A Feb. 7, 2019, fatal railyard incident in Baltimore shows why it’s important to make sure procedures and training materials are clear and consistent.
The incident occurred when a Norfolk Southern Corporation railroad conductor was killed when he became pinned between two railcars while performing switching operations.
Investigators with the National Transportation Safety Board (NTSB) found inconsistent wording in Norfolk Southern’s conductor training program may have contributed to the incident.
Engineer gets reminder about rule
On the morning of the incident, after uncoupling all but four railcars, the train’s engineer radioed the yardmaster and asked to move the train in reverse to the next switching location.
The yardmaster reminded the engineer that the conductor wasn’t allowed to ride on the sides of railcars while in the railyard and then approved the train’s movement.
As the train moved, the lead railcar, which the conductor was riding on, approached a slight curve where three railcars were being stored on an adjacent track.
When the train entered the curve the distance between the train and the stationary railcars narrowed to 9 inches.
The train continued in reverse and the engineer passed the conductor lying between both tracks. The engineer stopped the train and radioed for emergency assistance but it was too late and the engineer died from his injuries.
‘Lack of clear messaging’
NTSB investigators found the conductor, for unknown reasons, chose to ride on the side of the railcar despite the company’s rule prohibiting employees from doing so within railyards and other close-clearance locations.
Close-clearance locations for the railyard were identified in the terminal instructions, but investigators found the information was “inconsistent and lacked clear messaging, which could lead an employee to misinterpret the instruction and ride on the side of railcars where these restrictions apply.”
Further, Norfolk Southern training programs for conductors didn’t emphasize and test on the close-clearance restriction locations and location-specific hazards within the railyard. This could lead to employees having inadequate knowledge to safely work in those areas.
The NTSB recommended Norfolk Southern review and revise its terminal instructions and training program to ensure clarity and emphasize close-clearance restriction locations and location-specific hazards.
