The National Transportation Safety Board (NTSB) on Sept. 24 issued the final report for its investigation of a Aug. 6, 2023, accident, in which a CSX Transportation conductor trainee was fatally injured during switching operations at the Class I railroad’s Cumberland, Md., rail yard.
The accident’s probable cause, according to the NTSB, “was the accident train’s movement through an unidentified and unmitigated close clearance location that resulted in the employee being caught between the side of the railcar he was riding and equipment parked on an adjacent track.”
What Happened?
On Aug. 6, 2023, about 11:42 p.m. local time, a CSX conductor trainee was riding on the side of a railcar during an eastbound shoving movement that passed through a temporary close clearance location—“a narrow [seven-inch] gap between his train and three locomotives temporarily stored on an unusually close adjacent track,” according to the NTSB report (download below). During this movement, he was caught between the railcar and a locomotive handrail. The agency said he was taken to a nearby hospital, where he later died. The conductor, riding a different ladder on the same railcar through the same gap, was not injured, NTSB reported. Visibility conditions at the time of the accident were dark and clear (the yard was illuminated by artificial light), and the temperature was 73˚F.
NTSB Analysis
“CSX operating rules prohibit employees from riding equipment through close clearances,” according to the NTSB report. “However, the accident location as not marked or otherwise identified as a close clearance location. The conductor rode the side of a railcar past the parked locomotives and gave no instructions to the engineer to slow or stop until after the trainee was struck. This indicates that the conductor did not see that the parked locomotives had created a close clearance even as he rode through the gap. Similarly, the conductor trainee made no radio communications during the shove, indicating that he was either unaware of the danger until he was struck or did not know how to react to the approaching close clearance. The parked locomotives created a close clearance location because the city track where they were positioned was unusually close to the freight track being used by the accident train. The distance between the track centerlines was slightly more than 11 feet—or 3 feet less than both the current AREMA standard and the CSX standard for new or reconstructed track.” Based on NTSB measurements on the scene, the agency said that “an additional 3 feet of clearance would have prevented the accident.” It noted that “[t]here is no evidence that the conductor realized that parked equipment on roughly parallel adjacent track could create a close clearance situation.” In his interviews, the NTSB reported, “the conductor stressed paying attention to his trainee and to the shoving movement itself, and close clearances did not come up during the job briefing immediately before the accident.” Additionally, “[h]e was concerned that his trainee might not be comfortable with riding on the lead railcar, but he did not recall ever noticing that the locomotives were unusually close to the freight track,” according to the NTSB. “Though he could recall a method for identifying a close clearance near a switch point, he did not recall any guidance or rule for identifying a close clearance between parallel tracks far from a switch, and the NTSB’s investigation has not identified any such guidance or rule at CSX other than general familiarization with a yard.”
“The danger posed by unusually close-set parallel tracks was not effectively accounted for in CSX training, operating rules, or yard signage,” the NTSB concluded. “Because the conductor did not see that the parked locomotives had created a temporary close clearance, and CSX did not provide signage or other tools to help him identify the hazard posed by track centerlines that do not meet modern standards, he and his trainee rode through the close clearance, resulting in the trainee’s death.”
Since the accident, NTSB said, CSX has “identified close clearances between track centerlines and added them to its close clearance list, closed the city track in Cumberland Yard, and made changes to its training program intended to improve the safety of field training.” Additionally, the Federal Railroad Administration, Switching Operations Fatality Analysis (SOFA) Working Group, and International Association of Sheet Metal, Air, Rail and Transportation Workers (SMART) have issued alerts about hazards related to this accident.
