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10 $2,754 Conductor of train No. 1 examined regis

ter and failed to note that train No. 2

had not arrived. 3 3,025 Operator failed to deliver meeting order. 4,100 Conductor and engineman, who had been

on their triponly 15 minutes, overlooked

meeting order. 17 6,430 Engineman and fireman of empty engine

overlooked meeting order. 27 8,691 Conductor and engineman (experienced)

forgot meeting order. Injuries of pas

sengers slight. 3 13,000 Mistake of dispatcher; sent conflicting or

ders when he could and should have used the “duplicate form," sending the orders to the two trains in the same

words. 3 13, 400 East-bound train had order to run 6 hours

and 20 minutes late; ran 6 hours and 5

minutes late. 5 15,000 Operator (experienced) reported that a

train had not passed, when in fact it had, thereby leading to the delivery to another train of an order which caused

collision. 115,000 Engineman (who was killed) started from

station, at beginning of trip, without order from conductor and without going to dispatcher's office for orders, as required by rule. Conductor, being in the

office at the time, was left behind. 2 20,000 Block signalman admitted west-bound

train to block section occupied by an

east-bound train. 25 20,000 Freight, waiting on a side track, ordered

to meet3 trains, was started out after 2 trains had passed; conductor, engineman, and flagman, while waiting, had slept, and on waking assumed that 3

trains had passed. 8 21,575 Conductor and engineman of freight over

looked meeting point. (See further note

in text below.) 23 25,797 Engineman (who was killed) overlooked

order to reduce speed on entering side track at small station where main track was obstructed. Engineman, of 30 years' experience, on duty 4 hours.

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One accident shown in this bulletin was a collision due to failure in block working, and one other was a collision which occurred on a line equipped with automatic block signals, but while a train was running “permissively.” All the other collisions occurred where the block system was not in use. Two of them, Nos. 8 and 24, resulted, between them, in the death of 44 persons and the injury of 40. Item 24 is a pronounced illustration of how concurrent errors of a conductor and an engineman may quickly produce disastrous results. Seventeen passengers and 5 employees and other persons were killed, in this case, in consequence of a lack of care in reading a telegraphic order on the part of the conductor, combined with the neglect on the part of the engineman of his plain duty to read the order himself and not trust to any other person's reading. On many railroads there is a rule requiring the conductor and the engineman each, after reading a telegraphic order, to read it to an assistant (brakeman or fireman). This rule appears not to have been adopted on the road where this collision occurred.

Item 8, a collision killing 22 persons, appears to have been due to gross negligence of an engineman. The specific charge in the report made by the railroad company is that he failed to have his train charged with air; but it is further stated that on approaching the station where the preceding train was standing, and while still a mile off, he failed to see a fusee signal which had been displayed on the track to stop him, and did not shut off steam until warned by his fireman, who had seen the fusee. As the hour was about 3 o'clock in the morning, and as the engineman had not been sleeping during the time allowed him for resi in the preceding day, there is strong ground for the inference that he was asleep at his post. On being aroused by his fireman, this engineman sounded the whistle as a signal for the application of hand brakes; but it appears that the cars of the train-most of them platform cars fitted for carrying large wagons—had no brake wheels in position by which the brakes could be put on by hand. The safety of the train, therefore, so far as the means of stopping it was concerned, depended wholly on the power brake, and this failed by reason of the negligence of the engineman. The air-brake apparatus was found to be in perfect order after the collision, and it was in good working order when the train began its trip before the collision.

The engineman who was at fault in this case had been running this engine only about ten days. He had been in the service of the company about eighteen months. The officers of the road believe that after the last stop was made before the collision (about one hour before) the engineman put his air-brake valve in such a position as to shut off the flow of air from the main reservoir to the pipe leading through the train ; and with the supply thus cut off the air would slowly leak from the train pipe, making the brakes inoperative.

The twenty-ninth accident, a butting collision, disastrous both to persons and. to property, affords an illustration of the need of reading all telegraphic orders aloud, in the presence of two or more persons, if the orders are to be depended upon for the safety of life and limb.

This case differs from item 24 in that there was no requirement that the order should be read aloud in the presence of the telegraph operator or be signed for. The rule requiring these safeguards was relaxed, as is customary, because the order did not restrict the rights of the train to which it was sent; that is to say, it permitted this train to go farther than it would have gone if the order had not been issued. But it permitted it to go farther only as against a certain opposing train; and the reading into the order of the name or designation of another train, of which the dispatcher issuing the order had no thought, had the effect, of course, of nullifying all the calculations of the dispatcher and of the men in charge of the opposing train or trains.


No. 4 happened about 8 p. m. to an eastbound passenger train, running at about 40 to 45 miles an hour. It struck an obstruction, consisting of heavy timbers 21 feet long, derailing the entire train except the two rear cars. The timbers had fallen from a car in a westbound train on the adjacent track by reason of stake ties parting and stakes breaking. In the darkness this was not observed by the men in charge of the train. The timbers (a full carload) were loaded at a lumber yard, and the cause of the accident is reported as “carelessness on the part of employees of the lumber yard in not selecting stakes of good quality and size to make the load secure and failure of car inspectors to detect this defect.” The timbers were loaded by the shipper, and the load was inspected by the agent of the railroad company at the shipping station. It was also inspected by two successive conductors, who were in charge of the train which hauled the car to the first division point, and by the car inspector at this division point. This inspector has been in the employ of the company in this capacity of car inspector for sixteen years.

Before the car left this place the load was inspected by the assistant yard master and by the brakeman, who was charged with the duty of putting the car into the train for its trip over the next division; and, finally, by the conductor of this last train. The car was a platform car and the load was 5 feet 10 inches high. The stakes at the sides, set in pockets of the ordinary pattern, were connected across the top of the load by ties consisting of boards, each board being nailed to the side of a stake on one side of the car and in the same manner to a stake on the opposite side. The passengers who were killed were nearly all of them scalded by steam which escaped from the dome of the engine, which, as a result of the wreck, was left in such a position as to emit steam into the leading passenger car, which was the smoking car. The passengers in the other cars escaped injury.

This quarter there were five other derailments, which were caused by objects on the track which had fallen from cars, as follows:

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Collision No. 6, resulting in the death of 32 passengers, was due to negligence on the part of the men in charge of both of the trains involved, combined with fire; the destruction of the two passenger cars of the foremost train by fire, which presumably started from their oil lamps, having been, according to the railroad company's report, a principal element contributing to the large loss of life and large property damage. The foremost train, an accommodation, was standing at a station, and had been so standing two or three minutes. It was behind time, and the following train, an express, was already due. Notwithstanding these facts the flagman did not go back to give a warning signal until after he had assisted the passengers to alight, and he was then able to go only about 200 feet before the express was upon bim. The engineman of the express could have seen the local train's red lights (on the rear car) at a point 2,800 feet in the rear. Presumably, the flagman's knowledge of this fact affords a partial explanation of his neglect. On the other hand, the omission of the engineman of the express to apply the brakes and reduce the speed of his train appears to be taken by the officers of the road to prore that he was not keeping a good lookout, and therefore did not observe the red light of the standing train as soon as he should have observed it. The flagman of the standing train testifies that the engineman of the express did not give the whistle signal, which should have been sounded as an acknowledgement that he saw the flagman's light. The flagman had been in the service of the company five months. The conductor in charge of this train, who should have seen that the flagman promptly performed his duty, has been in the service fifteen years, and liis record is reported as good. The engineman oï the express has been in the service twenty-six years, and his record is reported as first class.

Collision No. 10 occurred at a time when a violent storm of wind and snow prevailed. Of the men whose contradictory testimony is noted in the table, the station agent has been in the service of the company thirty-five years, the engineman twenty-six years, and the fireman three years, and all are reported as having clear records. The statements of these men were given not only to the officers of the road, but also before a coroner. If the signal was in the

stop” position, the fact that the light had been extinguished afforded no excuse to an engineman for disregarding it, as it would be his duty in such a case to reduce his speed, or, if necessary, to come to a full stop, in order to learn the reason why the light was not burning or to be able to see the signal by the light of the locomotive headlight. The agent testified that the same light had been extinguished by the wind before on the same evening, and that the light of another lamp of the same style had also been blown out.

The causes of collisions 1 and 8 are explained in the table as fully as it is possible to explain them from the reports. The 17 persons killed in the first mentioned were all employees, being laborers on a work train, while the 16 killed in the other were all passengers. The fact that such terrible results may be produced by such simple lapses must be taken to indicate either a grave defect in the methods of managing trains or serious deficiencies in the qualifications of the man or men at fault.

The men responsible for collision No. 9 were the conductor and engineman in charge of the work train. They had been in the service of the company five years; the conductor was 28 years old and the engineman 36. By way of explanation of his error the engineman said that his engine was not working properly, and that in looking for the trouble more time was consumed than he was aware of. The supply of water in the tender had also run low, and he was anxious to reach a water station. In this case, as in No. 1, the victims were all employees on a work train.

Derailment No. 1 and all of the five most prominent collisions occurred under circumstances which have been repeated in hundreds of collisions, and these circumstances are the result of defects for which the block system is universally looked upon as the remedy. That is to say, the block system, while not doing away with every element which contributed to the causes of these collisions, does introduce principles of a different character and does promote habits of obedience and precision which have been found to greatly reduce the death and damage record.


The circumstances of collision No. 18 are typical of those features of train management which give rise to the charge, often repeated in various public prints, that American railroad management is reckless. The men in charge of the passenger train in this case had positive written orders to look out for (and meet) a freight train, with an engine of a certain number, at a certain place. This order was delivered to and read by both the conductor and the engineman. The freight train hadnot reached the appointed meeting place, and the only thing to be done by the men in charge of the passenger train—the regular and usual thing—was to stop their train and wait until the freight train should arrive. But another freight train was there on the side track, and it was assumed that that was the one specified in the meeting order. The conductor apparently made no effort to identify the engine on the side track, trusting that his engineman would do so; and the engineman evidently was willing to take the risk of passing on (at full speed, no stop being required at that station for leaving or taking passengers), knowing that if his assumption proved wrong he would in all probability cause much damage to property, if not great loss of life. In point of fact, he caused both.



Collision No. 9 is notable as being the fourth case recorded recentiy as due to precisely the same error in reading a written order—the overlooking of “ 2d,”

Second.” Two such cases appeared in Bulletin No. 8 and a third in Bulletin No. 9. This would seem to point obviously to the need of a change in the scheme of numbering or naming trains, or in writing the numbers or names in dispatcher's orders.

The accident most fatal to passengers in this quarter was a derailment (No. 7 in the table). The cause, however, was one which constantly recurs in the collision record—forgetfulness on the part of an engineman. In this case the man at fault was killed. The circumstances show the weakness and insufficiency of the requirement-ostensibly a safeguard—that the conductor of a train, equally with the engineman (so far as possible), shall guard against disaster. This requirement is found in all rule books. Theoretically, the conductor in this case, having in his possession a copy of the slow order, could have had his mind on the matter, approaching the sidetrack, and his hand on the emergency brake valve with which every car is equipped, and thus could have stopped the train in spite of the engineman's failure to act. But, practically, this safeguard fails in a large percentage of the emergencies which it is designed to provide for. The inadequacy of the requirement that the fireman shall be an assistant lookout man is also illustrated in this case. To be of sufficient value as a lookout to be relied upon firemen must not only be intelligent and experienced, but must also be trained in lookout duties.

Collisions 4, 5, and 16 occurred on block-signaled lines. No. 5 killed three passengers. This case is somewhat similar to a notable one recorded in Bulletin No. 7 (January, 1903), where over 100 persons were killed or injured (23 deaths). In both cases the automatic block-signal equipment of the road was complete and in good order.

H. Doc. 146, 58–3—24

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