BALTIMORE (WJZ) — The National Transportation Safety Board released a report Thursday detailing the findings of its investigation into the February 2019 death of a Norfolk Southern railroad conductor killed at the Bayview Rail Yard.

Federal investigators found that the conductor was riding on the side of a railcar while performing switching operations about 7 a.m. Feb. 7, 2019, when he was pinned between the car he was on and a stationary car on a neighboring track.

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The report noted that before the accident, employees requested to move the train to its next location after unhooking all but four railcars. In response, the yardmaster reminded the engineer that the conduct was not supposed to ride on the side of the railcars before approving the request.

When the train began moving, it approached a curve where three stationary railcars were sitting on a neighboring track—with only nine inches of clearance separating the moving and non-moving cars. Once employees realized the conductor was hurt, they halted the train and called for help.

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Investigators found that Norfolk Southern had rules forbidding employees from riding on the side or end of railcars in close-clearance spaces. They also noted that even though these rules were contained within terminal instructions, the information was unclear, which could result in confusion.

“We also found that the Norfolk Southern training program did not emphasize and test on the close-clearance restriction locations and location-specific hazards within the Baltimore Consolidated Terminal, which could lead to employees having inadequate knowledge to safely work in these areas,” the report stated.

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In response to the employee’s death, the NTSB recommended that the company revise its terminal instructions for close-clearance spaces. Additionally, the board suggested that the company adjust its training program to highlight close-clearance spaces and location-specific dangers.

CBS Baltimore Staff