从“危情时速”大片看“OCB”

关于“组织公民行为”的一个典型个案，2001年5月15日发生在美国俄亥俄州CSX铁路公司的一辆无人驾驶火车紧急制动停车事件，可以从中看个究竟。

这辆火车头SD-40-2 携22节满载、25节空载、共近50节车厢、拖重达2898吨，由于司机下车拉道闸而意外加速到12mph ，外加雨天因素，由此导致司机没有能够及时登上车、在够到把手被拖行80英尺后摔下火车，从而使火车在无人操控的情况下行驶了近66多英里；后被CSX 员工以非凡的“组织公民行为”多方营救，在俄亥俄州肯顿（kenton.ohio）、近67英里标志处，由司机驾Q63615号火车头赶上SD-40-2号, 在时速50mph 的情况下连接并启动动态刹车装置，时值路过南Kenton31道岔与等候在那里的CSX 高级员工 Jon Hosfeld 跑步赶上速度降到 12mph 的SD-40-2号火车头，立刻关死制动终于使这辆“脱缰野马”般的火车停了下来，避免了一场车毁人亡恶性事故的发生。

2010年上映的《危情时速 》（Unstoppable )，将这个真实事件做了艺术化再现，故事场景改在宾夕法尼亚州南部的布鲁斯特市，丹泽尔·华盛顿（Denzel Washington） 饰演的资深火车机师弗兰克·巴恩斯即将提前退休，作为拥有丰富阅历和经验的老员工，虽然对公司出于人工成本考虑雇用相对便宜却没有经验的新员工表示不满，却也无可奈何；这天早晨，弗兰克迎来了新的搭档——年轻气盛的领航员威尔·科尔森（克里斯·佩恩 Chris Pine 饰），着手进行新老交接班工作。与此同时，位于北部的富勒站出现状况，满载危险化学品的777号列车在无人驾驶的情况下径自开走，如野兽般咆哮着冲向人口密集的城镇……危险随时降临，弗兰克和威尔即将度过“惊心动魄”的一天，故事由此展开。

这天早晨，位于宾州维金斯（Wilkins）的富勒桠（Fuller Yard）与往常一样人来人往、车水马龙。晚班的人员一心想要早点回家，而早班的同事正拿着咖啡来接替他们的工作。正当两位工人在休息空档狼吞虎咽地吃着早餐时，他们接到指令要求将一列最新列车移到另一条不同的轨道。富勒桠似乎要准备迎接一场从纽约欧林（Olean）出发的小学生户外教学，这两名工人觉得有些厌烦，但仍很认命地开始移动这列野兽─777号机车；就在这时，其中一位工人为了取巧让工作快点完成而做了个错误举动，导致火车头配备了最新计算机化时钟与警笛、搭载39节车厢的这列新机车，转眼间就变成了一只脱缰野马般横冲直撞的移动火药库。

与此同时，在200英里之外，布鲁斯特（Brewster）的明构（Mingo）车场，这天早晨也一如往常车来车往、熙熙攘攘。老铁路员工们在准备上工之前，用他们最后一杯咖啡的时间读着工作数据。正当他们聊到那些菜鸟领航员们令人失望的表现时，刹车机师法兰克发现其领航员是新来的威尔，他虽然不是很高兴，不过也并没有说什么。法兰克有累积了28年岁月的工作经验，一登上装配老旧六轴车头的1206号列车，很自然地就把刚受训4个月的新手威尔比了下去……影片相结合地呈现了职场处于职业玻璃顶的老人与新人之间的常态矛盾冲突情景。

两个车场的员工们，一如既往地干着同样琐碎的日常小事，他们谁都没有想到，这天下午即将有一场可怕的事故发生，考验着两名平凡小卒是否有足够“底气”或“运气”成为不平凡的大英雄 。在这部好莱坞大片中，英国著名导演托尼·斯科特（Tony Scott，1944～2012）用“硬桥硬马、稳扎稳打”的经典方式精彩再现了这场可能会夺走数十万人的灾难临界点，而两位主演丹泽尔·华盛顿和克里斯·派恩也将面对灾难时的人心波动情景演绎得淋漓精致；该片段在风驰电掣的镜头中，以精湛的技术手段成功展示了这个重要的“危情时刻”——不仅仅是随时可能会爆发的灾难，更多的是灾难中闪闪发光的人性，尤其是一位高级工程师员工和他年轻工友们临危不惧力挽狂澜的“组织公民行为”及其自我奉献精神——为这个真实事件改编的故事更增添了一份显得夸大而不夸张、紧张而又轻松、充满张力而又扣人心弦的娱乐气息。

虽然影片主角是两个普通铁路工人，但依然是“孤胆英雄拯救世界”的好莱坞式经典老套路旧模式，编导通过自己蒙太奇手法及朴实表达方式，不露痕迹折射呈现出“组织公民行为”的社会责任感和人性关怀人文关爱两大主题。对于一个天天和铁路打交道的人来说，这部电影或许会充满亲和感，因为其主要道具就是铁路、机车、道岔、脱轨器、弯道、限速、信号机、调车场、侧线……这些可能对一般观众而言很陌生，但对于铁路工人来说那是天天挂在嘴边、写在纸上、看在眼里、记在心里的日常工作景象，对于他们来说“在惊心动魄中感觉平淡无奇”或“在平淡无奇中让人惊心动魄”，可能最本真新奇的一种观感体验。

就蒙太奇手法而言，电影最成功之处就是营造了一种令人揪心的气氛，就像托尼所说的“以80ｋｍ速度开始，以240ｋｍ速度结束”。其实，火车到最后的时速也就是80英里，换算成公里数是128ｋｍ/ｈ；即使技术水平发达如北美，他们的货运列车时速也不会超过120ｋｍ/ｈ，只有高速铁路才能超越200km/h这个坎。只因为司机一个失误就造成一列时速并不快的列车开启自动驾驶脱马由疆，加速度随着时间推移逼近极限、滚滚铁龙横冲直撞，似乎要碾碎敢挡在它面前的任何障碍物，本来会损失一个亿的事故逐渐演变成损失几十个亿甚至搭上成千上万人命的大灾难……于是乎，“危情时刻”间，日常平凡而临危不惧的“超人”来了。

在特技摄影镜头中，一个离婚的老头，一个快离婚的小伙，一列咆哮的火车，一群不知所措的观众，视觉效果极其震撼的大片就这样完成了。整部影片自始至终，都是在拍摄汽车赶火车、人追火车、飞机追火车，就差火箭追火车……；而情节发展却平淡无奇——一个老头导演加上一个老头演员，登上一台老掉牙的机车，配合着老得快退休的铁路主管，吼叫着一个谈不上好看的半老徐娘……对此，除了铁杆铁路迷们，其他“局外人”或许很少能对这种“危情时刻”的钢铁庞然大物感同身受。但是，一个普普通通的司机，在危机时刻挺身而出，不要劳保，不要退休金，不要几十年如一日的付出，这是一种怎样的“大无畏革命牺牲精神”啊！说它是一部北美主旋律电影，或许一点都不夸张。

《危情时速》真正吸引人的是它叙事的真实大背景。一桩企业日常运营中意外发生的大事故，却有着艺术创作作品的所有巧合因素，仿佛冥冥中有一个天才的“编剧”在控制，让两个如此有戏的主角凑在一起，经历了惊心动魄的“危情时刻”。一个是经验丰富的老司机，对官僚和关系网有着极度的抵触；一个是菜鸟级别的驾驶员，疑似因为裙带关系而调来班组。而他们两个又同时面临着家庭关系的危机，或青春期女儿对独身老爸的叛逆，或怀疑妻子外遇而几乎家暴被法庭隔离无法见到孩子的苦闷；两个普普通通的小人物，带着各自的心思和麻烦上路，然后在一个“危在旦夕”的关键时刻，在光天化日万众瞩目之下，做出了一个性命攸关、或许自己也会后怕的人生大抉择，最终成为力挽狂澜的大英雄，并顺带也把自己的家庭问题“买一送一”解决了，可谓一个典型“好莱坞式皆大欢喜”或“美剧式大团圆”！

这部经典美国式主旋律影片，给此岸观众最大的“震撼”或许不是别的，而是“芸芸众生小人物才是创造人间奇迹的真主体”的美人神话故事。这是一种没有敌人的战斗，却有着高强度的张力和对抗性，在各部门工作的铁路员工们，带着各自认真的态度，“齐心协力”共同对抗这场因个人疏忽而可能产生的巨大灾难；一个个平时充当社会底层基石的普通人，因为彼此依赖相互信任、因为公民意识、因为社会责任，在关键时刻转身变成力挽狂澜、创造奇迹的大英雄……什么是“公民社会”？何为“组织公民行为”？什么是美式特色的主流价值观？这就是。

这是一种此岸观众所不熟悉的动人真实，没有那种我们习以为常的通稿话语——“事故发生后，各方高度重视，迅速成立相关工作组开展事故调查及善后处理工作，奥巴马和克林顿先后作出批示，全力以赴、不惜一切代价……”，以及“组织召开全市铁路交通安全工作紧急会议，举一反三开展安全隐患大整治、大排查，确保铁路交通安全有序”等等说辞，这场彼岸意外大事故的处理方式体现出的，是对生命的尊重、对真实的尊重，当事人不刻意为了媚上而蒙蔽真相、践踏事实，而是以身作则自然释放出普通小人物身上潜移默化深入骨髓的公民意识和社会责任感及其所蕴藏的巨大能量，这才是我们所稀罕的，也是本土民众所期望看到而现实中却不可得的！ 　

附录：

The Culprit

罪魁祸首

Photo by Pat Huemmer, copyright © April 6, 2002

Photo used courtesy of Mr. Huemmer and RR Pictures Archives

Subject: CSX 8888 Runaway Investigation

主题：CSX 8888列车失控调查

CSX 8888 Runaway Investigation, received by Email on November 5, 2001.

Unmanned Train Movement

In accordance with your instructions, the following report summarizes the work of the investigation committee which was assigned to review and analyze the events of May 15, 2001, in which a locomotive with cars departed from Stanley Yard on the CSXT near Toledo, Ohio and traveled south to Kenton, Ohio, with no crew member on board. I was assisted in this review by MPE Inspector Mike Lusher and OP Inspector Ed Scalzitti, both of whom responded initially to the incident, and by Chief Inspector Harold Rugh, who provided essential technical information.

无人驾驶列车运行

根据您的指示，以下报告总结了调查委员会的工作，该委员会负责审查和分析2001年5月15日的事件，在该事件中，一辆载有车辆的机车从俄亥俄州托莱多附近的CSXT上的Stanley Yard出发，向南行驶到俄亥俄州的肯顿，车上没有机组人员。MPE检查员Mike Lusher和OP检查员Ed Scalzitti（他们两人最初都对事件做出了回应）和首席检查员Harold Rugh（他提供了重要的技术信息）协助我进行了审查。

Synopsis

On May 15, 2001, at approximately 12:35 p.m., DST, an unmanned CSX yard train consisting of one model SD-40-2 locomotive, 22 loaded, and 25 empty cars, 2898 gross trailing tons, departed Stanley Yard, which is located in Walbridge, Ohio. The uncontrolled movement proceeded south for a distance of 66 miles before CSX personnel were able to bring the movement under control. At the time of the incident, the weather was cloudy with light rain. The ambient temperature was 55 degrees Fahrenheit. There was no derailment of equipment or collision. There were no reportable injuries as a result of the incident.

提要

2001年5月15日，美国夏令时下午12时35分左右，一列无人驾驶的CSX车场列车驶离位于俄亥俄州沃尔布里奇市的斯坦利车场，该车场由一辆SD-40-2型机车、22辆满载机车和25辆空车组成，总拖运吨数为2898吨。在CSX人员能够控制移动之前，不受控制地向南移动了66英里。事发时，天气多云，有小雨，环境温度为华氏55度。事故中，没有设备脱轨或碰撞，没有可报告的伤亡情况。

Circumstances Prior to Incident

Yard crew Y11615, consisting of one engineer, one conductor and one brakeman, reported for duty at Stanley Yard, Walbridge, Ohio, at 6:30 am, DST, May 15, 2001. After the normal job briefing with the trainmaster, crew Y11615 performed routine switching assignments until approximately 11:30 am, at which time the crew received new instructions and a second job briefing. A few minutes before 12:30 p.m., the crew entered the north end of track K12, located in the classification yard, with the intent to pull 47 cars out of K12 and then place these cars on departure track D10. Locomotive CSX 8888 was positioned with the short hood headed north. The engineer was seated at the controls on the east side of the locomotive.

The locomotive coupled to the 47 cars on track K12, as instructed and planned. The air hoses between the locomotive and the cars were not connected, as is normal during this kind of switching operation. The air brakes on the cars were therefore inoperative. The brakeman notified the engineer by radio to pull north from K12. After the rear or 47th car passed the brakeman's location, he walked west to position the switch for the reverse movement to proceed into the assigned track D10.

The movement continued north out of K12 passing the conductor, who was positioned on the ground at the "Camera" switch. The conductor advised the engineer by radio of the number of cars that had passed him and received an acknowledgement from the engineer by radio.

事件发生前的情况

2001年5月15日夏令时上午6:30，由一名工程师、一名售票员和一名刹车员组成的Y11615号机组，到俄亥俄州沃尔布里奇市斯坦利场上班。在与列车长进行正常工作简要通报后，Y11615号机组执行常规转换任务，直到上午11:30左右，机组收到新指令并做了第二次工作通报。下午12:30前几分钟，机组人员进入位于分级场的K12轨道北端，打算从K12中拉出47辆车，然后将这些车放在发车轨道D10上。CSX8888机车的定位是短引擎盖朝北，工程师坐在机车东侧的操纵台上。

按照指示和计划，机车连接至K12轨道上的47节车厢。机车和车厢之间的空气软管没有连接，在这种切换操作中属于正常情况。由于机车上的空气制动器不能工作，刹车员借助无线电通知工程师从K12向北驶去。在后面或第47节车厢通过制动员的位置后，他向西走去，定位倒车开关，进入指定的轨道D10。

从K12向北移动，经过位于地面“摄像机”开关处的导体，列车长通过无线电通报工程师经过他的车辆数量，并通过无线电收到工程师的确认。

The Incident

With eight cars remaining to pass over the "Camera" switch, the conductor notified the engineer by radio to prepare to stop. The engineer did not respond to his communication. The conductor again notified the engineer when four cars remained to clear the switch, but again there was no response from the engineer. The conductor then ordered the engineer to stop movement, but again there was no response from the engineer and the movement continued.

In his interview, the engineer stated that as he pulled north out of K12, he was notified by radio by the conductor that the trailing point switch for track PB9 off the lead was reversed. The engineer understood that it would be necessary for the movement to be stopped short of the PB9 switch in order to line the switch for movement further along the lead. Neither the conductor nor the brakeman were near the PB9 switch, and the engineer intended to stop his train, dismount from the locomotive, and align the switch to its normal position, if necessary. The speed of the movement up the lead had now reached 11 mph. The engineer observed the reversed switch, but due to the wet rail conditions and the number of cars coupled to his locomotive, he foresaw that he could not bring the equipment to a stop prior to passing through the misaligned switch.

The engineer responded by applying the locomotive's independent brake to full application. The independent brake applies the brakes on the locomotive but does not apply the brakes on the individual freight cars. In addition, he reduced brake pipe pressure with a 20 psi service application of the automatic brake valve. The automatic brake is pneumatic braking system designed to control the brakes on the entire train. Still certain he would not stop short of the switch the engineer attempted to place the locomotive in dynamic brake mode. The dynamic brake utilizes the locomotive propulsion system to brake the train. Dynamic braking is analogous to down shifting a truck or automobile. Unfortunately, the engineer inadvertently failed to complete the selection process to set up the dynamic brake. Under the mistaken belief that he had properly selected dynamic brake, the engineer moved the throttle into the number 8 position for maximum dynamic braking. The engineer believed that the dynamic brake had been selected and that additional braking would occur. However, since dynamic brake set up had not been established, the placing of the throttle into the number 8 position restored full locomotive power, instead of retarding forward movement of the train.

While the train was still moving at a speed of approximately 8 mph, the engineer dismounted the locomotive and ran ahead to reposition the switch before the train could run through and cause damage to the switch. The engineer was successful in operating the switch just seconds before the train reached it. The engineer than ran along side the locomotive and attempted to reboard. However, the speed of the train had not decreased as the engineer had expected but had increased to approximately 12 mph. Due to poor footing and wet grab handles on the locomotive, the engineer was unable to pull himself up on the locomotives ladder. He dragged along for approximately 80 feet until he released his grip on the hand rails and fell to the ground.

Unable to reboard and stop the movement of his train, the engineer ran to contact a railroad employee, not a member of his crew but in possession of a radio, located at the north end of the yard. This employee immediately notified the yardmaster of the runaway train. The yardmaster promptly notified the Stanley tower block operator and the trainmaster. The Toledo Branch train dispatcher located in Indianapolis was also notified. The movement was now proceeding southward on the Toledo Branch (Great Lakes Division) governed by Traffic Control System (TCS) Rules. The time was approximately 12:35 p.m.

The brakeman observed the train depart the yard but did not initially see the engineer on the ground. The brakeman and another employee used a personal vehicle to pursue the train to the next grade crossing to attempt to board the train. Their immediate concern was for the safety of the engineer, who they feared may have suffered a heart attack while at the controls of the locomotive. At the grade crossing, the two employees were unable to board the train as the speed had increased to approximately 18 mph as it passed the mile post 4. Local authorities and the Ohio State Police were notified of the runaway train at approximately 12:38 p.m.

发生事故

还有八节车厢要通过“摄像头”开关，列车长通过无线电通知工程师准备停车，但工程师没有对他的通信作出回应。列车长再次通知工程师，还有四节车厢需要清除道岔，但工程师还是没有回应。列车长随后命令工程师停止移动，但工程师仍然没有回应，继续移动行进。

在采访中，工程师表示，当他从K12向北驶出时，列车长通过无线电通知他，PB9号轨道的牵引转辙器与导线相反。工程师理解，有必要在PB9开关附近停止移动，以便使开关沿导线进一步移动，但列车长和制动员均未靠近PB9道岔，工程师打算停车，于是从机车上下来，并在必要时将道岔对准其正常位置。这时，机车引擎速度已经达到了每小时11英里。工程师看到了反向道岔，但由于轨道潮湿、牵引车厢数量多，他预见到在通过未对准道岔之前是无法停止设备的。

工程师的第一反应是充分应用机车的独立制动器，而不在单个货车上应用制动器，并通过20 PSI自动制动阀维修应用降低了制动管压力。自动制动器为气动制动系统，用于控制整列车上的制动器。工程师仍然确信他不会在没有开关的情况下停车，试图将机车置于动态制动模式，利用机车来推进系统制动列车，类似于卡车或汽车的下移。不幸的是，工程师无意中未能完成设置动态制动器的选择过程。由于错误地认为他正确地选择了动态制动模式，工程师将油门移动到8号位置以获得最大动态制动，以为已选择了动态制动器并将发生额外制动。然而，由于动态制动装置尚未建立，将油门置于8号位置可能恢复全部机车功率，而不是阻碍列车向前移动。

当列车仍以大约8英里/小时的速度行驶时，工程师卸下机车，向前跑去重新定位道岔，以免列车通过并损坏道岔。工程师在列车到达道岔前几秒钟成功地操作了道岔，然后沿着机车边跑试图重新上车。然而，列车速度并没有如工程师预期的那样降低，而是提高到大约12英里/小时。由于机车上的底脚不好、把手潮湿，工程师无法爬上机车的梯子，他被拖了大约80英尺，直到松开扶手摔倒在地。

由于无法重新上车并停止列车运行，工程师跑去联系一名铁路员工，该员工不是他的机组成员，但他拥有一台位于车场北端的无线电。这名员工立即将失控的火车通知了场长，场长立即通知了斯坦利塔楼运营商和列车长，紧接着位于印第安纳波利斯的托莱多支线列车调度员也收到了通知。于是，无人驾驶列车按照交通控制系统（TCS）规则，在托莱多分支（大湖区）向南推进，时间大约是下午12点35分。

制动员观察到列车离开车场，但最初没有看到地面上的工程师。制动员和另一名员工使用个人车辆追赶列车至下一个平交道口，试图登上列车。他们最关心的是这位工程师的安全，他们担心这位工程师可能在控制机车时心脏病发作。在平交道口，两名员工无法登上列车，因为列车通过4英里标杆时，速度已升至约18英里/小时。在下午12:38左右，当地政府和俄亥俄州警察接到了关于失控列车事故的通知。

Attempts to Stop the Runaway

At a siding called Galatea, near mile post 34, at approximately 1:35 p.m., the train dispatcher remotely operated the switch for the train to enter the siding. Previously a portable derail had been placed on the track in an attempt to derail the locomotive and thereby stop the movement. The portable derail was, however, dislodged and thrown from the track by the force of the train passing over it, and the movement of the train was not impeded.

Northbound train Q63615 was directed by the dispatcher into the siding at Dunkirk, Ohio. The crew was instructed to uncouple their single locomotive unit from their train and wait until the runaway passed their location. at approximately 2:05 p.m., the runaway train passed Dunkirk, and the siding was lined for the crew of Q63615 to enter the main track and to pursue the runaway train.

At Kenton, Ohio, near mile post 67, the crew of Q63615 successfully caught the runaway equipment and succeeded in coupling to the rear car, at a speed of 51 mph. The engineer gradually applied the dynamic brake of his locomotive, taking care not to break the train apart. By the time the train passed over Route 31 south of Kenton, the engineer had slowed the speed of the train to approximately 11 mph. Positioned at the crossing was CSX Trainmaster Jon Hosfeld, who was able to run along side the unmanned locomotive and climb aboard. The trainmaster immediately shut down the throttle, and the train quickly came to a stop. The time was 2:30 p.m. and the runaway train had covered 66 miles in just under 2 hours.

An examination of the controls confirmed that the locomotive independent brake had been fully applied, automatic brake valve was in the service zone, and the dynamic brake selector switch was not in the braking mode. All brake shoes had been completely worn to the brake beams.

The railroad was prepared to place an additional fully manned locomotive ahead of the runaway south of Kenton, if necessary, to further slow the train. This rather hazardous option was fortunately not required.

试图阻止失控列车

下午1:35左右，在34英里桩附近一条名为Galatea的侧线上，列车调度员远程操作道岔，让列车进入侧线。此前，在轨道上放置了一个便携式脱轨器，试图使机车脱轨，从而阻止列车移动。然而，移动式脱轨器被飞驰而过的火车从轨道上抛出，没有成功。

在调度员指挥下，北行列车Q63615进入俄亥俄州敦刻尔克的侧线。机组人员接到指示，将他们的单一机车单元从列车上断开，并等待失控列车离开其位置。下午2点05分左右，失控列车驶过敦刻尔克，Q63615号机组人员在侧线上排成一行，进入正线，追赶失控列车。

在俄亥俄州肯顿市67英里标杆附近，Q63615的机组人员成功地抓住了失控机车，并成功地以51英里/小时的速度连接到后面的汽车上。工程师逐渐使用机车的动态制动器，尽量不使火车断裂。当列车通过肯顿以南的31号公路时，工程师已经将列车速度降低到大约11英里/小时。在十字路口，CSX列车长乔恩·霍斯菲尔德（Jon Hosfeld）沿着无人驾驶机车的一侧运行并爬上火车，立即关闭油门，列车很快停了下来。当时是下午2点30分，这列失控的火车在不到2小时的时间里，已经行驶了66英里。

对控制装置的检查确认，机车独立制动器已用尽，自动制动阀处于工作区，动态制动选择器开关未处于制动模式，所有制动蹄都已完全磨损到制动梁上。

铁路公司准备在失控的肯顿南部增加一个全人驾驶的机车，如果必要的话，使火车进一步减速。幸运的是，这一相当危险的选择已经没有必要了。

Post Incident Investigation

The engineer of Y11615 was slightly injured, but he declined medical treatment. He was released from service with his crew at 5:30 p.m. The CSX did not require Drug or Alcohol testing of the crew, nor was federal testing required.

The engineer first hired on the Pennsylvania Railroad in 1966, and he was promoted to engine service in 1974. He received his most recent check ride with a supervisor in January 2001. The engineer's discipline record is clean.

A Federal Railroad Administration Motive Power and Equipment Inspector arrived at the location where CSX 8888 was stopped and performed a full mechanical inspection. He found all systems to function normally, including sanders, headlight, auxiliary lights, bell, horn and the alerter. The brake cylinder piston travel could not be determined, because all brake shoes were completely burned off.

事后调查

Y11615的工程师受了轻伤，但他拒绝接受治疗。下午5:30，他与其他员工一起下班。CSX没有要求对员工进行药物或酒精检测，也没要求进行联邦督查。

1966年，这位工程师第一次受雇于宾夕法尼亚铁路公司；1974年，他被提升为火车司机。2001年1月，他与一名主管进行了最后一次检查。工程师的专业记录是清白的。

一名联邦铁路局动力和设备检查员抵达CSX 8888停止的位置，并进行了全面的机械检查。他发现所有系统都能够正常工作，包括砂光机、前照灯、辅助灯、电铃、喇叭和报警器。但无法确定制动缸活塞行程，因为所有制动蹄都已完全烧坏。

Conclusions

结论

Air Brake System

Locomotive CSX 8888 is a model SD-40-2 manufactured by General Motors Corporation (EMD). This unit is equipped with 6L type air brake system. The Alerter system is connected directly to the air brake system which functions to provide an automatic full service penalty application of the air brake system, and a power knock out (PC) caused by failure to acknowledge the time out feature usually about 40 seconds. When the Alerter time out has expired, the engineer must acknowledge by tripping the acknowledging switch which will reset the time out feature. The Alerter system is nullified when locomotive brake cylinder pressure of 20 psi is developed in the Independent Application and Release pipe. This also prevents the P2A Application Valve from triggering a service brake application and PC action.

When the engineer of Y11615 placed the locomotive independent brake valve into full application, a design pressure was developed in the brake cylinders, depending on the type of relay valve, which nullifies the Alerter System. Had the engineer not placed the independent brake into the full applied position and caused a build up of brake cylinder pressure, when the time out feature had expired, the system would have functioned causing not only an application of the locomotive brakes but a PC trip which would have resulted in a Power Knock Out bringing the movement to a stop.

According to the interview of the engineer, he made a 20 psi brake pipe reduction with the automatic brake valve before dismounting the locomotive. This by no means would have provided any braking power in as much as the brake pipe was not connected to the cars and the system was not charged.

空气制动系统

CSX 8888型机车是由通用汽车公司（EMD）制造的SD-40-2型机车，本机组配备6L型空气制动系统。警报系统直接连接到空气制动系统，该系统的功能是提供空气制动系统的自动全常用惩罚应用，以及因未确认超时功能而导致的断电（PC），通常约为40秒。当警报超时过期时，工程师必须通过跳闸确认开关进行确认，该开关将重置超时功能。当在独立应用和释放管中开发20 psi的机车制动缸压力时，警报系统无效。这还可以防止P2A应用阀触发行车制动器应用和PC动作。

Y11615的工程师将机车独立制动阀完全应用时，制动缸中产生了设计压力，这取决于中继阀的类型，从而使警报系统失效。如果工程师未将独立制动器置于完全应用位置，并在超时功能过期时造成制动缸压力积聚，该系统的功能不仅会使机车制动器有效，还会导致PC跳闸，从而导致电力中断、及时停止移动。

根据工程师的采访，他在拆卸机车之前使用自动制动阀对制动管进行了20 psi的减压，由于制动系统中没有提供，因此制动系统中没能连接任何动力。

Dynamic Brake

General Motors Model SD-40-2 dynamic brake system is established by placing the selector lever into Dynamic Brake Mode. This will convert the traction motors to generators to produce voltage and amperage which is dissipated in the form of heat through the braking grids. Excitation for the fields of the traction motors is developed through the main generator and is regulated by increasing main generator outputby increasing diesel engine rpm. This increase in engine rpm is accomplished by increasing throttle position 1 (setup) through 8 positions. The effectiveness of the dynamic brake system is generally maximized at speeds above 40 mph. At very speeds, below 10 mph, the dynamic brake system is not effective.

When the engineer failed to properly move the selector lever into the dynamic brake mode, the traction motors remained in the motoring mode. By placing the throttle handle into number 8 position in this set up, maximum locomotive power was thus developed and diesel engine rpm would increase in a like manner to dynamic braking. Without first observing the load meter, and at low locomotive speeds, it may be difficult to determine immediately if the locomotive was in braking or power mode.

动态制动

通用汽车SD-40-2型动态制动系统是通过将选档杆置于动态制动模式来建立的。把牵引电机转换成发电机，产生电压和电流，并通过制动格栅以热量的形式散发出去；牵引电机磁场的励磁通过主发电机产生，并通过增加柴油发动机转速增加主发电机输出进行调节，发动机转速的增加是通过将油门位置1（设置）增加到8个位置来实现的。当车速超过40 mph时，动态制动系统的效率通常达到最大；当车速低于10 mph时，动态制动系统无效。

当工程师未能将选档杆正确移动到动态制动模式时，牵引电机保持在电机模式。在这种设置中，通过将油门手柄置于8号位置，从而开发出最大机车功率，柴油机转速将以与动态制动相同的方式增加。在不首先观察负荷表的情况下，在低机车速度下，可能很难立即确定机车是否处于制动或动力模式。

Commentary

In the days following the incident, state and local officials expressed concern about the potential for this type of event to occur in the future. While FRA does not dismiss any potential safety concern, the exact circumstances that combined to cause this incident are highly unlikely to recur. It is not uncommon, today, for our inspectors to observe an engineer bring his locomotive to a full stop, dismount his locomotive and operate a switch. This is done safely and in accordance with railroad safety rules and does not pose any special hazard to employees or the general public. Railroad operating rules generally prohibit any employee from dismounting, or mounting, moving equipment. Engineers are required by railroad operating rules to apply a hand brake and take other steps at the control stand to immobilize the locomotive before dismounting.

FRA does have an initiative which will minimize the possibility of runaway equipment resulting from unsecured equipment left unattended in a yard. This issue falls under the umbrella of the Switching Operations Fatality Analysis (SOFA) program, in my view, and we have taken steps to emphasize the securement of equipment in our ongoing SOFA activities. For example, since the incident, State of Ohio and Federal inspectors have visited CSX and NS terminals in Ohio, and elsewhere, to review with railroad managers policies and procedures relating to switching safety, including securement. We have not been able to identify any systemic problems or shortcomings in training, supervision, or operating practices that are cause for alarm. Inspectors do observe various local, non-systemic safety issues, and they are addressed promptly with local managers, in accordance with our standard policy and practice.

I might comment further on why this incident is unlikely to recur. The cause of the incident was multiple gross errors in judgement by the locomotive engineer. For the incident to have occurred, each error needed to be committed in sequence. First, the engineer was not properly controlling the speed of his train on the lead, if he is unable to stop for a switch improperly lined. This is covered by the railroad's operating rules. Second, if the engineer cannot stop for a switch improperly lined, the correct action to take is simply run through the switch and then stop without backing up, to avoid derailing the train. Third, an engineer should never dismount his locomotive while it is moving, except in extremely rare emergency circumstances, such as an imminent collision. This is also covered by the railroad's operating rules. Fourth, the engineer should not have relied on dynamic braking at low speed, since dynamic brakes are ineffective at speeds of less than ten mph, except on an AC locomotive. This is well known among railroad engineers. Fifth, the engineer seemed to believe, in error, that an automatic brake application would improve braking power on single locomotive with the independent brake fully applied. Sixth, the engineer misapplied the selector handle for "power" or "dynamic brake," an error that can only be understood if we assume the engineer acted with extreme haste and negligence. That all of these actions were taken by an apparently well-qualified, fully rested employee with a good service record is simply incredible.

It should be remarked that this incident could only have occurred during freight car switching and not during passenger car switching. Most freight switching is done "without air," that is without air brakes functional in the train. This is the industry standard, and it has been so for many decades. Passenger switching, on the other hand, is usually performed "with air," that is with air brakes functional in the train. In addition, it should be noted that passenger coaches are rarely switched with passengers aboard, because of concerns with passenger safety. In those rare circumstances where passengers are on board during switching, the air brakes would always be fully functional.

Finally, this incident could not have occurred to either a passenger or freight train involved in over-the-road operations. Before any passenger or freight train embarks on a run outside of the yard where the train is assembled, federal regulations require that the train receive a thorough inspection of its braking system and that the brakes be 100% operational before the train is permitted to begin its journey.

实况报道

在事件发生后的几天里，州和地方官员对未来可能发生此类事件表示担忧。虽然FRA没有排除任何潜在的安全问题，但导致该事件的确切情况极不可能再次发生。目前，我们的检查员观察工程师将机车完全停下来、卸下机车并操作道岔，这种情况并不少见。这是根据铁路安全规则安全完成的，不会对员工或公众造成任何特殊危害。铁路运营规则通常禁止任何员工拆卸或安装移动设备，要求工程师在下车前在控制台上使用手制动器并采取其他措施固定机车。

联邦铁路管理局确实有一项计划，打算将最大限度地减少因未经保护的设备无人看管而导致设备失控的可能性。看来，这个问题属于开关操作事故分析（SOFA）计划的范畴，我们已经采取措施，于正在进行的SOFA活动中强调设备的安全性。例如，自事件发生以来，俄亥俄州和联邦检查员访问了俄亥俄州的CSX和NS码头以及其他地方，与铁路经理一起审查与转换安全（包括安全）相关的政策和程序，但无法确定培训、监督或操作实践中引起警报的任何系统性问题或缺陷。检查员确实观察到各种本地、非系统安全问题，并根据我们的标准政策和实践，与本地经理及时解决这些问题。

为什么这一事件不太可能再次发生？我可能会做进一步评论。事故原因是机车工程师的判断有多处严重错误，需要按顺序检测每个错误。首先，如果工程师不能停下来换一个线路不正确的道岔，他就没有正确控制列车的速度，这在铁路运营规则中有所规定。第二，如果工程师不能因道岔排列不当而停车，则应采取的正确措施是通过道岔，然后在不倒车的情况下停车，以避免列车脱轨。第三，工程师不得在机车移动时拆卸机车，除非在极为罕见的紧急情况下，如即将发生碰撞，这也包括在铁路运营规则中。第四，工程师不应该依赖低速时的动态制动，因为动态制动在低于10 mph的速度下无效，交流机车除外，这在铁路工程师中也是众所周知的。第五，工程师似乎错误地认为，在完全应用独立制动器的情况下，自动制动模式会提高单台机车的制动功率。第六，工程师误用了“动力”或“动态制动”的选档杆手柄，只有在我们假设工程师行事过于匆忙和疏忽的情况下，才能理解这一错误。所有这些行动都是由一名显然具备良好资质、充分休息、服务记录良好的员工采取的，这简直令人难以置信。

应注意的是，该事件仅可能发生在货车转换期间，而不可能发生在客车转换期间。大多数货物转换是在“没有空气”的情况下进行的，也就是说，列车上没有空气制动器。这是行业标准，几十年来一直如此；而乘客换乘通常是在“有空气”的情况下进行的，也就是说，空气制动器在列车中起作用。此外，也应注意的是，出于对乘客安全的考虑，客车很少与车上乘客换乘；在极少数情况下，乘客在换乘期间在车上，空气制动器将始终能够完全发挥作用。

最后，这起事件也不可能发生在涉及公路运营的客运或货运列车上。任何客运或货运列车在列车装配场外运行之前，联邦法规要求列车接受制动系统的彻底检查，并且在允许列车开始其行程之前，制动器100%运行。

链接：http://kohlin.com/CSX8888/z-final-report.htm