NTSB Final Report On The CSX Collision of April 15, 2024 Released This Week
Written by David C. Lester, Editor-in-Chief
NTSB
WASHINGTON, D.C. –– The National Transportation Safety Board this week released its final report on the April 15, 2024 head-on collision of two CSX freight trains.
Overview
According to the report, here is what happened:
“On April 15, 2024, at 1:20 p.m. local time, northbound CSX Transportation (CSX) intermodal train I03215 traversed a misaligned switch and collided head-on with stationary, loaded rock train L74314 while traveling about 28 mph on CSX’s Jesup Subdivision near Folkston, Georgia. Two crewmembers of train I03215 and one crewmember of train L74314 were hospitalized for non-life-threatening injuries.”
The NTSB investigation of the incident revealed the following:
”The NTSB determines that the probable cause of the CSX Transportation head-on train collision were an improperly lined dual-controlled, power-operated switch that a conductor did not know how to properly operate, and the conductor’s failure to verify its position as required. Contributing to the accident was CSX Transportation’s insufficient training (recurring) and failure to implement operational procedures, such as a restricted speed requirement and secondary verification of switch position, to mitigate the risk of misaligned switch accidents during a signal suspension.”
The NTSB Conclusion and “Lessons Learned”
“On April 18, 2024, CSX published a safety alert in response to the collision in Folkston, Georgia. The safety alert discussed operating requirements for dual-controlled, power-operated switches. The alert also emphasized that “all trains must approach all switches within the limits of the signal suspension at restricted speed until it is known they are lined for the authorized and intended route.” This change is intended to give train crews time to stop if they see that they are approaching a misaligned switch. In addition, CSX published a signal suspension safety bulletin that discusses signal suspension job briefing protocols and field management audits and testing. These protocols include secondary switch verification by including a signal maintainer in the job briefing and having the signal maintainer double-check a conductor’s alignment of each switch.
“This accident underscores the importance of proper switch protocols and train handling under conditions, such as a signal suspension, that prevent automated systems like positive train control from providing an additional margin of safety.”
Additional Background from the Report
“Before the collision, the track signals near the accident location were suspended for maintenance and upgrades, and movement through the area being controlled as track warrant territory. During the signal suspension, CSX assigned a conductor with 3 years experience to manually throw switches for train movements between tracks. This conductor was responsible for a total of four dual-controlled, power-operated switches, which can be operated either through the signal system or by hand. When interviewed by the National Transportation Safety Board (NTSB), the conductor said he confirmed these switches were reversed –– that is, lined to divert trains. He was later tasked with normalizing all four switches manually, or lining them not to divert trains off the track on which they entered the switch.
“Some dual-control power switches, such as those the conductor was lining, can be difficult to operate because of the transition from powered to manual (or ‘hand-throw’) mode. Unlike single-controlled manual switches, when switching dual-controlled power switches to hand-throw mode, the hand-throw lever may need to be cycled back and forth to line the switch to the intended position. This is necessary because the internal components and locking mechanisms sometimes disengage during the transition from powered to hand-throw mode. During his interview, the conductor reported varying levels of resistance as he attempted to normalize all four switches, an indication that some had disengaged locking mechanisms.”
You can read the entire report here.
