(erielack) Memorandum on CSX Runaway (off-topic)

["David Green" <davandli_@_empacc.net>]

This is off-topic but it provides a very detailed description of every 
event leading up to the CSX Runaway last May.  I thought it would be of 
interest due to the explanations of diesel locomotive operation.

This is off the CRTS list, courtesy of Tim Heckman.

- - Dave Green, ELHS #1366

- ----- Original Message -----
  From: John Krattinger
  Sent: Tuesday, November 06, 2001 9:21 PM
  To: AAA
  Subject: CRTS Update #11-23

  CRTS Update #11-23
  Tuesday, November 6th, 2001 at 21:00 EST

  Memorandum on CSXT Runaway:

  In accordance with your instructions, the following report summarizes
  the work of the investigation committee which was assigned to review 
and
  analyze the events of May 15, 2001, in which a locomotive with cars
  departed from Stanley Yard on the CSXT near Toledo, Ohio and traveled
  south to Kenton, Ohio, with no crew member on board. I was assisted in
  this review by MPE Inspector Mike Lusher and OP Inspector Ed 
Scalzitti,
  both of whom responded initially to the incident, and by Chief 
Inspector
  Harold Rugh, who provided essential technical information.

  Synopsis:
  On May 15, 2001, at approximately 12:35 p.m., DST, an unmanned CSX 
yard
  train consisting of one model SD-40-2 locomotive, 22 loaded, and 25
  empty cars, 2898 gross trailing tons, departed Stanley Yard, which is
  located in Walbridge, Ohio. The uncontrolled movement proceeded south
  for a distance of 66 miles before CSX personnel were able to bring the
  movement under control. At the time of the incident, the weather was
  cloudy with light rain. The ambient temperature was 55 degrees
  Fahrenheit. There was no derailment of equipment or collision. There
  were no reportable injuries as a result of the incident.

  Circumstances Prior to Incident:
  Yard crew Y11615, consisting of one engineer, one conductor and one
  brakeman, reported for duty at Stanley Yard, Walbridge, Ohio, at 6:30
  am, DST, May 15, 2001. After the normal job briefing with the
  trainmaster, crew Y11615 performed routine switching assignments until
  approximately 11:30 am, at which time the crew received new 
instructions
  and a second job briefing. A few minutes before 12:30 p.m., the crew
  entered the north end of track K12, located in the classification 
yard,
  with the intent to pull 47 cars out of K12 and then place these cars 
on
  departure track D10. Locomotive CSX 8888 was positioned with the short
  hood headed north. The engineer was seated at the
  controls on the east side of the locomotive.

  The locomotive coupled to the 47 cars on track K12, as instructed and
  planned. The air hoses between the locomotive and the cars were not
  connected, as is normal during this kind of switching operation. The 
air
  brakes on the cars were therefore inoperative. The brakeman notified 
the
  engineer by radio to pull north from K12. After the rear or 47th car
  passed the brakeman's location, he walked west to position the switch
  for the reverse movement to proceed into the assigned track D10.

  The movement continued north out of K12 passing the conductor, who was
  positioned on the ground at the "Camera" switch. The conductor advised
  the engineer by radio of the number of cars that had passed him and
  received an acknowledgement from the engineer by radio.

  The Incident:
  With eight cars remaining to pass over the "Camera" switch, the
  conductor notified the engineer by radio to prepare to stop. The
  engineer did not respond to his communication. The conductor again
  notified the engineer when four cars remained to clear the switch, but
  again there was no response from the engineer. The conductor then
  ordered the engineer to stop movement, but again there was no response
  from the engineer and the movement continued.

  In his interview, the engineer stated that as he pulled north out of
  K12, he was notified by radio by the conductor that the trailing point
  switch for track PB9 off the lead was reversed. The engineer 
understood
  that it would be necessary for the movement to be stopped short of the
  PB9 switch in order to line the switch for movement further along the
  lead. Neither the conductor nor the brakeman were near the PB9 switch,
  and the engineer intended to stop his train,  dismount from the
  locomotive, and align the switch to its normal position, if necessary.
  The speed of the movement up the lead had now reached 11 mph. The
  engineer observed the reversed switch, but due to the wet rail
  conditions and the number of cars coupled to his locomotive, he 
foresaw
  that he could not bring the equipment to a stop prior to passing 
through
  the misaligned switch. The engineer responded by applying the
  locomotive's independent brake to full application. The independent
  brake applies the brakes on the locomotive but does not apply the 
brakes
  on the individual freight cars. In addition, he reduced brake pipe
  pressure with a 20 psi service application of the automatic brake 
valve.
  The automatic brake is pneumatic braking system designed to control 
the
  brakes on the entire train. Still certain he would not stop short of 
the
  switch the engineer attempted to place the locomotive in dynamic brake
  mode. The dynamic brake utilizes the locomotive propulsion system to
  brake the train. Dynamic braking is analogous to down shifting a truck
  or automobile. Unfortunately, the engineer inadvertently failed to
  complete the selection process to set up the dynamic brake. Under the
  mistaken belief that he had properly selected dynamic brake, the
  engineer moved the throttle into the number 8 position for maximum
  dynamic braking. The engineer believed that the dynamic brake had been
  selected and that additional braking would occur.

  However, since dynamic brake set up had not been established, the
  placing of the throttle into the number 8 position restored full
  locomotive power, instead of retarding forward movement of the train.

  While the train was still moving at a speed of approximately 8 mph, 
the
  engineer dismounted the locomotive and ran ahead to reposition the
  switch before the train could run through and cause damage to the
  switch. The engineer was successful in operating the switch just 
seconds
  before the train reached it. The engineer than ran along side the
  locomotive and attempted to reboard. However, the speed of the train 
had
  not decreased as the engineer had expected but had increased to
  approximately 12 mph. Due to poor footing and wet grab handles on the
  locomotive, the engineer was unable to pull himself up on the
  locomotives ladder. He dragged along for approximately 80 feet until 
he
  released his grip on the hand rails and fell to the ground. Unable to
  reboard and stop the movement of his train, the engineer ran to 
contact
  a railroad employee, not a member of his crew but in possession of a
  radio, located at the north end of the yard. This employee immediately
  notified the yardmaster of the runaway train. The yardmaster promptly
  notified the Stanley tower block operator and the trainmaster. The
  Toledo Branch train dispatcher located in Indianapolis was also
  notified. The movement was now
  proceeding southward on the Toledo Branch (Great Lakes Division)
  governed by Traffic Control System (TCS) Rules. The time was
  approximately 12:35 p.m.

  The brakeman observed the train depart the yard but did not initially
  see the engineer on the ground. The brakeman and another employee used 
a
  personal vehicle to pursue the train to the next grade crossing to
  attempt to board the train. Their immediate concern was for the safety
  of the engineer, who they feared may have suffered a heart attack 
while
  at the controls of the locomotive. At the grade crossing, the two
  employees were unable to board the train as the speed had increased to
  approximately 18 mph as it passed the milepost 4.

  Local authorities and the Ohio State Police were notified of the 
runaway
  train at
  approximately 12:38 p.m.

  Attempts to Stop the Runaway:
  At a siding called Galatea, near milepost 34, at approximately 1:35
  p.m., the train dispatcher remotely operated the switch for the train 
to
  enter the siding. Previously a portable derail had been placed on the
  track in an attempt to derail the locomotive and thereby stop the
  movement. The portable derail was, however, dislodged and thrown from
  the track by the force of the train passing over it, and the movement 
of
  the train was not impeded.

  Northbound train Q63615 was directed by the dispatcher into the siding
  at Dunkirk, Ohio. The crew was instructed to uncouple their single
  locomotive unit from their train and wait until the runaway passed 
their
  location. at approximately 2:05 p.m., the runaway train passed 
Dunkirk,
  and the siding was lined for the crew of Q63615 to enter the main 
track
  and to pursue the runaway train.

  At Kenton, Ohio, near milepost 67, the crew of Q63615 successfully
  caught the runaway equipment and succeeded in coupling to the rear 
car,
  at a speed of 51 mph. The engineer gradually applied the dynamic brake
  of his locomotive, taking care not to break the train apart. By the 
time
  the train passed over Route 31 south of Kenton, the engineer had 
slowed
  the speed of the train to approximately 11 mph. Positioned at the
  crossing was CSX Trainmaster Jon Hosfeld, who was able to run along 
side
  the unmanned locomotive and climb aboard. The trainmaster immediately
  shut down the throttle, and the train quickly came to a stop. The time
  was 2:30 p.m. and the runaway train had covered 66 miles in just under 
2
  hours.

  An examination of the controls confirmed that the locomotive 
independent
  brake had been fully applied, automatic brake valve was in the service
  zone, and the dynamic brake selector switch was not in the braking 
mode.
  All brake shoes had been completely worn to the brake beams.

  The railroad was prepared to place an additional fully manned 
locomotive
  ahead of the runaway south of Kenton, if necessary, to further slow 
the
  train. This rather hazardous option was fortunately not required.

  Post Incident Investigation:
  The engineer of Y11615 was slightly injured, but he declined medical
  treatment. He was released from service with his crew at 5:30 p.m. The
  CSX did not require Drug or Alcohol testing of the crew, nor was 
federal
  testing required.

  The engineer first hired on the Pennsylvania Railroad in 1966, and he
  was promoted to engine service in 1974. He received his most recent
  check ride with a supervisor in January 2001. The engineer's 
discipline
  record is clean.

  A Federal Railroad Administration Motive Power and Equipment Inspector
  arrived at the location where CSX 8888 was stopped and performed a 
full
  mechanical inspection. He found all systems to function normally,
  including sanders, headlight, auxiliary lights, bell, horn and the
  alerter. The brake cylinder piston travel could not be determined,
  because all brake shoes were completely burned off.

  Conclusions:
  Air Brake System:
  Locomotive CSX 8888 is a model SD40-2 manufactured by General Motors
  Corporation (EMD). This unit is equipped with 26L type air brake 
system.
  The Alerter system is connected directly to the air brake system which
  functions to provide an automatic full service penalty application of
  the air brake system, and a power knock out (PC) caused by failure to
  acknowledge the time out feature usually about 40 seconds. When the
  Alerter time out has expired, the engineer must acknowledge by 
tripping
  the acknowledging switch which will reset the time out feature. The
  Alerter system is nullified when locomotive brake cylinder pressure of
  20 psi is developed in the Independent Application and Release pipe.
  This also prevents the P2A Application Valve from triggering a service
  brake application and PC action.

  When the engineer of Y11615 placed the locomotive independent brake
  valve into full application, a design pressure was developed in the
  brake cylinders, depending on the type of relay valve, which nullifies
  the Alerter System. Had the engineer not placed the independent brake
  into the full applied position and caused a build up of brake cylinder
  pressure, when the time out feature had expired, the system would have
  functioned causing not only an application of the locomotive brakes 
but
  a PC trip which would have resulted in a Power Knock Out bringing the
  movement to a stop.

  According to the interview of the engineer, he made a 20 psi brake 
pipe
  reduction with the automatic brake valve before dismounting the
  locomotive. This by no means would have provided any braking power in 
as
  much as the brake pipe was not connected to the cars and the system 
was
  not charged.

  Dynamic Brake:
  General Motors Model SD-40-2 dynamic brake system is established by
  placing the selector lever into Dynamic Brake Mode. This will convert
  the traction motors to generators to produce voltage and amperage 
which
  is dissipated in the form of heat through the braking grids. 
Excitation
  for the fields of the traction motors is developed through the main
  generator and is regulated by increasing main generator outputby
  increasing diesel engine rpm. This increase in engine rpm is
  accomplished by increasing throttle position 1 (setup) through 8
  positions. The effectiveness of the dynamic brake system is generally
  maximized at speeds above 40 mph. At very speeds, below 10 mph, the
  dynamic brake system is not effective. When the engineer failed to
  properly move the selector lever into the dynamic brake mode, the
  traction motors remained in the motoring mode. By placing the throttle
  handle into number 8 position in this set up, maximum locomotive
  power was thus developed and diesel engine rpm would increase in a 
like
  manner to dynamic braking. Without first observing the load meter, and
  at low locomotive speeds, it may be difficult to determine immediately
  if the locomotive was in braking or power mode.

  Commentary:
  In the days following the incident, state and local officials 
expressed
  concern about the potential for this type of event to occur in the
  future. While FRA does not dismiss any potential safety concern, the
  exact circumstances that combined to cause this incident are highly
  unlikely to recur. It is not uncommon, today, for our inspectors to
  observe an engineer bring his locomotive to a full stop, dismount his
  locomotive and operate a switch. This is done safely and in accordance
  with railroad safety rules and does not pose any special hazard to
  employees or the general public. Railroad operating rules generally
  prohibit any employee from dismounting, or mounting, moving equipment.
  Engineers are required by railroad operating rules to apply a hand 
brake
  and take other steps at the control stand to immobilize the locomotive
  before dismounting.

  FRA does have an initiative which will minimize the possibility of
  runaway equipment resulting from unsecured equipment left unattended 
in
  a yard. This issue falls under the umbrella of the Switching 
Operations
  Fatality Analysis (SOFA) program, in my view, and we have taken steps 
to
  emphasize the securement of equipment in our ongoing SOFA activities.
  For example, since the incident, State of Ohio and Federal inspectors
  have visited CSX and NS terminals in Ohio, and elsewhere, to review 
with
  railroad managers policies and procedures relating to switching 
safety,
  including securement. We have not
  been able to identify any systemic problems or shortcomings in 
training,
  supervision, or operating practices that are cause for alarm. 
Inspectors
  do observe various local, non-systemic safety issues, and they are
  addressed promptly with local managers, in accordance with our 
standard
  policy and practice.

  I might comment further on why this incident is unlikely to recur. The
  cause of the incident was multiple gross errors in judgement by the
  locomotive engineer. For the incident to have occurred, each error
  needed to be committed in sequence. First, the engineer was not 
properly
  controlling the speed of his train on the lead, if he is unable to 
stop
  for a switch improperly lined. This is covered by the railroad's
  operating rules. Second, if the engineer cannot stop for a switch
  improperly lined, the correct action to take is simply run through the
  switch and then stop without backing up, to avoid derailing the train.
  Third, an engineer should never dismount his locomotive while it is
  moving, except in extremely rare emergency circumstances, such as an
  imminent collision. This is also covered by the railroad's operating
  rules. Fourth, the engineer should not have relied on dynamic braking 
at
  low speed, since dynamic brakes are ineffective at speeds of less than
  ten mph, except on an AC locomotive. This is well known among railroad
  engineers. Fifth, the engineer seemed to believe, in error, that an
  automatic brake application would improve braking power on single
  locomotive with the independent brake fully applied. Sixth, the 
engineer
  misapplied the selector handle for "power" or "dynamic brake," an 
error
  that can only be understood if we assume the engineer acted with 
extreme
  haste and negligence. That all of these actions were taken by an
  apparently well-qualified, fully rested employee with a good service
  record is simply incredible.

  It should be remarked that this incident could only have occurred 
during
  freight car switching and not during passenger car switching. Most
  freight switching is done "without air," that is without air brakes
  functional in the train. This is the
  industry standard, and it has been so for many decades. Passenger
  switching, on the other hand, is usually performed "with air," that is
  with air brakes functional in the train. In addition, it should be 
noted
  that passenger coaches are rarely switched with passengers aboard,
  because of concerns with passenger safety. In those rare circumstances
  where passengers are on board during switching, the air brakes would
  always be fully functional.

  Finally, this incident could not have occurred to either a passenger 
or
  freight train involved in over-the-road operations. Before any 
passenger
  or freight train embarks on a run outside of the yard where the train 
is
  assembled, federal regulations require that the train receive a 
thorough
  inspection of its braking system and that the brakes be 100% 
operational
  before the train is permitted to begin its journey.

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