The National Transportation Safety Board (NTSB) on Oct. 29 released the final report for its investigation of the Sept. 17, 2023, accident involving a CSX mechanical department employee who was struck and killed by a pair of remote-control locomotives during switching operations in Walbridge, Ohio.
The accident’s probable cause, according to the NTSB report (download below), “was the failure of the accident carman to comply with the CSX operating rule that required an employee to stop and look both ways before fouling a track. Contributing to this accident was the failure of the accident carman to conduct a thorough job briefing as prescribed by CSX operating rules before the accident.”
What Happened?
On Sept. 17, 2023, about 3:24 a.m. local time, a member of a CSX mechanical department crew (the accident carman) was struck and killed by a pair of remote-control locomotives during switching operations in a remote-control zone (RCZ) on the Walbridge Yard lead track in Walbridge. At the time of the accident, according to the NTSB report, “the accident carman was walking across multiple tracks to line and lock a switch to prepare for railcar inspections.” The locomotives were being used to perform switching operations under the control of a single remote-control operator (conductor) “positioned on the lower ladder on the west side of the trailing locomotive,” the report said, and “[a]s the accident carman began crossing the lead track to access the switch, he was struck by the locomotives,” which were traveling south about 10 mph (see Figure 1, top). According to the NTSB, visibility conditions at the time of the accident “were dark and clear, but the area was illuminated with overhead lighting” and the temperature was 63°F with no precipitation.
NTSB Analysis
The NTSB found that the following factors did not contribute to this accident: fatigue, drug or alcohol use, cell phone use, train handling, mechanical defects, or track defects. It noted that the records reviewed by NTSB investigators “demonstrated that both the accident carman and the conductor had been sufficiently trained, evaluated, and qualified on the CSX operating rules relating to performing work while on or about tracks.” The conductor involved in this accident “had properly established an active RCZ before the accident and was authorized to operate within that zone without leading-end protection,” according to the NTSB, which noted that “[d]uring his interview with NTSB investigators, the yardmaster stated that because the accident carman was only placing locks on the switches, he was required to provide his own protection. He stated that because there was no equipment entering the RCZ, and no switches being thrown, the RCZ remained active and did not require the conductor to operate his locomotives from the leading end.” The NTSB reported that based on the information provided by CSX employees and a review of the radio recordings provided, “investigators determined that while the conductor gave the accident carman permission to ‘lock up 3 and 5’ tracks within his zone, the crew did not perform a detailed job briefing as required in CSX rule 502.3.” The omission of a job briefing “resulted in a lost opportunity to review hazards, including the presence of remote-control locomotives in the area,” the NTSB reported. While the “accident carman had been sufficiently trained, evaluated, and qualified,” according to the NTSB, “given the proximity of the locomotive to the accident carman as he approached and then crossed over and onto the active track, the accident carman failed to adhere to CSX operational rule 2100.4, which directs employees to look both ways before crossing a track. This failure was consistent with inattention to surroundings and contributed to the accident.”
As a result of this accident, CSX issued a safety alert and held safety meetings “to discuss and emphasize the safety alert, briefings, situational awareness, and knowledge of emergency action plans,” according to the NTSB. Additionally, it said, CSX is “working to modify its remote-control locomotive software to provide more frequent audio warnings [bell rings on the locomotive] and better protect employees from lapses in attention.”
Before the accident, the locomotive bell rang for 5 seconds at the start of every movement, the NTSB reported. “With the modified software, that same bell will now ring automatically for 5 seconds for every 250 feet traveled,” it said.
Additionally, CSX has “replaced remote-control locomotive warning signs throughout the yard” and “modified the rules on permission needed for entering the RCZ.”
On Sept. 29, 2023, the Federal Railroad Administration issued Safety Bulletin 2023-07, in reference to this accident, reminding all railroads and railroad employees of the “importance of maintaining constant situational awareness when approaching or fouling railroad tracks.”
