What Happened
What Happened
On April 15, 2024, at 1:20 p.m. local time, northbound CSX Transportation (CSX) intermodal train I03215 traversed a misaligned switch and collided head-on with stationary, loaded rock train L74314 while traveling about 28 mph on CSX’s Jesup Subdivision near Folkston, Georgia. Two crewmembers of train I03215 and one crewmember of train L74314 were hospitalized for non-life-threatening injuries.
What We Found
What We Found
The NTSB determines that the probable cause of the CSX Transportation head-on train collision were an improperly lined dual-controlled, power-operated switch that a conductor did not know how to properly operate, and the conductor’s failure to verify its position as required. Contributing to the accident was CSX Transportation’s insufficient training (recurring) and failure to implement operational procedures, such as a restricted speed requirement and secondary verification of switch position, to mitigate the risk of misaligned switch accidents during a signal suspension.
What We Recommended
On April 18, 2024, CSX published a safety alert in response to the collision in Folkston, Georgia. The safety alert discussed operating requirements for dual-controlled, power-operated switches. The alert also emphasized that “all trains must approach all switches within the limits of the signal suspension at restricted speed until it is known they are lined for the authorized and intended route.” This change is intended to give train crews time to stop if they see that they are approaching a misaligned switch. In addition, CSX published a signal suspension safety bulletin that discusses signal suspension job briefing protocols and field management audits and testing. These protocols include secondary switch verification by including a signal maintainer in the job briefing and having the signal maintainer double-check a conductor’s alignment of each switch.
This accident underscores the importance of proper switch protocols and train handling under conditions, such as a signal suspension, that prevent automated systems like positive train control from providing an additional margin of safety.
