What Happened
What Happened
On August 27, 2024, about 10:10 p.m. local time, a Norfolk Southern Railway conductor was seriously injured while coupling railcars at the Lambert’s Point Yard in Norfolk, Virginia. The conductor was part of a crew using locomotives to move railcars that had been gravity fed (rolled down-grade without a locomotive) into a yard track. The conductor made several attempts to couple a railcar to his train by directing the engineer in the lead locomotive to reverse short distances to bump the couplers together. During the last of these attempts, contact between the couplers caused the free-rolling railcar to travel up-grade. The conductor asked the engineer to stop the train and secure it against movement, a step normally taken before working between rail equipment. Shortly afterward, after the train itself had been secured and was not in motion, the railcar rolled back down-grade and struck the conductor.
What We Found
What We Found
The NTSB determines that the probable cause of the Norfolk Southern Railway (NS) conductor being struck and injured by a railcar was his working in the path of free-rolling stock without first confirming that it was stationary or securing it against movement; NS operating rules did not explicitly instruct employees to ensure that separation was maintained on downhill grades by securing railcars against movement, and the rules' incomplete coverage of switching operations on a downhill grade reduced the conductor's ability to perform his duties safely.
What We Recommended
This accident occurred because a conductor was working near unsecured equipment. NS had rules about minimum separation distances, but these rules could have made clearer both the hazard posed by free-rolling stock on downhill grades and the actions employees should take to mitigate it. Following the accident, NS issued a special instruction for Lambert’s Point Yard to add safety procedures in the area where the accident occurred. These procedures include a doubled separation distance of 100 feet between pieces of equipment and a directive to approach equipment within 5 feet and ensure that it is completely stopped before fouling a track. If equipment is not completely stopped, it must be secured with hand brakes.
NS conducted a 10-day safety stand-down and training in August–September 2024. The training included issues specific to the accident and general safety training. NS also undertook a campaign of face-to-face contacts between employees and managers to confirm understanding of changed procedures; distributed a job aid with a review of rules, highlighted rule changes, and links to explanatory videos; and set up a supervisor verification program to confirm and document that employees had completed training and could access the job aid.
The FRA issued Safety Bulletin 2024-06 in response to this accident. The bulletin notes the importance of adequate training programs, risks associated with switching operations, and regular railroad review of operating rules. The bulletin also reminds railroads of FRA Safety Advisory 2013-03 and the Switching Operations Fatality Analysis Working Group’s Recommendation #1, both of which recommended ensuring that free-rolling stock is completely stopped and applying hand brakes when necessary before fouling a track.7
These postaccident actions underscore the importance of making sure employees know how to apply safety principles and general rules—like maintaining safe separation between pieces of equipment when fouling a track—in their actual operating environments, which may pose unique environmental hazards.
lthough the accident occurred because of unsecured equipment, the accident sequence began with an inspection that failed to identify a missing knuckle pin. After the accident, NS re-affirmed during pre-shift meetings with yard employees the importance of replacing missing knuckle pins during inspections, properly securing knuckle pins, and, if the pins cannot be replaced or secured, removing the affected railcars from service until they can be repaired.
