Controls of all kinds are great tools to use for mitigating hazards, but sometimes their use as the sole solution to a safety problem can still leave employees exposed. A combination of employee safety training along with suitable controls is always the best bet.
That’s because controls alone may only address one aspect of a given hazard. Having employees who are thoroughly trained about the hazard and associated controls will help to further reduce risk.
For example, take the 2022 collision between a train and a roadway maintenance machine (RMM). The collision resulted in the RMM being obliterated by the train. The machine’s operator was severely injured. A passenger on the train and two crewmembers were also injured.
What caused this incident? A malfunctioning railroad crossing alarm system? Nope. Investigators with the National Transportation Safety Board (NTSB) found that the alarm system was functioning properly. A mechanical malfunction with the train’s braking system? No, investigators found nothing wrong with that, either. Poor visibility? No. The incident occurred during a sunny, clear day.
NTSB investigators discovered that the railroad’s training for equipment operators failed to provide instructions on how to properly work around certain railroad crossings.
Work group had to set up at crossing near active track
The incident occurred on July 15, 2022, at about 11 a.m. A southbound Amtrak train carrying 31 passengers and 4 crewmembers was traveling from Sacramento to San Jose, California.
At the same time, a Union Pacific work group assigned to the Alameda County Regional Auto Theft Task Force was assigned to remove vehicles that had been abandoned along the tracks in the same area. The work group consisted of the RMM operator, a backhoe operator and a roadway worker-in-charge (RWIC). They planned on meeting at a specific crossing before starting the job.
There were two tracks in operation at the time, Main Track 1 and Main Track 2. The RWC had the dispatcher for this section of railway shut down Main Track 1 so the work group could get set up. Once they were ready to begin working, the RWC planned to also shut down Main Track 2.
The backhoe operator arrived at the crossing first and parked west of Main Track 1. He saw the RMM operator arrive in his machine about 40 minutes later. The RMM operator parked on Main Track 1 with the back end of the machine facing the same direction the train was approaching from.
This section of track was owned by Union Pacific and had a maximum operating speed for passenger trains of 79 mph. The crossing was equipped with active warning devices to indicate an approaching train. The warning devices were two sets of mast-mounted flashing lamps and two gates, one gate and one set of lamps for each direction the highway approached the tracks. Each gate extended across a single lane of traffic when lowered.
Operator didn’t see oncoming train despite warning signals
Not long after the RMM was parked on Main Track 1, the Amtrak train approached on Main Track 2. The engineer initially saw the RMM on Main Track 1. This wasn’t a cause for alarm as the engineer had often seen maintenance vehicles parked along the tracks.
The engineer began sounding the train’s horn as required while about 1,440 feet from the crossing and traveling at 73 mph. At the same time, the RMM operator finished prepping his machine and began to turn it toward Main Track 2. As he was making the turn, the crossing’s warning system had activated, indicating the approaching train. He failed to notice that the warning system activated and didn’t hear the train’s horn, so he continued to cross onto Main Track 2.
In response to the RMM suddenly fouling the track, the engineer attempted to apply the train’s emergency brake system. However, it was too late and the train struck the RMM at 68 mph and continued moving through the crossing.
The RMM was destroyed in the collision and the operator was transported to a local hospital for treatment of severe injuries. Equipment damage was estimated at $216,000.
The train was heavily damaged. One passenger was taken to the hospital for minor injuries. Two of the train’s crewmembers were treated for minor injuries at the scene. Damage to the train was estimated at $92,000.
Operator’s training failed to address a few specific safety issues
NTSB investigators inspected the crossing’s warning alarm system and the train’s horn and brake system and found that there were no malfunctions at the time of the collision. Weather was ruled out as a factor. There was no evidence of substance abuse, distraction or fatigue with anyone involved in the incident.
The NTSB found that the RMM operator failed to notice the approaching train, but investigators couldn’t determine why. They also couldn’t pinpoint exactly why he moved the machine onto Main Track 2.
Investigators did find that the RMM operator’s most recent training failed to “specifically address safe operation of RMMs over track at highway-railroad grade crossings.” Further, the RMM operator’s decision to cross Main Track 2 despite the sounding of the locomotive’s horn and a clear line of sight to the approaching train suggests that he “did not look or listen for trains before moving the RMM off protected track.”
Despite controls, training shortfalls caused incident
Union Pacific has since revised its training for RMM operators to include instructions on how to properly exit highway-railroad grade crossings safely when warning devices are activated or not present.
This revised training instructs operators to exit the crossing without fouling adjacent tracks when possible and, when fouling a track is unavoidable, to turn off audible distractions such as AM/FM radios, roll down a window to listen for trains or other equipment, and proceed only after confirming that there is enough sight distance to complete the movement safely.
In this incident, all of the controls needed to address the hazard worked as intended yet the collision still occurred. That’s because the lack of proper employee safety training completely negated the use of the multiple controls that were present. Because the employee didn’t understand the risk, and was completely unaware of the hazard, these controls were rendered useless. That is why a holistic approach to safety, one that uses training along with the use of appropriate controls, is always the best approach.