WASHINGTON — Inadequate training methods contributed to a November 2024 incident on the Coastal Carolina Railway in which a conductor suffered amputation of his left leg after being struck by a railcar in a gravity-drop move, the National Transportation Safety Board said its final investigation report released today (Dec. 8, 2025).
The Nov. 19, 2024, incident near Rocky Mount, N.C., saw the conductor release air from two gondola cars to allow them to roll down, climb onto the ladder of one of the cars while it was in motion, and then slip from the ladder as he attempted to secure the hand brake. He fell between the railcars and was struck by the second car. He ultimately underwent amputation of his left leg below the knee.
NTSB investigators found that one railroad rule required workers working between a cut of cars to perform tasks like securing hand brakes to do so from a platform on the railcar rather than the ladder, while a second rule did not address where the worker should be positioned. The railroad has no formal training or instructions for trainee conductors, according to the report, so trainees were expected to learn through on-the-job training mentored by qualified conductors. “This training method can introduce variance in techniques taught and can lead to inconsistencies in identifying safe practices for certain tasks,” the report reads. “Consequently, the railroad did not have a reliable, performance-based method to ensure their conductor trainees could safely perform gravity-drop moves.”
The railroad has subsequently revised its training to include what it calls a sound and well-defined training procedure for gravity-drop moves, taught by its most experienced conductors qualified to provide training in a consistent manner. The process includes performance-based evaluation in which the trainee is required to correctly perform a given procedure at least three times without intervention before being considered to qualify that procedure. The railroad also issued a general order on Feb. 28, 2025, with specific instructions on performing gravity-drop moves.
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