Does any other rail see the underlying issue here?

First - I have never been comfortable with the concept of one person crews, or RCO in most cicumstances. I'm not sure that alone would have prevented this death.

Second - The failure to repair cars reported defective in a timely manner contributed to the accident.

Third - The RCO operator made the final error, which unfortunately proved fatal, when he apprently ended up between moving equipment trying to resolve the knuckle issue.

Railroad accidents seem (at least to me) to follow a pattern - either there is a primary/singular obvious cause; or there is a chain of minor events, that by themselves are not a huge threat, but together create potential damage, injury or death.

In my opinion, this was a chain of events. Obviously the RCO operator should not have placed himself in a position of danger. If the current mantra of "All accidents are preventable" is really true, then the cars should have been repaired so operator did not have to deal with replacing a knuckle. Which means, the cars should have had missing knuckle pins replaced on the inbound inspection before they were humped. (By the description of the accident, I am assuming the cars involved where in the bowl of a hump.) Knuckle pins do break, which allows the knuckle to fall out when uncoupled - but can this truly be prevented?

Personally, I would have considered the use of a carmen under the utility employee rule to replace the knuckle as a safe and proper practice. However, reading the rule in GCOR (not used by CSXT), a utility employee could not perform this duty unless an engineer or another member of the crew is in the cab of the locomotive. The utility employee rule is in the blue flag section of the GCOR, even suggesting that this is how a carmen can work under a train crew's protection.

The basis from the utility employee comes directly from the Code of Federal Regulations - interperted and enforced by the FRA.

(Under definitions:) 49CFR218.5 Utility employee means a railroad employee assigned to and functioning as a temporary member of a train or yard crew whose primary function is to assist the train or yard crew in the assembly, disassembly or classification of rail cars, or operation of trains (subject to the conditions set forth in §218.22 of this chapter).

Subpart B—Blue Signal Protection of Workers

§ 218.21 Scope.

This subpart prescribes minimum requirements for the protection of railroad employees engaged in the inspection, testing, repair, and servicing of rolling equipment whose activities require them to work on, under, or between such equipment and subjects them to the danger of personal injury posed by any movement of such equipment.

§ 218.22 Utility employee.

(a) A utility employee shall be subject to the Hours of Service Act, and the requirements for training and testing, control of alcohol and drug use, and hours of service record keeping provided for in parts 217, 219, and 228 of this chapter.

(b) A utility employee shall perform service as a member of only one train or yard crew at any given time. Service with more than one crew may be sequential, but not concurrent.

(c) A utility employee may be assigned to and serve as a member of a train or yard crew without the protection otherwise required by subpart D of part 218 of this chapter only under the following conditions:

(1) The train or yard crew is assigned a controlling locomotive that is under the actual control of the assigned locomotive engineer of that crew;

(2) The locomotive engineer is in the cab of the controlling locomotive, or, while the locomotive is stationary be replaced in the cab by another member of the same crew;

(3) The utility employee established communication with the crew by contacting the designated crew member on arriving at the train (as defined for the purpose of this section as one or more locomotives coupled, with or without cars) and before commencing any duties with the crew.

(4) Before each utility employee commences duties, the designated crew member shall provide notice to each crew member of the presence and identity of the utility employee. Once all crew members have acknowledged this notice, the designated crew member shall advise the utility employee that he or she is authorized to work as part of the crew. Thereafter, communication shall be maintained in such a manner that each member of the train or yard crew understands the duties to be performed and whether those duties will cause any crew member to go on, under, or between the rolling equipment; and

(5) The utility employee is performing one or more of the following functions: set or release hand brakes; couple or uncouple air hoses and other electrical or mechanical connections; prepare rail cars for coupling; set wheel blocks or wheel chains; conduct air brake tests to include cutting air brake components in or out and position retaining valves; inspect, test, install, remove or replace a rear end marking device or end of train device. Under all other circumstances a utility employee working on, under, or between railroad rolling equipment must be provided with blue signal protection in accordance with §§218.23 through 218.30 of this part.

(d) When the utility employee has ceased all work in connection with that train and is no longer on, under, or between the equipment, the utility employee shall notify the designated crew member. The designated crew member shall then provide notice to each crew member that the utility employee is being released from the crew. Once each crew member has acknowledged the notice, the designated crew member shall then notify the utility employee that he is released from the train or yard crew.

(e) Communications required by §218.22(c)(4) and (d) shall be conducted between the utility employee and the designated crew member. This communications shall be conducted either through direct verbal contact, by radio in compliance with part 220 of this chapter, or by oral telecommunication of equivalent integrity.

(f) No more than three utility employees may be attached to one train or yard crew at any given time.

(g) Any railroad employee who is not assigned to a train or yard crew, or authorized to work with a crew under the conditions set forth by paragraph (b) of this section, is a worker required to be provided blue signal protection in accordance with §§218.23 through 218.30 of this part.

(h) Nothing in this section shall affect the alternative form of protection specified in §221.16 of this chapter with respect to inspection of rear end marking devices.

[58 FR 43293, Aug. 16, 1993, as amended at 60 FR 11050, Mar. 1, 1995]

The reasons I would guess the FRA found the practice of using a utility employee to assist in replacing a knuckle regards the wording of two sections, which I underlined for emphasis above. A carman as a utility employee could not assist in replacing a knuckle, and furthermore the RCO operator would have to be in the cab, nullifying any advantage of the assistance by another employee. Realistically, the hump tower would have that track locked out from their end, and the switch movement would be within a remote control zone under the direction of the RCO oeprator. So why is it proper under the rules, and presumably safe, for a train crew member to change a knuckle (or adjust a drawbar, or other minor repair/adjustment) by themselves, but for another qualified employee to assist them is not in compliance? And why is the untility employee rule even included under the blue signal protection section if its primary intent is only to allow a floating switchman to assist crews?

What the NTSB report dances around, but wasn't willing to state:

Additional contributing factors in this death were:

1. The failure of management and the FRA to agree upon, establish, and advice all affected employees a safe proceedure for replacing knuckles and other minor repairs, allowing other qualified employees to assist if needed, that is safe and complies with the regulations.
2. That the failure to provide this alternate proceedure created a situation requiring either the track be blue flagged to allow a carman to replace the knuckle, or the expectation that a one person crew must do the repair without assistance, both of which are impractical.
3. The failure of the FRA to review the present utility employee rules, and remote control operating and one person crew proceedures, to effect regulatory change to properly address this common situation while still providing a safe working enviroment.
4. That the inclusion of the utility employee rule under the Protection by Blue Signal section is misleading. The utility employee section should either be relocated, or the regulation rewritten to allow qualified employees to safely work under the protection of an assigned crew to affect minor or emergency repairs to cars and engines.
5. That the FRA should not simply issue violations, but should also review the circumatances that required the improper practice, and require that the inspecor and railroad managers develop alternate safe and compliant proceedures for consistent implementation.

It is sad that the very regulations and inspector that is supposed to protect us as railroad employees directly contributed to the chain of events that lead to this death.

My opinion .....