Federal investigators have reported that the 2023 death of a CSX Transportation train conductor trainee in Baltimore was caused by an unsafe riding position.
The National Transportation Safety Board (NTSB) warned that its investigation reveals broader safety and training gaps across the rail industry that have contributed to an increase in injuries and deaths among railroad workers.
On June 26, 2023, the trainee lost balance during a shoving movement at the Seagirt Marine Terminal in Baltimore, Maryland, a container terminal that handles 97% of container volume at the Port of Baltimore. NTSB said its investigators found that limited foot placement on the railcar contributed to the fall as the train was coming to a stop.
The CSX crew was shoving railcars around a curve approaching a highway-railroad grade crossing. The conductor trainer was on the west side of the lead railcar while the trainee was controlling the shoving movement from the east side of the lead railcar.
Just before the accident, the trainee radioed the engineer to stop the train within five railcar lengths. The conductor trainer recalled that as the engineer slowed the train, he felt slack run out of the railcars. As the slack action occurred, the conductor trainer abruptly slipped toward the train’s direction of travel, colliding with one of the two vertical handholds that he was standing between, which, along with his grip on both handholds, stopped him from falling from the equipment. However, when the conductor trainee experienced the slack action, his right foot lost contact with the railcar platform, and he slipped forward, lost his balance and fell into the train’s path.
The NTSB determined that the probable cause of the Baltimore fatal accident was the conductor trainee riding the intermodal railcar in an unstable position that left him vulnerable to slipping and falling into the train’s path. NTSB said CSX Transportation sent the trainee into the field without performance-based verification that he could safely ride an intermodal railcar.
“CSX did not adequately train or assess the trainee’s ability to safely perform the duties he would be assigned,” NTSB concluded. “Contributing factors included inadequate safety rules, insufficient instruction on intermodal railcars, and a lack of federal research to guide safe riding practices across the industry.”
The NTSB has been raising concerns about the increase in injuries and fatalities among railroad workers, particular those riding on the sides of moving railcars. In 2023 alone, there were 43 casualties reported while riding a railcar, including two employee fatalities, according to the agency. This marked a 2.9% increase over the historical average and a 4.7% increase compared to the previous year.
“The only number of acceptable railway worker deaths is zero,” said NTSB Chairwoman Jennifer Homendy. “Our investigations consistently show that improving safety means making sure that rail workers are adequately trained and clear safety practices are essential.”
Following the investigation, the NTSB issued five safety recommendations aimed at preventing similar incidents in the future. The recommendations address safety issues including updates to CSX’s safety rules and training on safe riding practices for intermodal railcars, and a call for federal research to establish clear safety guidelines for railcar riding equipment.
The NTSB recommended that CSX revise its operating rules to instruct employees on how to safely ride all the types of railcars that it has in various situations that employees might encounter, such as riding across highway-railroad grade crossings, and that CSX provide initial and annual recurring training to all employees on the revised operating rules.
After the incident, CSX said it would extend the CSX conductor training program from four weeks to five weeks to provide new hires with more hands-on experience before beginning on-the-job training. Nearly two years later, in February 2025, the workers’ union reported that CSX had cut funding to its conductor mentor program and reduced conductor mentor staffing. The NTSB said it contacted CSX to confirm this, and CSX said that it adjusts its conductor mentor roster as necessary as the number of newly hired conductors fluctuate.
The NTSB’s final report includes findings, probable cause, and safety recommendations.
Source: NTSB
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