E PLURIBUS UNUM

NATIONAL TRA S PORTATIO

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SAFE T Y

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National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Accident No.: DCA-04-FR-007 

Location: Queens, New York 

Date of Accident: March 10, 2004 

Time: 2:18 p.m. eastern standard time

1

Railroads: Long Island Rail Road and New York & Atlantic Railway 

Accident Type: Multiple highway/railroad grade crossing collisions 

Injuries: 4

Damages: $83,000

Synopsis 

On March 10, 2004, about 2:18 p.m., the crew of a Long Island Rail Road (LIRR) 

train, assigned to reposition equipment in various locations, left a locomotive (LIRR 160) 

unattended with only its air brakes applied. The locomotive was left on a descending 

grade in the Fresh Pond yard of the New York & Atlantic Railway (NYAR)2

 in Queens, 

New York. The locomotive rolled away and traveled through the yard and onto the 

Bushwick Branch of the NYAR, where it passed over seven passive grade crossings3

 and 

struck numerous vehicles before coming to a stop. Four occupants of three struck 

vehicles were seriously injured. A fire occurred when the locomotive came to a stop, 

after its collision with the last two vehicles. The LIRR estimated equipment damages of

$83,0004

; the NYAR estimated minimal damages. 

The Accident 

The LIRR train crew, assigned to reposition equipment, reported to work at Penn 

Station, New York, at 8:00 a.m. on March 10, 2004. The crew consisted of an apprentice 

engineer, an engineer, a conductor, and an assistant conductor/brakeman. The apprentice 

 1

 All times in this brief are eastern standard time. 

2

 The NYAR is owned by the Anacostia & Pacific Company, Inc., which also owns the Louisville & 

Indiana Railroad, the Pacific Harbor Line, and the Chicago Southshore & South Bend Railroad. 

3

 A passive grade crossing is not equipped with train-activated devices, such as flashing lights, bells, 

or gates. The crossing has grade crossing signs and pavement markings. 

4

 This damage is for railroad equipment and track appurtenances. No estimate was available for 

vehicular damage. 

NTSB/RAB-05/01 
 

engineer operated the train the entire day under the engineerís supervision. All 

crewmembers told investigators that they were well rested for the dayís assignments. 

The crew completed its first assignment of the day without event. The crewís 

second assignment was to go to the Morris Park, New York, engine house and take LIRR 

508, an out-of-revenue-service locomotive, to the NYAR yard in Fresh Pond. LIRR 508 

was to be interchanged to the Canadian Pacific Railway (CPR) for shipment to Altoona, 

Pennsylvania, for warranty/maintenance work. 

The crew arrived at Morris Park at 10:30 a.m. LIRR 508 was to be moved ìdead 

in towî (unpowered) in the middle of a group of three locomotives. Locomotives LIRR 

160 and LIRR 164 were to be the lead and trailing locomotives of the three-locomotive 

train, depending on the trainís direction of movement. Because LIRR 508 was a different 

type of locomotive,5

 the usual electrical cable connections between the locomotives could 

not be made. Therefore, whenever a movement took place, only the lead locomotive 

provided tractive power as the controlling locomotive. The train-line air brake and main 

reservoir hoses were connected between the three locomotives; the connection permitted 

the operation of the air brakes on all the locomotives. 

LIRR Morris Park mechanical personnel coupled the three-locomotive train 

(LIRR 160, 508, and 164) and performed the required air tests. The mechanical personnel 

gave the crew a completed LIRR brake test slip that indicated that the air brakes were in 

working order. The crew told investigators that they also performed a brake test before 

leaving the engine house and a running brake test after they left the engine house. They 

did not note any exceptions to the air brake system operation. 

At 12:00 noon, the crew moved the three-locomotive train from Morris Park to 

Jamaica Station, New York, with LIRR 164 as the controlling locomotive. At Jamaica, 

the train changed direction, and LIRR 160 became the controlling locomotive for the 

move to Long Island City, New York. At Long Island City, the crew changed ends again, 

making LIRR 164 the controlling locomotive. The crew told investigators that each time 

they changed ends, they tested the air brakes without noting any exceptions. The 

locomotive event recorder showed an air brake application each time the operating 

direction was changed. 

 5

 LIRR 508 was a DM30AC locomotive, which uses a 36-pin connection for multiple unit operation. 

LIRR 160 and 164 were MP15AC locomotives, which use a 27-pin connection for multiple unit operation. 

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Once the crew received permission from the yardmaster at Fresh Pond yard to 

enter the NYAR property, a NYAR pilot6

 joined the LIRR crew. The pilot instructed the 

crew to move onto the west leg of the wye7

 track and then proceed to the CPR 

interchange track, so they could put LIRR 508 on a train being prepared for movement. 

To facilitate this operation, the crew had to separate LIRR 160 from the train, thus 

leaving LIRR 160 on the wye track. The conductor and assistant conductor stated that 

they closed the brake pipe angle cock8

 on LIRR 508 and left the angle cock open on 

LIRR 160. They stated that they did not apply the locomotive hand brake on LIRR 160. 

They further stated that they heard a ìwhooshî of air as LIRR 164 and LIRR 508 pulled 

away from LIRR 160 and the air hose parted. They believed the sound indicated that the 

emergency brakes on LIRR 160 had applied. The assistant conductor said that he saw 

LIRR 160ís brake shoes against the wheels. The locomotive event recorder on LIRR 160 

recorded the loss of air brake pressure when LIRR 508 separated from LIRR 160, but it 

did not record an emergency application of the brakes. 

The crew then took LIRR 164 and LIRR 508 to the CPR interchange track, so 

they could couple LIRR 508 to the last car of a train that was being prepared for 

movement. The engineer stated that when they reached the interchange track, he got off 

the train and saw that LIRR 160 was not where the crew had left it. 

They had left the unattended LIRR 160 on a 1 percent descending grade. 

According to the LIRR 160 event recorder, after about 2 minutes 32 seconds, the 

locomotiveís brake cylinder air pressure had decreased to 0 pounds per square inch (psi). 

Twelve seconds later, LIRR 160 began to move. It traveled about 1 mile, gaining speed 

through the yard, and dislodged a temporary rail-mounted derail9

 at the entrance to the 

Bushwick Branch. A split-point derail there had been previously damaged; and, because 

replacement parts were not immediately available, a hinged derail had been installed 

temporarily between the damaged split-point derail and the entrance to the Bushwick 

Branch. The locomotive event recorder on LIRR 160 recorded the speed of the runaway 

locomotive as ranging between 6 and 8 mph as it approached the derail. 

LIRR 160 traveled about 1.2 miles on the Bushwick Branch, passing over seven 

passive highway/railroad grade crossings. The event recorder indicated that the 

locomotive traveled the total distance of about 11,692 feet (2.2 miles) in 16 minutes 9 

seconds and reached a maximum speed of about 31 mph. 

 6

 A pilot is an employee qualified on the physical characteristics and rules of the portion of a railroad 

over which movement is to be made. A pilot is assigned to a train when either the engineer or conductor is

not qualified for that area. 

7

 A wye track is shaped like the letter ìYî and has a connector between the two arms of the Y. It is 

used to reverse the direction of trains or cars. A train pulls completely over one arm of the wye and then 

the switch is thrown; the train reverses direction, moving back along the arm of the wye, then crossing over 

to the other arm, and then moving through it with the other end of the train leading. 

8 Angle cocks are valves at the ends of locomotives and cars that, when open, allow the air in the brake 

system to flow from car to car. When the angle cock is closed, air stays in the brake system. 

9

 A derail is a track safety device attached to one side of a siding or storage track; it is designed to

cause a car or locomotive to be derailed if it rolls free toward a main track. 

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During the runaway, LIRR 160 struck an automobile at one grade crossing and 

pushed it several hundred feet. The two occupants of this vehicle sustained serious 

injuries and required hospitalization. At another grade crossing, the locomotive struck 

two more automobiles, resulting in serious injuries to their drivers, who also required 

hospitalization. Two trucks were parked along the tracks near another grade crossing. 

The locomotive struck the trucks and pushed them about 800 feet westward beyond the 

crossing before it stopped. One of the trucks was carrying welding supplies, including 

acetylene and oxygen cylinders; the cylinders were damaged during the accident and 

caused a fire. The trucks were unoccupied; however, employees of the trucksí owner had 

to jump away from the track to avoid injury. 

As LIRR 160 collided with the automobiles and trucks, the struck vehicles were 

propelled in different directions and struck other vehicles. As a result, the accident 

damaged five other vehicles and a backhoe.10 (See figure 1.) 

The LIRR required postaccident toxicological testing of the four LIRR employees 

who had crewed the three-locomotive train. The test results were negative for drugs and 

alcohol. 

Figure 1. Locomotive after collisions.

Train Operations on NYAR 

All LIRR train movements on the NYAR are governed by the LIRR Rules of the 

Operating Department (effective June 18, 2001) and the LIRR Train Handling and 

 10 In total, 10 vehicles and a backhoe were damaged or destroyed. 

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Equipment Manual (effective January 1, 2002). NYAR Timetable No. 4 (effective 

September 19, 2003) governs train movements within the Fresh Pond yard and on the 

Bushwick Branch. 

Securing Unattended Locomotives 

Item 1.22 (a)(8,9), ìLocomotives Unattended,î in the LIRR Train Handling and 

Equipment Manual states that a locomotive left unattended must be secured with its hand 

brakes applied, air brakes must never be depended upon to hold equipment left standing 

and unattended, and both sides of one wheel must be chocked. A June 16, 2000, LIRR 

memo to all train and engine personnel addressed securing a ìlite11 locomotiveî by 

setting the hand brake or parking brake. Rule 961, ìSecuring of Trains,î in the LIRR 

Rules of the Operating Department states, ìa sufficient number of hand brakesÖ must be 

applied on all trainsÖ left standing or yarded on any track to make them secureÖ.î 

According to Title 49 Code of Federal Regulations (CFR) 232.103(n), which 

addresses securing unattended equipment, including locomotives, the ìair brake shall not 

be depended upon to hold equipment standing unattended on a grade.î The regulation 

further states that hand brakes are to be applied to secure unattended equipment. 

The crew did not apply the hand brake to secure LIRR 160 when they left it 

unattended, and they did not chock one of its wheels. When the conductor and assistant 

conductor were asked why they did not set the hand brake or chock a wheel, they 

responded that it was a ìfast switch operation,î during which they would leave the 

locomotive unattended for only a short period and that they were following a ìstandard 

practiceî that was ìdone all the time.î 

Operating Restrictions 

Train operations on the NYAR are authorized at ìrestricted speed,î defined in the 

LIRR operating rules as 

A speed, not exceeding 15 miles per hour, at which a train can be stopped 

within one half the range of vision, short of the next signal, another train, 

obstruction, or a switch improperly lined, looking out for broken rail or 

crossing protection not functioning. 

The NYAR timetable further limits the maximum authorized speed for the 

Bushwick Branch to restricted speed not to exceed 10 mph with the same attributes as 

above, between Fresh Pond yard and Bushwick Branch and not to exceed 5 mph through 

turnouts, sidings, grade crossings, and the English Kills drawbridge. 

 11 Lite means without cars. 

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Postaccident Inspection of LIRR 160 

LIRR 160 did not derail. The fire following the collision with the two trucks 

damaged the front of the locomotive. 

Investigators attempted to document the position of the control devices in the 

LIRR 160 cab.12 Investigators found the control devices in the following positions: the 

power was off (the knife switch was in the open position, and the generator field switch 

was in the down position); the automatic brake valve handle was in the off position; the 

automatic brake valve cut-out was set for trailing; the independent brake valve handle 

was in the released position; the independent brake valve cut-out was in the open ìlead or 

deadî position; the throttle was set to idle; and the reverser handle was set in the 

center/middle position and had been removed. 

An inspection of the LIRR 160 trucks and air brake system connections found the 

MU (multiple unit) connections as follows: the brake pipe angle cock was open at the 

rear of LIRR 160, where LIRR 508 had been uncoupled; and the main reservoir MU hose 

at the rear of LIRR 160 was curled up and resting in the locomotive coupler. The end 

cock13 associated with the main reservoir MU hose was open. All other air brake end 

cock MU connections were closed. 

Investigators were able to restart LIRR 160 and determine that the air compressor 

was in working order. The brake valve handles were set up to charge the brake pipe, but 

the brake pipe could not be charged. Some air brake components were damaged; there 

was leakage in the vicinity of the front truck and from the automatic drain valve on the 

No. 1 main reservoir. The brake cylinders on the front truck were cut out, and the 

automatic drain valve was plugged. Leakage tests were performed at varying levels of 

brake pipe pressure, and no leakage was noted for the first minute for the fully charged 

brake pipe and for 5 psi, 10 psi, 15 psi, and full service reductions. Investigators 

performed several tests to simulate an emergency application of the brakes with the angle 

cock being rapidly opened. All tests showed similar results. One test showed that brake 

cylinder pressure after 1 minute was 86 psi, but it decreased to 3 psi after 18 minutes. 

Another test with a normal emergency brake application using the locomotiveís 26L 

automatic brake handle showed brake cylinder pressure of 94 psi in 8 seconds and no 

leakage for 5 minutes. 

Safety Board investigators inspected two check valves on the LIRR 160 air brake 

system. (Check valves affect a locomotiveís ability to retain air pressure and maintain the 

application of the brakes.) Investigators found that the check valve on the No. 1 main 

reservoir had been bypassed when an air dryer had been installed with new direct piping. 

 12 A New York City firefighter was reported to have entered the cab and altered control device 

positions while attempting to shut down the diesel engine; the control devices the firefighter reportedly

adjusted were not identified.

13 An end cock is a valve that opens and closes the air connections between locomotives when they are 

coupled for MU operation. 

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With this check valve inoperative, the air pressure from the No. 1 main reservoir would 

be lost if the main reservoir MU connection were left open to atmosphere. 

Investigators found that the check valve on the No. 2 main reservoir had been 

installed upside down and was discolored at the bottom of the check valve seat. The 

purpose of this check valve was to protect against the loss of air pressure in the No. 1 

main reservoir from either a broken pipe or a failed air compressor. Normally, air is 

pumped into the No. 2 main reservoir, and the check valve stops the air from escaping. 

The No. 2 main reservoir provides the air pressure for the air brake system on the 

locomotive and the brake cylinders. 

The inside of the check valve is made so that the moveable valve does not rest 

evenly with the bottom of the pipe. When correctly installed, the piping is almost 

horizontal; any sludge or foreign matter in the air system flows to the lowest point in the 

piping. When the check valve is installed correctly, the moveable part of the check valve 

and the check valve seat do not line up with the bottom of the pipe, and the flange of the 

check valve creates a small ìdamî against the debris flowing in the bottom of the 

horizontal pipe. Thus, the check valve sits high in the pipe to avoid contamination. 

Because the check valve on LIRR 160 was upside down and the moveable part of the 

check valve and the check valve seat were even with the bottom of the piping, the check 

valve was more likely to stick open due to debris in the pipe. 

The main reservoir MU connection at the rear of LIRR 160 had been left open. 

Normally, a choke is present to allow the air compressor to maintain pressure in the No. 1 

reservoir in this situation. However, the choke was missing from LIRR 160. 

Consequently, once LIRR 508 and LIRR 160 were separated, the initial pressure in the 

reservoir was exhausted, and the air compressor could not maintain pressure in the 

system. 

Normally, the pressure in the No. 2 reservoir is protected by a check valve that 

does not allow the air to flow back toward the open MU connection. In this case, the 

check valve was installed upside down. During postaccident testing, the check valve was 

deliberately stuck open, and the loss of pressure nearly matched the recorded loss of 

pressure on the day of the accident. Given the valveís position, which would have 

allowed debris to enter the check valve seat intermittently, this check valve probably 

stuck in the open position on the day of the accident resulting in the air brake systemís 

failure to hold the standing locomotive. 

Investigators simulated the separation of the locomotives on the day of the 

accident using the air pressures from the event recorder readout. The main reservoir 

supply was dropped to 45 psi and the brake cylinder pressure was recorded when the 

locomotives were separated. When the brake pipe pressure dropped to 25 psi, an 

emergency brake application was initiated. The main reservoir MU end cock was then 

opened to the atmosphere, and the brake cylinder and main reservoir pressure dropped to 

0 psi in 3 minutes. 

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Railroads do not typically test check valves during periodic air brake inspections. 

During normal use, a check valve failure is not noticed, and a valveís intermittent 

obstruction by debris is difficult to detect. No backup exists for an inoperative check 

valve. If a locomotive compressor fails, a pipe cracks, or an MU end cock is left open (as 

happened in this accident), the check valve is the only protection for preserving the air 

pressure required to operate the brakes. 

Although the conductor and the assistant conductor/brakeman were convinced 

that the ìwhooshî sound they heard as they uncoupled LIRR 508 was an emergency 

application of the train brakes on LIRR 160, the event recorder on LIRR 160 did not 

record an emergency brake application. The recorder indicated that as the crew 

uncoupled LIRR 160, the brake cylinder pressure briefly increased from 40 to 45 psi and 

then started to decrease. The brake cylinder pressure decreased to 0 psi in about 

2 minutes 32 seconds. When the brake cylinder pressure reached 0 psi, the air brake 

system no longer provided a braking force to keep the brake shoes applied against the 

locomotive wheels. 

The air brake system and the hand brake were the only available braking systems 

on LIRR 160. With the air brakes released and no hand brake applied, the locomotive had 

no working braking system when the crew left it unattended. 

Crew Efficiency Testing 

The LIRR has an efficiency testing program to monitor crew compliance with the 

operating rules. The disciplinary record for the conductor of the accident crew showed 

that in May 2001, he had failed14 the efficiency program test for the LIRR Rules of the 

Operating Department Rule 961, ìSecuring Equipment.î In 2002, the LIRR refined its 

efficiency testing program and renamed it the Situational Awareness For Efficient 

Railroading, or SAFER program. The SAFER program was designed to cause face-toface interaction between the manager and the employee, thus preventing train 

accidents/incidents and personal injuries by improving employee operating and safety 

habits. The program requires managers to submit SAFER observations, including hand 

brake observations. From January 2001 to March 10, 2004, the LIRR conducted 918 

SAFER evaluations that specifically addressed the securing of equipment.15 These 

evaluations identified 24 instances of noncompliance. 

The NYAR conducts operational tests and inspections in accordance with the 

LIRR and NYAR timetables, special instructions, and safety and operating rules. Before 

the March 10, 2004, accident, no joint efficiency testing was conducted while LIRR 

crews were operating on NYAR property. 

 14 The conductor was suspended for 2 days as a result of failing the test. 

15 As established in LIRR operating rules 13, 803, and 961. 

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Highway/Railroad Grade Crossings 

When LIRR 160 rolled away and traveled about 2.2 miles, it traversed seven 

highway/railroad grade crossings on the Bushwick Branch. None of the grade crossings 

had active warning devices. Several years ago, the crossings had such devices, but by 

March 1990, the devices had been removed. The representatives for the New York State 

Department of Transportation (NYSDOT), the LIRR, and the NYAR could not provide 

any reason for the removal of the active devices. 

After the active devices at the seven crossings had been removed, both the LIRR 

and the NYAR required that train movements over the highway/railroad grade crossings 

(1) be made at 5 mph, (2) be preceded by the sounding of the locomotiveís bell and horn, 

and (3) at the train crewís discretion, be preceded by a flagman providing a visible 

warning to vehicular traffic. 

Numerous deficiencies and/or irregularities were found in the passive warning 

devices, the pavement markings, and the advance warning signs at the seven crossings. 

The NYSDOT stated that under New York Railroad law and the Manual for Uniform 

Traffic Control Devices16 (MUTCD), the railroad is responsible for the installation and 

maintenance of crossbucks at all public crossings. Also, under the MUTCD, local 

municipalities are responsible for the installation and maintenance of pavement markings 

and advance warning signs. 

Postaccident Actions 

LIRR 

The LIRR developed an action plan with two goals: (1) to address potential 

organizational, human factor, mechanical, and infrastructure causes of unsecured 

equipment, and (2) to study the incident to determine whether it indicated other potential 

or actual lapses of operational safety. The LIRR took the following steps immediately 

after the accident: LIRR managers met with all affected employees to discuss the 

potential causes of unsecured equipment; the LIRR increased focused operational 

efficiency checks to measure compliance with the rules and procedures for unattended 

locomotives; the LIRR established a management team to develop best practices; and the 

LIRR inspected the main reservoir systems of all 1,500- and 1,000-horsepower diesel 

locomotives for improperly installed check valves. 

The LIRR also reported that it is developing systems for overseeing LIRR 

employees operating on the NYAR, enhancing the qualifications of LIRR operating 

crews on NYAR territory, and reviewing operating rules and instructions to determine 

 16 U.S. Department of Transportation, Federal Highway Administration, Manual on Uniform Traffic 

Control Devices (Washington, DC: FHWA, 1988). This document defines the standards used by road 

managers nationwide to install and maintain traffic control devices on all streets and highways. 

9

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whether revisions are needed. In addition, the LIRR issued instructions to all LIRR train 

crews to coordinate with the NYAR when they are operating in the Fresh Pond yard. The 

LIRR also reminded the crews to apply hand brakes on ìall unattended cars and engines 

and cuts of cars and engines.î The split-point derail at the entrance to the Brunswick 

Branch was repaired and returned to service. 

FRA 

On March 11, 2004, the Federal Railroad Administration (FRA) advised the 

NYAR by telephone to protect all train movements on the Bushwick Branch with 

flagmen. On March 12, 2004, the NYAR issued General Notice No. 402, which stated, 

ìEffective immediately, all crossings on the Bushwick Branch must be flagged and 

protected.î 

The FRA held a community meeting on April 7, 2004, with Community Boards 1 

and 5, the NYAR, the New York City Department of Transportation (NYCDOT), and the 

NYSDOT to discuss the highway/railroad grade crossings in Queens and to facilitate any 

future actions. The LIRR was invited, but did not attend the meeting. At the meeting, the 

FRA suggested that the signage for the highway/railroad grade crossings involved in this 

accident be improved. The NYAR subsequently replaced the missing crossbuck signs at 

the crossings. The NYCDOT agreed to reconstruct the pavement at the crossings, update 

the standard advance warning crossing signs that were already in place, and repaint the 

advance warning pavement signs. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of 

the multiple highway/railroad grade crossing collisions in Queens, New York, on 

March 10, 2004, was the failure of the Long Island Rail Road conductor and assistant 

conductor/brakeman to secure the locomotive when they left it unattended on a 

descending grade. 

Adopted: April 18, 2005 

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