~i6-

Train operators and SEPTA. supervisors testified that it was a common occurrence for
pessengers to stand in the restricted area. One SEPTA supervisor testified"... at times,
we have to have people up there due to the fact that we're in the business of hauling
people, and we get heavy loads sometimes during rush hour. Ard that is permitted as lon
as there’s no conversations carried on."

SEPTA mechanics who inspect and repair equipment under the jurisdiction of the
FRA are required to protect the track they are working on by lining the track switch away
from the track they are working, securing the switch with a lock, and placing a blue signal
(flag). SEPTA has opted not to require mechanics viho work on the NHSL to so prote:t
themselves. NHSL mechanics are not required to line switches away from the track they
are working on or to secure the switch. Mechanics work daily on what are generally
termed "live" tracks.

Rail and bus routes operating out of the 69th Street facilities are served by the
same radio systern. The base station is powered by a General Electric 300-watt
transmitter and js monitored by the controller who can contact either buses or a railear
on either the Media-Sharon Hill or the Norristown rail lines. ‘The communications systems
in the central control facility are monitored by a tape recorder.

When the controlier wants to contact a car on the NHSL,-he transmits a tone signal

to that car, causing en annunciator to sound in the car. The car operator then verbally
answers the controller. If an operator wants to contact the controller, he depresses the

push-to-talk button on the handset and calls the controller. The on-board ecuipment, also

General Electric, are 50-watt transmitters. The system is not designed for car-to-car
communication.

During the time the operator of car 167 was attempting to notify the controller on
the day of the accident, a transmitter button on enother car, 164, had been intermittently
sticking. ‘The sticking button on car 164 permitted conversation on car 164 to mask the
voice of the operator of car 167 when he tried to report the emergency. SEPTA personnel
stated that they did know of any previous occurrences of stuck transmitter buttons. The
tape recorder on the communication system verified the stuck transmit button as well as

an attempt by snother caller trying to reach central control. SEPTA supervisors
identified the caller as the operator of ear 167.

The NH3L mechanics use a unique "flag" system for cars in the repair facil’ An
orange-colored flag is plaved in # holder on the and of the car being worked on; 4 vhite-
colored flag signifies that a car has been repaired but needs a test before it can be
returned to service. The absence of a flag indicates that either the car is inbound
defective (before the orange flag has been put on by 6 mechanic) or that the car has been
repaired and is available ‘or service; there is no way to distinguish which is the case.
There are no “Bad Order" cards affixed to the side of the car nor is there always on-board
documentation that a car is defevtive.

Meteorological Information

The temperature at the time of the accident was 74° F. It was daylight and clear.
There was no atmospheric restriction te visibility.

Medica! and Pathological Infisernation

‘Me majority of the injurles sustained by the passengers inwluded lacerations,
uubrasions, contusions, sprains, and strains. One passenger, a 30-year-old male was
admitted to Merey Catholic Medical Center with a fractured spine; he also had received a



Figure 6.~-60-series control location.

motors in a series arrangement. 2/ When the controller handle is moved through notches
three and four, the contacter relays configure the traction motors in a parallel
arrangement. The propulsion system is designed so that the controller handle can be
advanced immediately to the full power position and the increasing steps of power will
follow through the appropriate voltage and current combinations.

If the controller handle is set for full power and the car speed must be reduced, the
controller handle must be returned to the power off or zero power position and then
repositioned for the new speed desired. The traction motor electrical configuration would
not allow a power reduction by moving the controller handle counterclockwise from full
power to a midpoint position.

37 Series and parallel refer to the electrical arrangement of the armature of the traction
motors. In series, the armatures are connected in a manner to provide the greater power
needed for acceleration; in parallel the armatures are connected in a manner to provide
higher speeds after initial acceleration.



~20-

Deseription

Tested functioning and
sequencing of relay
contactors manually

Tesied minimum voltage cut
in and drop out of relays
and contactors

Measured the pressure of the
brake heads to the wheels in

straight air application

Brakeshoe surface comparison

betwee: shoes from car
167 anda "control" group of
random scrap shoes

Tested efficiency and
functioning of compressor
with governor bypassed

Inspected wheels, traction
motors, and undercarriage
for unusual wear or damage

Tested master controller for
position and contact

Brakeshoe pressure tests were performed on cars 167, 164, and 161.

All relays manually
funeticned and in
sequence

All contactors and relays
appeared to pick up and
drop out normacly

Brakeshoe pressure
approximately 3,500 psi

and consistent among all cars
tested

Shoes from car 167

showed more heat exposure
and metal flow than the
control group

Compressor continued

to pump past 130 psi

main reservoir pressure and
worked well

No exceptions were
found or notea

No exceptions were
found or noted

Pressure

teadings from car 167 ranged between 2,209 psi in emergency application to 3,600 psi in
straight air application. Car 164 ranged between 3,000 psi in both straight air and
emergency applications to 4,100 psi in both straight air and emergency applications. Car
161 was only partially tested; however, uniform measurements of 4,200 psi were noted.

Other Information

Toxicological Testing.—In December 1985, SEPTA began toxicological testing of
employees ir. cases where there was a reasonable suspicion that the employee was under
the influence of alcoho! or drugs. SEPTA records revealed that alcoho) and a number of
illicit drugs, including heroin, have been discovered as a result of the tests. On April 1,
1986, in an effort to upgrade supervisor proficiency in recognizing the symptoms displayed
by a person "under the influence" of drugs or aleohol, SEPTA sent 320 supervisors to a 2-
day training session, entitled “Program for Drug and Aleohol Detection,” at the
Pennsylvania Institute. The last of SEPTA's supervisors completed the training on
August 12, 1986.

2M Sree Rens Katt aaa



NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D. C. 20594

RAILROAD ACCIDENT REPORT

Adopted: Septe mber t, 1987

COLLISION AND DERAILMENT
OF SOUTHEASTERN PENNSYLVANIA TRANSPORTATION AUTHORITY
SINGLE CAR TRAIN 167
69TH STREET TERMINAL
UPPER DARBY, PENNSYLVANIA,
AUGUST 23, 1986

INVESTIGATION

The Accident

At 2:30 p.in., August 23, 1986, Southeastern Pennsylvania Transportation Authority
(SEPT A) electrically powered single-car tiain 167 (car 167) departed the 69th Street
Terminal in Upper Darby, Pennsylvania, northbound to Norristown, Pennsylvania, on the
outbound segment of a planned round trip on the Norristown High “peed Line (NHSL).
(See figure 1.) Car 167 was manned by a single operator, who stated that he took no
exception to the manner in which the ear handled in either power or braking modes during
the outbound trip. Car 167 arrived at Norristown at 3:01 p.m. At Norristown, the
operator changed from the operating position at the outbound end of the ear to the
operating position at the inbound end of the car. At 3:05 p.m., ear 167 departed
Norristown southbound to the 69th Street Terininal.

fn route from Norristown to Upper Darvy, car 157 made several station stops.
Several passengers stated that the train overshot a number of station platforms and
consequently had to back up in order to discharge and/or pick up passengers. In response
to a question as to why he overshot these stations (asked at a public hearing held by the
National Transportation Safety Board) the operator stated that ear 167 braked more
slowly than tie other cars. The operator said that when he departed the Bryn Mawr
Station, he advanced the controller handle (see figure 2) to enable the ear to move up and
over the crest of a slight upgrade, and then he manually returned the controller handle to
the "power off" position as the zar began to coast and gain speed.

After the train passed Wynnewood Road Station, a passenger signaled to get off at
the next station, Beechwood/Brookline. The ope.ator said he had not used the car
airbrake since leaving Bryn Mawr Station, and that at the time the car was coasting. He
stated that he applied the train brakes in a normal service application, but that as he
moved the brake handle, it did not have the normal resistance to movement that was
customary when the brakes were applied. The operator further stated that he did not feel
any retarding effect in the car movement. (‘The operator later testified at the Safety
Board's public hearing that prior to this he had not experienced any problems with the
brakes on this trip.) He also did not hear any air venting (a normal ind.cation of an
application of the brakes). He said he then checked the air pressure gauge and noted that
it did not register any brakepipe pressure but that it did indicate about 90 to 100 psi main
reservoir pressure.



~3h-

APPENDIXES
APPENDIX A
INVESTIGATION
1, Ingeazigetion

The National Transportaticn Safety Board was notified of the accident on
August 23, 1986. The Safety Board immediately dispatched an investigator from its
Washington, D.C., headquarters and an investigator from its Atlanta, Georgia, field
office. A Safety Eoard Member and four additionel investigators departed for Philadelphia
the following day.

Groups were formed to investigate operational, survival, human performance, and
vehicular aspeets of the accident. ‘The groups were composed of personnel from the
Southeastern Pennsylvania Transportation Authority and the United Transportation Union,
and were directed by Safety Board investigators.

2. Hearing

A public hearing was held in Philadelphia on December 3-4, 1986. Sworn testimony
was taken from 17 witnesses. Parties to the investigation were the Southeastern
Pennsylvania Transportation Authority and the United Transportation Union.



-17.

blow to the head and was transported unconscious to the hospital; this passenger died
December 10, 1986. Another passenger who was pregnant was treated as a priority E
patient at the triage center. One person in a telephone booth inside the terminal building .
was injured when a floor-mounted air conditioning unit was dislodged during the collision a
and fell on the telephone booth.

The operator of car 167 was taken to Laukenau Hospital in Philadelphia, primarily q .
for treatment of a foot injury which was caused when the car nose moved backward and :

pinned his leg in the wreckage. He also sustained a neck injury, bruises, and abrasions. A vs
SEPTA supervisor asked the operator to give blood and urine samples at the hospita? for =
toxicological testing. The operator complied with that request. Body fluid samples, -_

suitable for toxicological testing, were collected from the operator about 5 p.m. in the
emergency room of Lankenau Hospital where he was being treated. Tests results were
negative for the preser.ce of amphetamines, barbiturates, benzodiazepines, glutethimide,
narcotics and other bases, phenothiazines, phenytoin, and tricyclics. Initial screening for -
blood alcohol content (BAC) proved negative but a trace amount, 4 MG/DL (0.004 a)
percent), of blood «leohol was detected in subsequent gas chromatography-mass :
spectrametry analysis. Tests for cannabinoids (marijuana) were not conducted because

when the order for tests was written at Laukenhau Hospital, a requirement to test for

cannabinoids was inacvertently not transmitted to the testing facility.

According to a toxicologist at Laukenau Hospital, a reading of 0.004 percent BAC is 3
typically the result of electronic noise in the testing process or of endogenous alcohol, ’
which ean be present regardless of drinking, in the human body. The State of
Pennsylvania accreditation standard for reporting positive BAC levels is anything greater
then 20 MG/DL. Levels below 20 MG/DL are reported as zero BAC. The BAC techniques

used generally have a precision (reproducibility) level of plus or minus 4 MG/DL.
Emergency Response >

SEP'TA central control notified the Upper Darby emergency services dispatcher in
Upper Darby Township of the accident and requested assistance. ‘The Upper Darby
emergency services dispatcher in turn notified the Delaware County emergency services
dispatcher. The Upper Darby dispatcher directs heavy rescue and fire equipment, while
the Delaware County dispatcher directs ambulances and other rescue equipment. Basic
life support (BLS) units are attached to area volunteer fire departments. Advanced life
support (ALS) units are attached to area hospitals and to the Lime, Media, and Collingdale Ee /
Fire Departments. E/ ys

‘The first unit on the scene was an ALS unit from the Delaware County Memorial 3
Hospital. Personnel on board this unit observed some passengers exiting the terminal oe \
building on foot and observed about 25 persons on the adjacent platform, none of whom —_—
appeared to be seriously injured. Passengers reported that they exited! the car through
windows and doors on the undamaged end of the car. Thoy noted that only the operator
and one passenger (who had previously left the car to make an emergency call and then :
reboarded the car) remained aboard, both at the front of the car. Neither person was !
trapped and no extrication was required. :

A paramedic who was aboard the first arriving ALS unit took charge and became the ; 4
incident commander. A triage area was establishee on the platform. All persons who , 4
were transported to area hospitals were examined to determine the seriousness of their i
injuries, and then transported according to their priority. Two passengers were initially


-23-

Car 167 traveled about 3 miles under power with full braking applied while carrying
a full passenger load. Part of the 3 miles was up a steep grade. Cars in the 60-series
fleet are equipped with an overload relay for electrical circuit protection. During the
first few days of the on-scene investigation, SEPTA representatives dismissed the "power :
on/brake applied" theory because it was held that under such stress, the traction motors i
would have been creating so much electrical resistance that the overload relay would have :
operated and cut power. It became apparent from repeated tests that this was not
occurring. Not once did an overload relay open from an excess of current while
overcoming the brakes. Had an overload relay opened, power to the traction motors
would have been interrupted, car 167 would have stopped, and the accident would not have
occurred. The Safety Board believes that SEPTA should establish realistic standards for
the sensitivity of the electrical circuit protection on the 60-series cars.

in a letter dated March 6, 1987, the SEPTA general manager notified the Safety
Board that SEPTA had arranged to "Modify controller plates on the 60 series cars so as
not to allow any controller handles to mechanically 'hang up’ in series or parallel circuit.
This was complete as of August, 1926." In reviewing the maintenance records of the
NHSL equipment for April 29, 1987, the Safety Board noted that car 161 was reported \
defective for "A-end controller sticks." The defect was diagnosed as a "stuck finger"; 4
repairs made were reported as "filed finger." Apparently, SEPTA's modification of the _
controller plates to eliminate controller handle sticking was not successful in all cases,
and the Safety Board urges SEPTA to review its modification program to ensure that the
problem will be eliminated.

SEPTA Operational Procedures

The investigation of this accident revealed deficiencies in SEPTA operational
procedures in several areas. Several passengers stated that a person was sitting on the
operator's stool in the operating compartment sketching the operator before the accident.
The operator and the person sketching him reportedly were talking and laughing while the
train was en route. The activity on the operating platform may have distracted the
operator in performing his duties. This distraction in the moments preceding the
operator's initial recognition that the train was not slowing after he applied the brakes,
may have contributed to his failure to recognize that the contro’ler handle was not in the
power off position. SEPTA's operational rules prohibit passengers from being in the
operating compartment while a train is en route and a sign is posted to that effect in the
operating compartment. However, SEPTA supervisors and train operators repeatedly ;
stated that passengers do ride in the operating compartments daily, generally during rush
hours. The Safety Board believes that for a system of operational rules to be effective,
they must be uniformly and consistently enforced. Supervisors ignoring or condoning : :
violations of rules cast doubt in the minds of the employees as to the credibility and/or ; 4
applicability of the entire rules system. i 4

SEPTA's operating rules required its train operators to operate their trains in
accordance with speed restrictions on portions of the NHSL. However, at the time of this
accident, none of the 60-series cars wet'e equipped with speed indicators or speedometers,
and only one of the 200-series cars was so equipped. As early as 1976, the Board had
recommended that SEPTA equip its trains with reasonably accurate speed indicators.
While SEPTA subsequently equipped some of its cars with speedometers, it did not so
equip cars operating on the NHSL. SEPTA's method of using radar guns and flash cards
could only provide an operator information about his train speed at a given instant.
Further, SEPTA's belief that a train operator can judge train speed based on experience
gained driving an automobile (SEPTA required its train operators to be licensed
automobile drivers), is not supported by any empirical data of which the Safety Board is

ARMED meen Ane Hern nee


~19-

Tests and inspections were conducted at a SEPTA maintenance facility on car 167,
All airbrake tests were performed with "house air" 3/at 70 psi. Representatives from the
Safety Board and SEPTA were present during the testing. The test results were:

Test No.

1

Ww

li

Handbrake Cest, A-end
Handbrake test, B-end

Straight air, 4/
brake: application

Tightened B-end handbrake,
dragged car

Pu‘, brake handie in
emergency and moved car

Tested outside magnet
valves 5/

Measured piston travel on
ears 161, 162, 163, and
164 for comparison

Drained main reservoirs of
condensate and inspected
alrbrake system filters

Blew out pneumatic piping
in the relay contactor
cabinet

Operated A-end and B-end
brake valves, M24C, on
the B-end (undamaged)
mounting and tested
functions

Made leakage test in
alrbrake application
for 20 minutes

Results

Brakeshoes applied, ¢ 1/8-
inch pistor travel

Brakeshoes applied, 4 1,8-
inch piston travel

Brakeshoes applied,
3 7/8-inch piston travel

Wheels slid, brakes locked

Wheels slid, brakes lociced

Valves opened and
closed as designed

Piston travel varied
from 2 to 3 3/4 inches

Approximately 1/2 gallon
of water was drained, filters
were dirty, but functional

No debris or plugged
piping was found, all
pipes were clear and
funetioning

Both brake valves
functioned well.

No brake cylinder
leakage was detected
and brakes remained applied

37 Compressed air supplied from a permanent installation within a mechanical repair

facility.

4/ Brake pressure is spplied by air admitted directly through the brake control valve -not
By means of a reduction in brake pipe pressure.

5/ A valve that is opened and closed by an electromagnet.



~32-

APPENDIX B
PERSONNEL INFORMATION

Rail Car Operator Albert Cheshire, Jr.

Mr. Albert Cheshire Jr., 31, was employed by SEPTA on January 18, 1982, as a
busdriver. He was trained and qualified as a railear operator fu 1984. In 1985, he

returned to driving a bus and in 1986, to rail service. He was recertified to operate

railcars on June 28, 1986. He was current on the examinations and perfor mance
evaluations required by SEPTA at the time of the accident.

Road Supervisor Walter S. Simeox, dr.

Mr. Walter S. Simeox was hired by SEPTA in 1960 as a railear operator. He spent
about 4 years operating railear trains on various SEPTA lines, about 5 years as a
busdriver, and 8 years as a dispatcher. He had been a road supervisor for about 7 years
before the accident. Part of his function as a road supervisor was to administer

recertification examinations, including the performance evaluation of over-the-road
operation to railcar operators.

2, 5, GOVERNMENT PRINTING OFFICE 11907~184~-1911 50036



~14-

Although the cars now have speed indicators, among the skills that the students
were required to become proficient at, and to which they were exposed during OUT, was
estimating train speed. One technique that operating supervisors used to help operators
estimate their speed was the use of a radar gun. One supervisor operated the radar gun to
determine the speed of an approaching car, then an assistant held up 4 flash card with the
recorded speed printed on it for the operator to see. The radar gun was used sporadically
after the initial training was completed.

A SEPTA road supervisor testified that operators should be able to judge specd
based on experience gained while driving an automobile. SEPTA does require its railcar
operators to hold a valid automobile driver's license. At the time of the accident, SEPTA
reviewed annually the status of the driver's license of its operating employees. The road
supervisor further testified that he gave check rides "Maybe once or twice a month, if I
get the time."

Railear operators also were instructed in the methods for stopping a car under
normal conditions using service braking and in emergency stopping procedures.
Emergeney stopping instructions include the use of the emergency airbrake, the function
and use of the deadman pedal, operation and use of the manually operated handbrake, end
the technique of reversing the traction motors while under power. On severei occasions,
the operator of car 167 told Safety Board investigators that he was not awaze of the
procedure to reverse the motors as a method to stop a car in an emergency situation.

SEPTA training instructors stated that students are instructed in the procedure to
remove electrical power (by the overhead switch) from the car in the event of an
emergency. They stated however that students are not encouraged to remove the
electrical power, because such action would eliminate the protection afforded by the
deadman control. The operator of car 167 testified that he had not attempted to remove
the on-board electrical power during his efforts to stop the car because he believed it was
necessary for the electrical power to be on in order for the car to funetion. The operator
further testified that he was unsure if the airbrakes or handbrakes would work if the
power was off.

Training records indicate that the operator had received 20 days of training in 1984
and 20 days in 1985. The operator had requested additional training In 1984; he stated at
the time that his height (6 feet 3 inches) made it difficuit for him to smoothiy brake the
trains. (When standing the operator's eyes were above the top of the windshield causing
him to bend over or stoop to see forward properly). SEPA provided an additional 2 days
training. Examinations were administered both in 1984 and 1985; however, they did not
indicate a score, only that the tested employee had read and understood the corrections
made to the test. SEPTA's records indicated that in 1984 the operator had been
instructed in the procedure to reverse the motors for an emergency stop.

A recertification test consisting of a written examination containing 121 questions
(valued at 1 point each) and a performance eveluation (total attainable points 96) was
given to the operator on his return to the NHSL in 1986. ‘Three requirements had t’. be
met in order to be certified: (1) 85 percent on the road test during the performance
evaluation; (2) 85 percent on the fire and evacuation test during the performance
evaluation; and (3) 85 percent (184 points out of a possible 217 points) on a combined
written test score and the performance evaluation scores. The operator scored 100
percent on the road test, 100 pereent on the fire and evacuation test, and 80.16 percent
on the written test. The higher scores on the periormance evaluation brought his total
overall score to 88.94 percent. The SEPTA supervisor responsible for administering the
operator's recertification examination testified at the Safety Board's public hearing that
he had never disqualified or failed to recertify an operator on the NHSL.



~6-

A SEPTA employee who witnessed the accident was walking northward beside the
track as car 167 approached the 69th Street Terminal. When interviewed immediately
after the ancident he said that the car sounded like it was under power. He estimated
the car speed to be 20 to 25 mph at the time. (Later, at the National Trarsportation
Safety Board's publie hearing, he testified that he did not remember whether or not the
car was under power.) He testified that after the car passed him, he turned and saw it hit
the bumping block and the terminal building. He immediately went to a third-rail power
switch located near the passenger loading platform and opened the switeh to deenergize
the third-rail power in the accident area. When he contacted the controller, the operator
of car 167 had already informed the controller of the accident. The controller already
knew at that time that the power to the third rail had been deenergized.

Injuries to Persons
Injuries Crew Passengers Others Total
Fatal 0 0 0 ol
Serious 0 11 0 11
Minor 1 33 1 35
None 9 i 0 11
Total T 55 f 57
Train Damage

The forward end wall of the car was displaced rearward from about 1 foot at the top
to about 5 feet at the floor level where it was in contact with the end bulkhead. (See
figure 4.) The bottom of the end bulkhead was displaced rearward about 2 feet and was
resting against the first seat on each side of the aisle.

Both the left and right windshields were broken; the center windshield was intact.
Three side-facing windows were broken. The glass in both sectinns of the end bulkhead
was broken. All the broken glass was nonshatterproof.

Seven of the 28 bench seatbacks were bent forward at various angles; 1 seatback
was torn loose. Two seatmounts were torn loose, and one seatmount was twisted but
remained secure. Three seats were displaced upward; the displacement ranged from about
8 inches to about 1 foot. (See figure 5.)

Personnel Information

‘The operator of car 167 was hired by SEPTA in 1982 as a bus operator, a position he
held for about 2 years. During a "sign up" period fn 1984 which allows employees to
interchange between bus and rall service, he signed up for a rail car operator's position,
which he held for avout 1 year. During that year, he operated rail vehicles on both the
Media-Sharon Hill line and the NHSL. In 1985, the operator rotated out of rail service for
about a year and then back into rail service on the NHSL in June 1986.

I7"One passenger died 4 months later without ever having been discharged from the
hospital.

inh



~29-

SEPTA lacks adequate equipment maintenance standards for NHSL equipment.
SEPTA does not require switch lock Protection for workers on the NHSL.

The plate glass glazing on car 167 caused injuries which would not have
occurred had the car been equipped with safety glazing.

Tne National Transportation Safety Board determines that the Probable cause of the
accident was the failure of the operator to remove propulsion power from the ear and his
failure to use all available means to stop the car. Contributing to the accident was the
failure of SEPTA to adequately train the operator to use all means available to stop the
car.

RECOMMENDATIONS

As a result of its investigation of this accident, the National Transportation Safety
Board made the following recommendations:

~-to the Governor of Pennsylvania:

Initiate legislative action to establish a new independent agency, or
authorize an existing agency, to regulate and enforce the safely of rail
rapid transit systems in Pennsylvania. (Class 11, Priority Action)
(R~87-38)

~to'the Southeastern Pennsylvania Transportation Authority:

Evaluate and restructure the tailear operator recertification program to
include effective retraining of emergency procedures. (Class Il, Priority
Action) (R-387-39)

Revise the existing maintenance Standards program to include
comprehensive and specifie standards for the inspection, repair, and
replacement. of all parts and components used on the Norristown High
Speed Line. (Class II, Priority Action) (R-87--40)

Retrofit the ordinary plate glass glazing on the Norristown High Speed
Line equipment with glazing material that meets the safety standards
for the equipment used on the Regional Rail Division. (Class Uy, Priority
Action) (R-87-41)

Establish a positive method, through on-board documentation, to identify
defective equipment that is being routed into a repair facility on the
Norristown High Speed Line. (Class Il, Priority Action) (R-87-42)

Establish detailed procedures for switch lock protection for workers who
are on, under, and between equipment on the Norristown High Speed
Line. (Class il, Priority Action) (R-87-43)

Establish hours of service requirements for operators on the Norristown
High Speed Line. (Class Il, Priority Action) (R-87-44)



-26-

In this accident, the operator's failure to use all available means to stop the train
and his lack of knowledge about jacking the motors underscore the insufficiency of
SEPTA's recertification of him for train operation. The evidence shows SEPTA to have a
training deficiency that needs prompt attention and correction for safe rail operations.
The service supervisor testified at the public hearing that, as a result of the accident,
they were "reviewing, re-evaluating, and reformulating aspects of the training program."
When asked to provide details, he said they were considering increasing the amount of
training and improving the test program as a way to increase operator knowledge of
equipment. He also stated that more emphasis would be given to the procedure of jacking
the motors as well. The Safety Board believes that SEPTA should evaluate and
restructure its recertification program to provide more effective training. This could
include, for example, an additional day of "hands-on" training and demonstrations in
emergency procedures, and the development and review of an emergency procedures
checklist.

Survival Aspects

The emergency response personnel were prompt, efficient, and well organized in
their response efforts, despite initial difficulties they encountered in determining if the
third rail was deenergized.

The train operator realized before the point of impact that hn was not going to be
able to stop the train. He warned the passengers about th: impending impact and advised
them to move as far rearward as possible. The time it took to reach 69th Street affordec
them the opportunity to protect themselves as best they could.

When car 167 struck the bumping block, which was constructed of welded sections of
angle bar and bolted to the track, the bolts sheared and the bumping block remained
relatively undamaged. Virtually no energy was absorbed by the shearing of the bolts, and
consequently the spe:d of the car wes unchanged. The car then struck the terminal
building pushing the bottom front lace of the car back about 5 feet. The composite
concrete floor of tre car was stripped off the floor plates when the floor frame was bent
downward as it uncerrode the station platform.

All the traumatic injuries were as a result of secondary impacts with interior
structures, crimarily with the seatbacks in front of each seating position. The seriously
injured russenger was located at the forward bulkhead. Since the bulkhead was displaced
rearward, the stopping distance was shortened at this position, thereby increasing the G

joading for this passenger. The extent and type of his injuries indicated a heavy G-load
‘actor.

Several passengers received cuts. Given the nature of the failure of the ordinary
Plate glass in the side windows and end bulkheads, and the fact that some of the

passengers exited car 167 through the window openings, it is reasonable to assume that
the broken glass caused some injuries and further contributed to the severity of other
injuries. With the repeated failure of the glass experienced by SEPTA through vandalism
and other accidents on the NHSL, it should have been apparent tc SEPTA that superior
glazing material was desirable. Further, since SEPTA uses modern safety glazing on its
RRD, it {s apparent that SEPTA knew of the availability of such materials. Since SEPTA's
RRD operates through virtually the same type of territory as the NHSL, it seems the only

difference regarding glazing standards is that there are no State or Federal glazing
requirements on the NHSL equipment. The Safety Board recognizes that SEPTA is

currently planning to replace the plate glass side-facing windows on the NHSL equipment
with glazing equivalent to that required on its RRD equipment. The Safety Board believes

shh S ig RIEU Rar cin gn oce Catena entice a mete mene



#1 Power Point (series)



-2-

Norristown
Bridgepert
King Manor

Hughes Park

q Gulph Mills

4 \. wy Conshohocken Road
q \ 4 County Line
ma Radnor

Villanova ‘~,
Stadium

Garrett Hill

md Rosemont

Bryn Mawr

By
4 \ 1 “4 Haverford

Arémore Ave.

Ardmore Junction
Wynnewood Road

Penfield
{ West Overbrook
/ Parkview wy

iY
‘e  G69th St. Terminal

Beechwood—Brookline

Migure 1.--Norristown high speed line.


=~1§-

Five of the incorrect answers on the written test were on emergency procedures.
One question on the examination that the operator could not answer, ond left blank,
concerned reversing the traction motors in the event of a bruke failure. SEPTA said that
after an examination is corrected, a training supervisor reviews the missed questions with
an operator, giving the proper answers. The empty blank had been filled in by the
operator's service supervisor with the phrase "jacking the rotor." However, there was no
indication that there was any followup explanation or training provided to the operator to
assure that ne understood this or the other answers that he missed.

Method of Operation

SEPTA serves the greater Philadelphia area, providing rail con muter service on the
NHSL and the Regional Rail Division (RRD). The RRD is larger in terms of track miles,
personnel, and equipment. SEP'TA's method of operation on the NISL is not eovered by
Federal or State of Pennsylvania regulations; however, its lacger RRD operation comes
under the jurisdiction of the FRA.

Trains are operated on the NHSL 13.2-mile double main track by the indications of a
three-aspect, automatic block, color light signal system; bulletin orders; verbal or written
train orders; and schedules. The easterly track is designated for the movement of
northbound trains, and the westerly track is designated for the movement of southbound
trains. Traffic density is about 82 ‘rains in a 24-hour period.

A controller, located in a central control facility at 69th Street, directs the train
operation on the Norristown and the Media-Sharon Hill rail lines. In addition, the
eontroller directs the bus operation; the bus terminal is also located at the 69th Street
facility. The controller does not record any departure, passing, or arrival time for the
trains on either line. The primary means of contact between central control and a train
on either line or a bus is via radio. A backup telephone system extends along the roadway
of the NHSL by which train operators can contact central control.

Operating employees on the NHSL are governed by a portion of the Red Arrow
Division Rule Book which became effective in 1976, There is no maximum authorized
speed. The rulebook contains no reference to the use of radios on the WHSL. SEPTA
Notice Order No. N-86-45, issued July 29, 1936, relates to the radio notification of all
vehicles in the event of an emergency,

Trains are scheduled to depart cither the 69th Street ‘erminal or Norristown on
headways varying froin 30 to 2 minutes. ‘Trains depart the termiiais on sehedule
authority. A one-way trip in either direction takes about 31 minutes. Passengers signal
the operator that they want to board the train by operating a switch located on the
station platform, causing a white light to illuminate in approach to the station. If an
operator runs past a station, he can reverse the car to the platform if he has not passed an
automatic block signal.

At the time of the accident, » number of siow orders were in effect because of
track conditions. Slow order notices listing the speed restriction and thoir locations were

posted at the operators! on-duty point.

SEPTA operating rule 22, governing train operations on the NASL, states, in part,
that "Unnecessary conversation with passengers or employees riding on trains will not be
permitted." SEFTA supervisors interpret this rule to mean no passengers will be allowed
to ride on the operating platform icom which the ear is being operated. Signs restrictin:
passengers on the operating platform are posted inside the cars. (See figure 4





LISP SHORE ENGINE CT

[pteemear renee:

-21-

In January 1987, SEPTA instituted random toxicological testing of its employees.
On the first day of this program, samples were collected from 11 rai'zer operators before
labor unions representing SEPTA employees brought legal action to halt the program.

SEPTA Aceidents.--Since 1982, the Safety oard has investigated 17 accidents
involving the SEPTATM system. These accidents are categorized as: vollisions--8,
derailment--1, derailmert with subsequent collision--2, passenger fatality--2, employee
fatality--Z, and highway grade crossing—2.

ARALYSB
The Accident

The operator of car 167 said that when he departed the Bryn Mawr Station en route
to Upper Darby he advanced the controller handle to enable the car to move up and over
the crest of a slight upgrade and then he manually returned the controller handle to the
power off position. The operator did not attempt to stop the car at the Wynnewood Road
Station because there were no passengers who wanted to get on or off. When he
attemp..ed to stop the car at the Beechwood /Brookline Station by making a normal service
application of the train brakes, the operator said he did not experience a retarding effect
and thus made an emergency application of the brakes. When this failed, he attempted to
recharge the airbrakes (although he did not allow tho system sufficient time to recharge)
and made another emergency application. He then released the deadman pedal and
applied the handbrakes on both car ends. None of these efforts retarded the forward
movement of the car as it passed the Penfield and Parkview Stations and then struck the
69th Street Terminal building. There is no evidence that he manipulated the controller
handle at any time while trying to stop the car.

Running test 1-3, conducted with similar equipment, were unsuccessful in
recreating the sequence of events leading to the collision by having the controller handle
in the power off position and by using the braking techniques the operator of car 167 said
he used. However, examination of the controller from car 167 indicated that the
controller handle could stick in the third point of power when returned manually. Had the
controller handle never returned to the power off position from a full power position, as
the operator said it had, the car would have remained under ful! power, even though the
handle was partially returned. In subsequent running tests, 5 and 6, with the controller
from car 167 installed on the test car, the controlier did stick in the third point of power
after having been returned from the full power position. The tests showed that a similar
60-series car with the controller in the third point of power and with the brakes applied in
emergency could negotiate the grade past the Penfield Station and continue forward to
the point of collision. The Safety Board was unable to determine any way in which the
tes. car covid negotiate the grade with its brakes applied unless the car was under full
nower. Tne brake tests conducted after the accident, the comparison of the brakeshoes
on car 167 with the shoes from the test car on which the brakes were applied while the
car was under power, and the statements by the operator of car 167 that he had no
problems: with the brakes on car 167 until the time of the accident fudicate that the
brakes on car 167 were working well enough to stop the car if it had not been under
power. Therefore, the Safety Board concludes that the controller handle on car 167 was
not in the power off position during the accident sequence, as the operator believed, and
that the car was operating under power up to the collision.

Norristown Line Equipment Maintenance

A controller handle was reported stuck on another 60-series car on July 2, 1986,
52 days before this accident. Since the accident, SEPTA has retrofitted the 60-serles cars



PB87-916304

NATIONAL
TRANSPORTATION
| SAFETY

| BOARD

WASHINGTON, D.C. 20594

RAILROAD ACCIDENT REPORT

COLLISION AND DERAILMENT OF
SOUTHEASTERN PENNSYLVANIA
TRANSPORTATION AUTHORITY

SINGLE CAR TRAIN 167

69TH STREET TERMINAL
UPPER DARBY, PENNSYLVANIA
AUGUST 23, 1986

NTSB/RAR-87/04

UNITED STATES GOVERNMENT

REPRODUCED BY

U.S. DEPARTMENT OF COMMERCE
NATIONAL TECHNASAL
INFORMATION SERVICE
SPRINGFIELD, VA 22161



REQUIRED

Be yasuree et seat

Figure §.--Postimpact interior of car 167.

The operator's name was on a list of qualified available relief operators, and thus he
was subject te call for any shift assignment. He normally was off duty 12 to 14 hours
between assignments. There are no applicable Federal or State of Pennsylvania
require ments for hours of rest between tours of duty. The operator had worked an “early
shift" from 7:15 a.m. until 4.p.m. during the week before the accident. He had rested
from about 10 p.m., August 22, until about 6 a.m., August 23; he stated that he was well
rested at the time of the accident. He stated that he did not have any known chronic
medical problems and that he was not required to wear corrective lenses. SEPTA requires
annual medicai examinations for all NHSL operators.



Figure 4.--Car 167,



-28-

not appear to be any clear delineation of authority. The limited authority that exists in
the State agencies has been used to set only 8 few minor equipraent standards. Standards
for maintenance of way and operations are nonexistent. According to the State police
inspector, even the equipment standards are designed such that SEPTA is self-certifying.

After conducting a special investigation of the safety of the New York City
Transit Authority (NYCTA) in 1981, 7/ the Safety Board recommended that the State of
New York take legislative and/or executive action to authorize a new or existing
independent agency to oversee and regulate the safety of the NYCTA system.
Subsequently, the State estublished the New York State Public Transportation Safety
Board and empowered it to oversee and regulate rail rapid transit lines in the State. The
State of California also has established an agency that actively regulates rail rapid transit
systems. More recently, after investigating a series of accidents on the Greater
Cleveland Regional Transit Authority 8/, the Safety Board recommended that the State of
Ohio initiate legislative action to establish a new independent agency, or authorize an
existing agency, to oversee and regulate the safety of rail rapid transit systems in Ohio.
The Safety Board believes the State of Pennsylvania should take action to establish an
agency with oversight responsibilities for rail rapid transit systems.

CONCLUSIONS
Findings

1, The controiler handle probably stuck when the operator of car 167 last moved
the handle, and it did not return to the power off position before the accident.

Car 167 was being operated with the power and the brakes simultaneously
applied before and at the time of the collision; the brakes were adequate to
stop the car had it not been under power.

The operator did not use all available means to stop car 167, probably due to
his lack of effective training in emergency procedures.

The operator may have been momentarily distracted before the accident by
passengers on the operating platform.

The deadmen feature on car 167 was not of a fail-safe design.
There was no effective means to judge speed on car 167 before the accident.
SEPTA inconsistently enforced operational rules on the NHSL.

Operations on the NHSL are not regulated by either State or Federal
authority.

State regulatory and enforcement authority for equipment stendards is
minimal,

77 Special Investigation Report--"Eight Subway Train Fires on New York City Transit
Authority With Evacuation of Passengers" (NTSB-SIR-81-05).
8/ Railroad Accident Report--'Rear End Collision of Two Greater Cleveland Regional

Transit Authority Ked Line Rapid Transit Trains Near the West 98th Street Station,
Cleveland, Ohio, August 18, 1986" (NTSB/RAR-87/01),

Wreptaf peer peers y

pane



-29

that all glazing, including the interior bulkheads, should be the same standard as that
instalied on SEPTA's other rail equipment.

Toxicological Aspects

Toxicological tests conducted on body fluid sampies from the train operator involved
in the August 23, 1986, accident produced a trace alcohol reading. The tests were done by
an independent laboratory located in the Philadelphia area. A BAC of 0.004 is considered

negative by the State of Pennsylvania. The Safety Board does not believe alcohol was a
factor in this accident.

Oversight of SEPTA

In 1981, the Safety Board issued Safety Recommendations R-81-1 and -2 which
recommended that the U.S. Department of Transportation (DOT) propose legislation
authorizing the DOT to regulate the safety of federally assisted rail rapid transit systems
and, pending such legislation, require UMTA to establish Federal guidelines for equipment
and operations. The recommendations also suggested that the DOT conduct substantially
increased safety oversight of these systems. These recommendations were rejected by
the Secretary of Transportation on April 22, 1981. The Secretary stated that the DOT

was seeking repeal of Section 107 of the Nattonal Mass Transportation Aci of 1974 to
remove the Federal government from an intrusive role in rail rapid transit safety because

such a role is a local responsibility, best handled at the State and local level. Section 107
was subsequently repealed. However, Section 22 was amended to give the DOT authority
to investigate potentially unsafe conditions, to require corrective action, and to withhold
financial assistance if a corrective plan were not implemented.

The Safety Board subsequently reconsidered Safety Recommendations R-81-1 and -2
and closed them. However, the Safety Board also informed the DOT that it did not

believe that a total abdication of responsibility at the Federal level for safety on transit
systems was desirable.

Although the DOT has retained the authority to investigate potentially unsafe
conditions, the Safety Board has seen little evidence that the DOT is inclined to use this

authority. After accepting party status and agreeing to participate in the Safety Board's
public hearing concerning the August 23, 1986, collision, UMTA failed to send a
representative to the prehearing conference held the day before the hearing. After
inquiries were made, the Safety Board learned that UMTA had reversed its decision to

participate in the public hearing. The Safety Board believes it reflects poorly on the
willingness of UMTA to discharge their duties and responsibilities with regard to assuring

safe public transportation.

After SEPTA accidents on December 10, 1986, and January 26, 1987, the Secretary
of Transportation ordered UMTA to conduct a safety evaluation of SEPTA with initial
emphasis on the NHSL. UMTA's safety evaluation addressed the identical issues that were
developed in the Safety Board's investigation oi te August 23, 1986, accident.

SEPTA apparently chose to control the NHSL in a manner apart from its regional
rail operation. Substandard glazing practices, disregard for the safety of mechanics who
work under cars without switch lock protection, and lack of fundamental "hours of
service" requirements indicate that SEPTA needs oversight by an independent agency.

State regulatory and enforcement authority for the NHSL is fragmented between
the Pennsylvania Department of ‘Transportation's Bureau of Public Transit, the
Pennsylvania Public Utilities Commission, and the Pennsylvania State Police. There does

ror tenet
yew te, eh dia a ft



a Ja

-4-

According to the operator, he then placed the brake handle in the emergency
Position. (See figure 3.) The operator stated that he still did not get any retarding effec
and that he did not hear any air venting from the brakepipe or equalizing reservoir, as
would be expected with an emergency brake application. He stated that he then placed
the brake handle back in the release position so the air compressor could restore
brakepipe pressure (nominally 70 psi operating pressure). This normally takes 8 to 12
seconds. The operator stated that when he did not see any brakepipe préssure increase on
the gauge after about 3 seconds, he returned the brake handle to the emergency position.
The operator stated that he repeatedly attempted to contact SEPA central control by
radio to request assistance, but that he was unsuccessful.

The operator stated that after failing to get any retardation from the airbrakes and
failing to get a response from central control, he intentionally released the deadman
pedal. He further stated that he did not hear air venting from the brakepipe or the
equalizing reservoir and that he still did not perceive car 167 to be slowing. The operaior
did not inform the passengers of the brake problem. The passenger who had signaled her
desire to detrain at Beechwood/Brookline Station had come forward in the car and was
standing in the doorway separating the operating platform and the passenger
compartment. The operator informed the passenger that he would be unable to let her off
at the Beechwood/Brookline Station and that he would stop at the next stop, Penfield
Station. She testified that two other passengers were with the operator on the operating
platform. One passenger appeared to be an artist and was seated on the operator's
portable stool, sketching the operator; the second Passenger was standing near the side
entrance /exit door. Two other passengers stated that a young man was seated on the
operator's stool sketching a portrait of the operator, and that the "artist" and the operator
were talking and laughing together. The operator confirmed that passengers were in the
operating area, but he denied any knowledge as to what the seated passenger was doing
and denied talking and laughing with eny passenger.

Meanwhile, the operator had moved over to the manual handbrake control located to
his far right and cranked the brake wheel as tight. as he could to set the handbrake. He
said that he did not notice any braking response after setting the handbrake. The operator
stated that he again tried to radio central control to advise the controller of his problem
and to ask for instructions, but that he was unable to reach the controller, He then ran to
the rear of the cur and applied the handbrake located there. When the car did not slow,
the operator returned to the forward end of the vehicle and notified the passengers to
move to the rear of the car, that the car's brakes were not holding, and that there was
going to be a collision. Shortly afterward, at 3:42 p.m., car 167 overrode the bumping
block at the 69th Street Terminal and struck the terminal bullding.

‘The bumping block was constructed of welded sections of steel angle bar and was
bolted to the track through ihe web of the rail. The height of the terminal building floor
was such that when the car hit the terminal building, the floor of the car moved under the
building floor. Before the car stopped, the foree of the collision with the building pushed
the car nose back over the car operating platform about 5 feet, lodging it against the
bulkhead separating the passenger compartment and the operating platform. After the
crash, the operator was temporarily pinned in the operating platform because of the car
nose deformation. However, he extricated himself from the crushed operating platform,
went to a station platform telephone, and called central control to notify the controller of
the uccident and to request emergency assistance for the passengers. Of the 55
Dasseiigers on board, 44 were injured; 11 of the 44 injured passengers were hospitalized.
In addition, one person inside the terminal building was injured.



-18-

determined to be in serious condition; both of these passengers were transported within 9
minutes of the arrival of the first responding unit. Ail other persons were transported
within about 1 hour of the accident. ;

The incident commander initiated the County Disaster Plan whereby the county
dispatcher notifies the area haspitals who then activate their individual disaster plans.
Patients were transported to five loval hospitals and to two local medical facilities. The
incident commander testified that nc problems were experienced either on scene or with
the setivation and implementation of the disaster plan. However, initially there was
difficulty ascertaining if the electrical third rail was deenergized. Immediately after the
collision, smoke and heat were emi tting from under car 167, The fire department
considered using water to cool the arra but was unsure if the third rail had been
deenergized.

Tests and Research

Between August 25-27, 1986, a series of tunning tests using the same type of
equipment as car 167 were conducted on the NHSL. ‘The tests were conducted to
determine stopping capability under varicus power and braking conditions. Speeds were
determined by a handheld radar gun. Representatives from the Safety Board, SEPTA, and
the United Transportation Union were present during the tests.

Run 1.--The car departed ‘Wynnewood Roed Station with the controller handle in the
power off position. Beechwood/Brookline Station was passed at a speed of 10 mph. The
car drifted to a stop short of the erest of the grade just south of Penfield Station.

Run _2.--The car departed Wynnewood Road Station using full power.
Beechwood/Brookline Station was passed at 24 mph at which ti:ae the controller handle
was placed in the power off position. The car passed Penfield Station at 16 mph but
drifted to a stop short of the crest of the grade just south of Penfield Station. The car
held the grade without the brakes applied.

Run 3.--The car departed Wynnewood Road Station using full power and a speed of
27 mph was attained. ‘The controller handle was returned to the power off position just
before passing Penfield Station. The car slowed to about 4 moh but did pass the crest of
the grade just south of Fenfield Station. As the speed of the vehicle increased, the
handbrake was applied, taking 22 seconds to apply and the car was stopped in 430 feet.

Run _4.--Penfield Stetion was passed at 24 mph using full power but also with
application of the emergency brake using the brake valve. The car traveled over the crest
of the hill and proceeded toward the 69th Street Terminal. The car was stopped by

returning the controller handle to the power off position,

Run 5.--Car 164 was used for this test after the controller unit from ear 167 was
insta!led on the leading end. An examination of the controller from car 167 indicated that
the controller could stick in the third point of Power when returned manually. During the
test, the controller did stick in the third point of power after having been returned from
the full power position. While proceeding inbound from Wynnewood Rond Station at a
speed of 49 mph, with the controller stuck in the third point of power, an emergency
brake application was initiated at the brake valve. The vehicle passed by Penfield
Station, crested the hill, and proceeded toward the 69th Street Terminal. ‘The car was
stopped by returning the controller handle to the power off position.

Run 6.—Run 5 was repeated with the same results.



~24-

aware. Consequently, although SEPTA required its train operators to operate trains in
accordance with speed restrictions, there was no consistent and accurate means provided
to the operators which would enable them to determine their speeds at any given time.
Rather, operators were required to estimate the speed of their trains to comply with the
various speed restrictions.

Two earlier speeding violations by the train operator involved in this accident were
not listed on his disciplinary record in the proper chronological sequence. This suggests to
the Safety Board that speed restrictions may not have been consistently enforced on the
NHSL and that SEPTA's actual practice was inconsistent with its written policy.

The Safety Board is aware that subsequent to this accident, SEPTA installed speed
indicators on the NHSL equipment; however, the Safety Board has also been informed that
the digital speed indicators have such a proclivity toward erratia display that they are
repeatedly reported as being defective by the operators. This unreliable information és of
littie use to a train operator in attempting to maintain the appropriate speed of his train.
The Safety Board believes that SEPTA should take immediate action to correct the
erratic display of the in-cab speed indicators,

The Safety Board's investigation of this accident also revealed shortcomings in other
aspects of SEPTA's operating methods which, although not factors in this accident, could
compromise safety if the practice were to continue. SEPTA's failure to require switch
lock track protection for workers on the NHSL who are regularly on, under, or between
rolling equipment is inexcusable. The Safety Board finds no valid reason why each
manually operated switch providing access to the track on which work is being performed

should not be lined against movement and locked with an effective locking device, as is
done on SEPTA's other rail operations. The Safety Board does not believe it should be
necessary for an accident to occur before SEPTA institutes corrective procedures.

Also, SEPT A's "flag" system for identifying defective equipment on the NHSL does
not differentiate between equipment that has been repaired and equipment that is being
routed to the NHSL repair facility for repairs. In both eases, there is an absence of a
flag. In some instances, there may be an on-board defect report from the operator;
however, if the controller routes a car to the repair facility, it probably will not have on-
board documentation. The Safety Board believes that SEPTA should establish a positive
method with on-board documentation of identifying defective equipment.

SEPTA has failed to establish guidelines concerning the amount of time an NHSL
operator must be off duty between shifts. SEPTA does have "hours of service" standards
on other portions of its rail operations. The Safety Board does not understand why SEPTA
fails to operate the NHSI. in the same manner as its Regional Rail Division (RRD). There
are rore areas where ‘he RRD and the NHSL are similar than there are areas where the
NHSL is unique. The RRD's detailed instructions concerning operational, mechanical, and
maintenance-of-way systems could certainly aid the NHSL to function more safely.

SEPTA supervisors knowingly allowed operational rules violations to continue on the
NHSL. Over-the-road performance evaluation of NHSL operators by SEPTA supervisors
was sporadic, Operating rules violations on the NHSL were subjectively assessed. Safety
procedures established and proven effective on other portions of SEPTA were not
implemented on the NHSL by SEPTA supervisors. This leads the Safety Board to believe
that supervision of the NHSL was not aggressively pursued and that SEPTA's managerial
oversight of NHSL supervision was lacking.

,

SS ReSDIRE NE Eide ES Emon yen on ne

EERE Ae

RGSS RGA SEE Haas ora es ET



of

EXECUTIVE SUMMARY

On August 23, 1986, Southeastern Pennsylvania Transportation Authority (SEPTA)
single-car train 167 was en route to Upper Darby, Pennsylvania, on the Norristown High
Speed Line when a passenger requested to be let off at the Beechwood/Brookline Station.
The operator was unable to stop the car using normal braking. Subsequently, he applied
the airbrakes in emergency, released the deadman pedal, and applied the mechanical
handbrake on each end of the car. The car continued forward and began tc accelerate as
it descended the grade into the 69th Street Terminal at Upper Darby. The ear overrode
the bumping block at the end of the track, derailed, penetrated a terminal wall, and came
to rest about 6 feet inside the terminal building. Of the 55 passengers on board, 44 were
injured; 11 of the 44 injured passengers were hospitalized. In addition, one person inside
the terminal building was injured. The operator received minor injuries. Damage to the
equipment and building was estimated to be $225,000.

This accident report discusses the following safety issues:

1. SEPTA's mechanical requirements for its raik transit equipment;

2 methods of inspection and certification of rail transit equipment in
Pennsylvania;

3. SEPTA's managerial oversight and enforcement of its operational rules;
4. performance of the window glazing;

5. toxicological testing of employees in safety-sensitive positicns; and

6, SEPTA's operator training program.

The National Transportation Safety Board determines that the probable cause of the
accident was the failure of the operator to remove propulsion power from the ear and his
failure to use all available means to stop the car. Contributing to the accident was the

failure of SEPTA to adequately train the operator to use all means available to stop the
car.

As u result of its investigation, the Safety Board issued recommendations to the
Governor of Pennsylvania and the Southeastern Pennsylvania Transportation Authority.


-11-

Power Switch.--Cer 167 had an electrical power disconnect breaker accessible to
the operator located over the operating position at one end of the car. When this breaker
control is opened, prod.ilsion power is removed from the car.

Forward/Reverse: Switeh.--Car 167 was equipped with a forward/reverser switch,
also located over the o.erating position at each end of the car. The direction of travel of
the car could be reversed from either operating position of the car by positioning the
forward /reverser switch to reverse and operating the controller handle counterclockwise.

According to SEPTA, operators are instructed thut the reverser switch also can
serve as a last resort emergency stopping procedure. When the reverser switch is placed
in the reverse position while the car is moving forward, the controller handle can be
operated counterclockwise, as for a reverse move, and power will be applied to the
iceetion motors to reverse Ineir rotation. Thus, the traction motors will be attempting to
propel the car in the reverse direction, resulting in a retarding force. SEPTA refers to
the action as "jacking the motors." When the motors are to be used to stop the car, the
reverse power must te applied in short applications, i.e., apply revarse power for a matter
of seconds and return the controller handle to off. The cycle can be repeated. Applying
reverse power in a prolonged application should cause an electrical circuit protection fuse

to blow and no power would be available on the car. When reverse power is applied for a
prolonged period, the traction motors overheat and are ruined.

Deadman Control.--The deadman control on car 167 was designed to work when the
ear was standing o% when the traction motor is in the series transition. The deadman
pedal was designed in the 1120's to work in conjunction with the spring-loaded controller
hendle. If the deadiman pedal was not depressed when the controller handle was in the
power off position, or in the first two points of power, a penalty application of the
airbrakes would cecur. Advancing the controller handle to any rower point within the
series rarige would activate the deadman feature.

The deadman feature was not dependent on the speed of the vehicle but solely on
the controller position. if the controller handle was quickly and continuously advanced to
@ parallel power position from the off position, the deadman feature would be nullified.
However, the deadmen feature would function at any speed when the power control handle
was in the off position.

After the accident, SEPTA modified the deadman control to function in all
controller positions.

Handbrake.—Each end of the car was equipped with a wheel-operated handbrake
located” fo the operator's right. The handbrake was designed to provide a means of
applying the car brakes mechanically without air pressure. The brakeshoes were brought
against the wheel treads through a gear-driven system of rods and levers. To apply the
handbrake, the operator had to step on a pedal-activated pawl at the base of the
handbrake stand and turn the wheel clockwise. After the handbrake was applied, the
operator could release the pedal-activated pawl and the handbrake would lock in the
applied position. If the train brakes had already been applied by air in an emergency
application, the handbrakes would not provide any additional braking effort.

Glazing.—-Glazing material on the 60-series cars was glass. Maintenance records
indicate repeated instances of broken windows. SEPTA supervisors stated that vandals

throwing rocks and other projectiles was the most common cause of broken windows.



~13-

Brake piston travel was measured on five cars in the 60-series ficet after the
collision. Car 167 had the longest travel of any car measured. Median travel on the other
60-series cars was 2 7/8 inches; car 167 measured 3 7/6 inches.

With the exception of car 207, the cars were not equipped with any type of speed
indicator before the accident. Since the accident, the cars have been retrofitted with
speed indicators; hcwever, a review of the April 1987 maintenance records revealed that
the digital speedometers are routinely reported for "erratic display."

The cars receive a B-inspection semi-annually. The B-inspection is more
comprehensive than the A-inspection, but neither inspection involves the scheduled
replacement of parts or components vy any established standards of time or wear.
Periodic inspection and maintenance is not required by SEPTA for the airbrake system.

Pennsylvania requires an inspection of electric mass transit (EMT) vehicles at least
twice a year; however, EMTs may be inspected more frequently if a transit authority so
desires. The Pennsylvania Department of Transportation delegates regulatory authority
over SEPTA to its Bureau of Public Transit (BPT). To perform EMT inspections,
inspectors must be certified by the BPT. SEPTA recommends supervisory personnel from
SEPTA to the BPT as qualified to perform such inspections. The BPT subsequently
certifies these individuals. The Pennsylvania Publie Utilities Commission (PPUC) has very
limited authority over STM°TA, basically in those locations where SEPTA crosses a
highway.

The Pennsylvania State Police conducts routine records audits to determine that the
required inspections are completed. The actual inspections are not made in the presence
of the State Police nor does the inspecting trooper have a background in mechanical
inspection of rail rapid transit equipment. ‘The trooper who conducts the audits of the
State inspections on the NHSL testified that "we allow thern [SEPTAI] to self-certify
themselves." Since neither the BPT nor the State police had in-house rail rapid transit
experience in 1980, when BPT regulatory efforts began, SEPTA was allowed to write its
own inspection manual. There are no wear tolerances on any components delineated in
the manual. Due to the age of the equipment, few drawings are available representing the
original equipment or many of the modifications that have been completed over the years.

SEPTA's corporate structure does not give equipment maintenance jurisdiction of
the NHSL to SEPTA's chief mechanical officer (CMO), Rather, mechanical maintenance
authority for the NHSL is vested in a general superintendent. The general superintendent
is dependent on the CMO for much of his major maintenance material, such as wheels and
airbrake equipment.

Training

Initial training for a car operator is scheduled to last 20 workdays. The first 5 days
are comprised of classroom instruction which covers operational rules, safety rules, radio
communication, and emergency procedures. The next 5 days consist of on-the-job-training
(OJT) in whieh the student actually operates a train in revenue service under the
supervision of a SEPTA supervisor. This segment of the training is conducted exclusively
during daylight hours. The next 9 days are also OJT in revenue service; however, ths
instructor is a qualified instructor /operator (but not a SEPTA supervisor), and the training
may occur during any shift. On the 20th day, the student {s given a written examination.
The studant must correctly answer 85 percent of the questions to qualify.



ai -
i :
F
j
; af
’ ‘
a
Bl.
RB
a rn
A foe
|
-

ANALYSIS

The Accident... 2... a ee
Injuries to Persons. 2. 1. 1 1 ee ee
Train Damage... 6. eee ee ee
Personnel information te ew wee
Train Information ©... 6 + ee ee
General... 2.1. pes eee ee
The Controller... . eevee
Power Switeh. . . res
Forward /Reverse Switch . oro
Deadman Control. .... oe
Hand Brake . 2... ee eee
Giazing ©. 6 ee wee we we

Track Information... ...

Equipment Maintenance and Inspection Procedures se

Training «© 6 6 ee ee et ee
Method of Operation. . 2. 6. 2 oe

EXECUTIVESUMMARY....+.. 1... 6.
INVESTIGATION .. .

.

.

Meteorological Information... .. +.
Medial and Pathological Information. . .
Emergency Response... . 6 ee ee
Test and Research, 2... 6. ee wee
Other Information. .... eae

Toxicological Testing .. ... 6.

SEPTA Accidents... 1... e.

The Accident... 2. ew eee ‘
Norristown Line Equipment Maintenance .
SEPTA Operational Procedures .....
Training ©. 6 6 6 ee ee eee ee
Survival Aspects. . 6... ee ewe we
Toxicological Aspects . 2... ee eee
Oversight of SEPTA . 0. 0. ee ee
CONCLUSIONS. 2.6 6. we ee .
Findings «6 6 + eee wee eee
Probable Cause . - 2. 1 1 eee ee es
RECOMMENDATIONS. . 2... 2 ee ee
APPENDIXES 2.0.65 6. ese eee ee
Appendix A~Investigation. se ee we
Appendix B--Personnel Information. . . .
-iii-

CONTENTS

ve ew ee ee

.

.
.
.

.
.
.
.
.
.
.
.
.
.
‘
.

.

er ry v
ee 1
er 1
re 9
re 2 |
rr rr er 2
er re rs 2
|
we eee see ee Oh

oe 12

Ce ee 9
a
ee
rr rb)
ee

rr sone e 1

. er ee 2:
Per er 20

rs see OF
a 21
Cr rr
ee
ee
eee ee ee ee ON
er 7 A

Pe bid ibid 48

«



-22-

with a "power knock-out" feature that prevents simultaneous application of power and
braking. Given the potential consequences of a controller handle sticking in the power
mode, the Safety Board believes that SEPTA should have conducted a thorough
investigation into the July 2 report, instead of expending only 15 minutes to inspect the
vehicle and determine that no repair was necessary. Further, the Safety Board believes
that the power/brake interlock should have been installed on the 60-series cars long
before the accident.

Due to the relatively small pool of equipment being operated on the NHSL at the
time of the accident, the operators would become very familiar with the operational
characteristics of that equipment. The Safety Board's investigation established that the
60-series cars were being routinely reported by the operators for weak brakes, as well as
broken and maladjusted brakeshoes. Often the defect reports were on days subsequent to
brake attention and adjustments made by SEPTA mechanical forces, resulting in brake
attention about 3 out of every 4 days in the month before the accident.

SEPTA terms much of the repair work it does on the NHSL equipment as "preventive
maintenance." If a component is broken or if it malfunctions during an inspection it is
generally immediately repaired or replaced. In the rapid transit industry, this manner of
inspection and repair is generally termed "running repair" rather than preventive
maintenance where components are replaced at predetermined limits of time or wear. At
the time of the accident, there were no rudimentary scheduled maintenance requirements,
nor periodie attention to the airbrake system. There also were no condemning wear limits
for wheels or other components. The Safety Board does not consider the repair methods
on the NHSL to have been a preventive maintenance program.

Brake attention appeared to be extensive during the 2-month period preceding the
accident. However, brake attention appeared to be appreciably less following the
aceident. The significantly higher maintenance levels and failure rate suggests that there
may have been a deterioration of the braking effectiveness of the 60-sertes fleet
preceding this accident. Further, it appears that this deterioration may have been
brought under control following this accident.

Piston travel was measured on nearly all the cars in the 60-series fleet after the
accident. The piston travel on car 167 was longer than that of any of the other cars.
Without established standards, it is not possible to calculate travel limits for the
development of maximum braking retardation; however, as piston travel extends outward
toward the limit of its stroke, actual braking effectiveness decreases. SEPTA does have
established standards of piston travel for pneumatic brakes on its other rail equipment.
The Safety Board believes that SEPTA should establish specific limits for piston travel on
the NHSL equipment.

The deadman feature on the 60-series cars was not a fail-safe device. Most
deadman features in the rail and transit industry apply the brakes when the pedal is
released regardless of other factors, unless the brakes are already being applied. The
deadman feature on the 60-series cars only applied when the cat was stopped or the
controller handle was in the lower half of the power range (series). The deadman pedal
was designed in the 1920's to work in conjunction with the spring-loaded controller handle.
If the controller handle was in the parallel rang: or stuck before returning to the power
off position, the deadman feature was nullified. After the accident, SEPTA modified the
deadman control to operate in al] power control handle positions. The Safety Board
believes that SEPTA should have corrected this deficiency long before the accident.

ate cies aas

SASS ES

eR Re



TECHNICAL REPORT DOCUMENTATION PAGE

« Report No. 2.Government Accession No.
NTSB/RAR-B7 /04 P387-916304

3.Recipient’s Catalog No.

)4. Title and Subtitle Raitroad Accident Report--Collision
and Derailment of Southeastern Pennsylvania Transportation
Authority Single Car Train 167, 69th Street Terminal,

5.Report Date _—
September 1, 1987

6.Performing Organization

\12.Sponsoring Agency Name and Address

3.1986 Code
» Author (s B.Performing Organization
Report No.
5. Performing Organization Name and Address 1O.Work Unit No.
4486A
National Transportation Safety Board WW.Contract or Grart No.

Bureau of Accident Investigation
Washington, D.C. 20594

\3.Type of Report and
Period Covered

Railroad Accident Report
August 23, 1986

NATIONAL TRANSPORTATION SAFETY BOARD

Washington, BD. C. 20594

Th, Sponsoring Agency Code

15.Supplementary Notes

“NISB Form 1765.2 (Rev. 9/74)

16.Abstract’ On August 23, 1986, Southeastern Pennsylvania Transportation Authority
(SEPTA) single-car train 167 was en route to Upper Darby, Pennsylvania, on the
Norristown High Speed Line when a passenger requested to Le let off at the
Beechwood/Broukline Station. The operator was unable to stop the car using normal
braking. Subsequently, he applied the airbrakes in emergency, released the deadman
pedal, and applied the mechanical handbrake on each end of the car. The car continued
forward and began to accelerate as it descended the grade into the 69th Street Terminal
at Upper Darby. The car overrode the bumping block at the end of the track, derailed,
penetrated a terminal wall, and came to rest about 6 feet inside the terminal building. Of
the 55 passengers on board, 44 were injured; 11 of the 44 injured passengers were
hospitalized. In addition, one person inside the terminal building was injured. The
operator received minor injuries. Damage to the equipment and building was estimated to
be $225,000.

The National Transportation Safety Board determines that the probable
cause of the accident was the failure of the operator to remove propulsion power from the
car and his failure to use all available means (o stop the car. Contributing to the accident
was the failure of SEPTA to adequately train the operator to use all means available to
stop the car.

17. Key Words.

Collision; toxicologieat test; This document is available
brake system; equipment maintenance; regulatory to ‘ne public ae 1
oversight; supervisory oversight; training; the atone ean ca
“Hours of Service"; emergency procedures. nformation Service,

Springfield, Virginia 22161

TS Distribution Statement

| 15.Security Classification | 20.Security Classification | 21 No. of Pages | 22.Price

(of this report) (of this page)

UNCLASSIFIED UNCLASSIFIED 38



~30-

Take the necessary corrective action so that the in-cab speed indicators
figbday accurate and reliable train speeds. (Class 11, Priority Action)
R-87~

BY Th NATIONAL TRANSPORTATION SAFETY BOARD

. iy /s/ JIM BURNETT
i ‘ Chairmen

4 /s/_ PATRICIA A, GOLDMAN
; | q Viee Chairman
I

i /s/ JOHN K, LAUBER
1 4 Member

ina ae PHAM SS heel cies eae ual eRe tctaramen i +

i /s/) JOSEPH T. NALL
. Member

/s/ JAMES L, KOLSTAD
Member

; | September 1, 1987 :

BMRB ets FILES

AA ENE MEAS ii

i
i
i
i



r
Ef
x

ee
cs
4

Training

Initial training of railcar operators consisted of classroom instruction coupled with
extensive over-the-road evaluations by both SEPTA supervisors and qualified train
operators. However, previously qualified railear operators who had rotated between bus
and rail service were only required to pass a written and field examination in a
recertification program that generally lasted a single day.

The operator of car 167 was qualified by SEPTA on the characteristics of the
equipment and territory of the NHSL. He had passed his recertification examination when
he returned to rail service from bus service about 2 months before the accident.
However, he was not given any refresher training about railcar operations at that time,
and this may partially account for his failure to exercise all of the options available to
stop the car before the accident. Had the operator turned off the overhead power or
reversed the traction motors, the latter of which was taught during his initial railear
training in 1984, car 167 would have stopped before colliding with the terminal building.

The operator had missed test questions on the recertification examination about
emergency procedures, including that of reversing the traction motors as an emergency
means of stopping a railear, and although his service supervisor had filled in the words
‘Jack the motors" in the blank spot on the examination, there is no evidence that the
operator was ever provided with an explanation of, or training on, this procedure. There
is little doubt that the operator was making considerable effort to stop the train. It also
is apparent that sufficient time was available to the operator to attempt different
methods of stopping. Since the operator made these efforts and had the necessary time to
stop the train, the fact that he was unable to do so indicates that he was not adequately
trained to deal with emergency situations.

Based on SEPTA's system o” requalification, an operator could qualify with a score
as low as 73 percent on the written portion of the examination. The Safety Board is
concerned that SEPTA's recertification program would permit operators to return to rail
service even if they did not correctly understand 27 percent of the questions on a written
examination.

Research in education and training 6/ has established basic principles which can be

applied to the training of rail operators. One principle addresses the most effective way
to learn a complex task. Essentially, related subtasks or components of a larger and
complex task should be practiced in a spaced manner (ie., distributed practice) rather
than all at once (i.e., massed practice). Ttis would provide an opportunity for the trainee
to absorb new information in an organized way through actual rehearsal. Another learning
principle, important for emergency situations, which by their nature occur infrequently,
stresses the importance of overlearning, or learaing beyond a eriterion level to that
almost like @ reflex. Under emergency or stressful conditions, human tendency is to
revert to Jong-used, engrained patterns of behavior. If new skills have been acquired to
perform a particular task, oppertunities should be provided to practice those new skills so
that they will prevail when the circumstances call for them. A third principle concerns
the quality and quantity of feedback given for performance of new skills. The feedback
must be specific enough to be informative while reinforcing important aspects of

performance. It must also be immediate enough to be corrective, yet not to the point
where it becomes a distraction.

87 Goldstein, 1, Training: Program Development and Evaluation, Books/Cole Pub. G.,
1974; and Gagne, R.M., The Conditions of Learning, Holt, Rinehart, Winston, 197",



-9..

A review of the operator's service record revealed that he had been verbally warned
on July 9, 1986, for operating a car at 50 mph and on July 11, 1986, for operating at 47
raph; both violations were in 25 mph zones. On duly 15, 1986, the operator failed to
report for duty at the proper time. These reprimands were not entered on his service
record in chronological order. ‘the July 15 incident appeared on the record before tiie
July 9 or July 11 incidents.

Train Information

General.—-At the time of the accident, SEPTA operated 12 cars on the NHSL, 6 of
which were 60-series cars. The 60-series cars were built by the Brill Company of
Philadelphia, Pennsylvania, in the 1920's and they were equipped with cast-iron
brakeshoes,

Car 167 {a 60-series car) was built in 1927 and rebuilt in 1931. The car was 50 feet
6 inches long, 9 feet wide, and 12 feet 8 inches high. There were 28 bench seats in tne
car. Propulsion power was provided by four axle-mounted traction motors (one per axle)
which developed 100 horsepower each. Electric power was picked up from a 600-vult d.c.
third rail that paralleled the running rails. Primary power for on-yoard conimunications,
fare collection, and emergency lighting equipment was obtained from a 12-volt battery
auxiliary system.

Cav 167 had operating controls at each end, on the left side of the car relative to
the direction of travel. The car could be operated either by the operator sitting on a
portable stool or from a standing position.

Car 167 had been involved in an on-board fire on July 18, 1986. Detailed records of
the damage resulting from the fire were not available; however, the car was removed
from service for 10 days while repairs were made.

The Controlier.--Propulsion power is regulated by a controller handle mounted on a
controller contact box immediately in front of the operating position on each end of thie
car. (See figure 6.) The controller handle can be rotated clockwise from the off position
to the full power position. When the spring~loaded controller handle is released, it is
designed to return to the power off position. The controller handle has a spring-loaded
detent protruding from the bottom which, when in travel, moves over two raised
projections on the top plate of the cuntroller box.

, During the investigation, it was discovered that the controller handle from car 167
woul’ sometimes stick on the raised projection of tue controller plate and not return to
the power off position. SEPTA mechanical supervisors stated that before the accident
they were not aware that a controller handle could stick. Maintenance records indicate
that before the accident, on July 2, 1986, car 164, and after the accident, on
April 29, 1987, car 161 were reported defective due to a sticking controller. Both cars
were 60-series cars. SEPTA records indicate that in the first incident 15 minutes were
devoted to an inspection of the problem; no defects were found, and no repairs were
made. Since the accident, SEPTA has modified the propulsion system to open the line
switches during an emergency or deadman brake application and thus remove power. This
precludes simultaneous brake and power applications.

In its clockwise rotation, the controller handle is moved through four notches.
Contactor switches are electro-pneumatically positioned to provide the power appropriate
for the position of the controller handle. When the controlier handle is advanced through
the first two of four notches, the contactor relays electrically configure the traction

WAwegenetuislige: @

PET ERE BREA S B oy 2 HEIS WEBatosns



~12-

Other portions of SEPTA's fleet that operate under the auspices of the Federal Railroad
Administration (FRA) are equipped with approved safety glazing. The operational
environment of the NHSL is simflar to other SEPTA raii divisions.

Track Information

The track on the NHSL is laid to raifroad standard gage, 56 1/2 inches, on treated
timber ecrussties. Both welded and jointed rail is used. The maximum grade is 2 1/2
percent, and the mininium curve radius on the main track is 716 feet. Southward from
Wynnewood Road Station to Parkview Station, there are descending gradients varying
from 0.5 to 2.5 percent. At Parkview Station, a 1.S-percent ascending gradient extends
southward for about 2,000 feet, after which the gradient descends at 2.5 percent until
just before entering the 69th Street Terminal where the track becomes level.

The third rail, which provides electrical propulsion power for the NHSL, is covered

by a protective wood board; in some areas, a plastic cover had been installed to replace
the wood board.

By dialing through the telephone network to a specific number, the controller
(dispatcher at 69th Street) can remotely deenergize the power on the third rail, on a
system basis, for either track. Individual sections cannot be remotely deenergized. The

third-rail system has automatic circuit breakers which have to be reset manually when
they are tripped.

Equipment Maintenance and Inspection Procedures

Cars on the NHSL are given an A-inspection twice weekly, even though the cars may
be used every day. The A-inspection is d‘ided into nine major divisions; d.c. pickup,
interior electric, interior carbody, exterior carvady, exterior electric, trucks, air, clectric
and air valves, and emergency ecuipment. Multiple items are detailed under each major
division. Results of the inspection are recorded on SEPTA's "Preventive Maintenance
Work Sheet (R.A.D. Norristown Line)." After each item is a column whieh can be coded
in one of four ways: () O.K., (A) Adjustments Made, (Q) Repairs Needed, or (#) Repairs
Made. Adjacent to this column is another column for the mechanic who inspected
individual item to enter his initials.

A tnaintenance log, "P&W~-Defects." was used to record road failures and inspection
defects on NHSL equipment. A review of the logs revealed that car 167 experienced 16
road failures and 21 inspection defects in the 43 calendar days it was operational before
the accident. Eight road failures were for "weak brakes," and 12 inspection defects were
for brake adjustments. Also, during the same period, car 167 received additional
brakeshoe attention 13 times; brake adjustments would be made routinely at the same
time.

In July 1986, brake deficiencies accounted for 46 percent of the reported defects on
the 60-serles cars. From August 1-23, 1986, brake deficiencies accounted for 62 percent
of the reported defects on the 60-series cars. Between August 1 and the day of the
accident, 61 percent of the defects reported on car 167 were for brake problems. Car 167
had not received any adjustment on the day of the accident. SEPTA's records detail
several instances where 60-series cars were reported as having defective brakes or
needing brake attention twice in the same day. There was one instance where car 168 was
reported three times in the same dey. Safety Board staff conducted a review of NHSL

mechanical records in May 1987. Brake deficiencies were reported only 5 times during
April °