C3RS Inside The Rail – Issue 15

Engineering Close Call Event

 

A Manager provides insight into how a communication breakdown during an emergency repair caused a close call event involving energized electric rail.

 

The Construction gang was on the rail repairing a pole line cable that came down during the overnight storm with Track and Time and an electrified rail outage. During the cleanup, an electrified rail man told us the rail became re-energized through a back feed. We had crews actively working on removing strand and cable that could have been in contact with the electrified rail. There were no injuries and everyone stepped clear of anything metal.

 

 

C³RS Expert Analyst’s Callback Summary:

 

The reporter, a Manager, stated that a crew of fifteen plus employees were working on Track and Time authority issued to them by the Dispatcher… The reporter explained that the crew was not certain as to the exact circumstances involved, but at some point the power was restored to the track segment where all the employees had been working. During the cleanup process, the Electric Traction Manager informed the Manager that the electrified rail had become energized due to a train down the line “bridging the gap.” None of the employees were making contact with the tracks at that time…

Signal Department Close Call Event

 

A Signal Maintainer explains how human factors and deviating from procedure set up a close call event when disconnecting breakers in a signal bungalow.

 

At the Interlocking, I was removing old equipment to be salvaged. The last piece of equipment to be removed were snow blower breakers. All of the breakers were in the off position. I had cut out four of the smaller breakers before I got to the large main breaker… On the fifth wire, I saw a bright flash from the sixth wire. I believe that making an assumption that the power had been turned off along with not having a multi-meter available to verify, was the cause of this incident. I believe that it is imperative to always verify that the circuit is not live before disconnecting anything from it.

 

 

C³RS Expert Analyst’s Callback Summary:

 

The reporter, a Signalman, was working alone disconnecting power to equipment near control points that were going to be upgraded. Power had been shut off several weeks prior. The reporter said there were no lights in the bungalow and assumed the power was off on the circuits as well, but did not initiate steps to verify they were off. The Signalman was unaware the circuits were on a separate feed and that they were energized… The third wire to be cut had faulty insulation and touched the breaker panel, which was connected to the ground and created a flash and an arc… To prevent mishaps like this in the future, the reporter said there needs to be an Electrician or other qualified employee to perform electrical work. The Signalman also recommended improved communication among the crafts as well as implementing a proper Lock Out/Tag Out procedure.

Transportation Close Call Event

 

Protecting a shove at restricted speed as a train approached a blind curve, a Conductor discusses why communication and situational awareness are so important.

 

The Train departed Station X on time. We were shoving with the Dispatcher’s permission on a routine move to Station Y. We received a restricting indication at the Interlocking, which was a blind curve. After making the curve, I observed two track workers sitting in the gauge working on a metal box. I blew the proper whistle warning and the workers immediately jumped out of the gauge…

 

 

C³RS Expert Analyst’s Callback Summary:

 

… The Conductor was in the rear control car and was in control of the shoving move. The crew was in the process of shoving their train one mile so they could pull into the other station… The reporter suspected the workers were contractors who were stealing foul time as they had no authority to occupy the track as the train had a restricting signal… The reporter concluded by saying there was no Foreman present to obtain Track Authority for the workers.

Mechanical Close Call Event

 

Communication and job safety briefings are critical to railroad safety. Here is a report from a Machinist highlighting an instance where neither were properly applied in a blue flag protection situation.

 

Blue lights were removed by a Laborer from the end of the track and train before an onboard brake test was completed. Lack of communication to the Electricians on the other end of the train in the cab car left them unprotected by blue lights. It was discussed about, what and why it happened afterward.

 

 

C³RS Expert Analyst’s Callback Summary:

 

The reporter, a Machinist, conveyed the Laborer was the employee that called in Blue Light Protection. While sitting in the engine the reporter observed the Laborer remove the blue light, which left the Electrician unprotected… The reporter cited a lack of communication as the contributing factor to the event. In the future, better communication by everyone in the group will help prevent incidents like this from happening again.

Dispatcher Close Call Event

 

A Dispatcher shares a deviation from track blocking procedures that could have resulted in a serious incident.

 

… Foreign Carrier’s Train arrived in the Station after midnight with an extra electric engine that had to be removed and brought to the Foreign Carrier’s Yard. I gave the appropriate signals for the light engine to proceed west and switch blocked the route. I realized after the light engine had already made its way to the Yard, I had the switch blocked as necessary. I did not apply a track block to prevent the Foreign Carrier’s Train from coming in on top of the light engine. That being said, no signal was given on top of the light engine and no incident occurred.

 

 

C³RS Expert Analyst’s Callback Summary:

 

The reporter, a Dispatcher, stated that the move being made with the train was routine. However, in this particular instance the Dispatcher was distracted due to working from a different location than normal. The reporter explained that periodically, the Dispatchers are required to work from a different location so that the usual dispatching office can be disinfected for COVID-19. Therefore, there was an unusual amount of noise and activity, which is a distraction.

Report Intake By Craft

January through December 2021

 

Transportation – 2,824

Engineering – 108

Mechanical – 72

Monthly Report Intake

Previous 3 Months

 

October – 287

November – 301

December – 261

Inside The Rail – Issue 15

 

 

Online Resources

 

 

NP-2022-01-XX-ARC

NASA Confidential Close Call Reporting System | c3rs.arc.nasa.gov