak train at Ivy City has been reported (by me) over two weeks ago. I spoke directly via telephone  with a railroad accident investigator to apprise the NTSB of the glaring contradiction. No action has yet been taken. " 

 

As you said, no action taken, i.e., you spoke with a railroad accident investigator, but that is not responding.

 

charlie hebdo Snippy replies to people (as you just did to Dave) is guaranteed to get you nowhere.

 

daveklepper

I would like to encourage posters to put information into their postings and not just URLs.  Often, it takes no more time to type what the information is than it does to accurately duplicate the URL, and it certainly saves the readers' time.

 What you refer to as a "snippy"(your slant) reply is merely a response to a niggling request.
 
You think Dave Klepper's (who, along with Johnny, is one of the nicest, mildest-mannered members on here) request was "niggling"?  Your response was downright [I'll let others be the judges].
 

  • Member since
    May 2015
  • 1,836 posts
Posted by 243129 on Sunday, May 5, 2019 2:59 PM

charlie hebdo

 

 
243129
243129 wrote the following post 1 hours ago: charlie hebdo I was trying to help you. Using standard manners of presentation is as important in certain arenas as proper training and instruction is in your former career. I feel that my presentation was stated clearly.

Self-insulated from a mild suggestion.

charlie hebdo "When in Rome..." if you want the NTSB to respond. The NTSB did respond. I spoke wth a railroad accident investigator via telephone.

"A major contradiction in the NTSB report of June 27, 2017 concerning the deaths of two CSX employees who were hit by an Amtrak train at Ivy City has been reported (by me) over two weeks ago. I spoke directly via telephone  with a railroad accident investigator to apprise the NTSB of the glaring contradiction. No action has yet been taken. " 

 

As you said, no action taken, i.e., you spoke with a railroad accident investigator, but that is not responding.

 

charlie hebdo Snippy replies to people (as you just did to Dave) is guaranteed to get you nowhere.

 

daveklepper

I would like to encourage posters to put information into their postings and not just URLs.  Often, it takes no more time to type what the information is than it does to accurately duplicate the URL, and it certainly saves the readers' time.

 What you refer to as a "snippy"(your slant) reply is merely a response to a niggling request.
 
You think Dave Klepper's (who, along with Johnny, is one of the nicest, mildest-mannered members on here) request was "niggling"?  Your response was downright [I'll let others be the judges].
 
 

 

 

You have contributed nothing on topic other than Dr.Phil like observations, semantic distortions and 'tutorials'.

If you have nothing to contribute to the contradiction in the NTSB report please do not clog up my thread with your attempts to derail.

FYI Dave Klepper contributed nothing on topic only a petulant criticism of the way it is presented.

I welcome all opinions and observations of the topic presented. If you have nothing to offer on topic you are not welcome.

  • Member since
    January 2014
  • 8,221 posts
Posted by Euclid on Sunday, May 5, 2019 3:35 PM

The NTSB does not say that the employees were required to obtain protection to walk on the Amtrak tracks.  They do say that per General Safety Rule 10, the operating crews were not prohibited from walking either on or near the Amtrak tracks.

Rule 10 only requires employees to “Stop and look in both directions before making any of the following movements:  - Fouling or crossing a track…”

So the CSX employees were fouling a track and they were required to look both ways before fouling.  However, if they did that, the rule would allow them to maintain fouling while walking on the track for an indefinite distance without further looking.  What is missing from Rule 10 in this case is a requirement to look back at specified intervals during the continuous fouling associated with a long walk on the track, in line with it. 

So it is true that Rule 10 does not prohibit employees from walking on a track lengthwise with it, however the rule also does not provide any procedure for employees to walk lengthwise on the track, as the CSX employees were doing.  Rule 10 does require employees to be alert while on or near tracks, but a fully alert person could still be blindsided by a train if it sneaks up on them from behind and its horn warning is merged with the horn warning of a second train approaching from their front, on a track that they are not fouling. 

Therefore, without a means to seek protection on the Amtrak property; and without a requirement to do so; and with no rule telling them not to walk on the Amtrak track— there was nothing in the rules governing the action of the two employees in walking lengthwise on the Amtrak track. 

This leaves the obvious question:  If the two conductors were not doing anything wrong, how could the cause of their deaths be their fault as the NTSB determines with their Probable Cause in their report? 

The apparent reason for a lack of CSX rules covering this situation is that it occurred off of CSX property.  So the only stipulation that would come into play here would be the trespass laws that would have prohibited the two CSX employees from walking on the Amtrak Track.  I must assume that the NTSB does not want to address this issue in their report on the accident.

In my opinion, NTSB does not want to venture into the consideration that the actual cause of this accident was trespassing on Amtrak property, even though it is hard find a reason otherwise.  So, in my opinion, that is why they offered this muddy account in which they state what was not required, and what they wish were required; and then blame the cause on something that was not required.  Perhaps this is the first train fatality caused by trespass in which that critical fact is not mentioned. 

Join our Community!

Our community is FREE to join. To participate you must either login or register for an account.

Search the Community

Newsletter Sign-Up

By signing up you may also receive occasional reader surveys and special offers from Trains magazine.Please view our privacy policy