# Railroad Accident Report 92-01

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Derailment and Collision of Amtrak Passenger Train 66 with MBTA Commuter Train 906 at Back Bay Station, Boston, Massachusetts, December 12, 1990
PB92-916301 NTSB/RAR-92/01
NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C. 20594
RAILROAD ACCIDENT REPORT
DERAILMENT AND COLLISION OF AMTRAK PASSENGER TRAIN 66 WITH MBTA COMMUTER TRAIN 906 AT BACK BAY STATION BOSTON, MASSACHUSETTS DECEMBER 12, 1990
US GOVERNMENT PRINTING OFFICE 1990 0-942 855
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NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON. D.C. 20594
RAILROAD ACCIDENT REPORT
ADOPTED:FEBRUARY 25, 1992
NOTATION 5434A
Abstract: At 8 23 a m on December 12, 1990, National Railroad Passenger Corporation (Amtrak) passenger train 66, consisting of a two-unit locomotive, two material handling cars, five passenger cars, one dining car, and two baggage cars, derailed and struck Massachusetts Bay Transit Authority (MBTA) commuter train 906, consisting of one locomotive, six passenger cars, and one control car, as both trains entered Back Bay station in Boston. Massachusetts
In this report the following safety issues are discussed: tram operations and speed limits, locomotive engineer training and Federal Railroad Administration certification, and locomotive event recorder data
As a result of its investigation, the Safety Board made recommendations addressing these issues to the National Railroad Passenger Corporation, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, and the United Transportation Union
CONTENTS
| EXECUTIVE SUMMARY | v |
| INVESTIGATION | 1 |
| The Accident | 7 |
| Injuries | 7 |
| Damages | 8 |
| Crew Information | 8 |
| MBTA Train 906 | 8 |
| Amtrak Train 66 | 8 |
| Train Information | 9 |
| MBTA Train 906 | 9 |
| Amtrak Train 66 | 9 |
| Tunnel. Signal, and Track Information | 10 |
| Tunnel | 10 |
| Signals | 10 |
| Track | 10 |
| Post Acident Track Examination | 10 |
| Operations information | 11 |
| Operating Procedures | 11 |
| Amtrak Train 66 | 11 |
| Management Oversight | 12 |
| Meteorological Information | 12 |
| Medical and Toxicological Information | 12 |
| Fire | 13 |
| Survival Aspects | 13 |
| Emergency Response | 13 |
| Passenger Evacuation | 13 |
| META Train 906 Crew | 14 |
| Amtrak Train 66 Crew | 14 |
| MBTA Train 906 Exits | 15 |
| Amtrak Train 66 Exits | 15 |
| Emergency Preparedness | 15 |
| Tests and Research | 19 |
| Speed Indicator Test | 19 |
| Maintenance Records | 19 |
| Locomotive Airbrake Valve Tests | 19 |
| Event Recorder Information | 19 |
| Event Recorder Tests | 20 |
| Sto ping Distance Simulation Tests | 22 |
| Braking Speed Simulation Tests | 24 |
| Amtrak's Postaccident Actions | 24 |
| Locomotive Engineer Training | 25 |
| Sources of Information | 25 |
| Program Organization | 25 |
| Classroom Training Phase | 25 |
| Physical Characteristics Familiarization | 26 |
| Simulator Training Phase | 27 |
| On-the—Job Training Phase | 27 |
| Final Evaluation of Apprentices | 28 |
| Program Administration | 28 |
| Development and Evolution of the Program | 29 |
| Engineers'and Apprentice Engineers‘ Concerns: | 29 ​ |
| FRA Engineer Certification | 29 |
| Event Recorder Regulations | 30 |
| ANALYSIS |
| General | 30 |
| The Accident | 31 |
| Advance Warning Devices | 32 |
| Brake Inspections and Test | 33 |
| Instructing Engrneer's and Apprentice's Performance Before Derailment | 33 |
| Locomotive Engineer Training and FRA Qualification | 35 |
| Locomotive Engineer Training Program | 35 |
| Amtrak Locomotive Engineer Training Deficiencies | 35 |
| Training and Qualification on the IIT Simulator | 37 |
| Training and Qualifications for instructing Engineers | 38 |
| Sources of Engineer Training Program Deficiencies | 38 |
| FRA Locomotive Engineer certification Requirements | 39 |
| Locomotive Event Recorders | 39 |
| Survival Aspects and Emergency Response | 40 |
| CONCLUSIONS |
| Findings | 40 |
| Probable Cause | 41 |
| RECOMMENDATIONS | 41 |
| APPENDIXES |
| Appendix A—Investigation and Hearing/Deposition | 43 |
| Appendix B—Personnel Information | 45 |
| Appendix C—Outline of Locomotive Engineer Training Program | 47 |
| Appendix D—Apprentice Performance valuation Farm to Be Completed by Instructing Engineers | 55 |
EXECUTIVE SUMMARY
At 8:23 am. on December 12, 1990, National Railroad Passenger Corporation (Amtrak) passenger train 66, consisting of a two-unit locomotive. two material handling cars, five passenger cars, one dining car. and two baggage cars, derailed and struck Massachusetts Bay Transit Authority (MBTA) commuter train 906, consisting of one locomotive, six passenger cars, and one control car, as both trains entered Back Bay station in Boston, Massachusetts
Operated by an apprentice engineer, Amtrak train 66 was traveling 76 mph, within a 30-mph speed restriction, on a 9" 30' curve when it derailed and struck META train 906 on the adjacent track. A fire ignited after the collision. On Amtrak train 66, 7 crewmembers and 43 passengers sustained injuries, on MBTA train 906, Screwmembers and 391 passengers were injured, and 7 firefighters sustained injuries Estimated damage exceeded $12.5 million
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the apprentice locomotive engineer to reduce speed in sufficient time to negotiate the curve into Back Bay station as a result of inadequate supervision provided by the locomotive engineer. Contributing to the accident was Amtrak‘s failure to provide adequate quality control oversight for its locomotive engineer training program, including the adequacy of selection and training for apprentices an selection and training of engineers who serve as supervisors to apprentices during on—the-job training Also contributing to the accident was Amtrak's failure to have advance warning devices for a speed reduction for the curve entering Back Bay station
The safety issues discussed in this report are:
* train operations and speed limits,and
* locomotive engineer training and Federal Railroad Administration certification, and
* locomotive event recorder data
As a result of its investigation, the Safety Board made recommendations addressing these issues to the National Railroad Passenger Corporation, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, and the United Transportation Union.
This work is in the public domain in the United States because it is a work of the United States federal government (see 17 U.S.C. 105).
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