The National Transportation Safety Board (NTSB) has completed its investigation into the death of a Norfolk Southern conductor while on duty at a facility in Baltimore.
The completed report is reproduced below.
On February 7, 2019, about 7:00 a.m. local time, a Norfolk Southern Corporation railroad conductor was fatally injured while performing switching operations at the President Street intermodal tracks section of the Bayview Yard of the Baltimore Consolidated Terminal, Baltimore, Maryland. The conductor was riding on the side of the leading railcar of train 38A during a reverse movement when he was pinned between the railcar he was riding and a stationary railcar on an adjacent track.
On the morning of the accident, after uncoupling all but four railcars, the train’s engineer notified the yardmaster by radio that the train was secured and asked to move the train to its next switching location. The yardmaster reminded the engineer that the conductor was not allowed to ride on the side of railcars within the intermodal facility tracks and subsequently approved the train’s movement. As the train reversed north, the lead railcar, on which the conductor was riding, approached a slight right curve where three railcars had been stored on an adjacent track. When the train entered the curve, the distance between the train and stored railcars decreased to 9 inches. As the train continued to reverse, the engineer passed the conductor lying between both tracks. The engineer stopped the train and radioed the yardmaster to report that the conductor was down and that emergency assistance was needed.
What We Found
Despite Norfolk Southern Corporation’s rules prohibiting employees from riding on the side or end of equipment in close-clearance locations, we found that, for unknown reasons, the conductor chose to ride on the side of the railcar in a close-clearance location, which resulted in his death. While close-clearance restriction locations for the Baltimore Consolidated Terminal were identified in the Harrisburg Division Timetable Number 1 terminal instructions, that 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. We also found that the Norfolk Southern training program did not emphasize and test on the close-clearance restriction locations and location-specific hazards within the Baltimore Consolidated Terminal, which could lead to employees having inadequate knowledge to safely work in these areas.
We determined that the probable cause of the fatality was the conductor riding on the side of a railcar for unknown reasons as the moving train approached stored railcars on an adjacent track, which resulted in decreased clearance, in a section of the Bayview Yard where Norfolk Southern Corporation’s terminal instructions and operating rules specifically prohibited riding railcars in the close-clearance restriction areas.
What We Recommended
As a result of this investigation, we made a recommendation to Norfolk Southern Corporation to review and revise the terminal instructions in the Harrisburg Division Timetable 1 that govern the close-clearance restriction locations within the Baltimore Consolidated Terminal and ensure the instructions contain consistent language related to close-clearance locations. We also recommended that Norfolk Southern Corporation revise the Baltimore Consolidated Terminal training and testing program to emphasize close-clearance restriction locations and location-specific hazards.
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