Time was, I used to get angry reading the NTSB investigation reports of railroad accidents. Now not so much, which some have mistaken as a sign of mellowing. Believe me, I'm not.
Sometimes, NTSB makes an assertion or an evaluation that makes me angry; sometimes it's the railroad. Sometimes it's a particular individual.
What? Maybe I read these reports because I want to be angry? I've never thought of that.
In any case, after reading NTSB's RIR-22/05 Alabama Export Railroad Fatal Collision with Maintenance-of-Way Equipment I wanted more information so I went to the investigation docket RRD21LR005 in order to read the IIC (Investigator-in-charge, I presume) factual report.
When I finished that, I wasn't angry, and that's the bad news, because the failures were so numerous by so many and so basic, I could feel nothing but sadness that these conditions could exist 192 years after the B&O opened the first 14 mile stretch of railroad in the US.
On November 17, 2020 an Alabama Export Railroad (ALE) switching crew, consisting of a brakeman, conductor, and engineer, split itself. The brakeman and engineer continued with their switching duties, while the conductor, holding dual certification as a locomotive engineer traveled alone to Belt Jct to move CN train A-48871-16 over ALE's Beauregard track to the ALE Mobile yard.
That same day a contractor's MOW crew with an ALE Roadway-Worker-in-Charge (RWIC) was on the rail with a boom truck and a back hoe changing out crossties on the Beauregard track. Clearly the potential for overlapping authorities for the train and the MOW crew existed.
Note: the fact that this track is named to honor the individual who ordered the firing on Fort Sumter at the start of the slaveholders' rebellion plays no part in my evaluation or my comments.
At about 1426 hours with a velocity of 19 mph, train A-48871-16 collided with the MOW equipment at MP 3.7. One contractor employee was killed and three were injured.
The ALE employee in charge was not injured. He had left the work area 15 minutes earlier, instructing the contractor employees to call him when they were clear of the track.
After the RWIC had departed, but before they had completed their work, the contractor employees removed the portable derails they had applied for protection to make the track "inaccessible."
The conductor/engineer operating the train proceeded onto the Beauregard track and the cab video records shows him using a cellphone for a considerable period of time, up to and including the moment of collision.
ALE could not provide a written copy of its program for qualification and certification of locomotive engineers.
ALE could not provide a written record of its program for observation and testing, including the use of unannounced tests, of locomotive engineers' proficiency.
ALE could not provide a written copy of instruction, reinstruction, and examination, to establish and maintain employee knowledge of the railroad's operating rules.
ALE could not provide a written copy of its program specifying the operational observations and testings the railroad's supervisors must conduct during their working periods.
Now any one of these things is enough to move the level of vulnerability of the railroad to a catastrophic operating failure by its employees from "likely" to "inevitable." All of them together move that vulnerability from inevitable to immediate.
However, there is at least one more systemic flaw in the operating procedures of ALE, one that was ignored, missed, lost, unexamined apparently by NTSB, FRA and everyone associated with investigating this incident.
That item is the type of roadway worker protection on the Beauregard track. According to the ALE employee timetable general instructions, the yard limits exist, and yard limit rules govern on the Beauregard track from MP 6.7 to MP2.
GCOR rule 6.13 identifies operations in yard limits: Within yard limits, trains or engines are authorized to use the main track not protecting against other trains or engines. Engines must give way as soon as possible to trains as they approach.
Engines must keep posted as to the arrival of passenger trains and must not delay them.
All movements entering or moving within yard limits must be made at restricted speed unless operating under a block signal indication that is more favorable than Approach.
Nothing in this definition nor in the maximum authorized speed automatically "converts" main track to non-controlled track.
Neither designation, "non-controlled track" nor "controlled track" exists in GCOR. These designations are utilized by FRA in specifying the types of roadway worker protection that may be utilized. Now the ALE RWIC thought, and the thought went unchallenged, that the Beauregard track was "non-controlled track," and therefore RWP could be established by making the track "inaccessible," as FRA provides in 214.327.
The problem is that the Beauregard track is not non-controlled track. It is controlled track, controlled by the train dispatcher located in Ft. Worth, Texas, employed by Nebraska Central Railroad Corporation.
49 CFR 214.7 states non-controlled track "means track upon which trains are permitted by railroad rule or special instruction to move without receiving authorization from a train dispatcher or control operator." Controlled track is defined in the same section: "means track upon which the railroad's operating rules require that all movements of trains must be authorized by a train dispatcher or a control operator."
This is not a technical difference. A roadway worker may not use for protection the methods specified in 214.327 when working on controlled track. Making a track inaccessible is an interruption of the authority for train movement and on controlled track the authority for all movement is the train dispatcher.
How do we know the Beauregard track is controlled track? Two months prior to this incident, ALE issued General Order 10-20 advising that each crew or worker working within the ALE yard limits must obtain authority for movement from the train dispatcher.
On November 17, the ALE RWIC did exactly that-- contact the train dispatcher before beginning work.
This is the saddest of sad cases where and when management, the industry regulator, and the investigating agency can't recognize or at least acknowledge the deadly confusion established by the misapplication of procedure and policy.
Maybe others, on other Class III railroads will before someone else gets killed.
David Schanoes
June 19, 2022
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