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NTSB Railroad accident brief contains contradiction Locked

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Posted by 243129 on Sunday, May 19, 2019 4:38 PM

Euclid
She said she saw trespassers every day, but normally they move. I do interpret that to mean that she intends to not apply brakes prior to impact because she expects them to move. You really don't know if they are going to move until the last half second or so.

Expects? Really? That in itself says volumes about lack of acumen for the position of locomotive engineer.

Euclid
But the job is not that easy. An engineer must assess each fouling trespasser or vehicle individually and not act according to one root assumption such as an assumption that most people will move.

Absolutely.

Euclid
Then the fact that they did not turn and look at #175 or acknowledge the horn signal in any way, should have told the engineer that the conductors were not aware of the train and there was a very good chance they they would not move in time.

Still she did not react.

Euclid
Engineers should be trained in recognizing this type of two-train distraction, and watching out for the possibility of it distracting people fouling the track.

Agreed. Testing for acumen would also enter in to it. 'What if' situations should be part of the testing.

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Posted by Euclid on Sunday, May 19, 2019 7:14 PM

Electroliner 1935
 
Euclid
Engineers should be trained in recognizing this type of two-train distraction, and watching out for the possibility of it distracting people fouling the track.  And they should also be trained how to carefully handle the horn signals in this type of emergency.  Maybe some of the theory behind police car audio signals could be applied to passenger train locomotives.  What is needed is some signal that can bust through the sound of a train horn and be distinctly heard.

 

I am wondering what you say about the training. What would you have done if you were the engineer of Amtrak 175? How should the training be changed? And would the result be different? 

 

To answer your question as to what I would have done if I were the engineer of #175, I would have sounded the standard horn signal as follows:  Succession of short sounds = An attempt to attract attention to the train.  It is used when persons of livestock are on the track at other-than-road crossings at grade.

If I were the engineer of #66, I would not have sounded the horn if I was sure that the two conductors saw my train.  If I was not sure, I would have made two short toots.  The overall point would be for #66 to make as little horn sound as possible.

The following analysis includes my rationale for better training to address this unique distraction hazard:

In this case, both engineers saw the two conductors about the same time.  Both engineers saw that the two conductors were fouling the track for #175.  Both of them saw that the conductors were facing #66 and had their backs to #175.  Both engineers had air horns that can be heard a mile away.  Both engineers blew horn warnings at about the same time.  If either or both conductors had heard any air horn that they perceived to be behind them, that would have saved their lives and prevented any injury as well.

The two conductors saw one train (#66) approaching them and they knew they were in the clear of it.  There was no chance that they would have been hit by that train, and they knew that.  The two conductors also heard a horn sound, which they perceived to be coming only from #66, but it was also coming from #175; a train that they had not looked back to recognize.  So because the horn signal from #175 sounded like the horn signal of the train they were watching approach from the front, they failed to realize that #175 too was participating in the horn warning.  Clearly, the two conductors had to hear the horn warning from #175, but they mistook it for being only a warning from #66.

Therefore, the key to better training would be to prevent or at least limit the horn warning from the train (#66), which was not on course to strike the two conductors.  In fact, if #66 had not shown up at that precise moment, the two conductors would have heard #175 blowing behind them and they would have jumped out of the way in time to avoid injury or death. 

So the better training would be to instruct the engineer of #66 to limit horn warning to just the smallest amount of toot, if any at all.  At the same time, training should instruct the engineer of #175 to blow a very energized pattern of honks, perhaps in a prescribed and practiced pattern of rhythm and duration of each note.  In any case, it should generally fit the standard succession of short sounds that the rules call for in this type of emergency.   

Engineers should be trained to recognize the development of this unique danger.  Whenever two trains are converging on each other at high speed; if there are also a one or more people present near that point of convergence; this is the time for both engineers to recognize the great danger. 

If the people are merely close to the tracks, both trains should sound moderately urgent horn signal patterns with plenty of open space between the honks.

If the people are fouling one of the tracks, engineers should note whether they appear to recognize both trains approaching, just one train approaching, or no trains approaching.    

If they seem likely to be recognizing one train but not the other, then the track they are fouling must be considered in regard to with which train they recognize.

If they are fouling the track with the train they recognize, then horn signals from that train have little importance, because they see that train approaching.   But horn signals from the train they don’t recognize are quite important because they might jump into the clear of the train they recognize and into the path of the train they don’t recognize.

But the most critical situation is when people are fouling a track, and don’t recognize a train approaching on that track, while they do recognize a train approaching on the track they are not fouling.  This is the most critical scenario of this basic danger and this was what occurred at the Ivy City, D.C. accident.  In this case, a horn warning from the recognized train was almost irrelevant, but far more importantly, it distracted from the horn warning from #175 which was profoundly important and essential to saving the two conductors.   

Therefore, given that both trains gave horn warnings, it would have been best to use a specially prescribed warning that would leave spaces of silence for the other train’s horn warning to be heard and have its source direction perceived by the people on the track.   With that type of warning, it would have at least clarified the danger by limiting the mistaken perception that the two warnings were coming from just one train. 

When I refer to a specially prescribed warning, I am referring to developing a new warning signal that might improve on the standard warning for such emergencies which is the succession of short sounds mentioned above.  In any case, the horn signal used by the engineer of #175 (laying on the horn) is not the best signal to use, and is not correct according to the rules.  The point of this signal requirement, in the case of two trains converging on persons by the track, is to leave quiet space between horn sounds to leave room for horn sounds of the other train horn.  The quiet spaces also accentuate the intervening horn sounds, perhaps making them more noticeable than a long, continuous horn blow.  Laying on the horn might be effectively okay for some emergencies, but for this unique two-train distraction, it was a horn signal that could have done more harm as well as being of the benefit intended 

So that is the training that I would recommend.  In over a century of railroading, I doubt that this problem has ever been recognized as something that can be addressed.  Railroads have worked hard to develop loud whistles and horns that seem to match the level of danger trains can present.  But that loud warning poses a special, hidden danger if two trains sound it at the same time.  Maybe instead of just equipping every locomotive with a loud horn, there should be a secondary audible warning device that can cut through the warning of a loud locomotive horn, and eliminate the confusion of two loud horns sounding simultaneously.

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Posted by Electroliner 1935 on Monday, May 20, 2019 3:42 PM

HindSight is 20/20. This fatality could not have been avoided by any action that an engineer could have taken. You can yap as much as you want but the two men made a fatal mistake and forgot the rule to expect a train on ony track at any time and paid dearly for it. Amtrak's 175 engineer has to live with what happened and she was powerless to prevent it. I think it might be painful for her to think that she might have been able to do something and don't want to add to any pain she has.

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Posted by Euclid on Monday, May 20, 2019 4:07 PM

Electroliner 1935

HindSight is 20/20. This fatality could not have been avoided by any action that an engineer could have taken. You can yap as much as you want but the two men made a fatal mistake and forgot the rule to expect a train on ony track at any time and paid dearly for it. Amtrak's 175 engineer has to live with what happened and she was powerless to prevent it. I think it might be painful for her to think that she might have been able to do something and don't want to add to any pain she has.

 

The rule to expect a train on any track at any time goes without saying.  It is trite.  You could not cross a track if you truly expected a train at any time.  I don't blame either engineer for anything they failed to do.  What I have suggested is a matter of training going forward.  It could save lots of lives.  I doubt that it has ever been considered.  This accident is just an example of how it works.  I also don't blame the two conductors.  I am quite sure they were expecting a train at any time.  But I do blame CSX for sending them out there without protection.  They worry about about the little things and forget about the big things. 

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Posted by 243129 on Monday, May 20, 2019 8:08 PM

Electroliner 1935
This fatality could not have been avoided by any action that an engineer could have taken.

We will never know because she took no action until after the fact.

Electroliner 1935
the two men made a fatal mistake and forgot the rule to expect a train on ony track at any time and paid dearly for it.

Agreed. However proper training and lack of common sense might also be a factor.

YOU DO NOT INSPECT YOUR TRAIN FROM A LIVE TRACK WHEN THERE IS A SAFE ALTERNATIVE !

Electroliner 1935
Amtrak's 175 engineer has to live with what happened and she was powerless to prevent it. I think it might be painful for her to think that she might have been able to do something and don't want to add to any pain she has.

There were actions she could have taken that she did not.

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Posted by 243129 on Monday, May 20, 2019 8:14 PM

Euclid
What I have suggested is a matter of training going forward.

Going forward? They should have been trained properly in the first place.

Euclid
I also don't blame the two conductors.

Their poor judgement coupled with poor training and inexperience cost them their lives.

Euclid
But I do blame CSX for sending them out there without protection.

Not enough info to support that.

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Posted by BaltACD on Monday, May 20, 2019 9:31 PM

Training only goes so far - at some point the employee has to think and act upon the situation that is presenting itself in accordance with HIS best judgement applying the principles that he has been presented and had 'forced' into him by his training,

No matter how good the training - the employee has to THINK AND ACT on their own.  The best training in the world does not guarantee 100% compliance and application of the principles that were taught.  Human beings do not react to situations like robots.

In this incident, despite the training that had been done, the employees made multiple bad decisions that ended up costing them their lives.  Nothing 175's engineer could have done beyond NOT BEING AT THAT LOCATION AT THAT TIME would have prevented the outcome that happened.

Until we can develop technology that can download the final thouyghts of humans as they die and make those thoughts understandable to the living survivors we will never know what the CSX crew were thinking about in their final seconds alive.

Living people make decisions - sometimes they make the wrong one.

Never too old to have a happy childhood!

              

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Posted by 243129 on Tuesday, May 21, 2019 7:30 AM

BaltACD
Training only goes so far - at some point the employee has to think and act upon the situation that is presenting itself in accordance with HIS best judgement applying the principles that he has been presented and had 'forced' into him by his training,

This is why vetting is important in the hiring process.

BaltACD
Nothing 175's engineer could have done beyond NOT BEING AT THAT LOCATION AT THAT TIME would have prevented the outcome that happened.

You do not know that. We will never know for sure but any chance of affording those two individuals seconds to escape by retarding the speed was negated by the failure of the engineer to apply the brakes in emergency UNTIL AFTER IMPACT!

BaltACD
Living people make decisions - sometimes they make the wrong one.

In this case three people made bad decisions.

Just wait until the lawyers for the deceased receive the information that  emergency braking was not enacted until after impact.

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Posted by Deggesty on Tuesday, May 21, 2019 7:49 AM

Well said, BaltThumbs Up.

Johnny

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Posted by Euclid on Tuesday, May 21, 2019 8:13 AM

243129
 
BaltACD
Nothing 175's engineer could have done beyond NOT BEING AT THAT LOCATION AT THAT TIME would have prevented the outcome that happened.

 

You do not know that. We will never know for sure but any chance of affording those two individuals seconds to escape by retarding the speed was negated by the failure of the engineer to apply the brakes in emergency UNTIL AFTER IMPACT! 

I agree.  It seems like some people are forgetting that the point of making the emergency application without waiting until after impact is NOT to slow the train slightly for the ojective of striking the person with less force.  Of course the reduced force would still be way more than enough to kill the person.

Instead, the purpose is to reap the benefit of an increment of extra time before impact.  There is no guarantee that the person is going to remain unaware of the approahching train right up to impact. Just a thought entering their mind could cause them to turn and see the train coming up on them.  They could do that and leap out of the way in less than 1/2 second. 

Therefore, just the slightest lengthening of the train approach time is of infinite value in providing even the smallest increment of extra time availble for the person to inadvertently discover the danger. 

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Posted by BaltACD on Tuesday, May 21, 2019 11:51 AM

243129
 
BaltACD
Training only goes so far - at some point the employee has to think and act upon the situation that is presenting itself in accordance with HIS best judgement applying the principles that he has been presented and had 'forced' into him by his training, 

This is why vetting is important in the hiring process.

The Conductor would have passed your Vetting process - He was white and the son of a 20+ year railroader and had been working for a subsidary of the company for about 3 years before getting hired into Train Service.  He also had a clear crimanal record and passed the drug test.

Never too old to have a happy childhood!

              

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Posted by 243129 on Tuesday, May 21, 2019 12:00 PM

BaltACD

 

 
243129
 
BaltACD
Training only goes so far - at some point the employee has to think and act upon the situation that is presenting itself in accordance with HIS best judgement applying the principles that he has been presented and had 'forced' into him by his training, 

This is why vetting is important in the hiring process.

 

The Conductor would have passed your Vetting process - He was white and the son of a 20+ year railroader and had been working for a subsidary of the company for about 3 years before getting hired into Train Service.  He also had a clear crimanal record and passed the drug test.

 

His behavior, inspecting his train from a live track when there was a safer alternative, indicates he did not possess the acumen for the position nor was he trained properly for the position of conductor.

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Posted by BaltACD on Tuesday, May 21, 2019 12:10 PM

243129
 
BaltACD 
243129
 
BaltACD
Training only goes so far - at some point the employee has to think and act upon the situation that is presenting itself in accordance with HIS best judgement applying the principles that he has been presented and had 'forced' into him by his training, 

This is why vetting is important in the hiring process. 

The Conductor would have passed your Vetting process - He was white and the son of a 20+ year railroader and had been working for a subsidary of the company for about 3 years before getting hired into Train Service.  He also had a clear crimanal record and passed the drug test.

His behavior, inspecting his train from a live track when there was a safer alternative, indicates he did not possess the acumen for the position nor was he trained properly for the position of conductor.

And only by the grace of God did you avoid your screw ups and live past 25.  25 year olds don't have the same thought processes as 80 year olds.  When God's grace permits, one learns from their mistakes.  God graced you because as sure as you were once 25 you made hundreds of mistakes that could have ended it all.  ALL 25 year olds DO!

Never too old to have a happy childhood!

              

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Posted by charlie hebdo on Tuesday, May 21, 2019 12:21 PM

243129
We will never know for sure but any chance of affording those two individuals seconds to escape by retarding the speed was negated by the failure of the engineer to apply the brakes in emergency UNTIL AFTER IMPACT!

You said earlier that you had 5 fatal accidents. Did you always take the appropriate action in the cab to mitigate or prevent? 

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Posted by 243129 on Tuesday, May 21, 2019 12:30 PM

BaltACD
And only by the grace of God

You invoke God into this??? Enough said.

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Posted by 243129 on Tuesday, May 21, 2019 12:32 PM

charlie hebdo

 

 
243129
We will never know for sure but any chance of affording those two individuals seconds to escape by retarding the speed was negated by the failure of the engineer to apply the brakes in emergency UNTIL AFTER IMPACT!

 

You said earlier that you had 5 fatal accidents. Did you always take the appropriate action in the cab to mitigate or prevent? 

 

I most certainly did and I have no regrets for any of my actions. I learned my job from professionals and I learned it well.

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Posted by charlie hebdo on Tuesday, May 21, 2019 1:20 PM

243129

 

 
charlie hebdo

 

 
243129
We will never know for sure but any chance of affording those two individuals seconds to escape by retarding the speed was negated by the failure of the engineer to apply the brakes in emergency UNTIL AFTER IMPACT!

 

You said earlier that you had 5 fatal accidents. Did you always take the appropriate action in the cab to mitigate or prevent? 

 

 

 

I most certainly did and I have no regrets for any of my actions. I learned my job from professionals and I learned it well.

 

You dodged the question.  It's not about your regrets.  It's what you did or did not do.  Since those were all fatal, were they investigated?  What were the determinations of boards of inquiry (whatever name they were called then)?

Or are you actually claiming you never made a mistake in all those years?

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Posted by BaltACD on Tuesday, May 21, 2019 1:27 PM

243129
 
BaltACD
And only by the grace of God 

You invoke God into this??? Enough said.

We will take God out if it - by the grace of Satan you survived all your mistakes.  Or more precisely, through BLIND DUMB LUCK you survived your mistakes, and being 25 you made tons of mistakes.

Never too old to have a happy childhood!

              

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Posted by Euclid on Tuesday, May 21, 2019 2:26 PM
What is the basis for concluding that the two conductors should not have been walking on the track?  Railroaders frequently walk on tracks.  Usually, they cross over them, and in yards, they walk alongside of them because that area is level, so there is no reason to walk on tracks in a yard if walking in the track direction. 
 
The NTSB says this:  “The operating crews were not prohibited from walking either on or near the Amtrak tracks.”  From that official statement, I see no prohibition, and no rule that bans operating crews from walking in track direction while fouling the track.  Safety is relative, and nobody is expected to be 100% safe.  It would be safer not to walk on track.  It would be safer yet to not work for a railroad or not get out of bed every day.  
 
Whether fouling the track or not, the clearance is too little for being there as a train passes at 125 mph.  So what was the safer alternative?  What if their inspection required them to be on that side?  There was only one safe alternative, and that was to insist that CXS arrange for formal protection with Amtrak.  The NTSB says that was not a procedure that was in place to use.  If so, the only safe alternative would have been to the two conductors to refuse to inspect the train unless CSX moved it to a safe location. 
 
Is there a better alternative?
 
CSX has rules prohibiting every little thing that they recognize as being too unsafe.    Yet, the risk of those little worries pales by comparison to sending employees, without train traffic protection, into a stopped train inspection routine that took them into fouling space used by 125 mph passenger trains. 
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Posted by Electroliner 1935 on Tuesday, May 21, 2019 4:23 PM

Euclid
Whether fouling the track or not, the clearance is too little for being there as a train passes at 125 mph.  So what was the safer alternative?  What if their inspection required them to be on that side?  There was only one safe alternative, and that was to insist that CXS arrange for formal protection with Amtrak.  The NTSB says that was not a procedure that was in place to use.  If so, the only safe alternative would have been to the two conductors to refuse to inspect the train unless CSX moved it to a safe location.    Is there a better alternative?  

Euclid, On this I agree with you. After going to Google/maps and looking at the area, there is NO safe way to inspect a CSX train from the AMTRAK side other than by having a protection zone created by AMTRAK. The space between the CSX and AMTRAK tracks is not sufficient. If CSX rules call for the train to be inspected on that side of the train, then CSX is (should be) responsible for providing a safe means to do it and needs to resolve how. An inter-company agreement needs to exist to provide for this. And it could happen that an AMTRAK train with a problem might need similar protection from CSX. Heaven help them if a breakdown on an Acela should happen at a similar location. 

 

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Posted by 243129 on Tuesday, May 21, 2019 6:46 PM

charlie hebdo
You dodged the question. It's not about your regrets. It's what you did or did not do. Since those were all fatal, were they investigated? What were the determinations of boards of inquiry (whatever name they were called then)? Or are you actually claiming you never made a mistake in all those years?

Unlike you I dodge nothing. They were all investigated(of course) and it was determined that I took every action to mitigate the situation. I made no mistakes.

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Posted by 243129 on Tuesday, May 21, 2019 6:50 PM

BaltACD
Or more precisely, through BLIND DUMB LUCK you survived your mistakes,

No not "BLIND DUMB LUCK", I was mentored by professionals. Mistakes that I did make were inconsequential, minimized and correctable due to the aforementioned mentoring.

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Posted by matthewsaggie on Tuesday, May 21, 2019 7:17 PM

Not mentioned in all of this is that this track layout (equivalent of 4 mains) has existed since the completion of Union Station in 1908. B&O and PRR and successors shared this same r/w for 100+ years and no one killed before as far as we know and a situation that everyone was so used to no one considered it such a danger to write a special rule over. Now there will be a rule.

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Posted by charlie hebdo on Tuesday, May 21, 2019 7:49 PM

243129

 

I made no mistakes.
 

Mr. Perfect.  A true rarity. 

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Posted by 243129 on Tuesday, May 21, 2019 8:00 PM

charlie hebdo

 

 
243129

 

I made no mistakes.
 

 

 

Mr. Perfect.  A true rarity. 

 

No just a well trained professional.

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Posted by 243129 on Tuesday, May 21, 2019 8:04 PM

No photo description available.

This is for you Chuck!Laugh

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Posted by Euclid on Tuesday, May 21, 2019 9:03 PM

matthewsaggie

Not mentioned in all of this is that this track layout (equivalent of 4 mains) has existed since the completion of Union Station in 1908. B&O and PRR and successors shared this same r/w for 100+ years and no one killed before as far as we know and a situation that everyone was so used to no one considered it such a danger to write a special rule over. Now there will be a rule.

 

What would the rule say?

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Posted by 243129 on Tuesday, May 21, 2019 9:15 PM

Euclid
What would the rule say?

Use common sense.Wink

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Posted by charlie hebdo on Tuesday, May 21, 2019 9:31 PM

243129

 

 
charlie hebdo

 

 
243129

 

I made no mistakes.
 

 

 

Mr. Perfect.  A true rarity. 

 

 

 

No just a well trained professional.

 

More likely someone who has something to hide or is simply disingenuous. Or even a guy suffering from reaction formation,  like an Elmer Gantry type. 

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Posted by 243129 on Tuesday, May 21, 2019 9:36 PM

charlie hebdo
More likely someone who has something to hide or is simply disingenuous. Or even a guy suffering from reaction formation, like an Elmer Gantry type.

Your snarky assertions are those of one still stinging from previous b____ slappings.Laugh

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