NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

RAILROAD SPECIAL INVESTIGATION REPORT

PB2001-917005

NTSB/SIR-01/02

MARYLAND TRANSIT ADMINISTRATION

LIGHT RAIL VEHICLE ACCIDENTS AT THE

BALTIMORE-WASHINGTON INTERNATIONAL

AIRPORT TRANSIT STATION

NEAR BALTIMORE, MARYLAND

FEBRUARY 13 AND AUGUST 15, 2000

7413

Railroad Special 

Investigation Report

Maryland Transit Administration 

Light Rail Vehicle Accidents at the 

Baltimore-Washington International 

Airport Transit Station 

Near Baltimore, Maryland 

February 13 and August 15, 2000

NTSB/SIR-01/02

PB2001-917005 National Transportation Safety Board

Notation 7413 490 LíEnfant Plaza, S.W.

Adopted December 11, 2001 Washington, D.C. 20594
National Transportation Safety Board. 2001. Maryland Transit Administration Light Rail Vehicle

Accidents at the Baltimore-Washington International Airport Transit Station Near Baltimore,

Maryland, February 13 and August 15, 2000. Special Investigation Report NTSB/SIR-01/02.

Washington, DC.

Abstract: In 2000, the Maryland Transit Administration experienced two similar accidents in the same

location just 6 months apart. Both accidents involved the failure of a light rail vehicle train to stop at the

designated stopping point at the Baltimore-Washington International Airport Light Rail Station (BWI

Airport Station). The Safety Board’s investigation of the two accidents indicated that, although the direct

cause of each accident was different, aspects of the Maryland Transit Administration rail transit operation

common to the two accidents influenced both their outcomes. The first accident occurred about 2:37 p.m.

on February 13, 2000, when Maryland Transit Administration train 24, en route from Baltimore to the

BWI Airport, struck the hydraulic bumping post at the terminus of track No. 1 at the BWI Airport Station

and derailed. The second accident occurred about 7:14 a.m. on August 15, 2000, when Maryland Transit

Administration train 22, en route from Baltimore to the BWI Airport, struck the hydraulic bumping post at

the terminus of track No. 2 at the BWI Airport Station and derailed. 

The safety issues discussed in this report are the adequacy of requirements governing the use of

prescription and over-the-counter medications by light rail vehicle operators, the effect of sleeping

disorders on the performance of light rail vehicle operators, and the adequacy of the event recorders.

As a result of its investigation, the Safety Board issued safety recommendations to the Federal Transit

Administration, U.S. rail transit systems, and the Maryland Transit Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation,

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical

Information Service. To purchase this publication, order report number PB2001-917005 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
iii Special Investigation Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

February 13, 2000, Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Train 24 Operator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Train 24 Mechanical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Postaccident Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Meteorological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Toxicological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

August 15, 2000, Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Train 22 Operator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Train 22 Mechanical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Postaccident Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Meteorological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Medical and Toxicological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Information for Both Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Track and Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

MTA Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

February 13, 2000, Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

August 15, 2000, Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Medication Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Medication Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

MTA System Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Equipment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Bumping Posts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Seat Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Event Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Contents iv Special Investigation Report

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Appendixes

A: Accident Brief on February 13, 2000, BWI Accident . . . . . . . . . . . . . . . . . . . . 68

B: Accident Brief on August 15, 2000, BWI Accident . . . . . . . . . . . . . . . . . . . . . . . 71
v Special Investigation Report

Acronyms and Abbreviations

APTA -- American Public Transportation Association

BWI Airport Station -- Baltimore-Washington International Airport Light Rail Station

CFR -- Code of Federal Regulations

FRA -- Federal Railroad Administration

FTA -- Federal Transit Administration

LRV -- light rail vehicle

MDOT -- Maryland Department of Transportation

MTA -- Maryland Transit Administration
vi Special Investigation Report

Introduction

In 2000, the Maryland Transit Administration (MTA)1 experienced two similar

accidents in the same location just 6 months apart. Both accidents involved the failure of

an MTA light rail vehicle (LRV) train to stop at the designated stopping point at the

Baltimore-Washington International Airport Light Rail Station (BWI Airport Station). In

both cases, the train struck a hydraulic bumping post apparatus at the end of the track. The

Safety Boardís investigation of the two accidents indicated that, although the direct cause

of each accident was different, aspects of the MTA rail transit operation common to the

two accidents influenced both their outcomes. Consequently, the Safety Board developed

a special investigation report to address the safety factors affecting both accidents.

The first accident occurred about 2:37 p.m. (eastern standard time) on

February 13, 2000, when MTA train 24 (composed of a single LRV), en route from

Baltimore to the BWI Airport, struck the hydraulic bumping post at the terminus of track

No. 1 at the BWI Airport Station and derailed. The force of the collision detached the

bumping post from the track, and the front of the train, which was lodged against the

bumping post, was elevated about 3 1/2 feet into the air. Train 24 carried 26 people (25

passengers and 1 operator), 18 of whom were injured. Five of those injured had serious

injuries. The MTA estimated the cost of the accident at $924,000.

The second accident occurred about 7:14 a.m. (eastern daylight time) on

August 15, 2000, when MTA train 22 (composed of two LRVs), en route from Baltimore

to the BWI Airport, struck the hydraulic bumping post at the terminus of track No. 2 at the

BWI Airport Station and derailed. The bumping post separated from its attachment to the

track and came to rest in an inverted position. The leading LRV of the train came to rest on

top of the overturned bumping post and about 4 1/4 feet up in the air. The roof of this LRV

was partially embedded into the ceiling structure of the terminal building. Train 22 carried

22 people (21 passengers and 1 operator), 17 of whom were injured. None had lifethreatening injuries. The MTA estimated the cost of the accident at $935,000.

This special investigation report discusses the following safety issues:

ï The adequacy of requirements governing the use of prescription and over-thecounter medications by LRV operators,

ï The effect of sleeping disorders on the performance of LRV operators,

ï The adequacy of the event recorders.

As a result of its investigation of these accidents, the Safety Board makes

recommendations to the Federal Transit Administration, U.S. rail transit systems, and the

MTA. 

1 In 2000, when the accidents detailed in this report occurred, the MTA was called the Mass Transit

Administration. On October 1, 2001, the MTA changed its name to the Maryland Transit Administration.
1 Special Investigation Report

Factual Information

February 13, 2000, Accident1

Accident Narrative

The operator of train 24 said he reported for duty at the Maryland Transit

Administration (MTA) light rail operations center at North Avenue Yard in downtown

Baltimore, Maryland, on February 13, 2000, at 9:30 a.m. (eastern standard time) for his

10:01 a.m. assignment as an operator on the Central Light Rail Line System. (See figure 1

for the layout of the Central Light Rail Line System.) He said that he spoke to the train

dispatcher when he reported for duty. He said he received a light rail vehicle (LRV) train

at the sign-up location, performed an equipment inspection, and started revenue service

from Pennsylvania Station in downtown Baltimore to the Baltimore-Washington

International (BWI) Airport Station at 10:44 a.m.2 He said he arrived and departed the

BWI Airport Station and was relieved at the University of Baltimore/Mount Royal Station

between 12:15 and 12:30 p.m. The operator said this trip was uneventful and, when asked

about the stop at the BWI Airport Station, he said he had stopped his train about 20 feet

from the ìhigh block.î3

The operator said that during his break period (which he recalled as beginning

about 12:30 and ending about 1:40 p.m.), he had asked the train dispatcher for ìa couple

of aspirinsî because he had a headache. He said he took the aspirins and lay down for

about an hour. He said that after his break period, he took over operation of train 24 at the

University of Baltimore/Mount Royal Station about 1:42 p.m., proceeded north to

Pennsylvania Station, and departed Pennsylvania Station southward at 1:51 p.m. in

revenue service. Train 24 was composed of a single LRV and traveled along main track

No. 1.

The operator said the trip from Pennsylvania Station to the BWI Airport Station

was uneventful. He said he experienced no problems with the equipment, and he stopped

at every station. The maximum authorized speed limit for the section of track from

Pennsylvania Station to the BWI Airport Station was 50 mph.

One passenger told the Safety Board that he had a clear view of the operator at the

North Linthicum Station (three stations before the BWI Airport Station). The passenger

said that the operator received a green signal at the station and then sat motionless for 10

to 15 seconds while the train remained stationary. He recalled that the operator then shook

his head and body before beginning to move the train forward.

1 See appendix A for an accident brief on this accident.

2 LRVs typically require only a single vehicle operator, and usually no other crewperson is on the train.

3 The highblock is a raised concrete platform with handrails designed to assist in the loading and

offloading of disabled passengers. The highblock is the normal designated stopping point for trains.
Factual Information 2 Special Investigation Report

Figure 1. Layout of the MTA Central Light Rail Line System.

Cromwell Station/Glen Burnie BWI Airport

BWI Business District

Ferndale

Linthicum

North Linthicum

Nursery Road

Baltimore Highlands

Patapsco

Cherry Hill

Westport

Hamburg Street/PSINet Stadium

Camden Yards

Convention Center

Univ. Center/Baltimore Street

Lexington Market

Centre Street

Cultural Center

Univ. of Baltimore/Mt. Royal

North Avenue

Woodberry

Cold Spring Lane

Mount Washington

Falls Road

Lutherville

Timonium Business Park

Timonium 

Warren Road

Gilroy Road 

McCormick Road

Pepper Road

Hunt Valley

Penn Station

BLUE

Trains operate between

Hunt Valley and 

Cromwell Station/

Glen Burnie

YELLOW

Trains operate between

Penn Station and 

BWI Airport

N
Factual Information 3 Special Investigation Report

The last station stop before the BWI Airport Station was the BWI Business District

Station. The operator said the BWI Business District Station stop was routine; one person

boarded and no one detrained. From the BWI Business District Station to the BWI Airport

Station, the maximum authorized speed was 15 mph. Safety Board investigators asked the

operator to describe the portion of the trip between the BWI Business District Station and

the BWI Airport Station. He said:

The weather was still overcast. The signals were working fine. I didnít run any of

them. Went on in. Blew the horn at both of the stationsóI mean, grade crossings.

And went on in and took my time going on in. And that was it.

The operator said the last signal for his train before the BWI Airport Station (signal

BWI 15-6 at milepost 115) displayed a yellow aspect.4 According to several passengers,

train 24 did not stop or slow at the BWI Airport Station but continued through the station

until it struck the hydraulic bumping post5

 at the end of the station track. During

postaccident interviews, several passengers told investigating law enforcement officials

that it appeared to them that the operator may have fallen asleep before the impact.

About 2:37 p.m., upon its collision with the bumping post, the train derailed. The

force of the collision detached the bumping post from the track, and the front of the LRV,

which was lodged against the bumping post, was raised about 3 1/2 feet into the air. (See

figure 2.)

When asked to describe the collision, the operator said:

People started getting up to get off. The next thing I know, ëboom.í I looked

around, pulled back. I saw it right there at me. I went up into the window.

Safety Board investigators asked whether the operator had attempted to stop the

train by applying the brakes. With respect to the train brakes, the operator was unclear but

did not indicate that he had applied them. With respect to the emergency brakes, he stated:

I was up on that bumping post that quick. I donít even know if I hit the mushroom

[emergency stop button] or not. All I knew, I was up in the window and came back

down on the floor. And I was out. I donít know if I was out foróI donít know how

many seconds I was out, but I knew I was out.

(See figure 3 for photograph of cab interior, showing emergency stop button.)

4 A yellow aspect calls for the operator to proceed prepared to stop at the next signal.

5 A bumping post is an apparatus located just before the physical end of a rail track. It is designed to

stop runaway railcars and absorb the kinetic energy should a railcar continue to travel past the designated

stopping point and on toward the end of the track.
Factual Information 4 Special Investigation Report

Figure 2. Two views of train 24 in the station following February 13, 2000, accident; 

top photo shows side view of train after it traveled into the end of the line, bottom 

photo shows close-up of front car resting on the bumping post.
Factual Information 5 Special Investigation Report

The operator would not estimate how fast the LRV was traveling when it struck the

bumping post. In attempting to explain the accident, he stated, ìIt [the LRV] just took off.

I must haveówhen I turned around or something to see why are these people coming up

there like that, I must have hit it, and it took off on me.î

Injuries

Table 1. Injuries resulting from February 13, 2000, accident

a The categories in table 1 are based on the injury criteria defined at 49 Code of Federal Regulations 830.2, which the 

Safety Board uses in accident reports for all transportation modes. 

Figure 3. LRV cab interior; arrow indicates emergency stop button.

Injury Typea Crew, train 24

Passengers, 

train 24 Other Total

Fatal 0 0 0 0

Serious 0 5 0 5

Minor 1 12 0 13

None 0 8 0 8

Total 1 25 0 26
Factual Information 6 Special Investigation Report

Of the 18 people who experienced injuries, 13 had injuries affecting the head,

neck, or throat, as documented in their medical records. Several of the paramedic

responders to the accident told the Safety Board that they considered that some serious

facial and neck injuries to passengers had likely resulted from impact with the LRV

seating grabrails.6 The paramedicsí observations were consistent with statements made by

some of the injured passengers. Of the seven injured passengers who responded to the

Safety Boardís questionnaire concerning this accident, two ascribed their injuries to

striking a grabrail. A third recalled striking a seatback, without specifying which part of

the seatback. A fourth injured passenger stated that he hit ìa pole.î (Some of the seatback

grabrails had vertical metal stanchions attached to them. Vertical metal stanchions were

also attached to the end panel by each car door.)

Damage

The MTA estimated the cost of the accident at $924,000.

LRV. The outside front center panel of the single LRV car that made up train 24

was dented inward 1 to 2 inches immediately below the windshield. The ìAî (front) end

of the two-segment car sustained localized exterior side-sheet panel distortion. The front

propulsion truck had separated from the car body and was wedged against the rear support

legs of the bumping post assembly. The pantograph assembly on the roof of the car bodyís

ìAî end was substantially damaged.

Bumping Post. As a result of the accident, both running rails apparently fractured

at points immediately north of the bumping post assembly. The westernmost running rail

was fractured at a bolt hole at the attachment of the bumping post assemblyís front support

leg. The easternmost running rail was fractured at a joint weld about 40 inches before the

bumping post assembly. The bumping post had been pushed backward to the point at

which its rear legs were firmly wedged against the vertical face of the concrete service

platform that surrounded the track and ballast. The front of the bumping post assembly

had rotated upward about 3 1/2 feet, having pivoted about its rear support leg members

(forming an ìA frameî). Despite being displaced, the bumping post assembly did not

appear to be seriously damaged.

Train 24 Operator

During an interview following the February 13, 2000, accident, the operator

described his day up to the accident as ìan average day.î He said that nothing had

distracted him from his duties until the accident. He said he had felt rested when he

reported for duty, although he said that his head had felt ìfilled up.î When asked whether

he had been alert and attentive, the operator responded that he had ìtried to be.î When

asked whether he had dozed off any time after he began his second trip that day, the

operator responded, ìI couldnít tell you. I probably did doze. I donít know. But I doubt it.

I probably did doze off.î He also stated that he had ìfelt tired and nauseated all day.î

6 A seating grabrail is the handle bar that is fitted across the top of the seatback.
Factual Information 7 Special Investigation Report

The operator said he had no deadline for completing his trip to the BWI Airport.

He said he was familiar with the route between Pennsylvania Station and the BWI Airport

Station.

Medical Factors. The operator was 53 years old at the time of the accident. He

said he used reading glasses only to see close up. He said he had no difficulty seeing in the

distance. He stated that he had no problems with his hearing.

The operatorís most recent physical examination before the accident had been on

May 18, 1999. Based on the results of the examination, the operator was recommended to

continue as an operator and re-certified. The expiration date of his medical certificate was

May 18, 2001. The physician who performed the examination noted that the operatorís

hypertension was ìwell controlled.î He also referred to the operatorís use of medication

with the notation ìblood pressureótwo.î The operator told the Safety Board that for the

last several years he had taken the prescription medication Capozide twice daily to control

high blood pressure.

The operator said that he had undergone oral surgery for a dental abscess in

December 1999 and had been prescribed two medications, oxycodone and Tylenol 3

(acetaminophen with codeine), to alleviate the pain. He was also prescribed penicillin. His

dentist prescribed the oxycodone and penicillin, and his personal physician prescribed the

Tylenol 3. The operator recalled that both doctors told him the pain medications might

cause drowsiness, and he acknowledged that he did become ìa little drowsyî after he took

them. The operator said that his regular physician was aware that he was employed by the

MTA, but he was not sure whether the physician knew he operated a light rail train. He

said that his dentist was not aware of his occupation.

MTA records contained an application for sick leave submitted by the operator on

December 31, 1999. The form indicated that the operator suffered from a ìdental abscessî

and that he was unable to work from December 12, 1999, until January 2, 2000. It further

indicated that the operator was initially treated for the condition on December 4, 1999, and

last treated on December 22, 1999. The operatorís personal physician checked ìyesî to the

following question on the form: ìIs the patient able to perform his/her essential job

duties?î The physician released the operator to return to duty on January 2, 2000.

The operator told the Safety Board that on the morning of the accident, he had

taken one blood pressure pill, one Tylenol 3 pill, and one oxycodone pill. He said he had

also taken two aspirins about noon. He said he had not used any other over-the-counter or

prescription medications. He said he had not used alcohol or illicit drugs that day.

When asked whether the MTA had a policy with respect to an operatorís use of

medications, the LRV operator responded, ìIf you take it [medication], let them know.î

He said the MTA was aware that he took medication to control high blood pressure but

was unaware he had been taking the pain-relievers oxycodone and Tylenol 3. When asked

why he did not inform the MTA about the use of those medications, he stated, ìIt wasnít

that much and I wasnít going to take it that long. I was hoping I wouldnít take it.î
Factual Information 8 Special Investigation Report

When the Safety Board interviewed the MTA contract physician7 about the

operatorís use of prescription drugs, the contract physician said that the operator should

have informed the MTA of his use of all prescription medications and should have taken

himself out of service. The contract physician stated that, while the operator was not

required to inform the MTA of his use of medications, it was expected that the operator

would have done so.

MTA records showed that on June 20, 1994, the operator had tested positive for

cocaine metabolites during a random urinalysis. He was removed from service effective

June 24, 1994, and enrolled in a rehabilitation program. Over the following months, he

underwent substance abuse treatment. The treatment included a number of urinalysis and

Breathalyzer tests to detect drugs and alcohol (respectively), beginning on July 8, 1994,

and concluding on September 11, 1996. A letter dated February 8, 1995, to the MTA from

the medical review officer said that the operator ìÖis working and has been; he has

fulfilled the SAP [substance abuse professional] recommendations as of 1/25/95.î

A random alcohol test was administered to the operator on February 13, 1997. The

results were negative. Some weeks later, the MTA directed the operator to report to a

substance abuse professional, as the final step in completing his rehabilitation period. In a

letter dated April 29, 1997, the substance abuse professional informed the MTA that the

operator was continuing in recovery, and that further testing was not indicated.

The operator was subsequently tested for alcohol and drugs for ìreasonable causeî

on October 23, 1997, after he was involved in an accident (collision with a safety barrier).

The results were negative for the presence of alcohol and drugs. This was the last time the

operator was tested for alcohol or drugs until he provided breath and urine specimens after

the February 2000 accident.

Work/Rest Routine. The Safety Board asked the operator to describe his

work/rest schedule for the days preceding the accident, but the operator said he could not

recall a detailed work/rest history. During an interview on February 14, 2000, the operator

said that before the accident, he had been off duty his two regularly scheduled days,

Thursday, February 10, and Friday, February 11. He said that he had taken a personal day

on Saturday, February 12. He could not recall his sleep schedule for this period, except

that he thought he had retired about 11:00 p.m. on February 12. He said that on the day of

the accident, February 13, he had gotten up briefly between 7:00 and 7:30 a.m. He lay

back down until between 8:00 and 8:30 a.m., at which time he arose.

7 The contract physician served as the MTAís medical review officer and was responsible, among other

duties, for tasks relating to the commercial driverís license renewal process and the MTA drug testing

program.
Factual Information 9 Special Investigation Report

MTA time sheets showed that the operator went on duty at 10:04 a.m. on

February 13. They showed that he went on a break at 12:17 p.m. and returned to duty at

1:42 p.m. The accident occurred about 1 hour later. At the time of the accident, it appears

that the operator had been awake for between 6 and 7 1/2 hours and on duty for about

4 1/2 hours.

Certification and Training. The MTA had initially hired the operator as a

busdriver on September 6, 1974. He qualified as a light rail operator, the position he

occupied at the time of the accident, effective June 10, 1993. To qualify for the position,

the operator had to take a number of written tests. On June 7 and 8, 1993, the operator was

given seven written tests pertaining to light rail operations. He was also given a written

test that required him to name the stations throughout the MTA system. He received

passing scores on all tests.

According to the MTA, the operator received 60 minutes of alcohol and drug

training in a classroom setting in December 1994. The written training materials provided

to him at that time included information about alcohol and illicit drugs, including

marijuana, cocaine, amphetamines, phencyclidine, and opiates. The training did not

address over-the-counter or prescription medications.

On July 2, 1995, the operator received LRV operator troubleshooting training. On

March 6, 1996, he was given additional light rail operator tests, for which he received

passing scores. On that same day, he received stop signal compliance training, at the

conclusion of which he received a certificate of achievement.

When asked about previous accidents he had experienced as an LRV operator, the

operator recalled that a truck had backed out and hit his train some years before in

Baltimore. He also said that in 1996 or 1997, a train he was operating struck a barrier, for

which he was assessed 3 days off. The MTA light rail transportation superintendent

indicated that the operator had received MTA safety awards for accident-free operation in

1994 and 1996. (A number of MTA operators had received such awards.)

At the time of the accident, the operator had a class ìBî commercial driverís

license, issued on January 3, 1997, with an expiration date of January 5, 2002. On

March 14, 2000, MTA police conducted a review of the Maryland Inter-Agency Law

Enforcement System database and found no criminal or civil records on file regarding this

operator. His license had not been suspended, revoked, or disqualified; and no points had

been assessed as of the inquiry date.

Train 24 Mechanical

General Equipment. Train 24 consisted of a single-car LRV, which is a twosegment, electrically powered, self-propelled, six-axle, articulated passenger railroad car.

The LRV could be operated as a single unit or in consists of up to three vehicles. The LRV

operated on 750-volt DC current provided by overhead catenary and collected through a

pantograph mounted on its roof. The LRV was manufactured by ADtranz at Elmira, New

York, and accepted by the MTA on September 25, 1998.
Factual Information 10 Special Investigation Report

The LRV was 95 feet long, 9 feet 6 inches wide, and 12 feet 6 inches tall when the

pantograph was completely down. The LRV weighed 109,643 pounds, empty. It was

designed to accommodate 84 seated and 177 standing passengers.

The LRV was equipped with electrical (dynamic or regenerative) and mechanical

(friction) brakes, which included tread brakes and track brakes.8 The operator could

manually initiate the track brakes by pressing the TRACK BRAKES or EMERGENCY

STOP push-button (ìmushroomî). The LRV computer was programmed to automatically

engage the track brakes when the master controller was moved to the FULL STOP

position or when a trip stop violation occurred.

Preaccident Inspections. The LRV that made up train 24 received its annual

inspection and maintenance beginning on October 8, 1999. The LRVís braking rate test

was last performed during this annual maintenance and inspection. According to the

results of the brake rate test, the LRV could stop from a speed of 23 mph in about 125 feet

in service braking mode and in about 63 feet in emergency braking mode. The LRV had

received its 45-day inspection and maintenance on January 6, 2000.

Postaccident Examinations

Track and Signal. The Safety Boardís postaccident examination of the track and

signals showed no evidence of tampering, vandalism, or electrical problems. Routine track

and signal function tests were performed, and no exceptions were noted. The MTA signal

maintenance, inspection, and testing records indicated that the equipment was in

satisfactory condition and listed no exceptions that would have prevented proper

operation. Examination of the rail did not reveal any scratch marks, signs of abrasion, or

metal shavings.

Event Recorder. Each MTA LRV was equipped with an event recording system, a

software package provided by ADtranz as an upgrade to the LRVís main computer

system. The recording system did not continuously retain all data concerning the LRVís

operation; a specific trigger had to activate the systemís storage function. For the MTA

system, the trigger that activated the recorderís storage function was the application of the

LRVís track brakes while the LRV was traveling at least 10 mph. The system then stored

the operational data from 30 seconds before until 30 seconds after the triggering event.

The data were stored in one of two locations within the trainís central computer memory.

During the morning of February 14, 2000, after the LRV was re-railed, the main

battery power was restored to the LRV to permit access to the event recorder data. MTA

personnel connected a laptop computer to the trainís main computer using a serial cable.

Investigators sent a series of commands to the LRVís computer to create a printout of all

recorded parameters since the triggering event. This printout should have shown the data

broken up by three data spikesóthe first marking the beginning of the recorded event, the

second (30 seconds later) showing the location of the actual triggering event, and the third

8 Track brakes are devices that can apply additional braking directly to the track through use of

electromagnets when more braking effort is needed, such as in emergency braking.
Factual Information 11 Special Investigation Report

(30 seconds after the second) indicating the end of the recorded event. When the printout

was created, investigators saw an initial spike, flat-line data for 60 seconds, and a second

spike. No spike appeared at the point at which the triggering event should have been.

Repeated attempts to capture these data led to identical results.

On February 15, 2000, after the LRV had been moved to the MTAís North Avenue

Yard operations center, another attempt was made to download the event recorder data.

When the event log was accessed, it showed a triggering event as occurring during the

previous morning (February 14), shortly after investigators had initially accessed the

accident data. At no time since the accident (February 13) had the train experienced an

event that should have triggered the event recording system. At the time of the supposed

second triggering event, the LRV was incapacitated and not moving, and no track brakes

were applied.

Because the system was supposed to be capable of retaining two separate recorded

events, investigators expected that the second triggering event would have occupied the

second memory slot in the data log, but this memory slot was empty. The triggered event

from the time of the accident that investigators had originally detected was no longer

listed in the log.

ADtranz, the recorder manufacturer, was notified of the difficulties encountered

with the event recording system. Several ADtranz representatives came to Baltimore to

analyze the problem. Also, the downloaded data were sent to ADtranz for review. ADtranz

could not identify the problem through data review. The ADtranz representatives who

came to Baltimore studied the software schematics and ran tests on the rail car to

determine why the recording system was malfunctioning. By studying the schematics, the

representatives determined that the software was designed to store only one event at a

time. Two memory slots were available, but the first slot was erased immediately after the

second slot was filled, and vice versa. Accordingly, Adtranz determined that the software

was acting as designed but not as requested by the customer, the MTA.

Extensive testing could not reproduce the recording of an event without an actual

triggering event. The ADtranz representatives could not determine the cause of the

malfunction. ADtranz was unable to identify and resolve the problem.9

Security Video Recorder. The MTA LRVs were equipped with video recording

systems to enhance security on the LRVs. Each system consisted of six independent video

cameras, a VHS video recorder, and a multiplexing unit. The six cameras were distributed

through the LRV as three cameras per each half of the LRV, the two halves being separated

by the carís articulation. Each LRV had two cameras facing out from the articulation, one

directed at the left-hand door, the other at the right-hand door. Each LRV also had one

camera at the opposite end of the LRV, above the cab door, facing directly down the center

of the car.

9 ADtranz is no longer in business.
Factual Information 12 Special Investigation Report

Following the accident, the LRVís video equipment was brought back to the Safety

Board lab for analysis. Because of the location of the cameras, the videotape showed no

visible evidence of any collision. A time stamp on the tape provided by the multiplexing

unit showed that the tape ended about the same time the accident occurred (recorder

time 14:37:12).

On the videotape, Safety Board investigators were able to identify the image of the

highblock at the far northern end of the BWI Airport Station platform to the left of the rear

half of the car. Using measurements of the distance from this platform to the impact point

and the time that each picture was taken from this location to the end of the tape,

investigators calculated an estimated average speed of the train while traveling along this

platform as 15.64 mph.

Meteorological

The National Weather Service reported that the weather at the BWI Airport at the

time of the incident, in mid-afternoon daylight, was overcast and dry (no precipitation

recorded) with wind from the southwest at 4 to 6 knots, visibility of 10 statute miles, and a

temperature of 34° F. It was also reported that light rain/drizzle started about 1/2 hour after

the incident.

Toxicological

Pursuant to requirements at 49 Code of Federal Regulations (CFR) 654.33 and

653.45, the operator provided a breath specimen for alcohol testing and a urine specimen

for drug testing.10 The breath specimen was obtained at 7:12 p.m. and the urine specimen

at 7:20 p.m. on the day of the accident. No alcohol was present in the breath specimen.

The urine specimen tested positive for benzoylecgonine, which is the metabolite of

cocaine (quantified at 7,300 nanograms per milliliter), positive for morphine

(2,000 nanograms per milliliter), and positive for codeine (2,100 nanograms per

milliliter).

During his initial interview on February 14, 2000, the operator had said he had not

used alcohol or illicit drugs before reporting for duty on the day of the accident. The

Safety Board re-interviewed the operator to discuss the results of his postaccident

toxicology tests. The operator was asked to explain how cocaine had entered his system.

He responded that the pain associated with his oral surgery had been so severe he had

resorted to self-medication using cocaine, which he believed would numb his gums. He

said that late on Friday evening, February 11, between 11:30 p.m. and midnight, he had

rolled two wet cotton balls in cocaine powder and placed them in the corners of his mouth.

He said he then relaxed for some time, possibly several hours. He was unable to say how

much cocaine he had used. The operator stated that he had not smoked, intravenously

injected, or nasally ingested the drug. He said he knew that using cocaine was illegal and

that he should not have had it in his system.

10 As stated at 49 CFR 40.21(a), U.S. Department of Transportation postaccident drug testing

regulations require that employers test for marijuana, cocaine, opiates, amphetamines, and phencyclidine.
Factual Information 13 Special Investigation Report

The operator was asked whether he had received a copy of the MTAís August 1991

Interim Rules and Instructions for Employees, to which he responded that he believed he

had. He was also asked whether he had received the ìMTA Substance Abuse Prevention

Policy,î to which he responded that he believed a copy had been mailed to him. The MTA

provided the Safety Board with a copy of a signed acknowledgement from the operator,

dated January 9, 1995, that he had received a copy of this policy.

During the inspection of the accident train on the evening of February 13, 2000,

Safety Board investigators found three pills in the cabís control compartment. The

investigators provided the pills to an MTA police officer at the scene. The MTA police

sent the pills to the Maryland State police laboratory in Pikesville, Maryland, for

toxicological analysis.11 The laboratory reported that ìtwo red and white capsules, both

with the inscription ëDPI658,í were identified as oxycodone and acetaminophen, and one

white pill, bearing the inscription ë93-150í and ë3,í was identified as codeine and

acetaminophen.î

Emergency Response

Two Maryland Transportation Authority police officers12 stationed at the airport

were on routine foot patrol duty and standing at an airport police security podium inside

the International Terminal Building (about 75 feet from the BWI Airport Station entrance

door) when train 24 entered the station. They saw the LRV collide with the bumping post,

and they immediately notified their communications dispatcher by portable radio. The

communications center dispatched emergency resources to the scene. The resources that

responded ultimately included 9 additional Maryland Transportation Authority police

officers, 6 BWI fire and rescue units, 13 BWI fire and rescue personnel, 9 ambulances,

and 18 paramedic personnel.

The MTA also dispatched emergency resources to the scene upon receiving

notification, via a radio transmission from the train 24 operator, that the accident had

occurred. Because of a misinterpretation on the part of the MTA, the MTA at first

dispatched its response personnel to the grade crossing immediately north of the BWI

Airport Station. These personnel were shortly thereafter redirected to the actual location of

the accident by MTA operations control, which had gained additional information on the

accident circumstances.

One of the two Maryland Transportation Authority police officers who had

witnessed the collision arrived at the station platform moments after the accident occurred

and attempted to gain entry to the car via the LRVís left front door. The officer had not

received emergency access training with the LRV equipment and was unfamiliar with the

external emergency door release mechanism (situated behind an access panel). As he

11 Investigators asked the operator why his medication had been on the control cab floor. He said that

the pills had been in his shirt pocket, and the accident impact caused them to fly out of the pocket.

12 The Maryland Transportation Authority police, who operate from a command facility at the BWI

Airport terminal, provide police services for the BWI Airport. The departmentís territory includes the entire

airport facility, and foot-patrol duty stations for Maryland Transportation Authority officers include the

International Terminal Building and the BWI light rail station.
Factual Information 14 Special Investigation Report

approached the front door of the LRV, the officer saw a sign that read ìmanual door

releaseî adjacent to the service door. Seeing the door release ìservice buttonî on the side

of the car and believing that the sign referred to a manual door release mechanism, the

officer pushed the button.13 The service button did not open the door.14 After a brief search

for some other external door release mechanism, the officer called to the LRV passengers

inside the car through the glass window in the LRV door. The officer told one of the

passengers to access the interior emergency door release handle (located adjacent to the

door) by breaking open the plastic security cover and then to pull the release handle. The

passengerís action released the service door. The officer was then able to enter the LRV

and begin assisting the passengers to exit the train.

Other responding police officers15 and fire and rescue personnel arrived at the

scene shortly thereafter and began assisting the passengers. Paramedic personnel also

arrived and assumed principal responsibility for on-scene medical triage, stabilization, and

transport of the injured. The BWI fire and rescue chief established his incident command

location at the passenger ìpick-up and drop-off zoneî adjacent to main track No. 1. Fire

and rescue personnel stabilized the front of the LRV using hydraulic jacks, pneumatic

lifting bags, and portable cribbing blocks.

Responders transported the first injured person from the scene at 3:04 p.m. and the

last injured person from the scene at 3:34 p.m. The remaining train 24 passengers were

transported from the scene by 3:45 p.m.

August 15, 2000, Accident16

Accident Narrative

The train 22 operator told Safety Board investigators that he reported to work

about 3:00 a.m. (eastern daylight time) on August 15, 2000, at the MTA light rail

operations center at North Avenue Yard for his assignment as a Central Light Rail Line

System LRV operator. The dispatcher who saw the operator before the operator went on

duty said he did not notice anything unusual about the operatorís appearance or demeanor

at that time. The operator checked the condition of the train equipment and received the

clearances required for the trainís operation for his tour of duty.

The operator had completed one round-trip from Pennsylvania Station to the BWI

Airport Station and was making another identical trip when the accident occurred.

13 The LRVs were fitted with a door release service button on the LRVís exterior side panels, adjacent to

the main service doors (eight per LRV). Pushing this button would open the main service doors. Signage

next to the button read ìPUSH TO OPEN.î

14 MTA light rail maintenance staff indicated that the door release service button may not have

responded because of a lack of electrical power, due to the collision.

15 The forces involved included BWI Airport police officers and mutual aid support from the MTA

Police, the Anne Arundel County Police, and the Maryland State Police.

16 See appendix B for an accident brief on this accident.
Factual Information 15 Special Investigation Report

Train 22, a train consisting of two LRV units, was traveling down main track No. 2 for its

approach to the BWI Airport Station.17 From the BWI Business District Station to the BWI

Airport Station, the maximum authorized speed was 15 mph.

The operator recalled that during the final portion of the southbound trip to the

BWI Airport Station, he observed that the crossing gates for the last grade crossing before

the station (at Fuel Farm Road) were down, that the speed of his train was lessening, and

that the signal at milepost 115 (BWI 15-6) displayed a red over yellow aspect.18 The train

failed to stop at the BWI Airport Station and collided with the bumping post at the end of

the station track about 7:14 a.m. The bumping post separated from its attachment to the

track and came to rest in an inverted position with the front of the lead LRV resting on top

of the overturned bumping post. The roof structure of the lead LRV was partially

embedded into the (false) ceiling structure of the terminal building, which severed

and dislodged some fire suppression system water sprinkler piping in the ceiling.

(See figure 4.)

17 Because of the effects of the February 13, 2000, accident at this station, the MTA had taken track

No. 1 out of service at this location until repairs were made. (The MTA was unable to quickly obtain the

equipment needed to make the repairs following the accident.)

18 A red over yellow aspect tells the operator to proceed at restricted speed until the entire train has

passed a signal displaying a more favorable aspect.
Factual Information 16 Special Investigation Report

Figure 4. Two views of train 22 in station following August 15, 2000, accident; top 

photo shows side view of train after it struck the end of the line, bottom photo shows 

front car sitting on overturned bumping post.
Factual Information 17 Special Investigation Report

The operator said that the signal was the last thing he saw before he went ìout.î He

said he was not aware of anything until he returned to consciousness after the accident and

found the train up in the air and emergency personnel boarding it. The operator was unable

to say how long he had been unconscious or exactly what might have caused him to lose

consciousness.

Injuries

Table 2. Injuries resulting from August 15, 2000, accident

a

 The categories in table 2 are based on the injury criteria defined at 49 CFR 830.2, which the Safety Board uses in 

accident reports for all transportation modes. 

b

 The five passengers cited in this tabulation category were transported to local hospital(s) by local emergency response 

agencies, evaluated for injury, and then released, with no documented injury or treatment reported. Therefore, for the 

purposes of this tabulation, they were considered uninjured.

Of the 23 people on train 22, a total of 22 (all passengers) were transported from

the scene to local hospitals for medical evaluation and/or treatment. Of the 22 people

transported to local hospitals, 17 were documented as having received medical treatment,

and 5 were documented as having been ìexamined and releasedî without receiving

medical treatment. All those who were transported to local hospitals were released the

same day.

On the scene, local emergency medical service responders conducted triage and

stabilization (treatment) efforts within the forward car of the LRV. The emergency medical

service responders told the Safety Board that arm, leg, facial/neck, and spine injuries had

apparently been sustained by a number of forward-facing LRV passengers; the injuries

appeared to have resulted from passenger impacts with the seatbacks and seating grabrail

elements. The emergency medical service responders indicated that the injuries in this

incident seemed less severe than those they had observed following the February 13,

2000, collision at this location.

Injury Typea Crew train 22 

Passengers 

train 22 Bystanders Total

Fatal 0 0 0 0

Serious 0 0 0 0

Minor 0 17 0 17

None 1 5b 0 6

Total 1 22 0 23
Factual Information 18 Special Investigation Report

Damage

The MTA estimated the cost of the accident at $935,000.

LRV 5006 (lead car). The ìAî-end coupler assembly and the related electrical and

communications cables were extensively damaged. Many car body-mounted major

components showed evidence of movement from impact by fractions of an inch. The

slewing ring at the articulated (middle) truck was off center by about 1/16 inch. The

triangular catenary anchor mounted to the airport building ceiling tore a long rectangular

hole through the roof of the carís ìAî end. This hole destroyed the pantograph assembly

and traction motor blower housing.

LRV 5050 (trailing car). Impact forces cut the pantograph shear pin. The ìAî-end

coupler deformation tube was collapsed or pushed inward about 5 inches by the collision.

Bumping Post. Both running rails, to which to the bumping post apparatus

support legs were secured, had fractured. One of the running rails appeared to have

fractured at a bolt hole, and the other appeared to have fractured at a joint weld, about

57 inches before the front support leg of the bumping post apparatus. The bumping post

apparatus sustained impact damage, consisting of visible scoring or scraping damage and

loss of paint, measuring about 13 inches in length, on the hydraulic cylinder piston ram

element in the area immediately adjacent to the cylinder casing face. The exposed length

of the piston ram element was about 30 inches.19

Train 22 Operator

During his interview with Safety Board investigators on August 16, 2000, the

train 22 operator said that he had ìblacked outî before the impact with the safety barrier at

the BWI Airport Station.20 He said that, with respect to the day of the accident, he was

unable to remember anything after about milepost 115 (location of the last signal before

the BWI Airport Station) until he regained consciousness after the accident and saw

emergency personnel boarding the train. He said that he had never previously blacked out.

Medical Factors. The operator, who was 48 years old at the time of the accident,

told investigators that he had been off duty with a chronic back problem for about

2 months before the accident and had returned to work the day before the accident. He

stated that he had not used alcohol or illegal drugs before the accident. The operator said

that his vision was 20/20 and that his hearing was fine. Medical records identified the

operator as obese.

MTA records showed that the operatorís most recent physical examination before

the accident took place on August 18, 1999, at which time he was medically recertified as

an operator. The MTA records also showed that the operator sustained an on-the-job

19 The bumping post manufacturer indicated that the design of this equipment provides for the piston

ram element to return to its pre-impact length on being struck.

20 The train 22 operator made similar statements about blacking out to MTA personnel who arrived on

the scene shortly after the accident.
Factual Information 19 Special Investigation Report

injury, coded as a workerís compensation injury, on June 13, 2000. As a result, he was

disabled and unable to perform his duties from June 19 until July 15, 2000. He resumed

his duties on July 16, 2000. Two days later, on July 18, 2000, he sustained another on-thejob injury, also coded as a workerís compensation injury. MTA records contained a

disability slip dated August 7, 2000, indicating that the operator was under a physicianís

care from August 8 until August 13, 2000. He was permitted to return to work on

August 14, 2000, the day before the accident. The operator said that no MTA physician

had evaluated him upon his return to duty on August 14, 2000.

Records obtained from the train 22 operatorís personal physician showed that she

had examined him on several occasions in March and June 2000 for hypertension and

neck pain. The operator said that his personal physician was aware of his occupation.

The operator said he had taken 5 mg of Norvasc at about 1:30 p.m. on August 12,

2000, and 10 mg of cyclobenzaprine and 500 mg of Naproxen at about 3:00 p.m. on

August 14, 2000. Amlodipine, known by the trade name Norvasc, is a prescription

medication most commonly used to treat high blood pressure. It is also indicated for the

treatment of angina (chest pain due to reduction in blood flow to the heart).

Cyclobenzaprine is a prescription muscle relaxant, known by the trade name Flexeril.

Precautions accompanying the medication note that it may impair mental and/or physical

abilities required for the performance of hazardous tasks, such as operating machinery or

driving a motor vehicle. Naproxen is an anti-inflammatory medication, available over the

counter under the trade name Aleve. It is most commonly used to mitigate mild pain or

temporarily reduce fever.

The operator recalled that sometime between February and August 2000, he

showed one of his prescription medications21 to the MTA light rail superintendent and

another MTA supervisor. He said that the medication container had carried a safety

warning about operating machinery. He said that the MTA light rail superintendent told

him that the medication was a pain-reliever and that it was up to the operator to determine

whether he was fit to work. The operator said that several days later he became concerned

about the medication and wanted the MTA light rail superintendent to sign a pamphlet that

accompanied it. He said that, as this official was unavailable, he approached an MTA

supervisor. He recalled that the supervisor had advised him to use caution and signed the

pamphlet. When asked by the Safety Board to produce the signed pamphlet, the operator

was unable to do so.

On August 17, 2000, the Safety Board asked the MTA light rail superintendent

about the operatorís statements. The superintendent said that he was unable to remember

specifically whether this operator had approached him with a question about medication

use. He recalled that several operators had approached him with questions about

medication use. He told the Safety Board that he had responded by informing them that

using medications could cause drowsiness and that, if they were drowsy, they should not

operate a train.

21 The train 22 operator said he had used five prescription medications in the year before the accident.
Factual Information 20 Special Investigation Report

On October 18, 2000, the Safety Board discussed the operatorís statements with

the MTA supervisor the operator had named. The supervisor told the Safety Board that he

could not specifically recall the operator having shown him any medication, although he

thought it possible that during general conversation the operator may have mentioned that

he was taking medications. The MTA supervisor said he was certain he did not sign any

document or pamphlet that pertained to any aspect of medication use or associated

warnings for the operator.

The operator said that he was not aware of definite MTA policies or procedures

concerning medication use. He said that following the February 13, 2000, accident at the

BWI Airport Station, he had heard two conflicting views on this issueófirst, that the

MTA had procedures, directives, bulletins, or a policy that addressed use of medications,

and, conversely, that no such policies or procedures existed. He said that after the

February 2000 accident, the MTA appeared to have heightened awareness about

prescription medications (particularly those that bore warnings), but he had heard nothing

about prescription drugs from anyone associated with the MTA since about March 2000.

Work/Rest Routine. When asked whether he had felt rested on the day of the

accident, the operator responded that he had. The Safety Board asked the operator to

describe his work/rest schedule for the days preceding the accident. The operator recalled

that he awoke about 8:00 a.m. on Friday, August 11, 2000, ran several errands, and

returned home at noon. He said he left to travel to Philadelphia, Pennsylvania, about

1:30 p.m. and returned to Baltimore by 1:30 a.m., Saturday, August 12, at which time he

retired. He arose that day about noon and remained at home until about 8:00 p.m., when he

went out for dinner. He said that he returned between 10:30 and 11:00 p.m., at which time

he retired for the evening. He said he awoke at 10:00 a.m., Sunday, August 13, and

prepared for and went to church. He returned home by about 3:30 p.m. and lay down

about 4:00 p.m. He said that he did not actually sleep but rested from then until about

10:00 p.m., when he retired to bed for the evening. He recalled that he awoke the

following morning, Monday, August 14, about 2:00 a.m., and arrived for work by

3:00 a.m. He said that he worked until 11:10 a.m. and returned home. He retired for the

evening between 5:00 and 6:00 p.m. and awoke the following morning, Tuesday,

August 15, at 2:00 a.m. He said that he arrived for work about 3:00 a.m. At the time of the

accident, he had been awake for about 5 hours 15 minutes and on duty for about 4 hours

15 minutes. The operatorís work/rest history is displayed in table 3.
Factual Information 21 Special Investigation Report

Table 3. Train 22 operatorís work/rest history information

Certification and Training. MTA records showed that the LRV operator was

originally hired on September 27, 1974, as a bus operator. He remained in that position

until March 3, 1994, when he was certified as an LRV operator, the position he held at the

time of the accident. MTA training records showed that between February 28 and

March 2, 1994, the operator was given and passed seven light rail operator training tests.

On July 18, 1995, he took light rail troubleshooting training. On March 21, 1996, he was

given stop signal compliance training and re-administered light rail operator testing,

which he passed. The operator said that he had never received any alcohol or drug

training. MTA records showed two disciplinary reports for the operator.

First, on June 27, 1994, the operator was cited for ìViolation of MTA substance

abuse and rehabilitation agreement.î The operator had tested positive for cocaine on

March 7, 1994, and was removed from service. The operator requested and was granted a

leave of absence from March 17 to April 17, 1994, during which time he entered phase 1

of rehabilitation. The operator tested positive for cocaine on March 18, 25, and 30 and on

April 1, 1994. He repeatedly tested negative for illicit drugs between April 4 and June 16,

1994. Phase 2 of his rehabilitation began on April 26 and lasted until July 26, 1994. On or

about June 27, he again tested positive for cocaine and was cited for a violation of the

MTA substance abuse and rehabilitation agreement. He continued in the rehabilitation

program and provided numerous specimens. He was evaluated by a substance abuse

professional on February 24, 1995, and was reinstated on April 10, 1995. The operator

continued to provide specimens (negative for drugs) until June 2, 1997, at which time the

substance abuse professional recommended that no further follow-up testing be

conducted.

Second, in a July 9, 1999, disciplinary report, the operator was cited by the MTA

for the following complaints: ìMoved train without proper authorityî and ìReversed train

without permission, resulting in derailment.î After the MTAís investigation of the related

incident, he was reinstated and ultimately charged 3 days of lost time.

Day Time Activity Sleep Obtained That Night

August 11 8:00 a.m.

1:30 a.m. (August 12)

Woke up 

To bed 10 1/2 hours

August 12 12:00 p.m. (noon)

11:00 p.m.

Woke up 

To bed 11 hours

August 13 10:00 a.m.

4-10:00 p.m.

10:00 p.m.

Woke up 

Rested

To bed 4 hours

August 14 2:00 a.m.

3:00 a.m.

11:10 a.m.

5-6:00 p.m.

Woke up

Reported for duty

Went off duty

To bed 8-9 hours

August 15 2:00 a.m.

3:00 a.m.

7:14 a.m.

Woke up

Reported for duty

Accident occurred ---
Factual Information 22 Special Investigation Report

At the time of the August 2000 accident, the operator had a class ìBî commercial

driverís license, issued on April 8, 1996, with an expiration date of August 12, 2001. At

the request of the Safety Board, the MTA police conducted a review of the Maryland InterAgency Law Enforcement System database for the operator on August 30, 2000. The

review found no criminal or civil records on file. The operatorís license had not been

suspended, revoked, or disqualified; and no points had been assessed.

Train 22 Mechanical

Train 22 comprised two LRVs (LRVs 5006 and 5050) that had been coupled to

form a two-car consist. Each of the LRVs of train 22 was structurally identical to and

similarly equipped as the single LRV of train 24, which was described earlier.

Postaccident Examinations

Track and Signals. Postaccident inspection showed that the catenary system on

main track No. 1 into the BWI passenger platform, which had been damaged during the

February 13, 2000, accident, was not yet restored. Before the August 2000 accident, train

operations into the BWI passenger station had been restricted to loading and unloading

passengers on the track No. 2 side. Examination of the rail did not reveal any scratch

marks, signs of abrasion, or metal shavings.

Switch W115 was blocked and clamped in the reverse position, lining all train

movements into track No. 2. The selector lever on switch W115 was taken out of the

ìMotorî position and locked in the ìHandî position. With the selector lever of switch

W115 in the ìHandî position, the most permissive aspect that the signal system would

permit signal BWI 15-6 to display was a red over yellow aspect.

All signal units and signal cases were securely locked. No grounds or short circuits

were found. The sight line to the signals was not obstructed, and speed limit signs were

posted. The MTA signal maintenance, inspection, and test records indicated that the

equipment was in working condition and listed no exceptions that would have prevented

the signal equipment from operating properly.

Event Recorder. After the accident, the appropriate computer boards were

removed from each LRV and given to Safety Board investigators. The following day, a

Safety Board vehicle recorder specialist brought the computer boards to the MTAís North

Avenue Yard for download and readout. Because no triggering event had occurred (no

brake application), no data were recorded for this accident by either LRVís event recorder

system.

Security Video Recorder. The MTA chief of police took possession of the

security videotapes from both LRV cars upon his arrival at the scene. The security tapes

were brought back to the Safety Board laboratory for analysis.

The videotape from the first car showed the trainís operation until the accident.

The tape showed no visible evidence of any collision. A time stamp written on the tape by
Factual Information 23 Special Investigation Report

the multiplexing unit showed that the tape ended about the same time that the accident

occurred.22

The six cameras allowed the inside of the entire LRV to be viewed. However,

window glare from the sun made it difficult to identify any landmarks that the train had

traveled past. From the video system on the first LRV, Safety Board investigators were

able to isolate and identify one image outside the right side of the LRVís rear half and one

image outside the left side of the LRVís front half. The landmarks were identified as the

divergence of the rails into two parallel tracks shortly before the train reached the platform

and the corner of the wall of the airport building near the end of the track. Measurements

of the distance the train traveled between these two camera shots, coupled with the elapsed

time between the two shots, allowed investigators to estimate an average speed for the

train while traveling between these two points as 12.37 mph.

Meteorological

About 7:00 a.m. on August 15, 2000, local weather conditions were reported to be

clear, in daylight, with a temperature of about 68o F.

Medical and Toxicological

Toxicology. Pursuant to Federal postaccident toxicological testing regulations, the

operator provided a breath specimen at 10:54 a.m. and a urine specimen at 11:00 a.m. on

August 15, 2000 (about 3 hours 45 minutes after the accident occurred). Medical

personnel at Mercy Hospital, Baltimore, obtained a blood specimen for medical

evaluation. The Safety Board subpoenaed portions of the blood and urine specimens,

which subsequently underwent independent toxicological analysis at the Civil

Aeromedical Institute in Oklahoma City, Oklahoma. All specimens tested negative for the

presence of alcohol and illegal drugs. None of the test results indicated the presence of the

prescription muscle relaxant cyclobenzaprine (Flexeril). The urine specimen tested at the

Civil Aeromedical Institute revealed the presence of amlodipine.

Sleep Disorder Review. On August 18, 2000, the train 22 operatorís personal

physician noted in her records that the operator had been involved in a light rail accident

3 days before and had lost consciousness. About 2 weeks later, the physician referred the

operator to a sleep specialist because she suspected that the operator might be suffering

from a sleep disorder. On September 5, 2000, the operator was clinically tested for sleep

disorders at Good Samaritan Hospital in Baltimore. The hospital developed a sleep study

report for the operator that indicated a diagnosis of ìsevere obstructive sleep apnea

syndrome.î Obstructive sleep apnea (also known as OSA) is a chronic and debilitating

sleeping disorder that is often present for years or even decades before it is diagnosed.

Excessive daytime sleepiness is almost uniformly present in people who suffer from

obstructive sleep apnea.

22 The car computer time was compared to the actual time. The car computerís time was off by about

2 hours 42 minutes, so the time was corrected to make up for this inaccuracy.
Factual Information 24 Special Investigation Report

Typically, obstructive sleep apnea in an adult is exhibited after the subject goes to

sleep. Snoring proceeds at a regular pace for a time, often becoming louder, but is then

interrupted by a long, silent period during which no breathing occurs (apnea). The apnea is

then interrupted by a gasp for breath, and then the snoring returns to its regular rate.

During apneic periods, the oxygen level in the blood declines dramatically. Persistent low

levels of oxygen (hypoxia) cause the person to awaken repeatedly, often without being

aware of having done so. The obstruction of breathing that invariably results in gasping

for air prevents the person from reaching deeper stages of sleep. Individuals who suffer

from the disorder awaken poorly rested and, because they have been unable to obtain

restorative, uninterrupted sleep, go through the day feeling fatigued and disoriented.

The Good Samaritan Hospitalís report stated that the operator reported to the

examining sleep specialist physician that he had ìexcessive daytime sleepiness

sometimes.î The report stated that the operator had a self-reported Epworth Sleepiness

Scale23 value of 14. The values of the Epworth Sleepiness Scale range from 0 to 24.

Epworth Scale values for a person without excessive sleepiness would be 10 or less, while

values 11 through 24 indicate significant sleepiness.

The medical testing conducted on September 5, 2000, determined that the operator

demonstrated a respiratory disturbance index24 of 106 episodes per hour. A normal

respiratory disturbance index would be less than 5 episodes per hour; an index of 30

episodes per hour is considered to represent severe disturbance.

The examination also included the operatorís sleep latency.25 Individuals who are

not sleep-deprived will, on average, have a sleep latency of about 20 minutes. That is,

such people normally take about 20 minutes to fall asleep when placed in a dark, quiet

room.26 Under such conditions, the operator was found to fall asleep within a period

considerably shorter than 20 minutes.

The Safety Board sent the hospitalís report to the director of the Center for Sleep

and Respiratory Neurobiology at the University of Pennsylvania Medical Center,

Philadelphia, Pennsylvania. The director found ìThere is no question, based on the data

you sent me, that he [the operator] has severe sleep apnea associated with excessive

sleepiness.î The director also stated that he would ìexpect the driver to be excessively

sleepy and at risk for falling asleep inappropriately.î 27

23 The Epworth Sleepiness Scale is a questionnaire designed to measure the general level of daytime

sleepiness, called the average sleep propensity. The average sleep propensity is a measure of the probability

of falling asleep in a variety of situations. The conceptual basis of the Epworth Sleepiness Scale involves a

four-process model of sleep and wakefulness. An individualís sleep propensity at any particular time is a

function of the ratio of the total sleep drive to the total wake drive, with which it competes.

24 The respiratory disturbance index is the number of breathing pauses or decrements per hour of sleep.

25 An individualís sleep latency is the amount of time before the onset of a measurable sleep cycle.

26 Association of Sleep Disorders Centers Task Force on Daytime Sleepiness: Sleep, 9(4): 519-524

(Raven Press, 1986).

27 Quotes are taken from a November 16, 2000, facsimile communication from the director of the

Center for Sleep and Respiratory Neurobiology at the University of Pennsylvania Medical Center,

Philadelphia, Pennsylvania, to the Safety Board.
Factual Information 25 Special Investigation Report

According to the National Institutes of Health, obstructive sleep apnea is a

common condition, affecting more than 12 million Americans.28 The American Sleep

Apnea Association ìconservatively estimatesî that 10 million people remain

undiagnosed.29 Obstructive sleep apnea occurs in all age groups and in both sexes but is

more common in men. One organization reports that 4 percent of middle-aged men and

2 percent of middle-aged women have sleep apnea accompanied by excessive daytime

sleepiness.30 Risk factors include being male, being overweight, and being over 40 years

old. People most likely to have or develop obstructive sleep apnea include those who

snore loudly, are overweight, or have high blood pressure. People with some physical

anomaly in the nose, throat, or other parts of the upper airway are also prone to develop

obstructive sleep apnea.

Some sleep experts believe it may be possible to detect which safety-sensitive

employees may have a potential sleeping disorder by using questionnaires and/or

structured interviews and clinical data.31 The Union Pacific and CSXT Railroads told the

Safety Board that they are implementing questionnaire-based programs (provided by

vendors) to identify employees who may be disposed to have sleep disorders. The CSXT

Railroad told the Safety Board that, as part of a comprehensive sleep disorders screening

and treatment program that began in August 1998 and was administered by a confidential

third party,32 it mailed a questionnaire designed to detect people who might be disposed to

have sleep disorders to 2,386 employees on its Florence Service Lane (in South Carolina).

Of the 248 self-selected responses received, 136 responders were determined to be ìat

riskî for sleep apnea. Of those ìat riskî employees, almost half agreed to participate in an

overnight sleep evaluation. As a result of further diagnosis, 43 employees with sleep

apnea were successfully treated and, of these, 42 are continuing with appropriate therapy

on a long-term follow-up basis.

The Union Pacific Railroad informed the Safety Board that it offered

approximately 2,000 employees and their family members on the Fort Worth (Texas)

Subdivision the opportunity to participate in sleep disorder screening. The project began

with an awareness campaign; then, a questionnaire concerning disposition to sleep

disorders was mailed to the employeesí homes. Individuals who returned questionnaires

that indicated they might be at risk were assisted in obtaining clinical diagnoses. The data

generated from these efforts are undergoing analysis by a confidential third party.

28 Information obtained in early 2001 from the Home page of the National Sleep Foundation

<http://sleepfoundation.org>.

29 Information obtained in early 2001 from the Home page of the American Sleep Apnea Association

<http://sleepapnea.org>.

30 Information obtained in early 2001 from <http://www.apneanet.org>.

31 K. Kump, C. Whalen, P.V. Tishler, I. Brower, V. Ferrette, K.P. Strohl, C. Rosenberg, and S. Redline,

ìAssessment of the Validity and Utility of a Sleep-Symptom Questionnaire,î American Journal of

Respiratory Critical Care Medicine, 1994; Volume 150(3): pp. 735-741. And T. Ploch, C. Kemeny, G.

Gilbert, W. Cassel, and J.H. Peter, ìSignificance of a Screening Questionnaire for Diagnosis of Sleep

Apnea,î Pneumologie, March 1993; 47 Supplement 1: pp.108-111.

32 The CSXT Railroad told the Safety Board that it used a confidential third party to protect the

anonymity of its employees.
Factual Information 26 Special Investigation Report

Emergency Response

The investigation identified four approximately simultaneous ìinitialî

notifications of this incident that took place almost immediately after the accident. They

occurred when Maryland Transportation Authority police officers patrolling nearby were

alerted by the impact noise, when two telephone calls (one to MTA police via 911 and one

to the Maryland Aviation Administration33 operations center at the airport) were placed

from the accident scene, and when a ìwater flow alarm,î which was automatically

transmitted to BWI fire and rescue, was triggered.34 BWI fire and rescue, police,

emergency medical, and other emergency services resources from the BWI Airport, as

well as mutual aid resources, responded to the accident. The MTA also responded with

emergency resources.

About 20 Maryland Transportation Authority police officers were dispatched to

the scene; they assisted in the initial emergency extrication effort and provided site

security. The responding officers indicated that they did not have trouble in gaining

immediate access to the LRV. (Some of those responding stated that they had learned how

to access the LRV during the February 2000 accident.) Other responding mutual aid police

officers and fire and rescue personnel arrived at the scene shortly thereafter and assisted in

the Maryland Transportation Authority effort. Paramedic personnel then arrived at the

scene and assumed principal responsibility for on-scene medical triage, stabilization, and

transport of the injured.

The first responding unit from BWI fire and rescue arrived at the scene at

7:20 a.m., and 12 BWI fire and rescue emergency vehicles responded to the scene, with 28

BWI fire and rescue personnel. Following the prescribed incident response protocol, a

BWI fire and rescue chief assumed responsibility as incident commander and established

his incident command location adjacent to station track No. 1. BWI fire and rescue

personnel stabilized the front of the LRV, using hydraulic jacks, pneumatic lifting bags,

and portable cribbing blocks.

Fifteen ambulances responded to the scene, of which seven were used to transport

patients to local medical facilities. About 20 emergency medical personnel responded to

the scene, including the State medical director and the BWI medical director.

Patient triage was reportedly completed at 7:30 a.m. The first patient transported

from the scene to a hospital was transported via ambulance at 7:43 a.m. Ten patients with

injuries assessed by paramedic personnel as ìnot life-threateningî were transported via

commercial motorcoach to a local hospital for evaluation at 8:25 a.m. The last patient

transported from the scene to the hospital departed via ambulance at 8:27 a.m.

33 The Maryland Aviation Administration, which is a Maryland Department of Transportation agency,

owns and operates the BWI Airport.

34 The accident severed water sprinkler lines of the fire suppression system in the ceiling of the light rail

terminal. This event automatically triggered a water flow alarm to BWI fire and rescue services.
Factual Information 27 Special Investigation Report

Information for Both Accidents

Track and Signals

Track. The track structure on the Central Light Rail Line is predominantly a single

track main with sections of double track. MTA tracks are constructed with #115

continuous welded rail, manufactured by Bethlehem Steel.

The trackage right-of-way approaching the end of the track, where both accidents

took place, is approximately level and tangent. The BWI Airport Station has two service

tracks, which MTA light rail operations refer to as the No. 1 service track (the westernmost track) and the No. 2 service track (the eastern-most track), respectively. The two

service tracks are parallel and adjacent to each other, with a track-center distance35 of

about 30 feet. Each track can accommodate up to a three-car train. The tracks can be used

interchangeably, but the No. 1 track is designated for principal use at this station.

The posted speed limit for approaching the station was 15 mph. The double main

track enters the platform area on a descending grade of 0.70 percent. The main track

serves both sides of the concrete BWI passenger platform. The north end of the platform

has a highblock to assist in the loading and offloading of disabled passengers. In the case

of both accidents, a Cullen-Western-Hayes, Inc., WH bumping post was in place at the end

of the track to protect the terminal area from railcar intrusion. The bumping posts were

fixed to the rail with track bolts and were designed to stop runaway railcars and absorb the

shock should a collision occur.

Signals. Movement on the line is governed by operating rules and instructions and

the signal indications of an automatic interlocking signal system with automatic block

signals between interlockings. The signal system uses four-aspect colorlight-type signals.

On the BWI Airport extension, signals can display the following:

35 Track-center distance is the distance from the centerline of one track to the centerline of the other.

Rule Aspect Indication

4.4.1 Red Stop

4.4.2 Yellow Proceed prepared to stop at next signal

4.4.3 Green Proceed

4.4.4 Red over yellow Proceed at restricted speed until entire train has 

passed a signal displaying a more favorable aspect
Factual Information 28 Special Investigation Report

The distance from the last block signal, BWI 15-6, governing the route traveled by

both accident trains (February and August 2000) to the northern end of the BWI Airport

Station platform is about 360 feet. The distance from the northern end of the platform to

the bumping post is about 330 feet. Sight lines are clear and unobstructed from signal

BWI 15-6 to the end of the line.

MTA Operations

General. The MTA operates the Central Light Rail Line System, a surface-level,

light rail passenger transit operation that runs LRVs between Hunt Valley and Glen

Burnie, Maryland, with two track extensions: (1) from the University of Baltimore/Mount

Royal to Pennsylvania Station and (2) from Linthicum to the BWI Airport Station. The

MTAís Central Light Rail Line System is a 30-mile system that interfaces with MTA bus,

MTA subway, and Maryland Rail Commuter systems. It operates principally on private

right-of-way trackage, although a segment of its trackage, slightly less than 2 miles long,

operates in a street environment (on embedded running rails in the pavement) with

highway vehicle traffic, in downtown Baltimore.

The BWI Airport light rail extension, at the end of which both accidents occurred,

is about 4.8 miles long. The total distance from Pennsylvania Station to the BWI Airport

Station is about 11 miles. From Pennsylvania Station to the Camden Yards Station, the

LRV tracks run through city streets.

The MTA light rail superintendent told the Safety Board that the MTA provides

service between Baltimore (Pennsylvania Station) and the BWI Airport Station from

6:00 a.m. to 11:00 p.m. Monday through Friday, from 8:00 a.m. to 11:00 p.m. Saturday,

and from 11:00 a.m. to 7:00 p.m. Sunday. The superintendent said that ridership was

estimated at 28,000 on weekdays, 17,000 on Saturdays, and 10,000 on Sundays. The MTA

has 53 LRVs in its fleet.

The MTA light rail superintendent indicated that the MTA organization comprises

about 73 operators, 24 supervisors, 5 chief supervisors, and 5 dispatchers. The dispatchers

report directly to the superintendent.

The current operating rulebook for the MTA light rail is the Interim Rules and

Instructions for Employees, dated August 1991. The MTA director of transit operations

approved the rulebook in 1991. The light rail superintendent said that the MTA updates

the rulebook by issuing rail transportation bulletins.

Rule 3.19 of the MTAís Interim Rules and Instructions for Employees states:

Safety Stop: When making a stop at terminals, operators must use caution and

allow sufficient braking distance, determined by condition of rail, to bring train to

a stop not less than five feet from end of track, bumping post, or train ahead.

Most of the MTAís LRV operators became LRV operators after serving for a

number of years in another operational capacity, such as busdriver, for the MTA.

Opportunities to become LRV operators were offered mainly on a seniority basis.
Factual Information 29 Special Investigation Report

The MTA told the Safety Board that the MTA did not have a program to identify

safety-sensitive employees for sleeping disorders. In a fatigue management survey of 155

transit agencies conducted by the American Public Transportation Association (APTA),36

16 agencies (of the 141 agencies that responded to the question) reported that they provide

preplacement screening for sleep disorders, while 12 agencies (of the 134 agencies that

responded to the question) reported that their periodic operator physicals include

screening for sleep disorders. The Federal Transit Administration (FTA) does not require

rail transit agencies to have screening programs to detect safety-sensitive employees who

may have sleeping disorders.

According to the MTA light rail superintendent, MTA light rail operators are

trained for 8 weeks before becoming operators. This training includes familiarization with

the MTA Interim Rules and Instructions for Employees. Before the BWI accidents in

2000, the MTA did not provide recurrent training to its operators.37

Medication and Prohibited Substance Requirements. Section 1.6 of the MTA

Interim Rules and Instructions for Employees is entitled ìALCOHOL, ILLEGAL

SUBSTANCES, AND MEDICATION.î Section 1.6.2 states

Employees reporting for duty or while on duty, must not possess or be under the

influence of intoxicants, including alcohol, Controlled Substances, or any other

substance which may impair job performance.

On February 16, 2000, the MTA provided the Safety Board with an undated copy

of the Mass Transit Administration Policy on Substance Abuse Prevention. Title III,

Section A, of this document states, ìIt is the policy of the Mass Transit Administration to

take an active role in combating substance abuse throughout its public transportation

operations.î

Title III, Section B, of the policy states that the MTA dedicates itself to

ï Embracing and promulgating all appropriate initiatives that have a goal of

substance abuse prevention,

ï Promoting and increasing understanding of the dangers associated with

substance abuse through education and training,

ï Encouraging and assisting employees in confronting and rehabilitating

substance abuse problems, and

ï Removing from the public payroll any employees who are convicted of the

unlawful manufacture, distribution, dispensing, possession, or use of a

controlled substance in the workplace.

36 APTA is a private, nonprofit, international trade association that represents the North American

transit industry. APTA has more than 1,270 member organizations, which include transit systems, academic

institutions, and State associations and departments. APTA members serve more than 90 percent of those

people using public transport in the United States and Canada. The MTA is an APTA member.

37 Since the two BWI accidents, the MTA has told the Safety Board that it intends to provide recurrent

operator training.
Factual Information 30 Special Investigation Report

With respect to random drug testing, the MTA told the Safety Board that it follows

the requirements at 49 CFR Part 653, including having a random drug testing program

with provisions for appropriate follow-up to positive results, as well as having specific

requirements for treatment programs and the employeeís returning to duty. The MTA cited

49 CFR 653.63(d), which states that

The substance abuse professional shall determine the frequency and duration of

follow-up testing for a covered employee. Such employee shall be required to take

a minimum of six follow-up drug tests with verified negative results during the

first 12 months after returning to duty. After that period of time, the substance

abuse professional may recommend to the employer the frequency and duration of

follow-up drug testing, provided that the follow-up testing period ends 60 months

after the employee returns to duty. In addition, follow-up testing may include

testing for alcohol, as directed by the substance abuse professionalÖ.

The chief of the MTA benefits section, whose office is responsible for

administering the alcohol and drug testing program within the agency, told Safety Board

investigators in February 2000 that the MTA had no specific requirement for employees to

inform the MTA about their use of prescription medications. The chief stated that the

MTA followed applicable FTA regulations (49 CFR Part 653) pertaining to substance

abuse. In subsequent correspondence, dated June 22, 2000, the chief responded to a Safety

Board inquiry as to what would have happened had the train 24 operator told the MTA

about his use of prescription pain-relieving medications when he returned to work in early

January 2000. He wrote, ìThe current MTA Substance Abuse Prevention Policy does not

address this topic. If it did, procedures would presumably be outlined also.î

In a letter to the Safety Board dated June 12, 2000, the MTA light rail

superintendent indicated (in reference to employees returning to work after being off for

sick leave) that the agency does ìnot positively know whether a safety sensitive employee

is on medication when they return to work.î

On October 3, 2000, the MTA provided the Safety Board with written material

about the history of the MTA drug and alcohol policy and a summary of related recent

activities. Included in this document was the statement that in 1995 the MTA and

Amalgamated Transit Union Local 1300 adopted FTA alcohol and drug testing regulations

ìas a basis for the MTAís drug and alcohol testing policy.î The document also noted that

the MTA and Local 1300 had been working toward the development of comprehensive

drug and alcohol policies, and that the MTA had hired a consulting firm to

Conduct an independent assessment of our substance abuse program and

recommend additional improvements to our drug and alcohol policies, including

prescription and over-the-counter medication and fitness for duty evaluations.

The FTA drug testing regulations at 49 CFR Part 653, ìPrevention of Prohibited

Drug Use in Transit Operations,î make no specific reference to the use of prescription

and/or over-the-counter medications by transit vehicle operators or other safety-sensitive

employees. The Federal Railroad Administration (FRA) regulations at 49 CFR 219.101-
Factual Information 31 Special Investigation Report

103 address the use of controlled substances and medications by employees covered under

FRA rules as detailed below:

Sec. 219.101 Alcohol and drug use prohibited.

(b) Controlled substance. ìControlled substanceíí is defined by Sec. 219.5 of this

part. Controlled substances are grouped as follows: Marijuana, narcotics (such as

heroin and codeine), stimulants (such as cocaine and amphetamines), depressants

(such as barbiturates and minor tranquilizers), and hallucinogens (such as the

drugs known as PCP and LSD). Controlled substances include illicit drugs

(Schedule I), drugs that are required to be distributed only by a medical

practitionerís prescription or other authorization (Schedules II through IV, and

some drugs on Schedule V), and certain preparations for which distribution is

through documented over the counter sales (Schedule V only).

Sec. 219.102 Prohibition on abuse of controlled substances.

On and after October 2, 1989, no employee who performs covered service may

use a controlled substance at any time, whether on duty or off duty, except as

permitted by Sec. 219.103 of this subpart.

Sec. 219.103 Prescribed and over-the-counter drugs.

(a) This subpart does not prohibit the use of a controlled substance (on Schedule II

through V of the controlled substance list) prescribed or authorized by a medical

practitioner, or possession incident to such use, if

(1) The treating medical practitioner or a physician designated by the

railroad has made a good faith judgment, with notice of the employeeís

assigned duties and on the basis of the available medical history, that use

of the substance by the employee at the prescribed or authorized dosage

level is consistent with the safe performance of the employeeís duties;

(2) The substance is used at the dosage prescribed or authorized; and

(3) In the event the employee is being treated by more than one medical

practitioner, at least one treating medical practitioner has been informed

of all medications authorized or prescribed and has determined that use of

the medications is consistent with the safe performance of the employeeís

duties (and the employee has observed any restrictions imposed with

respect to use of the medications in combination).

(b) This subpart does not restrict any discretion available to the railroad to require

that employees notify the railroad of therapeutic drug use or obtain prior approval

for such use.

The above restrictions require consultation with a medical practitioner. Most overthe-counter medications are not covered by the regulation,38 and no requirement is

indicated for documentation of medical consultation.

38 There are substances that may be purchased without a prescription for which over-the-counter sales

must be documented. Even though these substances are available over the counter, they are considered

controlled medications. (Certain codeine-containing cough syrups fall into this category.)
Factual Information 32 Special Investigation Report

Oversight. The FTA required the Maryland State legislature to designate a

department to oversee the MTA.39 The Maryland Department of Transportation (MDOT)

was assigned the responsibility of providing MTA safety oversight. In fulfilling that

responsibility, MDOT has the power to audit and observe all ongoing operations at the

MTA. The MTA and MDOT both report to the Secretary of Transportation for the State of

Maryland.

System Safety Program Plan. Federal regulations at 49 CFR 659.31 require that

fixed guideway transit systems such as the MTAís Central Light Rail Line System must

develop and implement a system safety program plan that complies with the guidelines

provided in APTAís Manual for the Development of Rail Transit System Safety Program

Plans. According to this APTA document, a system safety program plan for such a rail

transit system ìestablishes the Safety philosophy of the whole organization and provides

the means of implementation.î APTA identifies the overall goal of system safety program

plans for fixed guideway transit systems as

To identify, eliminate, minimize, and/or control safety hazards and their attendant

risks by establishing requirements, lines of authority, levels of responsibility, and

accountability, and methods of documentation for the organization.[40]

A system safety program plan is a formal written document that identifies all

safety-related responsibilities and assigns the fulfillment of these responsibilities to

appropriate areas within the organization. It also establishes the specific safety objectives

and procedures of the organization. Each transit system develops its own system safety

program plan.

Once the program is in place, the transit system maintains internal oversight of its

own system safety program plan to ensure that all responsibilities are being fulfilled and

coordinated through monthly audits conducted by departmental safety officers and annual

audits carried out by the system safety department. The State regulatory agency

responsible for the transit system conducts mandatory audits of the system safety program

planís effectiveness every 3 years. Under its Safety Management Audit Program, APTA

will also provide, if requested and funded by the transit system, triennial formal

evaluations of how well a transit organizationís system safety program plan has been

implemented.

In 1997, while the MTA was developing a system safety program plan, APTA

performed an audit of the MTA and identified areas that needed corrective action. The

summary page of the APTA Preliminary Audit Report, dated June 15, 1998, stated that the

audit team found that

39 These regulations came about through rulemaking resulting, in part, from the Safety Boardís findings

in its safety study on Oversight of Rail Rapid Transit Safety, adopted on July 23, 1991 (NTSB/SS-91/02). In

this safety study, the Safety Board encouraged increased Federal involvement in State and local oversight of

rail rapid transit systems.

40 APTA, Manual for the Development of Rail Transit System Safety Program Plans (Washington, D.C.:

APTA, 1999), p. 8.
Factual Information 33 Special Investigation Report

[MTA] Management is aware of the safety goals and objectives stated in the

System Safety Plan. However, Management should establish and document more

maintenance and safety technical personnel training programs; establish and

ensure that all facets of system maintenance are fully coordinated with its safety

functions.

In the preliminary report, the APTA auditors stated that the majority of MTA

managers were unfamiliar with the MTAís system safety program plan and that, in many

cases, MTA managers did not have a clear understanding of system safety or their

respective roles in carrying out the system safety program plan. The APTA report further

stated that the distribution of the system safety program plan was not complete and its

implementation had not been properly tracked.

In January 2000, the MTA hired a contractor to address the corrective action plans

identified in the APTA audit. Among the actions the contractor was hired to undertake was

the implementation of the system safety program plan. The contractor told the Safety

Board that she considered the MTA system safety program plan she was provided by the

MTA in January 2000 to be ineffective. She said that when she began work on the

program, she believed some members of the MTA operations management did not accept

the validity of the overall system safety program plan concept. She stated that it has been

her experience that many operations-driven systems, such as the MTA, do not recognize

the need for system safety programs. The contractor said that she had conflicts with the

MTA superintendent of operations as she worked on the system safety program plan and

that the superintendent would not comply with her requests to assist in planning the

system safety program plan.

Members of the MTA system safety department stated during interviews that the

MTA system safety program plan had not been a working document before the contractor

was brought in to implement it. One employee stated, ìI mean, it [the system safety

program plan] was something that was put together because it was mandated, but it wasnít

something that we actually lived by.î

On December 1, 2000, the MTA underwent a significant management

reorganization, during which a number of managers were given positions involving

system safety. Among other developments, the MTA hired a new director of safety,

created the position of assistant director of safety, and added six more people, including a

system safety specialist, to the MTA safety staff.

Between January and March 2001, the contractor hired to implement the MTAís

system safety program plan completed the writing of the program and conducted 4 hours

of training on the program for all MTA operations managers. The contractor also helped

the MTA carry out several internal audits of its new system safety program plan before her

contract expired in March 2001.

Since March 2001, the MTA has assigned its new system safety specialist (hired in

December 2000) to redraft the system safety program plan provided by the contractor so

that it more closely suits the MTAís specific needs.
Factual Information 34 Special Investigation Report

MDOT has been overseeing the MTAís system safety activities. Since 1997,

MDOT has periodically met with the MTA concerning the corrective actions indicated by

the 1997 APTA audit of the MTA. In July 2000, MDOT completed its State oversight plan

and presented it to the MTA. In May 2000, a contractor hired by MDOT conducted the

mandatory triennial audit of MTA system safety, and MDOT has presented corrective

action plans to the MTA based on the findings of the 2000 audit. In addition, MDOT

participated in both of the BWI accident investigations and proposed postaccident safety

improvements.

Survival Aspects

Bumping Post. A bumping post assembly typically functions as a safety device to

afford end-of-track protection where the railroad ìrolling stockî equipment must come to

an absolute stop (or it will roll off the end of the track). The bumping post assembly is

attached to the running rails at the end of the track segment and is designed to absorb

kinetic energy when a moving railroad car contacts it.

Identical Cullen-Western-Hayes, Inc., WH hydraulic bumping post assemblies

were installed at the ends of the main No. 1 and 2 tracks when both accidents took place at

the BWI Airport Station in 2000. (See figure 5.) This bumping post incorporates a

mechanical striking block assembly that employs a kinetic energy absorption feature. The

bumping postís striking face is one end of a piston ram element, which, when it is

contacted by a railroad car coupler, exerts sufficient force to cause the piston ram element

to telescope inside a (closed-end) hydraulic cylinder sleeve. The attempted compression

and subsequent flow of hydraulic medium41 passing through a precision-sized orifice in

the piston ram, as it travels the length of its stroke, results in energy absorption.

41 The particular bumping posts at the BWI Airport Station terminus employed compression of

pneumatic gas, rather than hydraulic fluid, as the energy transfer medium.

Figure 5. Type of Cullen-Western-Hayes, Inc., WH hydraulic 

bumping post assembly involved in both accidents.
Factual Information 35 Special Investigation Report

The performance specification for the bumping post assembly cited by the

manufacturer was a 700,000-pound ìmaximum reaction forceî throughout its 30-inch

stroke, an energy absorption capacity of 1.4 million pound-feet, and a piston ram

element/stroke length of 30 inches. Engineering documentation submitted by the

manufacturer indicated that the bumping post structure could accommodate the impact

loading of a moving railcar.42 The manufacturerís documentation concerning the

installation of the bumping posts stated that

INSTALLATION SITE SHOULD NOT HAVE ANY RAIL JOINTS BETWEEN

THE BUMPING POST AND THE NEAREST SET OF TRUCKS OF THE

CONTACTING CAR. WHEN INSTALLED IN BALLASTED TRACK, THE

RAIL SHOULD ALSO EXTEND AT LEAST THREE TIE SPACES BEYOND

THE REAR OF THE BUMPING POST.

Seating. The MTA LRVs use seat assemblies and grabrails produced by the

American Seating Company of Grand Rapids, Michigan. Passenger seating on the LRVs

in the MTA fleet is provided on both sides of a longitudinally oriented center aisle

passageway. The seats are configured in a combination of transverse and longitudinally

mounted seat assemblies. The longitudinally mounted seats (which provide seating for 12

passengers per car) are attached to the car body floor in a pedestal arrangement and are

designed with a flip-up feature to provide space for wheelchairs.

The transverse-mounted model 850 BLR1 seats (which provide seating for 72

passengers per car) are attached to the car body sidewall in a pin-mounted cantilever

arrangement. The seat assembly consists of stainless steel stamped components, with the

seatback elements contoured and recessed into the seat frame, which is fitted with fabric

cushion padded inserts. The transverse passenger seat assemblies are fitted with 7/8-inchdiameter stainless steel grabrails, located across the top of the seatback. The American

Seating Company offers an alternate design for the seating grabrail made of a ìvandal

resistant energy absorbingî thermoplastic. (See figure 6 for photographs of seats equipped

with two types of grabrails.)

42 The manufacturerís ìCollision Energyî calculations indicated (to the effect) that the Cullen-WesternHayes, Inc., WH bumping post could structurally tolerate a 10-mph impact of a three-car LRV train (with

passengers).
Factual Information 36 Special Investigation Report

Figure 6. Top photograph shows LRV seats equipped with stainless steel grabrail 

(without a vertical stanchion); bottom photo shows seats equipped with thermoplastic grabrails (with a vertical stanchion).
Factual Information 37 Special Investigation Report

Tests and Research

Impact Calculations. During its investigation, the Safety Board made

calculations based on the available facts about the LRVs involved to determine the force

of the impacts that took place during the two BWI accidents that occurred in 2000. The

calculations indicated that the amounts of kinetic energy transferred into the CullenWestern-Hayes WH bumping posts during the collisions were about 934,800 pound-feet

in the February 13, 2000, accident and about 1.15 million pound-feet in the August 15,

2000, accident. The Safety Boardís calculations showed that in a hypothetical collision

between a Cullen-Western-Hayes WH bumping post and a three-unit LRV train filled to

occupant capacity, traveling at the posted speed of 15 mph, the kinetic energy that could

be transferred into the bumping post upon such an impact would be about 3.6 million

pound-feet.

The Safety Board further calculated the deceleration ìG forcesî43 that the LRV

passengers were exposed to during the accidents. The average level of G forces

experienced along the LRV longitudinal axis within the car during the accidents were

about -1.81 G for the February 13, 2000, accident and about -0.23 G for the August 15,

2000, accident.

Regulatory Requirements. The Safety Board reviewed current Government

regulations that would apply to light rail or transit passenger equipment crashworthiness

and related passenger safety issues. The review of current FRA and FTA regulations

indicated that there are no existing requirements that apply to LRV crashworthiness and

related passenger safety issues.

The Safety Board also reviewed existing self-regulatory standards or

recommended practices within the light rail and transit communities.44 Although LRVs are

not subject to these standards, APTA publishes the Manual of Standards and

Recommended Practices for Passenger Rail Equipment,45 which contains a section

addressing the ìStandard for Seating in Commuter Rail Cars.î Within this standard, APTA

details both static and dynamic testing requirements to ensure that the seats remain fixed

to the rail car under normal loading conditions and during crash conditions. In addition,

the standard specifies a dynamic longitudinal 8-G crash pulse used for sled testing to

simulate a rail car crash.

The Safety Board contacted American Seating, the manufacturer of the model 850

BLR1 railcar seats on the LRVs used by the MTA, to determine the level of

crashworthiness testing performed on these specific seat designs. American Seating

indicated that energy absorption testing was conducted on a model similar to the

model 850 BLR1 seat assembly; the testing is referred to as the ìGrabrail Head Form

43 A ìGî is a unit of force equal to the gravity exerted on a body at rest. Negative G force values

indicate deceleration.

44 Literature available from APTA was reviewed. In addition, literature from the Association of

American Railroads, a railroad industry trade association, was reviewed.

45 APTA, Manual of Standards and Recommended Practices for Passenger Rail Equipment, July 1,

1999 (Washington, D.C: 1999).
Factual Information 38 Special Investigation Report

Impact Test.î46 American Seating also indicated that it typically follows APTAís Standard

Bus Procurement Guidelines47 when designing new seating systems but that the seat

design used in the accident LRVs was developed before the release of the guidelines.

The Safety Board, in its review of the grabrail testing previously conducted by

American Seating, found that the seat type tested was not the same configuration as found

in the MTA LRV fleet48 and therefore requested American Seating to demonstrate grabrail

head form impact tests on an exemplar model 850 BLR1 railcar seat.

Grabrail Head Form Impact Testing. This energy absorption testing, in which the

grabrails were struck, longitudinally, by a 15-pound head form traveling at 15 mph, was

conducted with Safety Board staff present. The tests were performed on two

configurations of seats with stainless steel grabrails (with and without a vertical stanchion)

and two configurations of seats with thermoplastic grabrails (with and without a vertical

stanchion). Six different impact locations along the grabrails were tested. The testing

produced a range of Head Injury Criteria49 values, all of which were well below the

threshold value of 1,000.50 The highest recorded Head Injury Criteria value resulting from

the testing was 377, which occurred when a stainless steel grabrail with a vertical

stanchion was struck. The lowest value recorded from this testing was 76, which occurred

when a thermoplastic grabrail without a vertical stanchion was struck.

Other Information

Postaccident MTA Actions. In the aftermath of the two BWI accidents, the MTA

has taken a number of actions to improve its system safety.

For instance, as LRV trains approach the BWI Airport Station, they must now stop

at a red signal and then make a route selection at a push button before entering the station.

This red signal is protected by a trip stop. The speed limit for trains entering and leaving

the station has also been reduced to 5 mph. Trip stops and friction buffer stop end-of-line

collision protection have been provided for all four terminal stations on the MTA system,

including the BWI Airport Station.

The MTA has installed new interior and exterior emergency door release signage

on all its LRVs. The MTA also performed equipment familiarization and emergency

46 The Federal Government does not require this testing, and its adequacy has not been established for

LRVs.

47 APTA Technical Specification, Standard Bus Procurement Guidelines, pp. 51-56, April 28, 1999.

This standard details both static and dynamic testing for the bus seats. The dynamic testing subjects the seats

to a 10-G deceleration and evaluates the energy absorption of the seating system based on the maximum

head and femur loads to ATDs placed within the seating section.

48 The model 850 seat configuration tested by the seat manufacturer involved a different (floor/wall)

attachment arrangement and did not include a vertical stanchion support element; both factors were

identified as potentially influential to the impact test results.

49 See 49 CFR 571.201, Section 7, ìPerformance Criterion,î which describes the Head Injury Criteria

equation used to develop the data.

50 APTAís Standard Bus Procurement Guidelines specify a maximum Head Injury Criteria value of 400.
Factual Information 39 Special Investigation Report

procedures training with BWI fire and rescue employees (June 2000), carried out

equipment and familiarization training for the Maryland Transportation Authority police

(September 2000), and conducted an emergency drill with fire and rescue personnel from

surrounding jurisdictions (November 2000). Additional drills took place in 2001.

The MTA told the Safety Board, through an August 16, 2001, fax communication,

that it intends to ìexplore the redesignî of its LRV passenger seatback grabrails and to

ìchange the design of the rails and/or locate more impact-resistant materials for future rail

car orders.î

With respect to its drug and alcohol policy, the MTA put into effect (in September

2000) a new policy that provides for terminating all safety-sensitive employees who test

positive in an incident-based or reasonable suspicion alcohol or drug test. The MTA also

hired a consultant to conduct an independent assessment of the MTAís drug and alcohol

policies. The consultantís recommendations included improving the MTAís substance

abuse treatment program, implementing prescription and over-the-counter drug policies,

providing fitness-for-duty evaluations, and giving additional substance abuse training to

employees and managers. The MTA is working to effect the consultantís

recommendations and told the Safety Board that it has developed, but not yet enacted, a

draft ìprescription drug, over-the-counter drug, and fitness for dutyî policy.

The MTA has had an independent contractor conduct a safety assessment of its

light rail operations. The assessment was completed in October 2000, and the MTA has

developed a corrective action plan based on the contractorís assessment.

In March 2001, the MTA held a fatigue awareness training program for managers,

operators, and maintenance staff. In September 2001, some MTA personnel took part in

the Transportation Safety Instituteís Fatigue Awareness Seminar. The MTA also informed

the Safety Board that it is developing its own fatigue awareness training program and

policy.

The MTA completed a revision of its Light Rail rulebook in April 2001. Training

on the rulebook is part of the new annual recertification program for all operators,

maintenance supervisors, and track access and control personnel.

Previous Safety Recommendations. As a result of its investigation of the

collision involving two New York City subway trains on the Williamsburg Bridge in

Brooklyn, New York, on June 5, 1995,51 the Safety Board issued Safety Recommendations

R-96-20 and -21 to the FTA and APTA, respectively.

51 National Transportation Safety Board, Collision Involving Two New York City Subway Trains on the

Williamsburg Bridge in Brooklyn, New York, June 5, 1995, Railroad Accident Report NTSB/RAR-96/03

(Washington, D.C: 1996).
Factual Information 40 Special Investigation Report

R-96-20

In cooperation with the American Public Transit Association, develop a fatigue

educational awareness program and distribute it to transit agencies to use in their

fitness for duty training for supervisors and employees involved in safetysensitive positions.

R-96-21

Assist the Federal Transit Administration in developing a fatigue educational

awareness program for transit agencies to use in their fitness for duty training for

supervisors and employees in safety-sensitive positions.

In a letter dated May 1, 1999, the FTA informed the Safety Board that a fatigue

awareness program had been incorporated into the Transportation Safety Instituteís core

curriculum.52 The instituteís Fatigue Awareness Seminar includes modules that discuss the

major types of sleeping disorders, including sleep apnea. Based on the FTAís response, the

Safety Board classified Safety Recommendation R-96-20 ìClosed--Acceptable Actionî

on January 11, 2000. APTA responded to Safety Recommendation R-96-21 by conducting

research on the effects of fatigue on human performance and assisting the FTA in

developing a fatigue awareness program that has been incorporated into the

Transportation Safety Instituteís core curriculum. Accordingly, Safety Recommendation

R-96-21 is classified ìClosedóAcceptable Action.î

In August 1986, following its investigation of several accidents involving

operators of rail rapid transit trains who had used prescription or over-the-counter drugs,53

the Safety Board sent a letter to the Urban Mass Transportation Administration

(predecessor agency to the FTA), which stated that the Urban Mass Transportation

Administration ìshould take the lead in developing and implementing regulations to

address the growing concerns about drug use (licit and illicit) by rail rapid transit

operating employees.î The Safety Boardís letter further stated that ìThe framework for

the control of alcohol and drug use has already been developed by the FRAís regulations

and, with certain appropriate modifications, may be made applicable to rail rapid transit

systems.î The Safety Board recommended that the Urban Mass Transportation

Administration:

52 The Transportation Safety Institute is a major training and technical assistance organization for the

U.S. Department of Transportation, providing safety and security training to all department administrations

and other Federal, State, and local agencies, as well as to private industry. The institute began conducting

training in transit safety in 1976. The courses include a full range of training in bus and rail safety. Since it

began in 1976, the transit program has trained more than 60,000 students.

53 National Transportation Safety Board, Rear End Collision of Two Chicago Transit Authority Trains

near the Montrose Avenue Station, Chicago, Illinois, August 17, 1984, Railroad Accident Report

NTSB/RAR-85/11 (Washington, D.C: 1985); Metropolitan Atlanta Rapid Transit Authority, Atlanta,

Georgia, December 3, 1984, Railroad Accident Investigation ATL-85-FR004; and Rear End Collision of

Metro Dade Transportation Administration Train Numbers 172-171, 141-142, Miami, Florida, June 26,

1985, Railroad Accident Report NTSB/RAR-86/02 (Washington, D.C: 1986).
Factual Information 41 Special Investigation Report

R-86-36

Require rail rapid transit systems to institute procedures and information systems

to inform employees of the deleterious effects on work performance of some overthe-counter and prescription drugs.

R-86-37

Require the removal of employees from safety-sensitive positions if the rail rapid

transit medical department determines that the employeesí use of a prescription

drug will affect their work performance.

In Safety Recommendations I-89-4 through -12, issued to the Secretary of

Transportation in 1989, the Safety Board continued to address the uniform

implementation of testing programs in all modes of transportation. The Board urged the

Secretary of Transportation to include rail rapid transit in the then-ongoing efforts to

address these safety recommendations and, if necessary, to seek the legislative authority to

do so. Consequently, Safety Recommendations R-86-36 and -37, which were issued to the

Urban Mass Transportation Administration to address testing programs only in the rail

rapid transit industry, were classified ìClosedóAcceptable Action/Supersededî as a

result of Safety Recommendations I-89-4 through -12.

The Safety Board recommended, in its report on a 1993 train derailment in Mobile,

Alabama,54 that the U.S. Department of Transportation:

I-94-5

Require the modal operating administration to develop and disseminate bulletins,

notices, circulars, and other documents that call attention to the need for an

employee reporting procedure concerning the use of medication (over-the-counter

and prescription) while on duty and that the U.S. Department of Transportation

urge the transportation industry to develop and implement informational and

educational programs related to this subject.

In August 1995, the Safety Board classified this recommendation ìClosedó

Acceptable Action,î after the U.S. Department of Transportation issued the following

statement to be used by all its modal operating administrations:

The U.S. Department of Transportation reminds all U.S. Department of

Transportation industries of the potential threat to public safety caused by the onduty use of some over-the-counter and prescription medications by persons

performing safety-sensitive duties. As a result, we strongly urge all transportation

industry employers to include in their employee training materials appropriate

information to address this issue.

54 National Transportation Safety Board, Derailment of Amtrak Train No. 2 on the CSXT Big Bayou

Canot Bridge Near Mobile, Alabama, September 22, 1993, Railroad Accident Report NTSB/RAR-94/01

(Washington, D.C: 1994).
Factual Information 42 Special Investigation Report

On January 13, 2000, the Safety Board issued safety recommendations concerning

medication issues to the U.S. Department of Transportation, its modal agencies (including

the FTA),55 and the U.S. Food and Drug Administration. The Safety Board issued the

following safety recommendations to the U.S. Department of Transportation:

I-00-1

Establish, in coordination with the Federal Motor Carrier Safety Administration,

the Federal Railroad Administration, the Federal Transit Administration, and the

U.S. Coast Guard, comprehensive toxicological testing requirements for an

appropriate sample of fatal highway, railroad, transit, and marine accidents to

ensure the identification of the role played by common prescription and over-thecounter medications. Review and analyze the results of such testing at intervals

not to exceed every 5 years.

I-00-2

Develop, with assistance from experts on the effects of pharmacological agents on

human performance and alertness, a list of approved medications and/or classes of

medications that may be used safely when operating a vehicle.

I-00-3

Expressly prohibit the use of any medication not on the U.S. Department of

Transportationís list of approved medications (described in I-00-2) for twice the

recommended dosing interval before or during vehicle operation, except as

specifically allowed, when appropriate, by procedures or criteria established by

the applicable modal administration (the Federal Aviation Administration, the

Federal Motor Carrier Safety Administration, the Federal Railroad

Administration, the Federal Transit Administration, or the U.S. Coast Guard).

I-00-4

Evaluate the applicability of the restrictions (for vehicle operators) described in I00-2 and -3 to transportation employees in all safety-sensitive positions. If

appropriate, implement such restrictions within 2 years of their implementation

for vehicle operators.

The U.S. Department of Transportation replied to these recommendations in a

July 31, 2000, letter. With respect to the rail and rail transit aspects of Safety

Recommendation I-00-1, the Department stated:

The FRA has in place an extensive and effective post-accident toxicological

testing program. Following a qualifying accident, the FRA conducts drug and

alcohol testing on all fatally injured employees and a large percentage of

surviving employees. Tests are conducted for the five illegal drugs for which the

DOT tests plus two of the more common prescription medications. The FRA

program also has the capability of testing for any additional prescribed or OTC

medications that may have contributed to the cause of the accident. In the past, the

55 Safety Recommendations R-00-5 through ñ8.
Factual Information 43 Special Investigation Report

FRA has provided urine, blood, and tissue specimens to the Safety Board for

additional testing following certain major train accidents. We are not aware of any

instances where the Safety Board has found any additional drugs or OTC

medications in these specimens, and the FRAís post-accident testing over the

years has never indicated a causal relationship between the use of prescription

medications and the crash eventÖ. the FTA [does] not have statutory authority to

require post-accident toxicological testing of safety-sensitive personnel who are

killed in an accident.

In its July 31, 2000, response, the U.S. Department of Transportation also stated,

with respect to Safety Recommendations I-00-2 through -4, that:

We do not believe it is feasible to develop a list of approved medications that may

be safely used by safety-sensitive employees and employers. Currently, the

Physicians Desk Reference, which lists most of the prescription medications

available, is a volume of over 3,000 pages; the publication for OTC medication is

also large. To develop a list which would be continuously up to date is virtually

impossible. There would always be a ìlag timeî in which certain new drugs are

not listed, other drugs would have stopped being manufactured and have been

dropped from the list, and still others would have their names changed. Another

problem is that such a list would not address the interaction of different drugs.

Very few individuals would spend the time and effort to review drug interaction,

especially if a health care provider approved their prescription medication. The

development of a list (I-00-3) that expressly prohibits use of medications over

twice the recommended dosing interval is fraught with the same problems

identified above for the establishment of a list approving certain medications. In

reference to I-00-4, there is no distinction between vehicle operators and other

transportation safety-sensitive personnel in the Departmentís regulations

regarding drug testing. The same constraints placed on vehicle operators related to

drugs are placed on all safety-sensitive transportation personnel. In summary,

DOT shares your concern about the potential impact of the use of prescription and

OTC medications by safety-sensitive transportation personnel. The Department

does not believe a list of approved drugs is the correct approach.

In addition to the safety recommendations issued in January 2000 to the U.S.

Department of Transportation and its modal agencies concerning over-the-counter and

prescription medication use, the Safety Board asked the U.S. Food and Drug

Administration to:

I-00-5

Establish a clear, consistent, easily recognizable warning label for all prescription

and over-the-counter medications that may interfere with an individualís ability to

operate a vehicle. Require that the label be prominently displayed on all

packaging of such medications.

The U.S. Food and Drug Administration proposed that a joint U.S. Food and Drug

Administration/Safety Board public meeting_to include interested parties from the

Government, the transportation and pharmaceutical industries, and academia_be held to

discuss the various transportation safety issues concerning potentially sedating and
Factual Information 44 Special Investigation Report

impairing medications. Safety Board staffers worked with U.S. Food and Drug

Administration personnel to plan and establish the agenda for the meeting, which was held

on November 14 and 15, 2001, at Safety Board headquarters. Accordingly, the Safety

Boardís reply to the U.S. Department of Transportationís response to Safety

Recommendations I-00-1 through ñ4 has been deferred until the discussion at the meeting

has been fully reviewed and considered and the U.S. Department of Transportation has

been provided an opportunity to update its response subsequent to its participation in the

public meeting.

On November 14, 1996, as a result of the Safety Boardís investigation of an

accident on the Washington Metrorail system,56 the Safety Board issued Safety

Recommendation R-96-46 to the FTA, which called for the FTA to:

R-96-46

Develop, with the assistance of the American Public Transit Association,

guidelines for the monitoring/recording devices that capture critical performance

and event data for rapid rail transit cars and urge transit agencies to install these

devices on new and rehabilitated cars.

The FTA, with APTA, prepared a report, dated June 1998, entitled Event Recorders

for Rail Rapid Transit Systems. In a letter dated September 4, 1998, the FTA provided the

Safety Board with a copy of the report and indicated that the report would be distributed to

transit agencies developing specifications for rehabilitated and new rapid transit vehicles

and that the FTA would urge the installation of the devices. The report explored the

effectiveness and efficiency of using event recorders on rapid rail cars. It presented and

analyzed data; defined various aspects of using accident/incident event recorders; included

a cost, feasibility, and benefit analysis; and identified the technical requirements for these

devices in rapid rail transit. Based on this response, the Safety Board classified Safety

Recommendation R-96-46 ìClosedóAcceptable Actionî on January 6, 1999.

When, on November 14, 1996, the Safety Board issued Safety Recommendation

R-96-46 to the FTA, it also issued Safety Recommendation R-96-47 to APTA. The

recommendation asked APTA to:

R-96-47

Develop, with the assistance of the Federal Transit Administration, guidelines for

the monitoring/recording devices that capture critical performance and event data

for rapid rail transit cars and urge transit agencies to install these devices on new

and rehabilitated cars.

In addition to working with the FTA to develop the 1998 report on Event

Recorders for Rail Rapid Transit Systems, APTA has, through various APTA-sponsored

56 National Transportation Safety Board, Collision of Washington Metropolitan Area Transit Authority

Train T-111 with Standing Train at Shady Grove Passenger Station, Gaithersburg, Maryland, January 6,

1996, Railroad Accident Report NTSB/RAR-96/04 (Washington, D.C: 1996).
Factual Information 45 Special Investigation Report

conferences and symposiums, urged transit agencies to install these devices on new and

rehabilitated cars. Based on this information, Safety Recommendation R-96-47 is

classified ìClosedóAcceptable Action.î

Event Recorder Regulations. The FTA has issued no regulations that apply to

event recorders on LRVs.

The FRA regulations concerning the requirements for event recorders on railroad

locomotives are at 49 CFR 229.135. These regulations do not apply to event recorders on

LRVs. According to the railroad locomotive safety standard definitions provided at

49 CFR 229.5(g):

(g) Event recorder means a device, designed to resist tampering, that monitors and

records data on train speed, direction of motion, time, distance, throttle position,

brake applications and operations (including train brake, independent brake, and,

if so equipped, dynamic brake applications and operations) and, where the

locomotive is so equipped, cab signal aspect(s), over the most recent 48 hours of

operation of the electrical system of the locomotive on which it is installed. A

device, designed to resist tampering, that monitors and records the specified data

only when the locomotive is in motion shall be deemed to meet this definition

provided the device was installed prior to [insert the effective date of the rule] and

records the specified data for the last eight hours the locomotive was in motion.

APTA Event Recorder Working Group. APTA is sponsoring a working group

called the ìAPTA Rail Transit Standards Development Vehicle Inspection and

Maintenance Committeeî that is addressing event recorders on rail transit vehicles. It

consists of representatives from APTA, various transit properties, consultants, and

appropriate government entities. The committee is addressing only inspection and

maintenance standards and recommended practices for rail transit event recorders. The

committeeís recorder standard is expected to detail maintenance intervals and techniques

for data, voice, and image recording systems (where available) on transit vehicles. The

group defers to the Institute of Electrical and Electronics Engineers standard for any

recommended operational and crashworthiness standards. The committee expects to have

a final draft standard for rail transit event recording systems by the end of 2002.
46 Special Investigation Report

Analysis

General

Both accidents occurred during daylight hours, under satisfactory visibility and

track conditions. During postaccident investigations, investigators found nothing that

indicated that either train 24 or train 22 had any mechanical defects or deficiencies that

contributed to the accidents. Postaccident examinations of the signal system determined

that the equipment had not been tampered with or vandalized before either accident. All

evidence indicated that the track and rail signal systems had operated as designed during

both accidents.

February 13, 2000, Accident

About 2:37 p.m. (eastern standard time) on February 13, 2000, MTA train 24,

composed of a single LRV, traveling on the Central Light Rail Line System on a routine

trip from Baltimore to the BWI Airport struck a hydraulic bumping post apparatus at the

end of the BWI Airport extension line and derailed.

During postaccident interviews, the operator stated that the last signal before the

BWI Airport Station (signal BWI 15-6 at milepost 115) was yellow. This signal aspect

authorized him to ìproceed prepared to stop at next signal.î He expressed uncertainty

whether he had applied either the train brakes or the emergency brakes before the train

struck the bumping post. Several passengers stated, during their postaccident interviews,

that the LRV continued through the station without slowing or stopping until it struck the

bumping post. Security videotape evidence viewed after the accident indicated that the

average speed of the train while traveling along the BWI Airport Station platform was

15.64 mph, and the Safety Board found no physical track evidence (scratch marks,

abrasions, or metal shavings) that would have been consistent with severe braking at the

accident site. The Safety Board concludes that the train 24 operator failed to apply the

brakes to stop his train at the BWI Airport Station on February 13, 2000.

Because the conditions under which train 24 was operating were normal and the

Safety Board could not find any mechanical reasons why the operator failed to stop the

LRV at the BWI Airport Station, the Safety Board evaluated factors that might have

affected the operatorís performance during his approach to the station.

The operator described February 13, 2000, up to the accident as ìan average day,î

and said that nothing had distracted him from his duties. Nevertheless, evidence suggests

that he was operating his train in a state of reduced alertness. Some of his postaccident

statements indicated that he was confused about what had happened, and some of his

comments about his own condition were equivocal or contradictory. He told investigators
Analysis 47 Special Investigation Report

that he had felt rested when he reported for duty but also said that he had ìfelt tired and

nauseated all dayî and that his head had felt ìstuffed up.î When asked whether he had

dozed off at any time after he began operating the train to the BWI Airport on the accident

trip, the operator responded, ìI couldnít tell you. I probably did doze. I donít know. But I

doubt it. I probably did doze off.î

The operator told the Safety Board that on the morning of the accident day, he had

taken one blood pressure pill, one Tylenol 3 (which contains codeine), and one oxycodone

pill. The Tylenol 3 and oxycodone were pain-relievers that had been prescribed to the

operator after he had undergone surgery for a dental abscess in December 1999.

According to the operator, the prescribing physicians had told him the pain medications

might cause drowsiness, and he said that he did become drowsy after he took them. The

Safety Board is aware that the use of oxycodone and Tylenol 3 can result in sedation and

may impair judgment and performance.

Pursuant to postaccident drug testing regulations at 49 CFR 653.45 and 654.33, the

operator provided a breath specimen at 7:12 p.m. and a urine specimen at 7:20 p.m. on the

day of the accident. (Thus, both specimens were taken about 5 hours after the accident.)

The breath specimen was negative for alcohol. Toxicological test results for the urine

sample revealed the presence of codeine, morphine (the active substance to which codeine

is primarily converted in the body), and the metabolite of cocaine. These findings were

consistent with the operatorís statements regarding his non-use of alcohol and his use of

prescription medication but not with his statements regarding illegal substance use.

For some time after the accident, the operator had denied that he had used any

illegal drugs before the accident, but when he was informed of the toxicological test

results, he conceded that he had recently used cocaine. In his revised account, he claimed

that very late in the evening on February 11 (about 1 1/2 days before the accident), he had

rolled two wet cotton balls in cocaine powder and placed them in his mouth to relieve the

pain associated with his abscess condition.

The Safety Board does not find the operatorís revised story credible. Given the

expected rate at which cocaine metabolizes, the test results indicate relatively recent use of

cocaine rather than use more than 30 hours before the accident. The cocaine in the

operatorís system was almost certainly ingested within the 24 hours preceding specimen

collection and was likely taken within the 12 hours before the specimen was obtained.

Because no blood from the operator was available for analysis, the times and

amounts of ingestion cannot be more accurately determined, and it is not possible to

definitively determine from these data whether the operator was impaired by cocaine at

the time of the accident. Acute withdrawal from cocaine primarily results in depression

and fatigue, and the operator could have been suffering from these symptoms even if he

were not intoxicated by cocaine at the time of the accident.

Postaccident statements from passengers indicated that the operator appeared to

have been fatigued or otherwise impaired as the LRV approached the BWI Airport Station.

One passenger told the Safety Board that he saw the operator fail to respond for 10 to
Analysis 48 Special Investigation Report

15 seconds after the LRV received a green signal at a location three stations before the

BWI Airport Station. He recalled that the operator then shook his head and body before he

began to operate the train. Several passengers even said that it appeared to them that the

operator had fallen asleep before the accident occurred.

Given that the operator did not brake the LRV on the approach to the BWI Airport

Station, that he had taken prescription drugs liable to cause drowsiness on the day of the

accident and cocaine within hours before the accident, and that the passengers saw the

operator behave in a sluggish and inattentive manner shortly before the accident, the

Safety Board concludes that the effects of prescription pain-relieving medications and/or

recent cocaine use impaired the performance of the train 24 operator on February 13,

2000.

In 1994, this operator had tested positive for cocaine during a random drug test. He

had successfully completed the required MTA rehabilitation plan, and the substance abuse

professional responsible for his case told the MTA on April 29, 1997, that further testing

for illegal substances was not indicated. Federal drug testing regulations at

49 CFR 653.63(d) state that the substance abuse professional is responsible for

establishing the specifics of the follow-up testing program. The regulations further state

that after the first 12 months of testing (with negative results), the substance abuse

professional may recommend ìthe frequency and duration of follow-up drug testing,

provided that the follow-up testing period ends 60 months after the employee returns to

duty.î This operator had fulfilled the MTAís treatment program and returned to duty by

February 1995, about 5 years before this accident occurred.

Regarding his use of prescription medication, the operator told the Safety Board

that he believed he was required to inform the MTA about using the medications

prescribed for his oral surgery in December 1999, which he continued to use from the time

he returned to work in early January 2000 until the day of the accident. However, he stated

that he never informed anyone at the MTA that he was taking those medications.

August 15, 2000, Accident

About 7:14 a.m. (eastern daylight time) on August 15, 2000, MTA train 22, which

was composed of two LRVs, en route from Pennsylvania Station in downtown Baltimore

to the BWI Airport, failed to stop at the BWI Airport Station. The train continued through

the station, struck the hydraulic bumping post at the end of the track, and derailed.

The operator told the Safety Board that he had reported to work on the day of the

accident about 3:00 a.m. He had completed one round-trip from Pennsylvania Station to

the BWI Airport Station and was returning to the BWI Airport Station on a second trip

when the accident occurred at 7:14 a.m. He recalled that, during the last segment of the

trip to the airport, he saw that signal BWI 15-6 at milepost 115 displayed a red over yellow

aspect, which required him to proceed at restricted speed and to be prepared to stop at the

station.
Analysis 49 Special Investigation Report

The operator said that the signal aspect (on a signal about 690 feet before the point

of collision) was the last thing he saw until sometime after the accident. He said that the

next things he remembered were his train being up in the air (on the bumping post) and

emergency personnel boarding it. Presumably, the operator lost consciousness sometime

after he saw the signal at milepost 115. He was unable to say how long he had been

unconscious or exactly what might have caused him to lose consciousness. He said he had

not had any previous blackout experiences.

Because the operator lost consciousness well before the accident occurred and had

no recollection of the events immediately preceding the accident, it seems that the

blackout incapacitated the operator so that he could not perform his necessary duties,

including braking, as the train approached the BWI Airport Station. Therefore, the Safety

Board concludes that the train 22 operator did not apply the brakes to stop his train at the

BWI Airport Station on August 15, 2000. The Safety Board looked for possible reasons

for the operatorís blackout.

Medication Use

One factor that could have affected the operatorís alertness on the day of the

accident was his use of prescribed medications. The operator told the Safety Board that he

had been off duty with a chronic back problem for about 2 months before the accident and

had returned to work the day before the accident. The operator said he was taking

prescribed medications for high blood pressure and chronic back and neck pain at the time

of the accident.

About 3 hours 45 minutes after the accident, the train operator provided breath and

urine specimens, pursuant to Federal postaccident toxicological testing regulations. In

addition, medical personnel at Mercy Hospital in Baltimore obtained a blood specimen for

medical evaluation purposes, and the Safety Board subpoenaed portions of the blood

specimen for additional testing. All specimens tested negative for the presence of alcohol

and illegal drugs. Consequently, the Safety Board concludes that the train 22 operator was

not impaired by alcohol or illegal drugs at the time of the August 15, 2000, accident.

The urine specimen indicated the presence of amlodipine, a prescription

medication used principally to control hypertension. The Safety Board considers that the

presence of this medication would not typically impair performance.

Although the operator indicated that he had been taking the prescription muscle

relaxant cyclobenzaprine (Flexeril) for back pain, none of the test results indicated the

presence of this medication. In fact, cyclobenzaprine would likely not be detected in the

blood at the levels typically prescribed, so the operator could have had some of this

medication in his system. The operator said, however, that he had last taken 10 mg of

cyclobenzaprine about 3:00 p.m. on August 14, 2000, which would have been about 16

hours before the accident occurred. It is unlikely that such a dosage of this medication,

taken so many hours before the accident occurred, would have significantly impaired the

operatorís mental and/or physical abilities at the time of the accident. Nevertheless, the
Analysis 50 Special Investigation Report

Safety Board cannot absolutely dismiss this medication as a possible contributory source

of operator impairment, although it was not the primary cause of the operatorís blackout.

Obstructive Sleep Apnea

The Safety Board considered extreme sleepiness as a possible explanation for the

train 22 operatorís blackout. Little immediately apparent evidence supported this

possibility. The operator said he had felt rested before the accident. His work and rest

schedule indicated that in the days preceding the accident, he had had about 10 1/2 hours

of sleep in the night of August 11 to 12, about 11 hours of sleep in the night of August 12

to 13, about 4 hours of sleep in the night of August 13 to 14 (plus about 6 hours that day of

what the operator characterized as ìrestî), and 8 to 9 hours of sleep in the night of

August 14 to 15. While this schedule was somewhat irregular, the operator did have

adequate opportunity to obtain an average of more than 8 hours of sleep per night.

After the accident, however, the operatorís physician became concerned that the

operatorís unexplained loss of consciousness on the day of the accident might have been

caused by a sleeping disorder. On September 5, 2000, on the advice of his physician, the

operator underwent an evaluation by a sleep medicine specialist. The evaluation results

indicated that the operator suffered from severe obstructive sleep apnea.

During the assessment, the operator told the examining sleep specialist physician

that he had ìexcessive daytime sleepiness sometimes.î The evaluation indicated that the

operator had a self-reported Epworth Sleepiness Scale value of 14, while an Epworth

Sleepiness Scale value for a person without excessive sleepiness would be 10 or lower.57

In addition, the medical testing determined that the operator demonstrated a respiratory

disturbance index of 106 episodes per hour. A normal index would be less than 5 episodes

of disturbance per hour, while an index indicating ìsevereî disturbance would be anything

above 30 episodes per hour. Therefore, the operator had more than 21 times the number of

breathing pauses per hour than is considered normal and more than 3 times the number of

breathing pauses per hour than is considered severely disturbed. In addition, the

evaluation showed that the operatorís sleep latency period (the time it took for him to fall

asleep under optimum conditions) was shorter than that of an individual who is not sleepdeprived.

The Safety Board sent the full results of the operatorís medical sleep evaluation to

the director of the Center for Sleep and Respiratory Neurobiology at the University of

Pennsylvania Medical Center for assessment. This expert strongly supported the diagnosis

of severe obstructive sleep apnea and considered the operator at risk for falling asleep

inappropriately. Based on its review of the sleep evaluation evidence and the verification

of the evaluation findings by an independent expert, the Safety Board concludes that the

train 22 operator was suffering from severe obstructive sleep apnea at the time of the

August 15, 2000, accident.

57 The Epworth Sleepiness Scale has a range of 0 to 24. Epworth Scale values for a person without

excessive sleepiness would be 10 or less, while values 11 through 24 indicate significant sleepiness.
Analysis 51 Special Investigation Report

Obstructive sleep apnea is a medical condition that chronically prevents those

affected by it from obtaining restful sleep, creating circumstances that result in persistent

fatigue no matter how much sleep is obtained during any period. Medical authorities agree

that excessive daytime sleepiness is almost uniformly present in people who suffer from

obstructive sleep apnea, and constant fatigue is one of the symptoms of the disorder.

Because he had severe obstructive sleep apnea, the operator almost certainly had severe

and persistent fatigue. He likely was so accustomed to his habitual condition of tiredness

that he did not even clearly recognize that he was fatigued. On the morning of the

accident, this unrelieved fatigue appears to have caused the operator to fall asleep while he

was operating the train during the approach to the BWI Airport Station. 58 Consequently,

the Safety Board concludes that the chronic fatigue he was experiencing due to

undiagnosed obstructive sleep apnea likely caused the train 22 operator to fall asleep as

the LRV train approached the BWI Airport Station on August 15, 2000.

An estimated 10 million people in the United States have undiagnosed obstructive

sleep apnea.59 This is due in large part to a lack of awareness about and appreciation of the

symptoms of the disease. Its hallmarks, such as snoring and persistent fatigue, are often

considered mere annoyances rather than possible symptoms of a medical condition.

Consequently, people with sleep apnea frequently dismiss the indicators as insignificant.

A person educated about the disease, however, might recognize them as symptoms of the

condition and seek appropriate medical treatment. Similarly, if transit agencies were better

educated about and focused more attention on such disorders, they might be more aware

of those employees likely to have sleeping disorders and be better equipped to help

employees with sleeping disorders treat the conditions safely and effectively.

Consequently, the Safety Board concludes that better education about the risks posed by

sleeping disorders, the indicators and symptoms of such disorders, and the available

means of detecting and treating the conditions could help transit agencies and their

employees reduce the risk of safety-sensitive employees being impaired by chronic

fatigue.

As a result of its investigation of the collision involving two New York City

subway trains on the Williamsburg Bridge in Brooklyn, New York, on June 5, 1995,60 the

Safety Board issued Safety Recommendations R-96-20 and -21 to the FTA and APTA,

respectively.

58 It should be noted that the Safety Board has previously investigated an accident in which a transit

train operator fell asleep while operating a train, resulting in a collision with another train. The accident is

detailed in Railroad Accident Report NTSB/RAR-96/03, Collision Involving Two New York City Subway

Trains on the Williamsburg Bridge in Brooklyn, New York, June 5, 1995. In the Williamsburg Bridge case,

the operatorís condition was not attributable to a sleeping disorder.

59 Information obtained in early 2001 from the Home page of the American Sleep Apnea Association

<http://sleepapnea.org>.

60 Railroad Accident Report NTSB/RAR-96/03.
Analysis 52 Special Investigation Report

R-96-20

In cooperation with the American Public Transit Association, develop a fatigue

educational awareness program and distribute it to transit agencies to use in their

fitness for duty training for supervisors and employees involved in safetysensitive positions.

R-96-21

Assist the Federal Transit Administration in developing a fatigue educational

awareness program for transit agencies to use in their fitness for duty training for

supervisors and employees in safety-sensitive positions.

In a letter dated May 1, 1999, the FTA informed the Safety Board that a fatigue

awareness program had been incorporated into the Transportation Safety Instituteís core

curriculum. Based on the FTAís response, the Safety Board classified Safety

Recommendation R-96-20 ìClosed--Acceptable Actionî on January 11, 2000. APTA

responded to Safety Recommendation R-96-21 by conducting research on the effects of

fatigue on human performance and assisting the FTA in developing the fatigue awareness

program that has been incorporated into the Transportation Safety Instituteís core

curriculum. Accordingly, Safety Recommendation R-96-21 is classified ìClosedó

Acceptable Action.î

Although not specifically requested in Safety Recommendations R-96-20 and -21,

the Transportation Safety Instituteís Fatigue Awareness Seminar includes modules

addressing the major types of sleeping disorders, including sleep apnea. Such information,

once it filters down to individual transit operations and employees, should help heighten

awareness of the risks posed by such sleeping disorders and how these risks may be

alleviated. Before the BWI accidents took place in 2000, the MTA did not attempt to

educate its employees or managers about how sleeping disorders could negatively affect

the safety of the transit environment and about how such problems could be identified and

addressed. Following the accidents, in 2001, some MTA personnel participated in fatigue

awareness training, including the Transportation Safety Instituteís fatigue awareness

training. In addition, the MTA began developing its own fatigue awareness training

program and policy.

The Safety Board is pleased with these MTA efforts in the area of fatigue

awareness and encourages the MTA to develop a systematic and comprehensive program

that will ensure that MTA employees are kept aware of the various safety issues involving

fatigue, particularly fatigue caused by sleeping disorders. As indicated by the August 2000

accident at the BWI Airport Station, such disorders can have significant system safety

consequences. Given that a sleeping disorder may affect the performance of an operator

employed by any rail transit system, all such systems would benefit from including a

sleeping disorder component in their fatigue programs. Therefore, the Safety Board

believes that U.S. rail transit systems should ensure that their fatigue educational

awareness programs include the risks posed by sleeping disorders, the indicators and

symptoms of such disorders, and the available means of detecting and treating them.
Analysis 53 Special Investigation Report

According to some experts, it may be possible to identify safety-sensitive

employees who may have a sleeping disorder by using questionnaires and/or structured

interviews and clinical data.61 One method to determine whether testing for a sleeping

disorder might be warranted would be to administer a prescreening questionnaire designed

to extract information about the employeeís general physical characteristics, sleeping

habits, and daytime functioning. The Epworth Sleepiness Scale used in the early stages of

the sleep medicine evaluation of the train 22 operator is an example of such a prescreening

questionnaire.

Once the individual completes the prescreening questionnaire, it could be

evaluated by medical experts to determine whether the individual possesses predisposing

factors associated with a sleeping disorder, including being male, being overweight, being

over 40 years old, having high blood pressure, having some physical anomaly of the upper

airway, and having sleeping and waking behaviors (such as snoring) indicative of a

sleeping disorder. (The train 22 operator had all these predisposing criteria.) On the basis

of such an evaluation, the employee could then either be recommended for clinical

medical evaluation or determined to be at lower risk for sleep disorders.

The Union Pacific and CSXT Railroads have begun to use programs that rely on

specially designed prescreening questionnaires to determine their employeesí

predisposition to sleeping disorders. The data from the first Union Pacific program are still

being evaluated, but the initial CSXT program enabled the railroad to identify 43

employees with sleep apnea and have them treated for the disorder.

Medication Reporting Requirements

During these investigations, the Safety Board learned that, although the MTA had

substance abuse requirements addressing the use of alcohol and illicit drugs, it did not

specifically require that safety-sensitive employees report their use of prescription and

over-the-counter medications before operating equipment. Rule 1.6.2 of the MTA Interim

Rules and Instructions for Employees prohibited employees from reporting for duty or

being, while on duty, under the influence of ìintoxicants, including alcohol, or Controlled

Substances, or any other substance which may impair job performance.î (Italics added.)

The MTA, however, did not define ìany other substance which may impair job

performanceî as including prescription or over-the-counter medications, many of which

have side effects that can impair alertness and other job performance factors.

Both operators in the BWI 2000 accidents had been on medical leave for extended

periods shortly before their respective accidents. Both had been prescribed medications

that had possible side effects that included fatigue and drowsiness. Regarding the MTAís

61 K. Kump, C. Whalen, P.V. Tishler, I. Brower, V. Ferrette, K.P. Strohl, C. Rosenberg, and S. Redline,

ìAssessment of the Validity and Utility of a Sleep-Symptom Questionnaire,î American Journal of

Respiratory Critical Care Medicine, 1994; Volume 150(3): pp. 735-741. And T. Ploch, C. Kemeny, G.

Gilbert, W. Cassel, and J.H. Peter, ìSignificance of a Screening Questionnaire for Diagnosis of Sleep

Apnea,î Pneumologie, March 1993; 47 Supplement 1: pp.108-111.
Analysis 54 Special Investigation Report

policy about employees who had been on medical leave, the MTA light rail superintendent

stated in a June 12, 2000, letter to the Safety Board that the MTA does ìnot positively

know whether a safety-sensitive employee is on medication when they return to work.î

Prescription and over-the-counter medications can significantly affect the

performance of people taking them. Many such medications can make the patient drowsy

or dizzy, affect vision or hearing, or bring about other physical conditions that could

reduce the effectiveness of a safety-sensitive employee. It appears that the MTAís policy

regarding prescription and over-the-counter medications was to allow the employee to

make the final determination whether he or she was fit for duty while taking a medication.

But the MTA itself had no mechanism by which it could review the appropriateness of the

employeeís decision.

The physical condition of an employee who carries out safety-sensitive duties

should be of vital interest to any rail transit system management. Management is

responsible not only for the well-being of that employee but of the passengers and

coworkers the employeeís actions affect. Some medications, even when they are taken as

prescribed or recommended, may have the effect of degrading employee performance. In

some cases, legal substances such as over-the-counter and prescription drugs can impair

the condition of an employee nearly as readily as illegal drugs. Consequently, the Safety

Board concludes that because the MTA did not require safety-sensitive employees to

report their use of prescription and over-the-counter medications, it lacked information

that could have had a bearing on the condition and performance of such employees.

Safety-conscious rail transit agencies must consider an employeeís use of

substances, whether legal or illegal, that could negatively affect the employeeís

performance and put passengers and coworkers at risk. If use of a prescription or over-thecounter medication brings into question the performance of an employee responsible for

safety-sensitive duties, the employee can be temporarily reassigned to non-safetysensitive duties while taking the medication. But management cannot reassign its

employees if it does not know that they are using prescription or over-the-counter

medications that might cause impairment. Through postaccident interviews, the Safety

Board found that the two operators involved in the BWI accidents each had a different

perception about the MTAís policy concerning an operatorís responsibility for reporting

medication use. The train 24 operator was taking the pain-relievers oxycodone and

Tylenol 3 when he returned to work. He did not tell anyone at the MTA that he was taking

the medications, but he was under the impression that he was supposed to inform

someone. The train 22 operator had been prescribed and was taking pain medications to

deal with chronic back and neck pain, and at least one of the medications may have carried

a safety warning about operating machinery. The train 22 operator stated that he did not

believe he was obligated to show these medications to his MTA supervisors but that he

had done so on two occasions.

Thus, the operator in the February 2000 accident believed he was supposed to

report his medication use but failed to do so, while the operator in the August 2000

accident did not think he was obligated to report medication use, although he said he tried

to report it. At the same time, the chief of the MTA benefits section told the Safety Board
Analysis 55 Special Investigation Report

that the MTA did not require employees to inform the MTA about their using prescription

medications, while the MTAís contract physician told the Safety Board that employees

were expected to report medication use in at least some cases. On the basis of the

inconsistency evident at all levels within the organization about what was required for an

employee to fulfill the policy, the Safety Board concludes that MTA managers and

employees were confused about the requirements for reporting medication use to the

MTA.

The chief of the MTA benefits section told the Safety Board that the MTA

followed applicable FTA regulations pertaining to substance abuse and that, consistent

with those regulations, the MTA had no specific requirement that employees in safetysensitive positions inform the MTA about their use of prescription and/or over-the-counter

medications. The Safety Board reviewed the FTA drug regulations at 49 CFR Part 653 and

found no explicit reference to the use of prescription and/or over-the-counter medications

by safety-sensitive employees.62 Other rail transit organizations may also infer from the

lack of FTA regulations concerning the use of prescription and/or over-the-counter

medications that they do not need to require their employees to report their use of

prescription and over-the-counter drugs. Therefore, because the MTA may be only one of

a number of rail transit organizations that do not require their safety-sensitive employees

to report their use of prescription and over-the-counter medications, the Safety Board

believes that U.S. rail transit systems should require employees in safety-sensitive

positions to inform their supervisors when they are using prescription or over-the-counter

medications so that qualified medical personnel may determine the medicationís potential

effects on employee performance, and train the employees about their responsibilities

under the policy.

In contrast to the FTAís lack of such requirements, the FRA regulations at

49 CFR 219.103 specifically address the use of prescription and over-the-counter

medications by employees covered under FRA rules. The regulations permit covered

employees63 to use such medications, as determined by a physician or treating medical

practitioner, if ìuse of the substance by the employee at the prescribed or authorized

dosage level is consistent with the safe performance of the employeeís duties.î The FRA

regulations also require that, in the event that more than one medical practitioner is

treating the employee, at least one practitioner must be informed of all medications the

employee is taking and must conclude that the use of the medications is consistent with

safe employee performance. Moreover, the FRA regulations explicitly state, ìThis subpart

does not restrict any discretion available to the railroad to require that employees notify

the railroad of therapeutic drug use or obtain prior approval for such use.î

62 At the time of the accidents in 2000, 49 CFR Part 653, ìPrevention of Prohibited Drug Use in Transit

Operations,î was in effect. Effective August 2001, Part 653 was superseded by 49 CFR Part 655,

ìPrevention of Alcohol Misuse and Prohibited Drug Use in Transit Operations.î The Safety Boardís review

of the new FTA regulations at 49 CFR Part 655 found that they are also silent on the use of prescription and

over-the-counter medications by safety-sensitive employees.

63 In this context, covered employees are those who have been assigned to perform service subject to the

Hours of Service Act.
Analysis 56 Special Investigation Report

The Safety Board is concerned about the disparity between the FTA and FRA

regulations concerning substances liable to cause employee impairment. Because FTA

regulations do not specifically address the use of prescription and over-the-counter

medications by safety-sensitive employees, rail transit operations, unlike railroad

operations under the jurisdiction of the FRA, may not consider that they have the authority

to monitor medication use by safety-sensitive employees. In contrast to the railroads

regulated by the FRA, which may carry both freight and passengers, the rail transit

systems regulated by the FTA are responsible primarily for the transport of passengers.

Therefore, the Safety Board concludes that, in the interests of passenger safety, rail transit

systems should be at least as rigorous as FRA-regulated systems concerning possible

sources of operator impairment. In the view of the Safety Board, the need for rail systems

to be aware of medication use by operators is more pressing than ever when passenger

safety is at risk. Consequently, the Safety Board believes that the FTA should authorize

and encourage rail transit systems to require their employees in safety-sensitive positions

to inform the rail transit system about their use of prescription and over-the-counter

medications so that the rail transit system can have qualified medical personnel determine

the medicationís potential effects on employee performance.

MTA System Safety

The investigations of the BWI accidents in 2000 indicated that impaired operators

caused both accidents; the train 24 operator was impaired by prescription pain-relieving

medications and cocaine, and the train 22 operator was impaired by severe obstructive

sleep apnea. Although the Safety Board appreciates that no employee oversight program is

perfect, the Board is concerned that, within about 6 months, two significantly impaired

employees operated LRV trains, resulting in two accidents that put passengers and

employees at risk. Consequently, the Safety Board examined the system safety approach

used by the MTA at the time of these accidents.

The MTA told the Safety Board that it used a system safety program plan as the

basis for its overall safety policy. The Safety Board considers the appropriate use of

system safety program plans by rail transit systems to be a reliable means of establishing

and maintaining safe operations because such plans, when fully implemented, provide the

standard for safe procedures in all operational departments, and periodic audits (monthly,

yearly, and triennially) confirm that the safety standards are being satisfied. Audits are

conducted by the organization itself, by the State regulatory agency, and (upon request) by

APTA. A well-drafted and fully implemented plan would ensure that the organizationís

approach to safety concerns was systematic, consistent, and verifiable. In the case of the

BWI accidents, for example, the plan, had it been properly developed and carried out,

would have ensured that the MTAís drug and alcohol policies were clearly communicated

to all personnel and that emergency drills were conducted on a regular basis. Depending

on the specific elements of the program, it might even have provided more effective

means of identifying operators with performance problems.
Analysis 57 Special Investigation Report

The Safety Board found, however, that the MTAís efforts to put its system safety

program plan into service did not indicate that the MTA management was fully committed

to and involved in the system safety program.

The limited nature of the system safety program planís application to MTA

operations appears to have been recognized within the MTA. Members of the MTA system

safety department, which was responsible for carrying out the system safety program plan,

told the Safety Board that before January 2000, implementation of the MTA system safety

program plan had not been energetically pursued. In reference to the system safety

program plan, one department employee said, ìIt was something that was put together

because it was mandated, but it wasnít something that we actually lived by.î

Those who reviewed the MTA system safety program plan from outside the MTA

also expressed doubts about the success of the program. The 1998 preliminary report of

the 1997 APTA audit of the MTA stated that the APTA auditors found that most MTA

managers were unfamiliar with the system safety program plan and that many MTA

managers did not seem to fully understand system safety or to appreciate managementís

role in fulfilling the system safety program plan. The APTA report further stated that the

system safety program plan had not been comprehensively distributed and that the MTA

had not adequately tracked the progress of the system safety program planís

implementation.

The contractor hired by the MTA in January 2000 to put the system safety program

plan into effect told the Safety Board that the system safety program plan that the MTA

had initially provided her was not adequate to address the MTA operation. She also said

that in the early stages of her effort, some of the MTA operations management accepted

neither the existing system safety program plan nor even the necessity of having such a

plan. She further stated that the MTA operations superintendent refused to cooperate with

her as she worked to develop and implement the system safety program plan.

Since the BWI accidents, however, the MTA has taken action to forward the

implementation of its system safety program plan. About 4 months after the August 2000

accident, the MTA underwent a management reorganization, which appears to have put in

place managers more receptive to the system safety program plan concept. The MTA also

hired additional safety personnel at this time. The contractor hired by the MTA to put the

system safety program plan into effect completed the writing of the program in early 2001.

She conducted 4 hours of training on the program for all MTA operations management

and helped the MTA carry out internal audits of its new program before her contract

expired in March 2001. Since March 2001, the MTA has assigned its own system safety

specialist (hired in December 2000) to rewrite the MTA system safety program plan to

tailor it more closely to MTA operations.

In addition, following the accidents, the MTA had an independent contractor

conduct a safety assessment of its light rail operations. The assessment was completed in

October 2000, and the MTA has developed a corrective action plan based on the

contractorís assessment. The MTA also completed a revision of its Light Rail rulebook in

April 2001. A new annual recertification program for all operators, maintenance
Analysis 58 Special Investigation Report

supervisors, and track access and control personnel includes training on the revised

rulebook.

Further, in May 2000, MDOT had a contractor carry out its triennial audit of MTA

system safety. Since that time, MDOT has been working with the MTA to implement

corrective actions based on the results of the 2000 audit.

Therefore, the Safety Board concludes that before the two accidents at the BWI

Airport Station in 2000, the MTA had not successfully implemented a comprehensive

system safety program plan throughout all levels of the organization; however, efforts to

do so are now underway.

Equipment Issues

Bumping Posts

Engineering documentation submitted by the Cullen-Western-Hayes bumping post

manufacturer indicated that the bumping post structure could accommodate the impact

loading of a three-car light rail train moving at 10 mph. However, the manufacturer

presented no evidence demonstrating that the bumping post could safely stop such a train

as might be encountered at the BWI Airport Station location (traveling at 15 mph or more

with a full passenger load).

According to the Safety Boardís calculations, based on the specifications provided

by the manufacturer and available LRV weight, speed, and other data, this bumping post

design had insufficient kinetic energy attenuation capacity for the combination of potential

train speeds and/or train weights that might be encountered at the BWI Airport Station

location. The manufacturerís performance specification for the bumping post assembly

stated that the bumping post had a kinetic energy absorption capacity of about 1.4 million

pound-feet. Safety Board calculations showed that the approximate amounts of kinetic

energy transferred into the Cullen-Western-Hayes WH bumping posts in the February and

August 2000 BWI Airport Station accidents were about 934,800 pound-feet and

1.15 million pound-feet, respectively. Both these energy levels are below the 1.4 million

pound-feet specification cited by the manufacturer, and yet the bumping posts did not

function successfully in either collision. (The failures were due to improper installation of

the bumping posts, which will be discussed later in this section.)

Even if the bumping post assembly could fulfill its specified kinetic energy

absorption capacity of 1.4 million pound-feet, its capacity would still be deficient in some

scenarios that could quite likely occur at the BWI Airport Station. The Safety Boardís

calculations demonstrated that in a hypothetical ìworst-case scenarioî collision between a

train and the bumping post at the BWI Airport Station, involving a three-unit LRV train

filled to occupant capacity traveling at 15 mph,64 the kinetic energy that could be

64 The posted speed limit approaching the station was 15 mph.
Analysis 59 Special Investigation Report

transferred into the bumping post upon such an impact would be about 3.6 million poundfeet. The Cullen-Western-Hayes WH bumping post system, even if it performed up to its

own specification, could only absorb about 40 percent of the kinetic energy of this worstcase impact.

The Safety Board further calculated that the bumping post design provided an

insufficient deceleration stopping distance, which allowed substantial deceleration

G forces to be exerted upon the LRV occupants. The average level of G forces

experienced by the LRV occupants in the 2000 BWI accidents, along the LRVís

longitudinal axis, were about -1.81 G for the February accident and about -0.23 G for the

August accident.65 A ìsafe stopî can be accomplished by providing a longer stopping

distance (as compared to that found in the Cullen-Western-Hayes WH bumping post

system), which is available in alternate design end-of-track protection equipment.

The Safety Board concludes that the Cullen-Western-Hayes WH bumping posts

installed on both service tracks at the BWI Airport Station were the wrong end-of-track

protection devices for this location because their kinetic energy absorption capacity was

inadequate for some light rail operations possible at this location and their design did not

provide an adequate deceleration stopping distance for the BWI Airport Station stop.

In addition, the bumping posts had been installed in such a way that they could not

perform optimally. Postaccident technical examination of the bumping post equipment at

the BWI Airport Station showed that the bumping post assemblies on both service tracks

had not been installed in accordance with the manufacturersí installation instructions. In

both cases, the running rail joints had been situated, contrary to the manufacturerís

directions, too close to the base of the bumping post assembly, so that the anchorage of the

bumping post assembly could not benefit from the weight of the front half of the LRV that

it was intended to service. Consequently, the Safety Board concludes that the bumping

posts at the BWI Airport Station struck during the February and August 2000 accidents

had been improperly installed.

Since the August 2000 accident, the MTA has replaced the Cullen-Western-Hayes

WH hydraulic bumping post equipment at the terminus at the BWI Airport Station with

friction buffer stop equipment. The Safety Board reviewed the friction buffer stop

apparatus and found it to be an engineered ìenergy retardation deviceî that is fitted to the

running rails of stub-end tracks and employs a ìfriction shoeî clamping mechanism that

secures the assembly to the head of the running rail. When struck, the friction buffer stop

is pushed along the running rail surface in a controlled manner. As the device moves along

the rails, the kinetic energy of the moving rail vehicle is transferred into heat energy in the

buffer stopís friction shoe, causing the vehicle to come to a stop. The friction buffer stop

equipment should provide improved energy attenuation protection and end-of-line

collision protection at the BWI Airport Station. Before the August 2000 accident, the

Central Light Rail Line System had friction buffer stop equipment installed on all its stub65 The impact also resulted in substantial downward G forces, which could not be quantified in this

investigation. These downward forces may also have caused some of the injuries.
Analysis 60 Special Investigation Report

end station tracks except the BWI Airport Station. Since the August 2000 accident,

friction buffer stop equipment has been installed at the BWI Airport Station.

Seat Assembly

The MTA LRVs have seat assemblies and grabrails that are produced by the

American Seating Company. Information provided by the seating manufacturer indicated

that the seats are subjected to limited testing to determine their crashworthiness properties.

The entire seating system has not been, nor is it required to be, subjected to full static and

dynamic tests.

Generally speaking, using energy-attenuating seat structures and assemblies may

reduce the likelihood and severity of passenger injuries resulting from a collision. Further,

seat designs focusing on the seatbackís ability to contain the passenger within the seat may

reduce the passengerís exposure to less occupant-friendly surfaces inside the LRV.

The Safety Board documented a number of facial and neck injuries in the February

and August 2000 BWI accidents that reportedly resulted from passenger impacts with the

transverse-mounted passenger seatbacks and stainless steel seat grabrails. The steel

grabrails were not wrapped or covered with any energy-attenuating material.

Despite the passenger head and neck injuries resulting from these accidents, the

Safety Board did not find compelling evidence that the stainless steel seating grabrails on

the LRVs involved in the BWI accidents had inadequate energy absorption capabilities.

According to the results of energy absorption testing conducted by American Seating, in

which the stainless steel and the thermoplastic grabrails of LRV seats were struck with

equal force by a head form, the Head Injury Criteria values calculated were generally

somewhat higher for the stainless steel grabrails than for the alternative thermoplastic

grabrails. However, the two sets of Head Injury Criteria values resulting from the

testingófor the grabrails made of stainless steel and those made of thermoplasticówere

both well below the threshold value of 1,000 and even below APTAís guideline value of

400 for bus grabrails.

Since the accidents at the BWI Airport Station in 2000, the MTA has

communicated to the Safety Board its intention to explore the redesign of its LRV

seatback grabrails. The MTA has further stated that it ultimately intends to change the

design of the stainless steel grabrails and/or use more energy-attenuating materials in its

future rail car procurements. The Safety Board encourages the MTA to pursue this course

of action.

Event Recorders

The two BWI investigations showed that each MTA light rail car contains a system

for preserving a limited amount of train performance data in the event of an incident that

meets a specific triggering requirement (in this case, an application of the track brakes at a

train speed of at least 10 mph). The system consists of a software package that modifies

the LRVís central computer system so that performance data may be stored within the car
Analysis 61 Special Investigation Report

computerís memory. The data saved cover from 30 seconds before until 30 seconds after

the triggering event.

When investigators first examined the available event data for the February 2000

accident, they determined that the event recorder had recorded a triggering event that

occurred about the time of the accident. Further analysis, however, showed that the data

recorded were inconsistent with the known facts of the accident event (that an LRV had

collided with a bumping post).

A day after the initial examination of the recorder and its data, investigators found

that the recorder had in the meantime documented another triggering event, which

occurred after the postaccident data download. The time that the recorder showed as the

occasion of this second triggering event preceded any postaccident movement of the LRV;

the car was at rest throughout this period. Consequently, investigators determined that the

LRV did not, in fact, experience a valid triggering event at this time. The data from the

second triggering event overwrote the data from the event that had occurred on the day of

the accident, even though the MTA had requested that the system be set to allow two

separate triggering events to be saved before overwriting. The manufacturer was unable to

explain exactly why and how these problems occurred.

In addition to the problems encountered while attempting to access the February

2000 accident data, the Safety Board identified several other specific weaknesses in the

MTAís event recorder system. One significant deficiency is the dependence of the system

on a trigger to begin recording. The accident scenarios presented by the two accidents at

BWI, as well as many other potential accident scenarios, would not necessarily provide

the triggering event necessary to activate the recording system. Also, the amount of time

captured by this system (30 seconds before the trigger and 30 seconds after the trigger, for

a 1-minute total) does not provide enough information to determine how the train was

being operated before the accident. Sometimes trending data are helpful to determine

unsafe operating practices, and no such data are available on this system. Installing a

system that continually monitors and records data can eliminate this deficiency. FRA

regulations at 49 CFR 229.5(g) state that an event recorder should monitor and record data

ìover the most recent 48 hours of operation of the electrical system of the locomotive on

which it is installed.î Having the previous 48 hours of operational data available increases

the likelihood that trend data will be available if needed for the investigation.

Another major deficiency of the current MTA recording system is its reliance on

the functionality of the carís computer system. In an accident, the carís computer system

could be compromised. Installing a recording system as an integral part of the computer

system leaves the recording vulnerable not only to the trauma associated with the accident

itself, but also to any electronic anomalies present in the computer. Having a separate,

self-contained recording system would eliminate the possibility of the computer system

compromising the recorded data.

A final weakness in the current recording system is its reliance on the carís central

power source. The possibility exists for the car to lose power during an accident sequence.

Under such a circumstance, the unpowered recording system could fail to receive and
Analysis 62 Special Investigation Report

record significant operational and performance data during the accidentís progression.

Providing nominal battery back-up power to the recording system for several moments

after power is lost would eliminate this deficiency and ensure that all relevant operational

data are stored and kept ready for analysis.

Given the irregularities in the data recording and retention encountered following

the February 2000 accident and the deficiencies of the system detailed above, the Safety

Board concludes that the event recording system in place on the MTA light rail cars is

inadequate to serve as a reliable accident investigation tool. Therefore, the Safety Board

believes that the MTA should install, on all its LRVs, independent event recorders that

record and retain the most recent 48 hours of data, store data in nonvolatile memory, and

have a back-up power source that would enable the entire recording system to function if

electric power is lost to the car.

No current Federal regulations apply to event recorders on LRVs. On

November 14, 1996, as a result of the Safety Boardís investigation of an accident on the

Washington Metrorail system,66 the Safety Board issued Safety Recommendation R-96-46

to the FTA, which called for the FTA to:

R-96-46

Develop, with the assistance of the American Public Transit Association,

guidelines for the monitoring/recording devices that capture critical performance

and event data for rapid rail transit cars and urge transit agencies to install these

devices on new and rehabilitated cars.

The FTA, with APTA, prepared a report, dated June 1998, entitled Event Recorders

for Rail Rapid Transit Systems. In a letter dated September 4, 1998, the FTA provided the

Safety Board with a copy of the report and indicated that the report would be distributed to

transit agencies developing specifications for rehabilitated and new rapid transit vehicles

and that the FTA would urge the installation of the devices. The report explored the

effectiveness and efficiency of using event recorders on rapid rail cars. It presented and

analyzed data; defined various aspects of using accident/incident event recorders; included

a cost, feasibility, and benefit analysis; and identified the technical requirements for these

devices in rapid rail transit. Based on this response, the Safety Board classified Safety

Recommendation R-96-46 ìClosedóAcceptable Actionî on January 6, 1999.

When, on November 14, 1996, the Safety Board issued Safety Recommendation

R-96-46 to the FTA, it also issued the parallel Safety Recommendation R-96-47 to APTA.

The recommendation asked APTA to:

66 Railroad Accident Report NTSB/RAR-96/04.
Analysis 63 Special Investigation Report

R-96-47

Develop, with the assistance of the Federal Transit Administration, guidelines for

the monitoring/recording devices that capture critical performance and event data

for rapid rail transit cars and urge transit agencies to install these devices on new

and rehabilitated cars.

In addition to working with the FTA to develop the 1998 report on Event

Recorders for Rail Rapid Transit Systems, APTA has, through various APTA-sponsored

conferences and symposiums, urged transit agencies to install these devices on new and

rehabilitated cars. Based on this information, Safety Recommendation R-96-47 is

classified ìClosedóAcceptable Action.î

APTA is also sponsoring a working group called the ìAPTA Rail Transit Standards

Development Vehicle Inspection and Maintenance Committee.î The groupís efforts are

limited to providing inspection and maintenance standards and recommended practices for

event recorders on rail transit vehicles. The committee expects to have a final draft

standard for recording systems for rail transit vehicles by the end of 2002. 
64 Special Investigation Report

Conclusions

Findings

1. The train 24 operator failed to apply the brakes to stop his train at the BaltimoreWashington International Airport Station on February 13, 2000.

2. The effects of prescription pain-relieving medications and/or recent cocaine use

impaired the performance of the train 24 operator on February 13, 2000.

3. The train 22 operator did not apply the brakes to stop his train at the BaltimoreWashington International Airport Station on August 15, 2000.

4. The train 22 operator was not impaired by alcohol or illegal drugs at the time of the

August 15, 2000, accident.

5. The train 22 operator was suffering from severe obstructive sleep apnea at the time of

the August 15, 2000, accident.

6. The chronic fatigue he was experiencing due to undiagnosed obstructive sleep apnea

likely caused the train 22 operator to fall asleep as the light rail vehicle train

approached the Baltimore-Washington International Airport Station on August 15,

2000.

7. Better education about the risks posed by sleeping disorders, the indicators and

symptoms of such disorders, and the available means of detecting and treating the

conditions could help transit agencies and their employees reduce the risk of safetysensitive employees being impaired by chronic fatigue.

8. Because the Maryland Transit Administration did not require safety-sensitive

employees to report their use of prescription and over-the-counter medications, it

lacked information that could have had a bearing on the condition and performance of

such employees.

9. Maryland Transit Administration managers and employees were confused about the

requirements for reporting medication use to the Maryland Transit Administration.

10. In the interests of passenger safety, rail transit systems should be at least as rigorous

as Federal Railroad Administration-regulated systems concerning possible sources of

operator impairment.

11. Before the two accidents at the Baltimore-Washington International Airport Station in

2000, the Maryland Transit Administration had not successfully implemented a

comprehensive system safety program plan throughout all levels of the organization;

however, efforts to do so are now underway.
Conclusions 65 Special Investigation Report

12. The Cullen-Western-Hayes WH bumping posts installed on both service tracks at the

Baltimore-Washington International Airport Station were the wrong end-of-track

protection devices for this location because their kinetic energy absorption capacity

was inadequate for some light rail operations possible at this location and their design

did not provide an adequate deceleration stopping distance for the BaltimoreWashington International Airport Station stop.

13. The bumping posts at the Baltimore-Washington International Airport Station struck

during the February and August 2000 accidents had been improperly installed.

14. The event recording system in place on the Maryland Transit Administration light rail

cars is inadequate to serve as a reliable accident investigation tool. 
66 Special Investigation Report

Recommendations

As a result of its investigation of both accidents discussed in this report, the

National Transportation Safety Board makes the following safety recommendations:

To the Federal Transit Administration

Authorize and encourage rail transit systems to require their employees in

safety-sensitive positions to inform the rail transit system about their use of

prescription and over-the-counter medications so that the rail transit system

can have qualified medical personnel determine the medicationís potential

effects on employee performance. (R-01-25)

To U.S. rail transit systems

Require employees in safety-sensitive positions to inform their supervisors

when they are using prescription or over-the-counter medications so that

qualified medical personnel may determine the medicationís potential

effects on employee performance, and train the employees about their

responsibilities under the policy. (R-01-26)

Ensure that your fatigue educational awareness program includes the risks

posed by sleeping disorders, the indicators and symptoms of such

disorders, and the available means of detecting and treating them. 

(R-01-27)

To the Maryland Transit Administration

Install, on all your light rail vehicles, independent event recorders that

record and retain the most recent 48 hours of data, store data in nonvolatile

memory, and have a back-up power source that would enable the entire

recording system to function if electric power is lost to the car. (R-01-28)
67 Special Investigation Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARION C. BLAKEY

Chairman

CAROL J. CARMODY

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: December 11, 2001

Recommendations
68 Special Investigation Report

Appendix A ñ Accident Brief on February 13, 

2000, BWI Accident

Railroad Accident Number: DCA-00-MR-004

Rail System: Maryland Transit Administration Central Light Rail 

Line System

Train: Light Rail Vehicle Train 24

Accident Type: Collision with bumping post

Location: Baltimore-Washington International Airport light 

rail transit station

Date and Time: February 13, 2000, at 2:37 p.m.

Fatalities/Injuries: No fatalities; 18 injuries (5 serious)

About 2:37 p.m. (eastern standard time) on February 13, 2000, Maryland Transit

Administration (MTA)67 train 24 (composed of a single light rail vehicle [LRV]), en route

on the Central Light Rail Line System from Baltimore, Maryland, to the BaltimoreWashington International (BWI) Airport, struck the hydraulic bumping post68 at the BWI

Airport Station and derailed. The force of the collision detached the bumping post from

the track, and the front of the train, which was lodged against the bumping post, was

elevated about 3 1/2 feet into the air. Train 24 carried 26 people (25 passengers and 1

operator), 18 of whom were injured. Five of the injured had serious injuries. The MTA

estimated the cost of the accident at $924,000.

Accident

The train 24 operator reported for duty at the MTA light rail operations center in

downtown Baltimore on February 13, 2000, at 9:30 a.m. for his 10:01 a.m. assignment as

an operator on the Central Light Rail Line System. He began revenue service from

National Transportation Safety Board

Washington, D.C. 20594

Railroad Accident Brief

67 In 2000, when this accident occurred, the MTA was called the Mass Transit Administration. On

October 1, 2001, the MTA changed its name to the Maryland Transit Administration.

68 A bumping post is an apparatus located just before the physical end of a rail track. It is designed to

stop runaway railcars and absorb the kinetic energy should a railcar continue to travel past the designated

stopping point and on toward the end of the track.
69 Special Investigation Report

Pennsylvania Station in downtown Baltimore to the BWI Airport Station at 10:44 a.m. He

arrived at and departed the BWI Airport Station and was relieved at the University of

Baltimore/Mount Royal Station between 12:15 and 12:30 p.m. The operator said this trip

was uneventful.

During his break period (between about 12:30 and 1:40 p.m.), the operator asked

the train dispatcher for ìa couple of aspirinsî because he had a headache. The operator

said he took the aspirins and lay down for about an hour. After his break, he took over

operation of train 24 at the University of Baltimore/Mount Royal Station about 1:43 p.m.,

proceeded north to Pennsylvania Station, and departed Pennsylvania Station at 1:51 p.m.

southward in revenue service. Train 24 was composed of a single LRV and traveled along

main track No. 1.

The operator said he experienced no problems with the equipment, and he stopped

at every station during the trip from Pennsylvania Station to the BWI Airport Station. The

maximum authorized speed limit for the section of track from Pennsylvania Station to the

BWI Airport Station was 50 mph.

One passenger told the Safety Board that he had a clear view of the operator at the

North Linthicum Station, which is located three stations before the BWI Airport Station.

The passenger said that the operator received a green signal at the station and then sat

motionless for 10 to 15 seconds while the train remained stationary. He recalled that the

operator then shook his head and body before beginning to move the train forward.

From the next to last station on the line to the BWI Airport Station, the maximum

authorized speed was 15 mph. The operator said the last signal for his train before the

BWI Airport Station (signal BWI 15-6) displayed a yellow aspect. A yellow signal aspect

calls for the operator to proceed prepared to stop at the next signal. According to several

passengers, train 24 did not stop or slow at the BWI Airport Station but continued through

the station until it struck the hydraulic bumping post at the end of the track. During

postaccident interviews, several passengers told investigating law enforcement officials

that it appeared to them that the operator may have fallen asleep before the impact.

Safety Board investigators asked the operator whether he had attempted to apply

any brakes to stop the train. With respect to the train brakes, the operator was unclear but

did not indicate that he had applied them. With respect to the emergency brakes, he said he

did not know whether he had applied them.

Operator

During initial interviews, the operator said that he had undergone oral surgery for a

dental abscess in December 1999 and had been prescribed two medications, oxycodone

and Tylenol 3 (acetaminophen with codeine), to alleviate the resultant pain. The operator

was aware that the pain medications could cause drowsiness, and he acknowledged that he

did become ìa little drowsyî after he took them.

Appendix A
70 Special Investigation Report

The operator told the Safety Board that on the morning before the accident, he took

one blood pressure pill,69 one Tylenol 3 pill, and one oxycodone pill. He also said that he

took two aspirins about noon. He said that he did not use any other over-the-counter or

prescription medications. He said he did not use alcohol or illicit drugs on the day of the

accident.

Pursuant to regulations at 49 Code of Federal Regulations 654.33 and 653.45, the

operator provided a breath specimen for alcohol testing and a urine specimen for drug

testing about 5 hours after the accident. No alcohol was present in the breath specimen.

The urine specimen tested positive for benzoylecgonine, the metabolite of cocaine

(quantified at 7,300 nanograms per milliliter), positive for morphine (2,000 nanograms

per milliliter), and positive for codeine (2,100 nanograms per milliliter).

For some time after the accident, the operator had denied that he had used any

illegal drugs before the accident, but when he was informed of the toxicological test

results, he conceded that he had recently used cocaine. In his revised account, he claimed

that very late in the evening on February 11 (about 1 1/2 days before the accident), he had

rolled two wet cotton balls in cocaine powder and placed them in his mouth to relieve the

pain associated with his abscess condition.

The Safety Board does not find the operatorís revised story credible. Given the

expected rate at which cocaine metabolizes, the test results indicate relatively recent use of

cocaine rather than use more than 30 hours before the accident. The cocaine in the

operatorís system was almost certainly ingested within the 24 hours preceding specimen

collection and was likely taken within the 12 hours before the specimen was obtained.

Probable Cause

The Safety Board determines that the probable cause of the February 13, 2000,

accident at the Baltimore-Washington International Airport rail transit station was the

train 24 operatorís impairment by illicit and/or prescription drugs, which caused the

operator to fail to stop the train before it struck the bumping post at the terminus.

Adopted: December 11, 2001

69 The operator told the Safety Board that for the last several years he had taken the prescription

medication Capozide twice daily to control high blood pressure.

Appendix A
71 Special Investigation Report

Appendix B ñ Accident Brief on August 15, 

2000, BWI Accident

Railroad Accident Number: DCA-00-MR-006

Rail System: Maryland Transit Administration Central Light Rail 

Line System

Train: Light Rail Vehicle Train 22

Accident Type: Collision with bumping post

Location: Baltimore-Washington International Airport light 

rail transit station

Date and Time: August 15, 2000, at 7:14 a.m.

Fatalities/Injuries: No fatalities; 17 injuries

About 7:14 a.m. (eastern daylight time) on August 15, 2000, Maryland Transit

Administration (MTA)70 train 22 (composed of two light rail vehicles [LRVs]), en route

from Baltimore, Maryland, to the Baltimore-Washington International (BWI) Airport,

struck the hydraulic bumping post71 at the BWI Airport Station and derailed. The bumping

post separated from its attachment to the track and came to rest in an inverted position.

The leading LRV of the train came to rest lodged on top of the bumping post and about

4 1/4 feet up in the air. The roof of this LRV was partially embedded into the ceiling

structure of the terminal building. Train 22 carried 22 people (21 passengers and 1

operator), 17 of whom were injured. None had life-threatening injuries. The MTA

estimated the cost of the accident at $935,000.

Accident

The train 22 operator reported to work at 3:00 a.m. on August 15, 2000, at the

MTA light rail operations center for his assignment as a Central Light Rail Line System

National Transportation Safety Board

Washington, D.C. 20594

Railroad Accident Brief

70 In 2000, when this accident occurred, the MTA was called the Mass Transit Administration. On

October 1, 2001, the MTA changed its name to the Maryland Transit Administration.

71 A bumping post is an apparatus located just before the physical end of a rail track. It is designed to

stop runaway railcars and absorb the kinetic energy should a railcar continue to travel past the designated

stopping point and on toward the end of the track.
72 Special Investigation Report

LRV operator. The operator had completed one round-trip from Pennsylvania Station in

downtown Baltimore to the BWI Airport Station and was making another identical trip

when the accident occurred. Train 22, a two-LRV-unit train, was traveling down main

track No. 2 during its approach to the BWI Airport Station.72

The operator recalled that signal BWI 15-6, the last signal before the BWI Airport

Station, displayed a red over yellow aspect. A red over yellow signal aspect tells the

operator to proceed at restricted speed until the entire train has passed a signal displaying a

more favorable aspect. The LRV failed to stop at the BWI Airport Station and collided

with the bumping post at the end of the track about 7:14 a.m. The bumping post separated

from its attachment to the track and came to rest in an inverted position with the front of

the lead LRV resting on top of the overturned bumping post.

The operator said that the signal was the last thing he saw before he went ìout.î He

said he was not aware of anything until he returned to consciousness after the accident and

found that the train was up in the air and emergency personnel were boarding the train.

The operator was unable to say how long he had been unconscious or exactly what might

have caused him to lose consciousness.

Operator

About 2 weeks after the accident, the operatorís physician referred the operator to

a sleep specialist because she suspected that the operator might be suffering from a sleep

disorder. On September 5, 2000, the operator was clinically tested for sleep disorders at

Good Samaritan Hospital in Baltimore. The hospital developed a sleep study report for the

operator that indicated a diagnosis of ìsevere obstructive sleep apnea syndrome.î

Obstructive sleep apnea is a chronic and debilitating sleeping disorder that is often present

for years or even decades before it is diagnosed. Because excessive daytime sleepiness is

almost uniformly present in people who suffer from obstructive sleep apnea, chronic

fatigue is one of the symptoms of the disorder.

The Safety Board sent the hospitalís report to the director of the Center for Sleep

and Respiratory Neurobiology at the University of Pennsylvania Medical Center,

Philadelphia, Pennsylvania. This expertís review of the report found ìThere is no

question, based on the data you sent me, that he [the operator] has severe sleep apnea

associated with excessive sleepiness.î The director of the Center for Sleep and

Respiratory Neurobiology also stated that he would ìexpect the driver to be excessively

sleepy and at risk for falling asleep inappropriately.î 73

72 Because of the effects of a February 13, 2000, accident at this station, the MTA had taken track No. 1

out of service at this location until repairs were made.

73 Quotes are taken from a November 16, 2000, facsimile communication from the director of the

Center for Sleep and Respiratory Neurobiology at the University of Pennsylvania Medical Center,

Philadelphia, Pennsylvania, to the Safety Board.

Appendix B
73 Special Investigation Report

Probable Cause

The Safety Board determines that the probable cause of the August 15, 2000,

accident at the Baltimore-Washington International Airport rail transit station was the

train 22 operatorís severe fatigue, resulting from undiagnosed obstructive sleep apnea,

which caused the operator to fall asleep so that he could not brake the train before it struck

the bumping post at the terminus.

Adopted: December 11, 2001

Appendix B