Crossing
Cases:
1. Family of four
in vehicle stopped prior to a lowered crossing gate. Gate began to rise and vehicle moved forward
toward track. Crossing warning devices
immediately reactivated and gate began to re-descend. Vehicle was trapped between the lowered gate
behind it and the track in front of it.
Freight train struck vehicle, killing all four occupants. Investigation determined that improper crossing
signal design caused the gates to rise and then re-descend while a train was
approaching.
2. Freight train
struck a semi-trailer of logs at a crossing, derailing the lead locomotive and
demolishing the truck. Available sight
distance down the track in both directions was severely restricted by standing
freight cars on an adjacent track that were parked too close to the
crossing. Inspection of the locomotive’s
event recorder data revealed that the train had been exceeding the maximum
authorized track speed for over a half-mile prior to impact. Had the train’s speed not exceeded that
permitted, the train’s arrival at the point of impact would have been delayed
such that impact between the train and truck would not have occurred.
3. Freight train
struck a semi-trailer at a private, unprotected crossing that led into a rock
quarry. Sight distance for trucks
leaving the facility was severely restricted by vegetation. IWT inquiry focused on why the railroad had
not previously installed active warning devices at the crossing at its own
initiative and funding, as the subject collision was the latest of eleven (11)
such events at that location.
4. A motorist
stopped at a crossing behind a lowered gate with no train approaching. After a short period of time, the gate began
to ascend. As he started forward, the
gate abruptly re-descended, striking the roof of his vehicle. As the motorist got out of his vehicle and
began to push the gate upwards and off of his vehicle, the gate began to rise
of its own accord. As the motorist was
getting back into his vehicle, the gate re-descended, striking him in the
head. Investigation revealed that frequent
false-activation of the gates at the crossing had been ongoing for some time,
and was traced to the signal maintainer’s failure to maintain a circuit
junction box at the crossing in a water-tight and rodent-free condition. As it was, rodents chewed the insulation off
of wires in the junction box, causing them to electrically short together. This condition combined with excessive
corrosion on the wire terminals caused by frequent water entry into the
junction box, causing the crossing to fail intermittently.
5. Motorist struck
by freight train at unprotected crossing.
Investigation focused on sight restriction caused by railroad
maintenance building constructed too close to the track and crossing (in
violation of State statute), extremely poor crossing surface (focusing motorist’s
attention to successfully negotiating the crossing and not to looking out for
approaching trains), and crossbuck improperly oriented with respect to the
track.
6.
Motorist
approached a busy eight-track grade crossing. Crossing had two gates for
motorists traveling in this direction, one gate prior to the first track and
another gate prior to the third track. Motorist stopped at the second set of
gates, with his vehicle between tracks 2 and 3, for a train on the third track.
During a lengthy wait for the switching move to clear the crossing, he decided
to turn around and return in the direction from which he came. He executed a
“K-turn,” proceeded in the opposite direction, and was struck by a passenger train
on the first track. Subsequent investigation revealed a misprogrammed
crossing controller unit, causing the crossing warning devices to activate both
gates simultaneously upon the approach of a train (potentially trapping
motorists on the tracks, between the two lowered gates), instead of in sequence
(first the “outer” gate and then the “inner” gate, preventing vehicles from
being trapped between them). As such, the crossing warning devices were
functioning in a less safe manner than designed. During a site inspection more
than one year after the accident, the same controller was observed to be still
functioning in the misprogrammed fashion.
7.
SUV
containing three teenage boys was struck by a freight train at a crossing. The
one surviving teenager stated that the flashers were not working as they
approached the crossing. Since the accident, the crossing had been moved 300
feet to the west to straighten the highway approach, with new warning devices
installed. Counsel retained IWT to create a video and motion-picture film-based
documentary depicting what the teenagers would likely have seen while
approaching the crossing, both with the flashers working and not working. IWT
supervised the re-installation of active warning devices at the original
location, tested them to ensure compliance with FRA and railroad
specifications, and re-enacted the accident.
8.
A
motorcyclist was proceeding down a gravel-covered country road at night at a
high rate of speed. Upon descending a hill, he came to an unprotected railroad
crossing (having only a crossbuck, no flashers or gates). Unable to stop, he
collided with the side of the passing 60 MPH freight train, suffering
amputation of 3 of his 4 limbs and other serious injuries. Investigation
centered on the actions of the motorcyclist, reflectivity of the crossbuck, and
reflectivity of the passing freight cars.
9.
School
bus driver stopped her bus at a red traffic light just beyond a crossing,
unaware that the rear of her bus was fouling the track. Bus was struck moments
later by a commuter train, resulting in seven fatalities. Investigation focused
on the design of the traffic signal interconnection circuits and the
calculation of the minimum required warning time for the automatic warning
devices.
10. Driver of a
15-passenger van came to a stop behind lowered crossing gates. After the train
passed, the gates began to ascend and the driver began to ascend the steep
uphill grade to the crossing. As he passed the ascending gate, the gate
reversed direction and began to descend. Driver became stuck in deep snow at
the top of the grade, and was struck by a commuter train. Investigation focused
on the actions of the driver and the locomotive engineer, as well as the
adequacy of the warning time afforded by the automatic warning devices.
11. Train crew
switching cars stopped a cut of freight cars over a passive highway grade
crossing at night, without placing flares or stationing a flagman at the
crossing. A vehicle approaching in heavy fog ascended a short grade to the
track and collided with the side of the standing train. Investigation addressed
the actions of the train crew, lack of reflectivity of the freight cars, and
the absence of the required crossbuck sign for vehicles traveling in the same
direction as the accident vehicle.
12. A motorist,
familiar with the 5-track crossing, followed other vehicles around lowered
gates and was struck by a passenger train. Investigation addressed the actions
of the motorist and the reliability of the automatic warning devices, which had
a long-standing history of false activation. Several false activations of the
flashers and gates were in fact observed during the post-accident site
inspection.
13. A vehicle
approaching a crossing at night was struck by an eastbound freight train,
resulting in the death of all three occupants. One year prior to the accident,
the cantilever flashing light signal at the crossing had been knocked down by
an over-height truck. The cantilever was replaced by a mast-mounted flashing
light unit while a new cantilever was procured and assembled at the site. The
new cantilever laid in the ditch adjacent to the crossing, fully assembled, for
approximately one year while the mast-mounted flasher remained in service.
Three days after the accident, the mast-mounted flasher was replaced with the new
cantilever. Investigation dealt with the effectiveness of cantilever-mounted
flashers as opposed to standard mast-mounted flashers, and the nature of the
delay in installing the replacement cantilever.
14. Switching crew
was backing a cut of cars over a four-lane highway with operating
cantilever-mounted flashing lights at night when an approaching vehicle struck
the side of the lead car as it traveled over the crossing. Investigation
focused on the actions of the motorist, operation of the automatic warning devices,
and the length of time that elapsed between the instant at which the crossing
flashers began to operate and the instant of time at which the leading edge of
the train physically occupied the crossing.
15. Motorist was
struck and killed by a freight train at a grade crossing. Investigation
revealed that the active warning devices at the crossing had been removed from
service earlier in the day by the Signal Maintainer. The Train Dispatcher
failed to pass the information along to his relief dispatcher. As a result, a
subsequent train entered the out-of-service crossing at maximum track speed and
collided with the highway vehicle. Contributing to the accident was the failure
to properly maintain a track battery and replace the exhausted battery when it
was discovered four days prior to the accident, instead of removing the
crossing from service.
16. Flashers and
gates were taken out of service (i.e. - temporarily configured so as to not
activate for approaching trains) to eliminate false activations due to excessive
road salt in the crossing area. Signal maintainer applied a "stop and
protect" order with the train dispatcher, instructing all train crews to
stop and manually flag the head-end of their train over the crossing until
further notice. Engineer of approaching train became confused as to whether the
crossing he was approaching was in fact the subject crossing, causing him to
begin his brake application and speed reduction too late. Instead of stopping
prior to the crossing and manually flagging highway traffic to a stop before
proceeding, the train crew entered the crossing at 38 MPH, striking a vehicle
and fatally injuring two occupants. Investigation centered around train crew
physical characteristics qualification, and practice of leaving crossings out of
service for extended periods due to road salt contamination.
17. A motorcyclist
stopped at a grade crossing behind lowered gates. After the train passed, the
gate began to ascend. As he began to move forward, the gate on his side of the
track unexpectedly started back down, striking him on the top of the head and
knocking him from the bike. Investigation determined that gate redescent was likely a "tail-ring," caused when
the receding train momentarily lost shunt, prompting the crossing predictor
unit to reset and then reactivate as though another train was approaching. The
crossing predictor unit's internal event recorder noted 63 similar occurrences
prior to the subject accident, likely the product of extremely rusty rail.
18. Railroad
on-track self-propelled brush cutter was struck by a vehicle as it passed over
a four-lane highway, resulting in driver fatality. Investigation centered on
visibility of crossing flashers and employee's crossing flagging procedures.
19. Local freight
crew cleared their locomotive and cars in a siding adjacent to a busy highway
crossing, awaiting the passage of a passenger train before resuming their
switching work. Crossing flashers and gates failed to activate for the
approaching passenger train until it reached the edge of the highway. Passenger
train entered the four-lane crossing at 70 MPH, colliding with two
semi-trailers and one automobile, causing fatal injuries to the automobile
driver. Cause of accident was the freight crews' failure to remain off of the
fouling track circuit on the siding. They slowly creeped up to the derail and
onto the fouling track circuit as the passenger train approached, anticipating
their reentry onto the main line after the passenger train had passed. The
predictor timed out against the resulting shunt, effectively shortening the
crossing track approach circuit to that point, approximately 30 feet from the
crossing. This occurred after the passenger train had already passed the last
intermediate signal prior to impact.
20. A truck driver
hauling a low-boy trailer carrying an excavator became hung up on a humped
grade crossing. Trailer was struck by a commuter train (traveling 70 MPH in a
59 MPH zone), resulting in the complete destruction of the trailer and
excavator. Investigation delved into state high/wide/heavy route permitting
procedures, lack of signage at crossing, humped nature of crossing, and
additional braking distance required due to overspeed nature of approaching
train.
21. Driver
approaching a four-quad gate crossing drove through the lowered gate and was
broadsided by a 70 MPH passenger train, resulting in three fatalities.
Investigation focused on driver human factors, four-quad gate crossing design,
and crossing event recorder data analysis.
22. A motorist
stopped behind a lowered gate at a crossing. No train was seen or heard to be
approaching. Gate began to ascend, and motorist began to move forward. As soon
as the gate attained the vertical position, it began to re-descend, trapping
the subject motorist and several others between the lowered gates. Train
entered the crossing and struck the subject vehicle, resulting in four
fatalities. Cause was found to be a crossing design error wherein the
crossing's predictor unit was terminated with a wide-band shunt instead of a
narrow-band shunt, and was operating on a frequency that was too close to that
of an adjacent crossing. Investigation hence center on failure to adhere to
manufacturer's recommended design practices and generally-accepted industry
standards.
23. Passenger
train struck a vehicle at a crossing, killing the vehicle's passenger. Warning
time was verified by the crossing's event recorder to have been 6 seconds
(should be a minimum of 20). Cause was found to be a buildup of rust and scale
on the tread of the wheels of the passenger train, causing a loss of shunt on
the crossing's approach circuit.
24. A brakeman was
riding the leading edge of a seven-car cut, being pushed by two locomotives,
operating the locomotives via a remote-control beltpack.
He approached a grade crossing at which he was required to stop prior to
shoving over the highway, due to an "island only" approach track
circuit that extended only 65 feet beyond the edge of the highway. He
failed to stop his shove move as required, entered the crossing at 7 MPH,
struck a cargo truck, and was crushed between the truck and the train.
Criminal charges were filed against the truck driver for failing to stop short
of the crossing. Investigation revealed that, due to the angle of the
truck's approach, none of the crossing flashers were visible to the driver, the
train itself was not visible to the truck driver due to the crossing's extreme
skew angle with the track, the train failed to sound its horn as it entered the
crossing, and the train failed to stop short of the crossing and proceed over the
crossing only with flag protection, as required. As a result, the
defendant was found not guilty of all charges.
Pedestrian
Cases:
1. A pedestrian,
crossing four high-speed tracks of Amtrak’s Northeast Corridor, was struck by a
train traveling 115 m.p.h. and killed.
Several years prior to the accident, a pedestrian bridge over the tracks
at the location had been retired, but the entrance to the tracks at the
location was never fenced over on either side of the tracks. Analysis focused on proper procedure for
pedestrian bridge retirement, railroad fencing practices along high-speed
tracks, and human factors considerations as applied to pedestrians crossing
high-speed tracks.
2. A pedestrian
crossing a track at night apparently tripped over the rail and fell, striking
his head and face on the adjacent rail.
He apparently managed to pull himself off of the track to a position
approximately 15 feet from the track.
The crew of a passing freight observed the non-moving victim and continued
without stopping to their final terminal about 15 minutes away. Upon their arrival, they informed the train
dispatcher that they had observed what appeared to be a corpse and requested
that the train dispatcher send EMS to the location. Dispatcher was recorded on surveillance
footage sitting at his desk for several hours thereafter, focused on a personal
electronic device, and never notified EMS or law enforcement to respond to the
scene. The following morning, a
pedestrian walking his dog observed the unconscious pedestrian lying on the
ground in the same general vicinity as in the report of the evening before, in
10oF weather. Unconscious
pedestrian was transported to the hospital, but died enroute. Investigation centered on train dispatcher’s
duty to report unconscious individuals on railroad property, and his use of an
unapproved personal electronic device while on duty.
3.
Individual
in a motorized wheelchair was attempting to negotiate a sidewalk crossing over
a main track, adjacent to a highway grade crossing having flashers and gates.
Wheelchair’s front wheels became stuck in the flangeway of the near rail. A
freight train approached, activated the crossing warning devices, and struck
and fatally injured the wheelchair’s occupant. Investigation examined the
sidewalk crossing surface for potholes and width of the flangeway, as well as
the operational characteristics of the wheelchair.
4.
Two
college students were walking across a single-track railroad trestle (that had
no walkway) when a freight train approached from behind them. Both individuals
began to run along the trestle away from the approaching train. One student
jumped off the trestle into the water before the train reached them, while the
other student was struck and seriously injured 5 feet from the end of the
trestle. Investigation centered on human factors issues associated with
trespass, and a full audibility analysis of the locomotive horn.
5.
A
passenger de-training at a high level platform fell
between the passenger car and the platform, suffering contusions. Investigation
determined the likely size of the gap and compared the value to ADA
requirements and generally-accepted industry practices.
6.
A
switch crew was shoving a long string of loaded double-stack cars into a yard
track for unloading. A truck driver was working adjacent to the track, coupling
his tractor and chassis in preparation for loading. During the coupling
process, he momentarily stepped from between the tractor and chassis onto the
adjacent track, where he was struck and killed by the leading end of the train.
Investigation focused on failure to protect leading end of shove move, failure
to warn employees in the area of a pending shove move, and failure to safety train
the decedent, who was an independent owner/operator, as to safety procedures to
follow while conducting work in an intermodal yard.
7.
A
15-year-old male and his dog, returning home from a grocery store via a
well-worn footpath over the tracks, passed through a gap in the right-of-way
fence, waited for the passage of one train, then were struck by an unseen train
approaching on the adjacent track as they tried to cross to the other side of
the track. Investigation focused on human factors, right-of-way fencing
and signage issues.
8.
Two
15-year-old males observed a standing railroad covered hopper car parked on a
siding under energized catenary. They climbed to the top of the car,
reached upward, and grasped the live 14,000-volt catenary wire. The
resulting arc blew both males off of the top of the car to the ground, causing
2nd and 3rd degree burns to approximately 75% of the body of each. IWT's
investigation dealt with manner of trespasser access to company property,
signage standards for warning of high-voltage hazards, and railroad company
practices for deenergizing catenary wires over siding tracks containing
standing railroad cars.
Train Collision/Derailment
Cases:
1. Train crew
approached a swing-bridge, but could not pass over it due to a red signal
immediately preceding the bridge.
Conductor walked out onto the bridge to inspect the rail locks. He determined the rail locks to be fully
driven, locking the bridge in place. He
radioed the dispatcher and, based on his observations, requested and received verbal
permission to pass the stop signal and move his train over the bridge. As the train was moving and partway across the
bridge, the bridge rotated under the train, misaligning the running rails, and
causing seven tank cars to derail. Four
of the seven fell into the river, and one ruptured, releasing a cloud of toxic
vinyl chloride gas. Investigation centered
on the operation of the wayside signal system that governed movements over the
bridge, design and operation of the rail locks, and the quality of the training
and supervision afforded to the conductor prior to the accident.
2. A new fully-automated
commuter rail system was undergoing final system testing prior to being placed
in service. Power distribution system
testing was being conducted wherein a train was loaded with concrete slabs
simulating the weight of passengers, with its speed-limiting system disabled, and
was being manually operated by an employee who was inexperienced in train
operation outside of the yard. The train
entered a 25 m.p.h. curve traveling 58 m.p.h.,
derailed, and plowed into a concrete wall adjoining the track. At impact, several concrete slabs flew
forward, pinning the operator to his control stand, resulting in his
death. Investigation centered on the
design of the test protocol, and the experience and training of the testing
coordinator.
3.
An
eastbound train took a siding in unsignaled territory
to await the passage of a westbound train on the main track, as instructed via
a written train order. The train order instructed the eastbound train to remain
in the siding until after the passage of a westbound train with a specific
locomotive on the head end. After the passage of one train (not the one they
had been instructed to wait for), the eastbound train’s conductor mistakenly
lined the switch reverse and proceeded eastward onto the main track. Their
train traveled five miles eastward before colliding head-on with the westbound
train, resulting in two fatalities. Investigation examined the human factors
and operating rules compliance issues associated with the eastbound crew, and
whether or not the accident would likely have occurred had the main line been
signaled.
4.
Two
switch locomotives pulling 85 cars without air derailed due to wide gage in a
yard and were pushed 300 feet by the weight of the following cars. The movement
came to a stop as the locomotives burrowed into the ground and came to rest at
a 45-degree angle. Locomotive engineer claimed a back injury from being thrown
against the control stand during the derailment sequence. IWT created
computer-generated animation, depicting the accident from both within the
locomotive cab and from the ground beside it, to demonstrate to a jury what the
locomotive engineer would likely have experienced during the derailment.
5.
A
locomotive engineer passed a red Stop Signal, colliding head-on with a
passenger train traveling in the opposite direction. Subsequent investigation
revealed a degenerative eye disorder on the part of the engineer, leading to
color blindness and a likely inability to distinguish yellow signals from red
ones. IWT worked in concert with NTSB and railroad personnel to produce a
broadcast-quality video and computer animation-based re-enactment of what each
locomotive engineer would likely have seen as their respective trains
approached the point of impact, synchronized with data taken from the
locomotive event recorders.
6.
A
locomotive engineer operating a commuter train passed an automatic signal
displaying Approach and made a flag stop to pick up passengers. Upon starting
up from the station stop, the engineer apparently forgot that he was operating
on an Approach indication and accelerated to maximum authorized speed. As his
train rounded a curve, interlocking home signals came into view displaying a
Stop indication. Engineer placed his train into emergency and slid through the
interlocking, colliding head-on with a passenger train traveling in the
opposite direction. Investigation focused on human-factors issues associated
with the actions of the commuter train engineer and conductor and design of the
recently reconfigured signal system.
7.
Train
proceeding on a Clear signal rounded a curve at 56 MPH and observed a Stop signal
at the interlocking ahead. Engineer placed train in emergency, causing a block
of loaded ballast cars on the rear of the train to run in, derailing the train
in three separate locations. Investigation determined cause to be a broken
track bond wire in advance of the interlocking, which caused the track circuit
to drop and the interlocking signal to dump to Stop in front of the train. Also
examined was train makeup, as the heaviest cars were placed on the rear of the
train.
8.
An
inexperienced operator was instructed to manually operate a remote-control
commuter train for testing purposes. Train had been loaded with concrete blocks
simulating the weight of passengers for braking tests. Automatic interlocks
designed to prevent excessive train speed were disengaged for the duration of
the test. Operator entered a 10 MPH curve at 50 MPH, causing the train set to
derail and collide with an adjacent concrete retaining wall. Concrete blocks
loaded in the passenger compartment flew forward on impact and pinned the operator
against the control stand, causing fatal injuries. Investigation focused on
operator and test supervisor training, quality of supervision, and propriety of
testing procedures.
9.
The
engineer of a passenger train apparently passed a red "stop" signal
and collided head-on with a freight train, resulting in 25 fatalities and over
100 injuries. Investigation revealed that the engineer had been texting
shortly before the collision. IWT conducted extensive visibility and
service testing of the wayside signal system to determine if it could have
displayed a clear signal, as five separate eyewitnesses said that it had.
Signal system event recorders indicated that the signal was red, and had been
for 43 minutes prior to the passenger train's passage. Event data from
the signal system, locomotives involved, GPS and cell phone records were all
synchronized to produce one unified second-by-second timeline of events leading
up to the collision.
10. The crew of a
local switcher completed their work and parked their two locomotives in a
non-signaled siding for the night. Upon leaving the area in a taxi, they
forgot to restore the track switch to the normal (straight) position.
Several hours later, a 40-MPH freight train approached the switch in the dark from
around a curve, was unable to stop short of the misaligned switch, and entered
the siding at track speed, colliding with the parked locomotives. Both
locomotives and 16 of 42 freight cars on the striking train derailed, including
three tank cars carrying chlorine. The tank cars ruptured, spreading a
toxic cloud throughout the community, causing 9 fatalities and over 500
injuries. Investigation focused on human factors actions of the crews and
whether the collision could have been prevented through the use of readily-available
signaling technology.
11. A commuter
railroad was upgrading its signal track circuits incrementally, mixing and
matching safety-critical track circuit components from different
manufacturers. Components had never been tested and certified to be
compatible with each other. During the course of the changeout program,
they changed the adjustment of a particular track circuit without performing
the required operational checks. The track circuit was so far out of
adjustment that it was unable to detect trains occupying it (indicated a
"Clear Block" even when it was occupied by a train). Track
circuit operated in this fashion for a significant period of time prior to the
crash. A passenger train stopped unexpectedly short of the station
platform, and was short enough in length that the entire train fit within the
track circuit. The track circuit showed a "Clear Block,"
allowing a following commuter train to be cleared to operate at track speed
into the occupied block. The following train collided with the rear of
the standing train, causing 9 fatalities and over 50 injuries.
Investigation centered on track circuit design, maintenance, and testing
procedures.
12. During the
course of two days of heavy rain, the railroad’s third-party weather prediction
vendor forecast “severe weather conditions” accompanied by rain-fall rates of
1.5” per hour with accompanying flash flooding warning. Approximately 28 hours after the cessation of
rain, a loaded stone train traveling along single track collided with a fallen
tree, causing the train to derail, injuring its crew. Investigation centered on railroad’s failure
to inspect track following storm but before first train movement, as required
by Federal regulation.
Federal Employer's
Liability Act (FELA) Cases:
1.
A
lineman trainee was dispatched to retrieve a tool from inside a “cat car” (a
specialized on-track machine used in the construction and maintenance of
overhead catenary wires and poles). He
ascended a seven-step portable staircase and crossed a platform to the level of
the cat car door. After entering the cat car and locating the tool, he exited
the cat car via the same door he had entered.
As he was locking the door on his way out, he stepped or slipped into the
space between the edge of the platform and the cat car, causing injury to his
left leg and hip. IWT was engaged to
examine the accident scene’s compliance with OSHA and ANSI standards and
practices.
2.
A
signal dept. trainee climbed a 90-foot steel catenary pole at night, along with
an experienced lineman, to change some insulators. A hand-line was extended downward from the
top of the pole to facilitate the upward transport of tools. The gang foreman failed to supervise or
secure the dangling end of the hand-line to the base of the pole. The dangling end of the hand-line became
entangled in a passing train, causing it to tighten and violently twist the
entire pole 90 degrees before the rope broke and the pole sprang back to its
original position, injuring both employees on the pole. Analysis centered on safety rule compliance
on the part of the supervisor and foreman and the quality of the prior job
briefing.
3. New Signal
Dept. employee climbed a pole to perform line work. While descending the pole,
he “gaffed out” and fell 20 feet to the ground, suffering a compound fracture
of the tibia. Investigation focused on the overall adequacy of the
pole-climbing training and supervision afforded to the employee prior to the
climb, and the employee’s comprehension and retention of the climbing
techniques he had been taught.
4.
Experienced
Signal Dept. employee climbed a wood pole to perform line work. As he reached
the top of the pole, the pole snapped at ground level and fell, causing the
employee to suffer a compound leg fracture. Investigation looked at the
technique used by the employee to inspect the pole for rot prior to climbing
it, and the railroad’s accepted procedure for pole inspection as compared to
that found elsewhere in the railroad and power utility industries.
5.
Track
Dept. employee obtained track time and blocking device protection at an
interlocking from the train dispatcher. Shortly thereafter, the train dispatcher
went off-duty. His replacement dispatcher, without contacting the Track Dept.
employee, removed the blocking device applied by the preceding dispatcher and
threw a power switch, trapping the Track Dept. employee’s foot and causing
crushing injuries. Investigation scrutinized the railroad’s procedure for
applying and removing blocking device protection for field employees.
6.
Track
Inspector obtained verbal permission from the dispatcher to change a bolt on a
power switch machine. Partway through the operation, the Trainmaster ordered
the power switch lined normal. The Operator complied, trapping the Track
Inspector’s hand in the switch point and causing crushing injuries.
Investigation examined the procedure by which power switches were removed from
service for maintenance, and the availability of suitable tools for clamping
switch points prior to working on them.
7.
A
Contractor’s employee was moving an on-track push cart loaded with rail. Push
cart was missing its handle, requiring employee to control its movements with
only a rope. Employee’s foot slipped off tie and fell between ties on elevated
track, causing a compound fracture. Investigation centered on human factors
issues surrounding need to properly inspect equipment prior to use, maintain
proper footing when walking, and use of proper footwear.
8.
Track
Dept. employee was operating a mechanized “walking hammer” machine in a rail
replacement crew, and was belted into his operator’s seat facing to the side,
the normal operator’s position for this machine. While “deadheading” to the
next work location at approx. 10 MPH, the machine struck a protruding lag bolt
on a crossing timber, bringing it to an abrupt halt. The employee remained
belted into the seat, but sustained a back injury. Railroad’s contract with the
machine supplier required the supplier to furnish machines with a minimum
ground clearance of 3 inches. Subsequent investigation of the machine involved
in the accident determined that its ground clearance was only 1.5 inches.
9.
Conductor
on a yard job was switching cars at night in a snowstorm when he apparently
stumbled while descending the steps of the moving locomotive preparing to
dismount. He fell onto the ground behind the locomotive and suffered the
amputation of both legs by the lead axle of the first car. Investigation
centered on the railroad’s approved method for dismounting moving equipment,
and found improper welded repairs to the locomotive’s stairwell, causing it to
function in a manner less safe than designed. IWT, in concert with
metallurgical and locomotive expert Tom Johnson and biomechanical expert Nat
Ordway, re-created the accident using computer-generated animation for
presentation to the jury at trial.
10. A freight
train struck and seriously injured a signal maintainer near a rail/highway
grade crossing. Investigation focused on the nature of on-track protection in
place for the signal maintainer and the actions of the train crew.
11. Three Signal
Dept. employees were cleaning snow and ice out of a power track switch near a
passenger station at night in a snowstorm. While huddled together in the middle
of the track, they were struck from behind by a commuter train, resulting in
one fatality. Investigation centered on motorman's failure to display
headlight, train horn packed with snow and inoperative, work crew's failure to
post watchmen as required by safety rules, and motorman's possession of
unauthorized reading material while on duty.
12. Signal
contractor was working on overhead catenary line when he inadvertently
contacted an energized wire, suffering 3rd degree burns over 40% of his
body. His initial contact with the wire caused protective circuit
breakers to open, lessening the damage. After the circuit breakers
opened, the Power Director attempted to manually reclose them without
investigating the cause of their opening. The re-energization shocked the
employee a second time, causing more extensive damage. Investigation centered
on lockout/tagout procedures and Power Director automatic circuit reclosing
procedures.
13. Electronic
technician needed to replace a blown high-voltage fuse on a steel catenary
pole. He possessed the proper extraction and replacement tool, which was
located in his truck, parked in the vicinity. Instead of descending the
pole to retrieve the proper tool, he apparently elected to perform the job with
his bare hands. While inserting the new fuse, he contacted live energy,
resulting in his complete loss of both hands. Investigation focused on
employee actions and quality of safety-related training and supervision.
14. Track Foreman
was blowing snow off of a pedestrian crossing at a station, at night, in a
snowstorm, on a curve, without a watchman, and without track authorization from
the train dispatcher. A freight train entered the platform and struck the
Foreman from behind, causing fatal injuries. Investigation focused on
on-track protection procedures and the nature of the relationship between the
Foreman's employer (commuter railroad) and the Class 1 freight railroad that
owned and dispatched the track involved.
15. Locomotive
engineer, while seated in his cab, leaned back in a stretching position and
inadvertently touched two exposed wires connected to the cab heater on the wall
behind him, causing second degree burns to his fingers and hand. IWT examined the cab heater and its unguarded,
exposed wiring.
Miscellaneous Cases:
1.
IWT
was retained by TTCI (Transportation Test Center, Inc.) in Pueblo, Co, to conduct
research and write a white paper, entitled Railroad/Highway
Grade Crossing Active Warning Device Activation Failures Due to Loss of
Shunt: Recent Causes and Strategies for
Mitigation. End clients for
white paper were the Association of American Railroads (AAR) and the Federal
Railroad Administration (FRA).
2. Engaged by
Elsevier Press, Ltd., London, England, to produce a complete rewrite of Chapter
147, entitled Railroad Accident
Investigation and Reconstruction, of their multi-volume international reference
work, the Encyclopedia of Forensic
Sciences – Second Edition (2014).
3.
Signal
maintainer reported a seemingly high number of signal system tests as having
been completed during a given period of time. He was brought in by his
employer for a hearing and dismissed. Employee filed suit to either
return to his former position or receive severance compensation. IWT was
retained to conduct a time study of how long it would likely take to perform the
reported tests.
4.
State
Department of Transportation moved to close one of three grade crossings
passing through village. IWT was retained by the village to study the
effects of such crossing closure on traffic and pedestrian flows and emergency
response times.
5.
(non-railroad) Electronic Technician working at a building
construction site attempted to repair a high-voltage device that he was neither
trained or licensed to work on, and that lay outside the scope of his assigned
work responsibilities. Without attempting to determine whether or not it
was energized or to apply lockout-tagout (LOTO) protection, he apparently
attempted to strip the insulation from a live wire while trying to effect the repair. His metal wirestrippers
conducted 277-volt energy through both arms and his torso, resulting in his
death. Investigation focused on the employee's lack of training,
licensure, and supervision, as well as overall LOTO procedures in place on the
overall jobsite at the time of the incident.