EuclidIs there any information that confirms the information given by Ms. Reese that says she began laying on the horn 10-20 seconds prior to striking the two conductors. Isn't all of this data about horn and headlights available from the event recorder?
Her convoluted and disjointed testimony is extremely hard to follow giving credence to my previous observation that she is marginally qualified. Not making an emergency application until after the impact is unconscionable.
I agree.
The obvious question is whether the two conductors received any horn warning at all from #175 prior to being struck by it. Why hasn't NTSB verified the claim of Ms. Reese that she began "laying on the horn" 15-20 seconds before impact?
Twice in his interview, the CSX engineer emphasized that the horn sound that he heard came after a train passed his locomotive. Unfortunaly nobody asked him if that was the only train horn sound he heard.
According to the Engineer Reese, she was laying on the horn for 15-20 seconds prior to imact. At 74 mph, that would be 2170 feet. The actual distance would have been considerably greater because the train was slowing for the signal ahead.
In any case, the horn of #175 (striking train) should have been heard by the CSX engineer for 15-20 seconds prior to impact. He says he heard it start about 3 seconds after impact.
In this unique type of distraction accident, the horn warning of #175 would have been absoluty, critically essential to saving the two conductors. Otherwise, the horn signal, headlight, and visual observation of #66 would have strongly pulled the attention of the two conductors away from anything behind them and toward #66 in front of them. Therefore the question of whether there really was any horn warning from #175 is of maximum importance in the cause of this disaster.
.
Corrected 5/10
Watching the situation unfold from 175 point of view. 66 approaching from the south,175 headed south, stopped CSX train on CSX main 2 parallel to Amtrak main 3, personnel on main 3 the track 175 is proceeding south on. From testimony 175 engineer had 15 -20 seconds to assess and react. When 175 sounded horn and no reaction was forthcoming from the two employees an emergency application should have been initiated immediately knowing that the two employees were distracted/focused on the northbound 66.
That engineer (175) exercised poor judgement and took away any chance for the victims to react. Milliseconds could have made a difference.
The event recorder data is published in the packet of information related to the NTSB investigation. I would like someone to verify my interpretation, but it is as follows:
The horn of Amtrak #175 (striking train) was sounded for approx. 7 seconds between 40-33 seconds prior to impact. There was no additional horn sounding during the next 33 seconds up to the point of impact.
So this would mean that the train was a minimum of 4,300 feet from striking the two conductors when the engineer began sounding the horn. Would it have been possible to see the two conductors at that distance? It would probably be more than 4,300 feet, considering that the train was decelerating for a signal ahead.
If seeing the two conductors at that distance would not have been possible, would there have been another reason to sound the horn at that location such as simply to warn the CSX train that was stopped there, but not to warn any particular person?
Here is the event recorder data for train #175:
https://dms.ntsb.gov/pubdms/search/document.cfm?docID=470777&docketID=62103&mkey=95451
243129Watching the situation unfold from 175 point of view. 66 approaching from the north,175 headed north, stopped CSX train on CSX main 2 parallel to Amtrak main 3, personnel on main 3 the track 175 is proceeding north on. From testimony 175 engineer had 15 -20 seconds to assess and react. When 175 sounded horn and no reaction was forthcoming from the two employees an emergency application should have been initiated immediately knowing that the two employees were distracted/focused on the southbound 66. That engineer (175) exercised poor judgement and took away any chance for the victims to react. Milliseconds could have made a difference.
Talk about a screwed up scenario. 66 was Northbound, 175 was Southbound - glad you know the railroad so well [/sarcasm]
For 175 - traveling at a speed in excess of 73 MPH (impact speed) - was coming off a left hand curve that ended approximately 1900 feet from the point of impact - 75 MPH has a vehicle traveling at 110 feet per second. While 175's engineer may have stated 15 to 20 seconds, I suspect the actual time was really much shorter. In my perusal of the NTSB data I did not see a recreation of when the CSX employees could have been seen - in the dark by the reflectance from their safety vests by 175's head light.
In times of stress, the actions of real seconds seem to our minds to take 'forever'; thus a individual's time estimate in a period of stress is open to question. I don't believe 175's engineer had the 15-20 seconds she stated - 10 second would be mroe like reality.
Never too old to have a happy childhood!
between the interviews of the CSX engineer and the #175 engineer, we have a major conflict. But both inerviews are very difficult assimilate due to the speaking syle of all involved.
We also have a major conflict between the locomotive event recorder from #175, and the testimony of #175's engineer regarding her claim of laying on the horn upon seeing the two conductors 15-20 seconds prior to impact.
With the missing pieces and conflicting information in the interviews and the conflict with the event recorder, it apparently leaves open the possibility that the engineer of #175 never saw the two victims until the moment of impact.
"Talk about a screwed up scenario. 66 was Northbound, 175 was Southbound - glad you know the railroad so well" [/sarcasm]
Good grief Charlie Brown!!!!! I did indeed transpose the direction. Oh the horror! However the scenario is intact when you correct 175 to south and 66 north. I had what they call in New England...a brain faht. If that is all it took to make your day I'm happy for you.
BaltACD I suspect the actual time was really much shorter. In my perusal of the NTSB data I did not see a recreation of when the CSX employees could have been seen - in the dark by the reflectance from their safety vests by 175's head light.
Transcript Page 12 lines 19-25:
She states a "cat pole away". Catenary poles are approximately 500 feet apart. So according to her and the rambling and confusing testimony, she traveling at 73 mph would have covered that distance in less than 5 seconds. All the more reason to instantly apply the brakes in emergency.
In order to obtain a clear(er) picture there are many more questions that needed to be asked but the NTSB did not do so.
EuclidWith the missing pieces and conflicting information in the interviews and the conflict with the event recorder, it apparently leaves open the possibility that the engineer of #175 never saw the two victims until the moment of impact.
She did not state such in her testimony on page 12 lines 19-25.
243129She states a "cat pole away". Catenary poles are approximately 500 feet apart. So according to her and the rambling and confusing testimony, she traveling at 73 mph would have covered that distance in less than 5 seconds. All the more reason to instantly apply the brakes in emergency.
5 seconds? It would not accomplish anything positive in terms of outcome other than letting her feel less guilty. And since this was a curve, would not an emergency application run some risk of derailment?
charlie hebdo5 seconds? It would not accomplish anything positive in terms of outcome other than letting her feel less guilty.
You don't know that. A fraction of a second can mean the difference between life and death. She eliminated that factor by not applying the brake to emergency.
Have you ever been involved in a fatal accident?
charlie hebdoAnd since this was a curve, would not an emergency application run some risk of derailment?
Highly doubtful.
If the distance from first sighting/start of horn was a cat pole, and if the cat pole distance is 500 ft., that would have been 4.5 seconds.
In other testimony, she says the time from first sighting/start of horn was 15-20 seconds. At 20 seconds, that would have been 2,170 ft.
If I am interpreting the event recorder graph correctly, she began blowing the horn 7 seconds prior to impact.
So the cat pole estimate does approximately correspond to the 7 second horn blast over one cat pole distance, leading up to impact.
But all of this may or may not correspond to the inerview of the CSX engineer, depending on what he meant when describing hearing a horn after the train passed his locomotive. His information about that is not complete enough to draw a conclusion as to its meaning.
Considering the distance conflict of 500 ft. versus 2,170 ft., I suspect the latter is incorrect and the former is correct. These measures are said to be the point where the two conductors first became visible, and 2,170 ft. seems way too far to be able to see the conductors.
EuclidConsidering the distance conflict of 500 ft. versus 2,170 ft., I suspect the latter is incorrect and the former is correct. These measures are said to be the point where the two conductors first became visible, and 2,170 ft. seems way too far to be able to see the conductors.
It does not alter the fact that the engineer on 175 did not do all that was in her power to mitigate the situation no matter the futility.
243129It does not alter the fact that the engineer on 175 did not do all that was in her power to mitigate the situation no matter the futility.
I understand that and agree. My only point was to clarify some of the conflicting details of distance and timing that are containted in the interviews, reports, etc. I will soon follow up with some further thoughts about the accident site.
Euclid 243129 It does not alter the fact that the engineer on 175 did not do all that was in her power to mitigate the situation no matter the futility. I understand that and agree. My only point was to clarify some of the conflicting details of distance and timing that are containted in the interviews, reports, etc. I will soon follow up with some further thoughts about the accident site.
243129 It does not alter the fact that the engineer on 175 did not do all that was in her power to mitigate the situation no matter the futility.
Sadly/tragically the 'conflictions' are numerous.
This link goes directly to the PDF of the Operations Factual Report.
https://dms.ntsb.gov/public/62000-62499/62103/622720.pdf
Look at page 5 showing a photo of the tracks and a CSX train at the accident site. Earlier, when I first looked at the accident report and the track diagram, I had the mistaken impression that the CSX and Amtrak tracks were separated by maybe 20-30 feet, as two completely independent double track systems. So I visualized the two conductors leaving the CSX tracks and walking over to a completely separate double track system owned by Amtrak.
But actually, all the tracks are right together as if it were a four-track mainline. So I don’t see any issue with the two conductors leaving CSX property and entering the property of Amtrak, as I had considered earlier. This has to be some kind joint use corridor agreement, at least at this location on the two systems.
If there was a boundary line that prohibited crews from passing from the CSX mainline to the Amtrak mainline, there would be no way for CSX crews to walk along their trains without crossing the boundary.
Even if the two conductors walked as close to their train as possible on the Amtrak side, they would have been dangerously close to Amtrak and very fast trains. If I am not mistaken, Amtrak trains can pass through this location at up to 125 mph. Therefore, a person walking in the center of the clearance space would be no more than 2 feet from the Amtrak train passing at 125 mph.
The CSX engineer expressed some surprise that the two conductors walked back along their train on the Amtrak side. As it turns out, they were actually walking within the foul zone of the Amtrak track. Was that against the rules or just ill-advised? How about if they had walked clear of the Amtrak foul zone, but only by a couple feet or so as they stayed as close as possible to the CSX train? Would that have been against the rules? Or was it just an acceptable level of danger?
The discussion in the NTSB report refers to advising the use of protection for anyone walking on or near the Amtrak track. But it is not clear as to what the actual requirement for protection is. They refer to a need for protection for employees leaving the CSX track and entering the track owned by another railroad company. However, in one paragraph, the NTSB seems to say that this protection is required; and they say that such a requirement could be instituted for this type of use. That makes it sound like it is not yet required.
I conclude that CSX employees should be prohibited of getting off of their train on the Amtrak side without having protection that would prohibit Amtrak trains from passing the CSX train. If that is not the case, why is it not? If it is the case, who had the responsibility of setting up the protection and preventing the two conductors from entering this danger zone before protection was established?
EuclidEven if the two conductors walked as close to their train as possible on the Amtrak side, they would have been dangerously close to Amtrak and very fast trains. If I am not mistaken, Amtrak trains can pass through this location at up to 125 mph. Therefore, a person walking in the center of the clearance space would be no more than 2 feet from the Amtrak train passing at 125 mph.
Poor training, poor vetting, inexperience and very poor judgement are the main factors which led to the demise of the two CSX employees.
Poor training, poor vetting, inexperience and very poor judgement is what led to the Amtrak engineer not applying the emergency brake until after impact. Unconscionable!
NTSB does not seem to be focusing on training and supervision.
Quote from the NTSB report on the Ivy City CSX employee fatalities. Consider the parts highlighted in red and blue:
“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.”
******************************************
Apparently when they say “they would need protection” they are not using the word “need” as an absolute rule requirement. Instead, they are using the word as the employees having a natural desire or good use for; or personal interest in acquiring.
So from that, it follows that there is no legal or rule requirement to have protection when occupying the foul zone of an Amtrak track.
The part in blue indicates that this protection could be routinely granted by the rules structure, and that the NTSB recommends doing so. They would not recommend doing so if a rule already required it.
So, clearly, there is no rule or instructional requirement for CSX employees to have obtained formal protection in order to enter upon the tracks of the Amtrak mainline. And yet, there is a process available to arrange that.
Therefore, for the NTSB to say that the probable cause of the accident was the two employees deciding to walk on the Amtrak track without protection seems short sighted. If protection was essential to the safety of the two conductors, the CSX Company should have required that protection by a rule. Then the CSX should have informed the employees of that requirement, arranged for the protection, and informed the employees when the protection was applied and it was therefore safe for them to enter this dangerous area next to the high speed Amtrak mainline.
So in my opinion, the true cause is that CSX did not use the available process to set up this protection for the two conductors as they performed their duty of inspecting their train, which was a procedure requiring them to be on or near the Amtrak mainline.
EuclidSo in my opinion, the true cause is that CSX did not use the available process to set up this protection for the two conductors as they performed their duty of inspecting their train, which was a procedure requiring them to be on or near the Amtrak mainline.
The TRUE CAUSE was the lack of situational awareness of the CSX employees being in the foul of Amtrak #3 track.
Where they were walking, they should have been looking over their shoulder for Amtrak traffic on #3 track every other or every third step as the progressed back to their locomotives. Amtrak 175's engineers statements indicated that while in her sight they never looked back or acknowledged the approach of 175. I am guessing they attributed any and all noise from 175 to Amtrak 66 that they could see approaching them, moving from South to North.
In this incident there were no procedures in effect for CSX to notify Amtrak of personnel near or on Amtrak right of way. I feel certain that has either changed or will be changed in the near future.
BaltACDThe TRUE CAUSE was the lack of situational awareness of the CSX employees being in the foul of Amtrak #3 track.
Lack of situational awareness is but one of the causes. Inadequate and poor training combined with a lack of common sense is what caused them to inspect their train from a live track when that task could have been accomplished from the other side.
BaltACDWhere they were walking, they should have been looking over their shoulder for Amtrak traffic on #3 track every other or every third step as the progressed back to their locomotives.
Training. Inexperience.
BaltACDAmtrak 175's engineers statements indicated that while in her sight they never looked back or acknowledged the approach of 175.
She had time to observe that action but never placed the brake in emergency to afford seconds or milliseconds for a reaction???
BaltACDIn this incident there were no procedures in effect for CSX to notify Amtrak of personnel near or on Amtrak right of way. I feel certain that has either changed or will be changed in the near future.
Common sense would be the procedure. If you have to inspect from that side you notify your dispatcher (CSX) who in turn would notify the Amtrak dispatcher. They did not.
BaltACD Euclid So in my opinion, the true cause is that CSX did not use the available process to set up this protection for the two conductors as they performed their duty of inspecting their train, which was a procedure requiring them to be on or near the Amtrak mainline. The TRUE CAUSE was the lack of situational awareness of the CSX employees being in the foul of Amtrak #3 track. Where they were walking, they should have been looking over their shoulder for Amtrak traffic on #3 track every other or every third step as the progressed back to their locomotives. Amtrak 175's engineers statements indicated that while in her sight they never looked back or acknowledged the approach of 175. I am guessing they attributed any and all noise from 175 to Amtrak 66 that they could see approaching them, moving from South to North. In this incident there were no procedures in effect for CSX to notify Amtrak of personnel near or on Amtrak right of way. I feel certain that has either changed or will be changed in the near future.
Euclid So in my opinion, the true cause is that CSX did not use the available process to set up this protection for the two conductors as they performed their duty of inspecting their train, which was a procedure requiring them to be on or near the Amtrak mainline.
There is no reason to believe that the CSX conductors were aware of any means to acquire protection while near the Amtrak mainline.
If looking back were always sufficient to provide situational awareness, why even have the concept of protection? If Amtrak trains can pass through there at 125 mph, a rough calculation shows that a train could come into sight and strike the person in about 9 seconds. So, in order to have a 5-second minimum warning to clear the track, it would require a person to look back every 4 seconds. And if a person is between the stopped CSX train and the Amtrak track, is 2 feet a safe clearance from a 125 mph train? And if it is not, a person would have to use some of those seconds to cross over the track in front of the approaching train to get further clearance.
And they would also have to cross completely over that second track to make sure no train approached on that track while they were clearing the first approaching train nearest the stopped CSX train.
Remember, that these two conductors were struck while walking on the track, but they were sent back there to walk, look, inspect, and mount/dismount equipment.
In this case, part of their loss of situational awareness was due to it being defeated by a second train while it was being focused on a first train. So their situational awareness was highly focused, but that focus became their distraction from the second train.
This situation could have occurred even closer to the track curve, and thus they may have needed to look back every single second for a safe margin.
You can’t be dodging bullets on a battlefield, and then if hit, be blamed for losing situational awareness.
EuclidYou can’t be dodging bullets on a battlefield, and then if hit, be blamed for losing situational awareness.
There's a better metaphor: if you're trying to dodge fire from one direction, and are hit by crossfire you didn't hear starting, can you be blamed for not keeping 360-degree lookout?
In my opinion, the 'protection' issue NTSB ought to be stressing in their 'recommendation' is the quick and positive establishment of 'protection' status by one railroad upon request from others. In this particular case, when conductors decided to walk back on the 'Amtrak side' they should have been able to radio either directly or through the 'head end' of their train and obtain at least the recognition they were there (I believe the PTC civil functionality allows, or if implemented correctly would allow, one-point enforcement of their protection shortly thereafter). Why this is not so is as mysterious as railroads not having radio bridge capability to first responders, especially with relatively newly developed SDRs.
At least part of the 'revised' training emphasis that comes out of this accident has to involve more than better rules comprehension and obedience. In my opinion no small part of this involved fatigue, a sense of irritation at various relatively dumb snafus on the trip, and dark conditions combined with ironically bright 'anticollision' lighting on 66's power. If they were, in fact, walking in the Amtrak gauge as 66's engineer stated, they were violating about every common-sense training precept even the most retarded railroading regimen would provide ... and we should ask, since we can't ask them why, what we should do with training to keep that sort of problem from occurring again.
Meanwhile, I have a problem with the idea that protection 'supersedes' the need for constant situational awareness on the railroad. I think I've ranted at some length about the similar impression that may be conveyed by PTC, and certainly is by most deterministic forms of automatic train control or 'vigilance devices' -- the idea that if the Man says you're protected, you don't have to keep watching out. Perhaps the idea is that your caregivers or your heirs can sue for large money damages if someone violates the protection. Alas! you have to be just as swivel-headed and alert for any hint of surprises as you would with no protection. What the order provides is additional insurance against the sort of thing you're being constantly vigilant to detect. No part of 'expect a train on any track in either direction at any time' ought to (or in my opinion should) be relaxed by any external order of protection.
They should not have been inspecting their train from a live track when a safe alternative was accessible and usable.
243129They should not have been inspecting their train from a live track when a safe alternative was accessible and usable.
Undeniable, and I can't imagine training that wouldn't stress taking that safe alternative (here, crossing over the consist to walk the last couple of hundred feet after the crossover up to the engine on the 'safe' side).
The training that was missing includes how you keep discipline when you are tired, frustrated, and in inclement or unexpected conditions. I'm disappointed that the NTSB has made no mention of this even while describing many details of the circumstances, most pointedly some that are visible in the interview language, that contributed to the accident.
The secondary issue for NTSB recommendations would be their thoughts about 'vetting' and how it might have affected the outcome. I have to tread somewhat carefully here, as there are political incentives associated with recent Amtrak hiring that I think can be seen with respect to both Ms. Reese and Mr. Bostian (and perhaps many others). What is needed is some analogue to ASVAB that finds the 'comers' who have the aptitude to become dedicated and sensible railroaders rather than job holders, and then a training system that develops and reinforces the right attitudes, not just the right knowledge of and obedience to rules.
And, if the current applicants fall short of the number needed going forward, what improvements in training ... or in job conditions ... need to be made to help the situation?
Overmod 243129 They should not have been inspecting their train from a live track when a safe alternative was accessible and usable. Undeniable, and I can't imagine training that wouldn't stress taking that safe alternative (here, crossing over the consist to walk the last couple of hundred feet after the crossover up to the engine on the 'safe' side). The training that was missing includes how you keep discipline when you are tired, frustrated, and in inclement or unexpected conditions. I'm disappointed that the NTSB has made no mention of this even while describing many details of the circumstances, most pointedly some that are visible in the interview language, that contributed to the accident.
243129 They should not have been inspecting their train from a live track when a safe alternative was accessible and usable.
Johnny
DeggestyPerhaps the people on the NTSB need some training in safety?
They aren't railroaders. They don't have much interest in knowing how to be railroaders. They don't seem particularly able to talk to railroaders or understand why their answers might be made in 'certain ways'.
Pity Bella didn't stick around long enough to make the case for rolling ad-hoc protection into the UI for her beloved PTC. It finally would have been appropriate.
I have the increasing impression that the NTSB methodology doesn't work nearly as well for railroad accidents as it did for air accidents. Certainly their recent 'conclusions' don't.
You keep harping on 'vetting'. What is your proper level of vetting?
Overmod Deggesty Perhaps the people on the NTSB need some training in safety? They aren't railroaders. They don't have much interest in knowing how to be railroaders. They don't seem particularly able to talk to railroaders or understand why their answers might be made in 'certain ways'. Pity Bella didn't stick around long enough to make the case for rolling ad-hoc protection into the UI for her beloved PTC. It finally would have been appropriate. I have the increasing impression that the NTSB methodology doesn't work nearly as well for railroad accidents as it did for air accidents. Certainly their recent 'conclusions' don't.
Deggesty Perhaps the people on the NTSB need some training in safety?
I can't find the information now, but I think I once read that NTSB investigation teams for rail accidents do include persons very familiar with railroads and/or the equipment used.
Somewhere in the info on this accident is mention that many railroaders prefer to walk on ties than on the ballast (where they should be) when they must inspect. The benefits and hazards of this practice are obvious to anyone even possessing an IQ in the low average range (80 to 89). I don't think this has much to do with training or experience and very little with "vetting."
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