Some questions are raised by the CSX accident at Ivy City, D.C. in which a conductor and student conductor were struck and killed by an Amtrak train.
In other discussion of this topic, some have expressed certainty that death of the two conductors was due to their negligence in deciding to walk on an Amtrak track as they returned to their locomotive. They were struck and killed by an Amtrak train approaching them from behind at the same moment that another Amtrak train was approaching on the other Amtrak track from ahead of them. So an obvious conclusion is that they were not paying enough attention, were not expecting trains on any track, any time, etc. And yet once a person decides a track is clear to cross, they have correctly ceased expecting a train. So the rule is somewhat of a platitude.
It is clear that had they not been fouling the Amtrak track, they would not have been struck. Yet their job on CSX required them to inspect a CSX freight train which meant walking along much of that train. I am not sure of which side it was necessary to walk in this particular case, but the point is that it could have been either or both sides. So my question goes to the larger premise of how it can be considered safe to inspect a train in such close proximity to the Amtrak line even if the inspecting personnel are not actually fouling Amtrak. Or more precisely, how do you work in such close proximity to the foul zone of a track without inadvertently entering it?
In their accident report, the NTSB says the following:
The only way we can ‘learn’ more about this incident is from technology that has not been invented ‘yet’ - downloading the last thoughts of the deceased so they can be read and ‘understood’ by those that continue to live.
Live track and you are “working”* less than 19 feet from the center of that live, controlled track without protection …YOU SHOULDN’T BE THERE
Train crews are NOT exempt from the FRA on-track safety rules. (all inclusive and obviously nobody was acting as a lookout here - situational awareness failure, they fouled a track they did not control or have access to control - technically they were unqualified trespassers on another railroad and obviously they also fouled the other railroad’s track to boot. Not Good. They were “working” where they should not have been.) The excuse that they were over where the walking was easier doesn’t fly.
Here in Denver, RTD (light rail) is having issues with UP and BNSF employees fouling their main track causing several near miss incidents.
Truly sad chain of events compounded by a 214 OTS violation.
(*) Out west on UP or BNSF and you are working on track machinery or on foot less than 24 feet (company rule exceeds FRA) from an adjoining live controlled track, you must be off the machinery and in the clear when another train or work equipment passes by on that controlled track. All work stops until the passing train or equipment is by you and you can see it’s clear. (Speed/ Vision Distance rule applies)
Knowing the last thoughts of the deceased is not necessary to preventing this from happening again. There is plenty that can be learned from this accident. And it should not have required this accident to learn what needed to be known. If any thought process needs to be examined, it is that of the NTSB.
In referring to whether or not the two conductors were prohibited from walking on the Amtrak track in the manner they did; I am stating the thought process of the NTSB as they detail in their accident report. Here is their thought process as extracted from their report. The following four statements are in sequential order and context, but broken out to make them clearer:
“The operating crews were not prohibited from walking either on or near the Amtrak tracks.”
“The NTSB believes that the crew should have been prohibited from walking near the live tracks of the other railroad.”
“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
Knowing the last thoughts of the deceased is the only way to intellegently formulate rules and instruction to prevent future individuals from being sucked into the same series of ‘trap events’ that caused the demise of the original individuals.
Today we can only surmise, withoug knowing, what they were actually thinking - whether their brains had even acknowledged the presence of Amtrak 175, let alone whether they had started to take avoiding actions. The human mind responds to many inputs - both internal and external, to be effective in prevention we need to know what inputs had control of the brain(s) in the final seconds and formulate strategys so that ‘proper’ self preservation thoughts take control of the brain at the earlies possible moment.
Writing arbitrary rules is a sure way to have them violated and generally with catastrophic consequences.
I assume their final thoughts were of great shock, surprise, and regret. I also assume that they were not aware of #175 coming up from behind them until either after the train struck them or just a second or two before it struck them. And I assume that they would not have been killed or injured had it not been for the unusual synchronicity of two Amtrak trains converging on them at precisely the same moment. If #66 was not approaching, they would have most assuredly heard #175 coming up behind them.
What we can learn is to understand the highly unique danger of this unusual type of accident. What protects people from it is far less dependent on how careful they are, but mainly dependent on the rarity of the necessary coincidence of two trains
Until you realize that ALL trains can be on you without your hearing them.
In the last 11 years - 4 employees of CSX’s Baltimore Division have been killed when being struck by trains that overtook them from behind.
In Philadelphia a Conductor was ridng on the 4th unit of the engine consist when the train was stopped at its crew change point - a following train on an adjacent track struck him in the center ditch between the tracks.
At Doswell, VA a local freight conductor was walking the brake release on his train, North to South, which was on #4 track (which was used as a siding at this location) when he was struck by a passing Southbound operating on the adjacent #3 track - The conductor had been informed that his train, in addition to its brake test, was being held for the Southbound.
And we have the two employees at QN Tower.
In all three of these incidents the employees were ‘near’ th
A few times at work I have been unlucky enough to find myself between two yard tracks that are both occupied by moving trains (usually one of them is my own train). It is surprising how small the space between tracks is and how little room for error there would be when walking with your head on a swivel.
15 mph seems like 100 when the cars are inches away.
When caught in that situation I will kneel, to avoid becoming disoriented and unbalanced and accidentally stumbling and falling between the moving cars.
The noise problem Balt mentions is very real, when next to a running locomotive one cannot hear much of anything else. Even your portable radio, with the speaker held next to your ear, is very difficult to hear. But the fact is that trains are big, noisy machines, and that is not going to change anytime soon.
A few years ago in Saskatoon, SK a 30-year conductor was struck and killed by a train on an adjacent main track, while he walked back to uncouple the head-end portion of his train. This was in daylight, with the oncoming train displaying blazing headlights and desperately whistling to try and warn him, to no avail. We still don’t know why he did not move, even though the outside-facing camera from the oncoming train caught everything.
One of the fears I always worked with was being party to an " Incident " where an Employee was struck by a train, either his own, or another in the line of duty.
It never happened.
However, I was On Duty when a Trainman reached in to open the knuckle and align the drawbar as the rest of his train was backing down to make the joint.
He did not move fast enough, the cars were too close, and his hand got coupled.
I was fifty miles away and missed one half of the conversation, but knew something had happened by the surge of panicked Radio Traffic.
I’d just like to add that there is a tendency among us all to promote ourselves to “expert” the longer we work at any given task. Doesn’t matter if you’re a T&E crew, a boiler mechanic, or an electrician. You get into a routine that you are comfortable with, before long that routine becomes your definitive standard for the “right way things are to be done”, and you get to a point where you no longer see any validity in questioning yourself.
That sense of self-assuredness can leave you vulnerable. Human nature, to a large extent.
That loss of situational awareness has cost its share of firefighters, who, unaware that the entire building is actually alight want to push on inside - “we got this.”
A fellow has created a website (and does lectures) entitled “Situational Awareness Matters.” It’s something we all need to be reminded of from time to time.
It’s truly amazing how quietly a “coasting” train can move along. I’ve been surprised a number of times standing trackside while facing one direction, only to have a train come by from behind me. First awareness being the blur as in comes into my field of vision.
So, I can kinda understand how a person who spends years walking along the side of trains for a living, could one day fall victim to their own complacency.
Few years ago NS was re-routing some east bound trains off the Waterlevel route and onto former NKP and PRR track to get the trains from Chicago into Ohio. They were operating a temporary fuel pad with a tanker truck near a fairly active junction with the former Wabash.
During the time that the fuel pad was in operation, passing trains on the adjoining tracks operated their bell function well before and well after the actual passing.
This seems like good practice to me. Making me wonder if something like this might have helped the conductors in the OPs story.
Of course in my example, all operating personnel were Norfolk Southern, so a coordinated solution was easy.
The trains in this Ivy City accident were not quiet. They were both blowing urgent horn warnings that could probably have been heard a mile away.
There is a category of accidents in which employees on the ground are struck by a train or rail equipment. I believe that at least 99% of them have heard and memorized the rule about expecting trains on any track, any time, etc., and they believe they are abiding by that rule all the time. It is a rule that requires no specific action or work other than to “expect.” It is also a rule that goes without saying. It is a rule that just can’t seem to know what real advice to give.
In the category of accidents in which employees on the ground are struck by trains, a more specific variation of this category is a subset in which employees have suddenly lost the protection of their hearing due to the sounds of two trains merging to the extent that they sound like one train. The mistake made by these victims is that they are not using their eyes enough when they encounter this blended sound of multiple trains. Yet, they are always “expecting trains on any track, at any time…” But here is the essence of the danger: People falling victim to it do not realize they are vulnerable. They don’t know what they don’t know. They don’t realize that they have suddenly, and by very rare circumstance, lost a critical part of their protection.
Other subsets of this category of accident have slightly different causes such as being distracted by one’s own thoughts to the extent that they completely lose situational awareness. Ot
Unless you have been in the Ivy City area, you have no idea just how noisy the area is. The highway New York Avenue runs parallell to the railraods on the East side of the right of way (if you consider the railroads running North-South) with all the noise that a urban 4+ lane highway generates. On the West side is Amtrak’s Ivy City servicing facility for both cars and locomotives. Even if there were no operating trains in the area - the area is still noisy - how noisy on a sound meter, I have no idea. DC Metro operates in the near area and generates its own noise factor to add to the cacaphony of all the other noises.
The ambient noise factor does not excuse the appearant lack of ‘personal attention’ to the CSX employees. They were within a car or two of their trains locomotives, walking South they had full view of Amtrak 66 headed North - and according to testimony of Amtrak 175’s Engineer, they never looked back to see 175 approaching.
I dare say the Conductor had more ‘training’ on his job functions than any of us have had. https://dms.ntsb.gov/public/62000-62499/62103/622765.pdf Unfortunately, the one real test of all this training - he failed and paid the ultimate price for his failure.
I can agree with most of your post, except that part. The potential for distraction is too big a variable to have 100% confidence that it will not be a factor.
Problems at home, problems with the boss, problems with creditors, etc…all are the types of things that a person might dwell upon spontaneously, at just the wrong moment. Even the most disciplined of minds ocassionally derail.
It would be nice to think that 100% of all accidents are preventable,…but due to the human factor I think that is a bit of a dream.
They never looked back because they never heard noise that they attributed to #175. They expected they would hear a train approaching from behind, and that there was no need to look for one. Despite the possibly high ambient noise, the horn of #175 would have cut right through it. If the ambient noise were like a continuous jet aircraft, the two employees would probably have realized that their hearing to detect a train was useless. So I doubt that ambient noise played much of a role.
The problem was that both engineers blew the loud horn at the same time. Of course the two employees heard the horn warning.
What part of “you were trespassing on the other guy’s railroad” isn’t registering here? They had no business being THERE. You were encroaching on ground controlled by somebody else that did not know you were THERE. If they were qualified on that territory, they should have known not to be THERE. (No idea if the conductor-trainee had any time on that territory in some other job classification.) The whole d*mned thing is troubling - situational awareness (again).
PS - Don’t try to erect a fence in the foul zone. If you do, you get the mess & dillema that METRA is stuck with.
It registers with me, but apparently not with the NTSB. As I mentioned at the start of this thread, they seemed to be dancing around variations on the theme of whether the two employees has a right to be where they were. They never made it clear. They said nothing about trespassing on Amtrak property. I see the property line marked in their diagram midway between the tracks of each company. But they say the diagram is not to scale, and they are right about that. The diagram makes it look like there is maybe at least 20 ft. between the nearest mains of the two companies.
But, in one of the photos related to the NTSB investigation, the adjacent mains of CSX and Amtrak appear no further apart than the two mains of each company. It looks like the property line is about 2.5 ft. from the side of a CSX train. It looks like a four-track railroad. How can they have the property line so closed to their trains? I was wondering if they might have some kind of agreement to allow joint use of t