What Happened
What Happened
On November 19, 2024, at 2:55 p.m. local time, a Carolina Coastal Railway conductor sustained serious injuries after being struck by a railcar during a switching operation on the Nash County Subdivision Main Track near Rocky Mount, North Carolina. The injured conductor was working to reposition two coupled railcars that had been gravity-dropped onto the track when the trailing railcar struck him, resulting in the amputation of his leg below the knee.
What We Found
What We Found
We determined that the probable cause of the Rocky Mount, North Carolina, Carolina Coastal Railway conductor accident was the conductor losing his grip while attempting to apply the hand brake from an unsafe position on the railcar. Contributing to the accident were inadequate training methods that likely led the conductor to perform an unsafe gravity-drop move.
What We Recommended
This accident underscores the importance of clearly defined procedures and the importance of thorough training that emphasizes safe positioning and technique when conducting gravity-drop switching operations. The conductor’s decision to apply the hand brake from the side ladder rather than the platform, as mentioned in Rule 612, combined with the lack of specific guidance in Rule 103-H, shows the need for a clearly defined and standardized written procedure for gravity-drop moves, as the lack of established routine contributed directly to the unsafe conditions that led to this accident. This highlights the importance of ensuring that all high-risk operations are governed by detailed, unambiguous instructions.
After the accident, the Carolina Coastal Railway informed NTSB that they have adopted a sound and well-defined training procedure for performing gravity-drop moves. Consistent procedures will only be taught by their most experienced conductors, who have all been designated as qualified to provide training in a consistent manner.
The revised training process includes performance-based evaluation in which the trainee is required to perform a given procedure no less than three times correctly without intervention before they are considered qualified to perform said task on the job. Each employee’s record of training will be maintained in that employee’s file along with all other personnel information related to performance qualifications.
Furthermore, Carolina Coastal Railway will be monitoring gravity-drop procedures and the adherence to the policy set forth in the same manner as in Title 49 Code of Federal Regulations Part 217.
Carolina Coastal Railway also corrected shortcomings regarding gravity-drop move procedures in their Rule 103-H, and on February 28, 2025, they issued General Order 3-25, which includes specific instructions on how to perform gravity-drop moves. Included in these instructions are the locations where an employee should be positioned to perform the various aspects of a gravity-drop move and when gravity-drop moves are allowed.
NTSB verification of the implementation of General Order 3-25 was provided by Carolina Coastal Railway via e-mail. See the public docket for further information pertaining to General Order 3-25.
