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The conductor made multiple attempts to couple two railcars by directing the engineer in the lead locomotive to reverse short distances to bump the couplers together. During the last of these attempts, one of the railcars rolled up grade. The conductor then fouled the track and went between the railcars to manually adjust the coupler on this railcar to facilitate the coupling process and was struck when the uncoupled railcar rolled back down grade toward him unexpectedly. The accident sequence began with an inspection that failed to identify a missing knuckle pin.
The NTSB is an independent federal agency which determines the probable causes of civil aviation, railroad, transit, highway, marine, pipeline, and commercial space accidents.
