PB96-916301

NTSB/RAR-96/01

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, DC 20594

RAILROAD ACCIDENT REPORT

COLLISION AND DERAILMENT OF TWO SUBWAY TRAINS

METROPOLITAN TRANSPORTATION AUTHORITY

NEW YORK CITY TRANSIT

IN BROOKLYN, NEW YORK, ON FEBRUARY 9, 1995

6531A
Abstract: On February 9, 1995, a Metropolitan Transportation Authority/New York City Transit

subway train collided with a stopped subway train. The rear-end collision, in which 11

passengers and 4 transit employees sustained minor injuries, occurred on elevated track south of

the Ninth Avenue station in Brooklyn, New York.

The major safety issues discussed in this report are the effectiveness of automatic stop arms to

ensure compliance with stop signals and the adequacy of transit system oversight to ensure

compliance with operating rules. The report also includes safety issues relating to speedometers,

radios, positive train separation, crashworthiness and occupant survivability, and emergency

response.

As a result of its investigation, the National Transportation Safety Board issued safety

recommendations to the Metropolitan Transportation Authority/New York City Transit.

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

aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967,

the agency is mandated by Congress through the Independent Safety Board Act of 1974 to

investigate transportation accidents, determine the probable causes of the accidents, issue safety

recommendations, study transportation safety issues, and evaluate the safety effectiveness of

government agencies involved in transportation. The Safety Board makes public its actions and

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

recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, SW

Washington, DC 20594

(202) 382-6735

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
COLLISION AND DERAILMENT

OF TWO SUBWAY TRAINS

METROPOLITAN TRANSPORTATION AUTHORITY

NEW YORK CITY TRANSIT

IN BROOKLYN, NEW YORK

FEBRUARY 9, 1995

RAILROAD ACCIDENT REPORT

Adopted: March 19,1996

Notation 6531A

NATIONAL

TRANSPORTATION

SAFETY BOARD

	
 
 
This page intentionally left blank
iii

CONTENTS

EXECUTIVE SUMMARY........................................................................................................... v

INVESTIGATION

Accident .......................................................................................................................................... 1

Injuries............................................................................................................................................. 4

Damages .......................................................................................................................................... 6

Personnel Information ..................................................................................................................... 6

B Train Crew............................................................................................................................. 6

M Train Operator ...................................................................................................................... 6

Train Information ............................................................................................................................ 7

Speedometers ............................................................................................................................ 8

Event Recorders ........................................................................................................................ 8

Radios........................................................................................................................................ 9

Track and Signal Information.......................................................................................................... 9

Operations Information ................................................................................................................. 17

Meteorological Information .......................................................................................................... 17

Toxicological Information............................................................................................................. 17

Emergency Response..................................................................................................................... 17

Crashworthiness and Control Compartment Survivability ........................................................... 18

Postaccident Tests ......................................................................................................................... 19

Other Information.......................................................................................................................... 20

Operating Rules Compliance .................................................................................................. 20

Rear-End Collisions Involving Keying By Signals................................................................. 21

Directives and Bulletins Concerning Keying By Signals........................................................ 21

Automatic Stop Arm Strike Mark Survey............................................................................... 22

Key-By Feature Deactivation .................................................................................................. 23

ANALYSIS

General .......................................................................................................................................... 24

Accident ........................................................................................................................................ 24

Effectiveness of Automatic Stop Arms to Ensure Compliance with Stop Signals ....................... 26

Adequacy of NYCT Oversight to Ensure Compliance with Operating Rules .............................. 27

Radio Procedures........................................................................................................................... 29

Positive Train Separation .............................................................................................................. 30

Crashworthiness and Occupant Survivability ............................................................................... 30

Emergency Response..................................................................................................................... 31
iv

CONCLUSIONS ......................................................................................................................... 32

PROBABLE CAUSE .................................................................................................................. 33

RECOMMENDATIONS............................................................................................................ 33

APPENDIXES

Appendix A--Investigation and Hearing ................................................................................. 35

Appendix B--B Train Personnel Information.......................................................................... 37

Appendix C--NYCT Rules Applicable to Report ................................................................... 39

Appendix D--Memorandum and Speed Calculations

 from NYCT Brake Systems Engineering Manager....................................... 43

Appendix E--NYCT B Form -- Operating Employee Evaluation Check List ........................ 47

Appendix F--NYCT Bulletin No. 15-95

 Deactivation of Key-By Feature - Signal D2-532 ......................................... 49
v

EXECUTIVE SUMMARY

At 2:39 p.m. on February 9, 1995, a Metropolitan Transportation Authority/New York

City Transit (NYCT) northbound M line subway train collided with the rear car of a stopped

NYCT B line subway train. The collision occurred on elevated track about 1,011 feet south of the

Ninth Avenue station in Brooklyn, New York. Four NYCT employees and 11 passengers

sustained minor injuries.

The National Transportation Safety Board determines that the probable cause of the rearend collision between the two subway trains was the inadequate oversight and compliance

program of the NYCT to ensure that train operators comply with the published operating rules.

Contributing to the collision was the design modification to the automatic key-by feature of the

automatic stop arm that enabled the operator of the M train to pass a stop signal contrary to the

published operating rules that require stopping at a red signal unless permission to pass is granted

by Rapid Transit Operations.

The major safety issues discussed in this report are the effectiveness of automatic stop

arms to ensure compliance with stop signals and the adequacy of NYCT oversight to ensure

compliance with operating rules. The report will also discuss safety issues relating to

speedometers, radios, positive train separation, crashworthiness and occupant survivability, and

emergency response.

As a result of its investigation of this accident, the Safety Board makes recommendations

to the NYCT.

INVESTIGATION

Accident

On February 9, 1995, at 2:39 p.m., a

Metropolitan Transportation Authority/New

York City Transit (NYCT)1

 northbound M

line route subway (M) train collided with the

rear car of a stopped NYCT B line route

subway (B) train in Brooklyn, New York.

The 10-car B train in passenger service had

departed the Stillwell Avenue station in

Brooklyn about 2:20 p.m. en route to 168th

Street station in Manhattan, New York. (See

figure 1.) The crew consisted of a train

operator and conductor. The conductor

stated that the last station stop before the

collision was the Fort Hamilton Parkway

(Fort Hamilton) station in Brooklyn. The

operator stopped the train after departing

that station at signal D2-518, which

displayed a stop signal because a preceding

northbound M train was stopped in the

Ninth Avenue station in Brooklyn. The train

operator stated that after waiting about 3

minutes, he felt a tremendous impact that

threw him toward the window. The

conductor stated he had no warning of the

impending collision, which occurred on the

elevated track about 1,011 feet south of the

Ninth Avenue station. (See figure 2.) He

assisted the passengers during the train

evacuation after the collision along the

elevated walkway to the Ninth Avenue

station. The crew, an off-duty employee, and

11 of the 150 passengers on the B train as

well as the M train operator sustained minor

injuries.

Earlier the eight-car M train had arrived

about 2:20 p.m. at the Ninth Avenue station,

 1

Known as the New York City Transit

Authority before April 4, 1994.

and all passengers were discharged. It was

then designated an M light2

 train and was

boarded by its relay operator at 2:21 p.m. He

was assigned to move the train south on

track D3/4 from the station to the 62nd

Street interlocking, then to cross the train

over, and to return it on track D2 to the

Ninth Avenue station, where it would

become a northbound passenger train to

depart at 2:46 p.m. The relay operator had

already made five similar trips on February 9

and was scheduled for an additional four

trips.

The operator told National Transportation

Safety Board investigators that once in the

control compartment of the south car, he did

a standing air brake test. After departing the

Ninth Avenue station about 2:25 p.m., he

performed a rolling and then a running air

brake test. He said that the air brakes worked

properly during the three tests. The operator

passed what he thought was a northbound M

train at the Fort Hamilton station and

another northbound train between the 50th

and 55th Street stations. The operator

continued that his train then proceeded

through the 62nd Street interlocking and

reached the 8 to 10 marker3

 on track D3/4

where he stopped it. He then went to and

entered the north car that he set as the

control car. He stated he performed a

 2

Passenger train operating without passengers.

3

Indicator to operator that end of 8- to 10-car train

has cleared interlocking.


4

standing air brake test and added that he

took no exception to the brakes or the

performance of the train while operating it.

After about 3 minutes, the train operator

received a proceed signal to move north

through the interlocking onto track D2 and

then proceeded through the 62nd Street, 55th

Street, and 50th Street stations without

incident. He told Safety Board investigators

that he received a yellow approach signal

(D2-541) as he approached the south end of

the Fort Hamilton station and that he could

see the next signal (D2-532), showing a red

light with a white light illuminated at the

bottom, as he entered the station. The signal

indicated, according to him, that “if I

approach it at the allowable speed, it will

clear for me.” He added, “The only reason I

entered the station is because I thought the

lunar white was illuminated. To me, it was

lit. If it wasn't lit to me, I wouldn't enter the

station because I'm not allowed to stop in the

station empty.” The operator continued that

as he approached, he observed the automatic

stop arm, located outside the left rail

opposite the D2-532 signal, and his train

was moving less than 10 miles per hour

(mph) when he saw the stop arm go down.

He stated that he could remember neither the

aspect of the signal when he passed it nor

the signal changing from the red aspect. The

operator said that he did not stop at signal

D2-532 but proceeded because the stop arm

went down and added, “That's usually the

last thing I look at when I operate -- the trip

arm. When it clears, I make sure it goes

down and I go.” He reported that he

accelerated to approximately 15 mph and

that he saw the B train ahead of him as he

rounded the right-hand curve. He stated that

he immediately released the power and

instinctively made a full-service brake

application but was unable to stop his train

short of the B train.

As a result of the impact, the rear car

4259 of the B train penetrated the lead

control car 4918 of the M train about 3 feet

(see figure 3), and the B train moved

forward about 10 feet. The third car 4939 of

the M train partially blocked track D3/4 after

the collision. (See figure 4.)

Injuries*

Type B Train

Crew

M Train

Crew

Passengers Total

Minor 3** 1 11 15

None 0 0 139 139

Total 3 1 150 154

 *Based on the injury criteria (49 Code of Federal Regulations [CFR] 830.2) of the International Civil

Aviation Organization, which the Safety Board uses in accident reports for all transportation modes.

**Includes off-duty employee.

6

Damages

The rear five cars of the B train and the

first five cars of the M train received

damages, according to the NYCT, in excess

of $1.5 million.

Personnel Information

B Train Crew--Appendix B provides

information about the professional

background and experience with the NYCT

of the 31-year-old operator and the 39-yearold conductor who were the crew of the B

train.

M Train Operator--The 28-year-old operator

reported for duty with the NYCT as a

conductor-in-training on November 27,

1989. He worked as a conductor on

subdivisions A and B before being promoted

to operator on June 6, 1993. After

concluding the operator induction course on

October 21, 1993, he was certified to

perform all duties of an operator. The

operator had successfully completed the

course series of written examinations on

NYCT operating rules and during interviews

with Safety Board investigators had

correctly described the provisions of rule 39

(i) that apply to light train operation (see

appendix C). The operator had no regular

duties and was assigned from the extra list

working in the yard, relay trains, and

passenger service. He stated that during his

16-month experience as a certified operator,

he worked “anywhere they needed me,

except work trains [used for track

maintenance], that's the only thing I'm not

qualified for.” In the 2 weeks before the

collision, he had operated primarily in

passenger service but had relayed trains 1

day.

The operator's personnel file contained

two disciplinary cases: absence from his post

and on an undocumented emergency in May

1991 and June 1992, respectively. Also in

the file were two operating employee

evaluations in which he received an overall

rating of acceptable in April 1994 and of

good 8 months later. A search of the NYCT

evaluation data base found two additional

evaluations for overall ratings of good on

January 24 and February 8, 1995.

The most recent NYCT medical

examination4

 of the train operator was on

April 12, 1994, in which he was assessed fit

for full work. Describing his health as good,

he said that he worked out at the gym as

much as possible accommodating his

irregular work schedule. The operator noted

that he had no problem or difficulty with his

hearing. He reported that he wore

prescription eyeglasses when driving an

automobile or operating a train and did so on

the day of the collision. His personnel record

card was stamped “MWG” (must wear

glasses); the personnel file contained

evidence that the operator was issued

prescription safety glasses in August 1992

and that the evaluating train service

supervisors observed him wearing

prescription glasses at least twice.

Safety Board investigators reviewed the

operator’s time and payroll records for the

 4

NYCT requires train operators and all other

employees whose duties regularly require them to be on

or near tracks or right-of-way to have periodic medical

examinations (every 2 years and annually for

employees under and over age 50, respectively).
7

30 days before the collision. He was on

vacation between January 10 and 14, 1995,

and then worked 7 consecutive days on his

return to duty before taking January 22 and

23 as his regular days off. During each of the

next two 5-day work weeks, he worked

about 42 and 41 hours, respectively. The

investigators then reconstructed the

activities of the operator for the 72-hour

period before the collision from NYCT

records and operator interviews. Although

February 6 was a regular day off for the

operator, he accepted an assignment that

began at 10 p.m. the night before and ended

at 6 a.m. on February 6. He said that he

returned home at 7 a.m., slept until about 2

p.m., was up for 3 or 4 hours, and then

napped from 6 to 10 p.m. in anticipation of

his midnight reporting time. The NYCT

records indicate that he worked from

midnight until 2 p.m. on February 7. The

operator said that he then went to the gym,

returned home for dinner, retired about 8

p.m., and rose about 3:30 a.m. on February

8. His work hours that day were from 4:57

a.m. until 2:02 p.m. The operator reported

that he had lunch at home before going to

the gym, returned home for dinner, and

retired between 10 and 11 p.m. On February

9, he rose about 7:30 a.m., ate breakfast,

began work at 8:45 a.m., and was on duty

about 6 hours at the time of the collision.

Train Information

The equipment involved in the collision

was built by the St. Louis Car

Manufacturing Corporation. The selfpropelled cars, operated in two-car pairs

with control compartments on opposite ends,

are powered by a contact, attached to each

car truck, collecting current from a "thirdrail" distribution system. The 10 R-40 type

cars (numbers 4351, 4350, 4275, 4274,

4329, 4328, 4347, 4346, 4258, and 4259) of

the B train were built in 1968 and 1969 and

were modified in 1987 and 1989 by

Sumitomo Corporation of America. The

control ends of each car were angled. The

eight R-42 type cars (numbers 4918, 4919,

4939, 4938, 4917, 4916, 4915, and 4914) of

the M train were built in 1969 and 1970. The

control ends of each car were the

conventional flat-end shape.

Representatives of the Safety Board, the

Office of the Inspector General

(Metropolitan Transportation Authority), the

New York State Public Transportation

Safety Board (NYSPTSB), and the NYCT

inspected the equipment after the collision

and found no defects. The trip cock5

 from

the lead car of the M train was examined and

showed no evidence of strike marks. During

its testing, the trip cock operated as

designed. The maintenance records of all

cars involved in the collision were also

reviewed. These records indicated normal

maintenance standards, and no collisionrelated maintenance conduct was

discovered.

Safety Board investigators performed air

brake and power tests of the collisioninvolved M train cars on March 3, 1995, at

the Coney Island train yard. The brakes and

brake rigging were checked and operated as

designed. After the brake valve on the lead

car was removed, it was bench tested and

also operated as designed. The power test to

check the traction motors in forward and

 5

Device mounted on each car that places train in

emergency braking when it strikes stop arm near track.
reverse indicated that the cars operated as

designed.

Speedometers--The M train was not

equipped with a speedometer. No Federal,

State, or local regulations require NYCT

trains to have speedometers. Instead of the

trains being equipped with speedometers,

according to the senior director of

Operations Support and Review for Rapid

Transit Operations (RTO), the operators are

“because right now, they don’t know how

fast they’re operating without the

speedometer. They’re guesstimating.” He

added that as an operator becomes more

experienced, the operator knows how fast he

is going. Answering the question of how he

estimated or determined speed, the M train

operator stated, “well, the series on a train of

two points is told to me to be estimated

between 15 and 18 mph. Three points of

power is full speed, whatever that could be -

REV /

PARALLEL

MAIN

OPERATING

HANDLE

HANDLE ‘ I

Figure 5--Master controller.

taught the relationship between the speed

and the master controller three points of

power (switching, series, and parallel). The

assistant chief mechanical officer explained

that a master controller has four positions:

off; switching (one point of power), for

speeds up to 10 mph; series (two points of

power), for speeds between 10 and 20 mph;

and parallel (three points of power), for

speeds as great as 55 mph, depending on the

grade. (See figure 5.)

The senior director further stated that

allowable speed is a judgment for operators

35, 40, depending on the grade, or

whatever.”

Event Recorders--Neither the B nor the M

train were equipped with event recorders.

No Federal, State, or local regulations

require NYCT trains to be equipped with

event recorders. In an April 1995 interview

with Safety Board investigators, the assistant

chief mechanical officer said that new

NYCT cars, expected to arrive by 2000, will

be equipped with

monitor several

including speed.

event recorders that will

train line functions,

8
9

Radios--The NYCT rule 20 (b) that

applies to the possessing and testing of

radios (see appendix C) states, “Each train

must be equipped with an operable Train-toWayside Radio.” In addition, the NYCT

bulletin number 45-94, which was issued in

June 1994 and was in effect at the time of

the collision, provided for train-to-wayside

communication. It directed that “all trains

using main line tracks, for any reason and for

any distance, must have an operable train to

wayside radio (either a train radio or

conductor's portable may be used).”

The assistant chief mechanical officer

stated that the only subway cars equipped

with built-in radios are on the new

technology trains and that older cars have a

bracket behind the operator's seat into which

an operator plugs a radio. The operator must

bring a radio onto the train. He added that

operators and conductors also may use

portable radios. During an interview with

Safety Board investigators, the M train

operator denied that he had either been

issued a radio or had one at the time of the

collision. The NYCT supervisory personnel

stated that the operator was given a radio;

however, the NYCT was unable to produce

documentation to that effect.

Track and Signal Information

The collision occurred on NYCT elevated

track about 23.5 feet above 10th Avenue

between 40th and 41st Streets in Brooklyn.

Tracks D1, D3/4, and D2 are on the west

side, in the center, and on the east side of an

open-deck, steel structure, respectively.

Trains traveling in a southward and a

northward direction use tracks D1 and D2,

respectively. Bidirectional train movements

are on track D3/4.

The track has a 0.7-percent ascending

grade in a northward direction. Its alignment

curves to the right with a 270-foot radius

(21o

 13’) from about 430 feet north of the

Fort Hamilton station to about 53 feet

beyond the point of impact (POI). A 15-mph

speed restriction sign in advance of the

curve is posted on the east side of the track

about 262 feet north of signal D2-532. A

building near the middle of the curve

obscures the line of sight through the curve.

(See figures 2 and 6.)

NYCT track personnel who were first on

scene observed that the rail surface was dry

and that skid marks on the rail head started

between 100 and 150 feet south of the POI.

Safety Board investigators detected no

preexisting track anomalies during their

postcollision track inspection.

The NYCT signal system consists of

automatic block wayside signals and

consecutive signal blocks governed by

automatic and interlocking signals.

Operating as a train control system, it

provides train detection and separation as

well as movement through interlockings.

Four light signals control northbound

movement on track D2 from the south end

of the Fort Hamilton station to the Ninth

Avenue station.

Signal D2-541, located about 300 feet

south of Fort Hamilton station (see figure 7),

displays either a red (stop) or a yellow

(proceed with caution, be prepared to stop)

aspect. Train occupancy of the track ahead

determines the signal aspect displayed. If a





found during their inspection that signal D2- also reviewed and indicated repairs were

532 and its corresponding circuits as well as made within NYCT maintenance

the relays, stop arm, and signals operated as requirements. The 12-month incident record

designed. Signal cyclic maintenance records disclosed no reportable signal incidents.

for the 13 months before the collision were

i

—— —— .—-—~—–—

Insulated Joint and Joint Marker

Signal D2-532%1

. 9 I *

Figure 1 l--Layout of insulated joint, signal D2-532, and automatic stop arm.

(Source: Adapted from New York City Transit drawings. Not to scale.)

15

17

Operations Information

The NYCT system consists of 25 lines,

identified by either letters or numbers. The

NYCT 1994 data indicated that its annual

ridership was approximately 1.8 billion. An

average of 3.4 million passengers rode on

weekdays and half that number on Saturday

and Sunday. Scheduled train trips, according

to the 1994 data, totaled about 2.2 million,

and 6,568 scheduled trips occurred daily.

Subway trains in passenger service are

crewed by an operator and a conductor. The

NYCT employs 2,841 operators and 2,408

conductors. The operator works the train

from the control compartment of the lead

car. The conductor is required to ride in the

center of the train.

The RTO control center coordinates all

train movement, governed by the Rules and

Regulations Governing Employees Engaged

in the Operation of the New York City

Transit System (revised 1992), the timetable,

the schedule, general orders, and bulletins.

The RTO reported that on-time train

performance as of February 1995 was 88.7

percent.

Train dispatchers and employees at the

control center communicate by radio with

operators. Safety Board investigators

reviewed the RTO control center radio tapes

from the day of the collision. No

conversations were recorded between

control center personnel and either the M

train operator or the B train crew. In

addition, no conversations were taped

between the crews of the M and of the B

train.

Meteorological Information

The weather at the time of the collision

was clear and sunny, and several inches of

snow covered the ground. The ambient

temperature was 29o

 F.

Toxicological Information

In compliance with the Federal Transit

Administration regulations on toxicological

testing for transit workers in safety-sensitive

positions, both train operators provided

breath and urine samples for toxicological

testing. An evidential breath testing device,

which prints the date, the time, and the test

results, was used in the breath alcohol tests.

The results for both operators were negative

(0.00 grams of alcohol per 210 liters of

breath). MetPath, Inc., a federally approved

laboratory, tested the urine specimens

provided by both operators for the presence

of amphetamines, cocaine, marijuana,

opiates, and phencyclidine. The laboratory

reported that the test results for both

specimens were negative.

Emergency Response

The collision was reported at 2:39 p.m. to

the Fire Department of New York (FDNY)

emergency response dispatch center. FDNY

units were dispatched at 2:41 p.m., and the

three engine and two ladder companies and

two rescue vehicles arrived on scene at 2:45

p.m. After an initial assessment by the onscene commander, additional assistance was

requested. (Ten emergency medical service

officers, 15 city police officers, and 10

NYCT rescue unit officers responded.) At

2:53 p.m., the FDNY requested confirmation
18

that the NYCT had shut off the power to the

third rail. The NYCT confirmed at 2:56 p.m.

that the power was shut off. FDNY

personnel with the assistance of the transit

police completed the evacuation of

approximately 150 people from the B train

at 3:15 p.m. The FDNY had established a

mobile unit command post, and the NYCT

had used a standard city bus as its command

post.

Crashworthiness and Control

Compartment Survivability

The lead car 4918 of the M train

underrode the anticlimber of the rear car

4259 on the B train, causing extensive

damage. The anticlimber was pushed in 5 to

6 feet and had the deepest penetration

slightly to the right of the center (facing

forward). The inner fiberglass was destroyed

with the left side deflected outward to the

first door. The interior floor of car 4259 was

penetrated and buckled upward and inward.

The third car 4939 of the M train derailed

and had displaced sideways. The car had

exterior damage to its right rear and had

interior panel displacement. The passenger

compartment had no interior car body

penetration.

The fourth car 4938 of the M train also

was derailed and displaced. The collision

post on the right side was bent about 1 foot

inward and over and was torn on the bottom

from the horizontal member. A break was

partially, but not completely, on the weld.

The interior of car 4938 had some

penetration at the right rear, and its ceiling

was displaced downward and backward.

The control compartment in lead car 4918

of the M train was constructed of structural

grade sheet metal and had angular corner

framing reinforcements. A full-sized,

outward swinging, hinged access door and a

sliding window were to the operator's left

and right, respectively. The lower half of the

door was compressively wedged and

distorted between the jambs. The M train

operator stated during an on-scene interview

that he was able to climb out of the damaged

compartment through a small opening in its

door. The door was warped inward about 1

foot at the top corner, and this warpage

created a triangular opening in the rear wall

that measured about 10 inches at the top and

tapered to zero at the bottom. The rear

bottom corner of the compartment was

displaced aft approximately 2 inches.

The rear car 4259 of the B train was

compressed against the front of the control

compartment, whose windshield was

shattered but remained within its frame. The

exterior car body panel below the windshield

was intact but distorted. The right front

cornerpost was displaced aft, and the right

front collision post (adjacent to the car end

door) was displaced aft about 2 feet. The 2-

foot-wide operator console was displaced aft

on the left side, and its kick panel had the

left front edge of the operator seat frame

embedded slightly into its surface. The rear

wall of the compartment behind the seat

frame was distorted aft. The right side of the

operator console appeared only negligibly

displaced aft. This displacement created a

triangular survival space that measured 6

inches on the right side and tapered to zero

on the left. The displaced compartment floor

left wiring and piping exposed. The

compartment ceiling remained intact and did

not collapse.
19

In addition, small indentations and

scratches were found on the inside surface in

the center of the control compartment

window. The window was open about 2

inches and could not be pushed aft into its

pocket. The operator stated that he removed

his control handle and attempted to break the

window. He gave up after striking it several

times and replaced the handle on the

console.

Postaccident Tests

Safety Board investigators conducted

visibility, sight-distance, stop arm, key-by

and stopping tests on February 11, 1995, at

the collision site. Equipment similar to that

of the trains in the collision was operated

during the tests. The weather conditions

were comparable to those on February 9,

1995.

A visibility test was performed about the

time the February 9 collision occurred when

the sun was reported to be shining over the

left shoulder of the M train operator as he

approached signal D2-532. As the test M

train approached the south end of Fort

Hamilton station, the sun was behind the

train approximately at the 7 o'clock position.

No ghost or phantom reflections were

observed from the three vertical color light

lenses on the signal.

Two sight-distance tests were completed:

the test operator in the M train was standing

during the first and sitting during the second.

The rear car of the test B train was placed at

the approximate POI. The test M train was

then operated from the Fort Hamilton station

northward, and its operator was instructed to

call out as soon as the rear car of the B train

came into sight. The test results recorded the

line of sight from the standing and the sitting

positions was 200 and 207 feet, respectively.

A stop arm test was done to determine

whether the raised stop arm would strike the

trip cock of the train and cause the train to

stop. The test operator was instructed to pass

the train over the stop arm moving at least 5

mph to ensure that the train did not activate

the key-by feature. Because the train was not

equipped with a speedometer, a radar gun

was used to indicate the speed (11 mph)

when the train reached the stop arm. The

stop arm did strike the trip cock, and the

action placed the train in emergency braking

and stopped the train within 55 feet.

The key-by feature of the stop arm was

also tested. As the test M train moved

toward the stop arm at less than 5 mph, the

operator observed the stop arm in the up

position. When the operator passed the IJ

(stop marker) and neared the stop arm, she

saw the stop arm move to the down position,

and the train was then stopped to determine

the operator's visibility of signal D2-532.

The test operator was directly across from

the signal, and she stated that she could not

see the signal aspect from the normal sitting

or standing positions. Signal D2-532 was

observed from the station platform, and it

displayed a red (stop) signal.

Five tests were performed to determine

stopping distances of the test M train. The

operator was sitting during all tests, and a

radar gun was again used to determine the

speed. The test B train was removed from

the collision site, and red flags were placed

to mark the position of the B train rear car.

A yellow flag marked the sight distance

point of 207 feet from the POI.
20

The first, second, and third stopping

distance tests were carried out at 15, 20, and

25 mph, respectively. When the train

reached the yellow flag during all three tests,

the operator applied a full-service automatic

brake application. The train stopped in tests

one, two, and three, respectively, 107.5, 71,

and 10.5 feet short of the POI. During test

four, the operator placed the train at 25 mph

in emergency air braking at the yellow flag,

and the train stopped 2.5 feet beyond the

POI.

The final test was done to verify the

collision speed estimated by the NYCT

brake systems engineering manager, who

considered in his calculations the 100 feet of

intermittent skid marks on the rails and the

10.5 feet of forward movement of the B train

rear car. (See appendix D.) He calculated

that the speed of the train where the skid

marks began and just before impact was

between 21 and 26 mph and between 13 and

17 mph, respectively. Using these

calculations, the operator accelerated the test

train to 25 mph and, allowing for brake

reaction time, placed the train in emergency

braking 40 feet before the skid marks began.

The test train passed the POI at 14 mph

while decelerating and stopped 30.5 feet

beyond the POI.

Other Information

Operating Rules Compliance--Safety Board

investigators questioned the senior director

of operations support and review for the

RTO in April 1995 as to whether the NYCT

is monitoring speeds at the 103rd Street

station, at the fixed 15 mph speed limit sign

north of the Fort Hamilton station, or at any

location on the system. The senior director

responded, “there is no program that we're

going to go out there and actually do speed

checks with radar guns at this time.” He also

said that the NYCT had no formal written

efficiency testing program; however,

unannounced testing was done at the Grand

and Graham Avenue stations on the L line.

He added that tests were conducted at only

these locations. The L line supervisors

observed 291 trains at stop signals between

October 1994 and March 1995. On the 6th

day of testing, a train was seen keying by

and passing a stop signal without

permission, which was the only stop signal

violation reported during the testing period.

Safety Board investigators also

interviewed NYCT managers and line

superintendents in April 1995 about the

NYCT methods used to ensure the operators

are complying with operating rules. The line

superintendents stated that among the

methods followed daily are: documented

critiques in which safety rules and

regulations are discussed with operators and

fitness-for-duty assessments of reporting

crews by crew dispatchers. The NYCT

additionally uses bulletin boards to convey

operation and procedure changes and safety

concerns, and the operators receive 15

minutes to review them at the beginning of

each assignment. All operators also receive a

3-day rules and regulations review course

every 2 to 3 years.

In addition, a train service supervisor

(TSS) observes the on-board performance of

an operator at least once every 6 months and

records the operator’s performance on the

“B-Form” (Operating Employee Evaluation

Check List). (See appendix E.) The TSS

receives classroom directions for completing

the form; however, no written instructions
21

are provided for the TSS. The B-Form uses

the rating system of good, acceptable, or

unacceptable, indicating the level of

competency for the 18 subjects listed that

the TSS believes is warranted for each. Only

the overall operation rating is recorded in the

NYCT computer data base.

The Safety Board has reviewed other

transit agencies’ oversight policies

concerning speed, signal, and operating rule

compliance. The Los Angeles Metropolitan

Transit Authority (California) and the

Massachusetts Bay Transit Authority

(Boston metropolitan area) conduct

unannounced proficiency testing for speed,

signal, and operating rules compliance by

operators. In Ohio, the Greater Cleveland

Regional Transit Authority (GCRTA) has a

written policy that outlines management

oversight for the training and testing of

operators to ensure rules compliance. In a

May 1995 letter, the GCRTA informed the

Safety Board that supervisors are

responsible for the conducting of

and documentation for a prescribed

series of safety tests which are as

follows:

o The daily ride check inspections,

o daily proficiency testing of

operators for compliance to signal

rules (red signal test), and

o speed limit compliance on the

Light Rail will be checked at least

bi-weekly by a Rail Supervisor

using radar.

Rear-End Collisions Involving Keying By

Signals--The August 1995 NYCT publication

Williamsburg Bridge Collision: Interim

Action Plan to Address Safety Issues lists

seven rear-end collisions, injuring 115

passengers and employees, that occurred

between July 1990 and February 1995. The

NYCT reported that six of the seven

collisions were caused by operators keying

by stop signals without permission.

The Safety Board investigated a rear-end

collision in October 1993 between two

NYCT trains at the Graham Avenue station

in Brooklyn.13 Two crewmembers and 64

passengers sustained minor injuries, and

total damages were estimated to exceed

$150,000. A train operator keyed by a stop

signal without permission and collided with

a stopped train. The Safety Board

determined that the probable cause of the

collision was the failure of the operator to

control the speed of his train and to stop in

compliance with a stop signal.

Directives and Bulletins Concerning Keying

By Signals--In the March 1995 interim NYCT

report of this collision to the senior vice

president in the Department of Subways, the

assistant vice president in the Office of

System Safety (OSS) stated, “The signal

system governing the movement of trains

system wide is dependent on operators

complying with standard operating rules.”

The OSS director of field operations also

told Safety Board investigators that the

system

is heavily dependent on operators

adhering to the rulebook when they

see signals and are interpreting

signals and how they operate their

 13Railroad Accident Report--Rear-End Collision of

Two New York City Transit Authority Trains, Graham

Avenue Station, Brooklyn, New York, October 7, 1993

(NTSB/NYC-94-FR-002A/B).
22

 train. ...the system is pretty much

dependent on that blue book over

there [NYCT rule book] for its

operation, and the best you can do

is remind.

One method that the NYCT used to

“remind” operators about keying by red

automatic signals was a series of directives

and bulletins.

The NYCT published Positive

Compliance Directive No. 90-01 (08/01/90)

after a July 1990 rear-end collision in which

a light M train operator keyed past a red

automatic signal and collided with a stopped

B train. This directive stated, “all employees

are re-instructed as to the contents of these

rules [rules 37 (m) and (n)14 concern

stopping for red automatic signals and

subsequently asking for permission to

proceed by at restricted speed].”

Bulletin No. 21:91 (01/25/91) was issued

after a chain-reaction collision involving

three work trains that occurred when a train

operator, without authorization, keyed by a

red automatic signal, was unable to stop, and

collided with a second train, which then

collided with the rear of another train. The

bulletin reminded operators that “they must

stop for a RED Automatic Signal” and after

receiving permission to pass that signal,

“proceed with RESTRICTED SPEED and

EXTREME CAUTION.”

Bulletin No. 39-94 (06/03/94) was

published in response to the NYSPTSB

recommendation that after the October 1993

rear-end collision at Graham Avenue station,

 14Revised rule book, effective March 1993,

renumbered rules 37 (m) and (n) as 40 (m) and (n).

the NYCT issue a safety bulletin concerning

the seriousness of passing red signals,

specifically grade time controlled signals.

The bulletin stated, “Historically, a number

of collisions have been caused by train

operators keying by red automatic signals

improperly and without authorization. In

light of this, train operators are reminded of

Rules 40(m) and 40(n).” The bulletin also

restated the rules for stopping at red

automatic signals and then proceeding at

restricted speed after permission had been

granted as a reminder to operators of their

duties.

The NYCT distributed Bulletin No. 35-

95 (03/22/95) after the February 9 Brooklyn

collision. The bulletin repeated to operators

that “[h]istorically, a number of collisions

have been caused by train operators keying

by red automatic signals improperly and

without authorization” and reiterated the

requirements of rules 40(m) and 40(n).

Automatic Stop Arm Strike Mark Survey--Stop

arm strike marks indicate that the trip cock

of a passing train has struck a raised stop

arm in conjunction with a red (stop) signal.

The strike leaves a discernible mark on the

stop arm; NYCT Policy/Instruction No.

11.006.2 requires the arms to be inspected

every 30 days and repainted, if necessary.

As a result of the Graham Avenue rearend collision, the NYCT surveyed the L line

stop arms for evidence of strike marks,

which was found on:

• 43 stop arms or 17 percent of the 252

inspected signals,
23

• 25 stop arms or 45 percent of the 56 grade

time signals, and

• 18 stop arms or 9 percent of the other 196

automatic signals.

Key-By Feature Deactivation--The NYCT

senior vice president in the Department of

Subways attended the sight-distance tests on

February 11, 1995. While at the collision

site, he directed NYCT employees to

deactivate the automatic key-by feature of

signal D2-532, and the work was completed

by the next morning. A bulletin advising

operators that the automatic key-by feature

had been deactivated was issued on February

14, 1995. (See appendix F.)

In September 1995, Safety Board

investigators queried the RTO about

operations at signal D2-532 for the 7-month

period after the key-by feature had been

deactivated. The RTO responded that:

• The deactivation of the key-by feature on

signal D2-532 has not caused any delays to

service on the B line.

• Only one console dispatcher could recall

an incident in which an operator requested

permission to key by signal D2-532, and in

that instance, the signal cleared before the

request was granted.

• No problems have been encountered since

deactivation of the key-by feature at signal

D2-532.

• Inspections have detected no strike marks

on the stop arm at signal D2-532 as of

September 12, 1995.

• Although no documentation is maintained,

the RTO estimates that on a typical day,

systemwide, about 15 to 24 train operators

call the command center for permission to

proceed past a red signal. Approximately 50

percent of the requests are granted.
24

ANALYSIS

General

The weather at the time of the collision

was clear and sunny and did not adversely

affect train operation. The postaccident

equipment inspection did not indicate any

equipment failure, and the operator reported

no mechanical problems while the M train

was en route. During the pre- and

postaccident inspections, no defects were

found in the track, and the signal system as

well as the stop arm functioned as designed

and modified. The Safety Board therefore

concludes that neither the weather, the train

equipment, nor the track either caused or

contributed to the collision.

A review of the crewmembers' work

records and their postaccident interviews

indicated no evidence of fatigue. All

crewmembers had passed the NYCT

medical examinations and had the necessary

initial training to competently perform their

duties. The toxicological tests for alcohol

and drugs were negative for both operators.

Consequently, the Safety Board concludes

that no crewmember fatigue was indicated,

that crewmembers had the necessary initial

training to competently perform their duties,

and that neither alcohol nor drug use was a

factor in the collision.

Accident

As the M train operator approached

signal D2-541 south of the Fort Hamilton

station, the signal was yellow, instructing

him to proceed and to be prepared to stop at

the next signal at the north end of the

station. However, he knew, as he had

correctly answered NYCT examination

questions on rule 39 and had also correctly

described provisions of that rule to Safety

Board investigators, that as the operator of a

light train, he was not permitted by rule 39

to stop in the station. The operator told

investigators that he could see the next

signal (D2-532) showing red with a white

light illuminated at the bottom as he entered

the station; however, signal D2-532 was not

equipped with a lunar white light. He said

that he thought if he approached the signal at

the allowable speed, it would clear. The

operator likely slowed his train while

entering the station because he presumably

anticipated that signal D2-532 would clear

on time. The operator conceded in

subsequent interviews that signal D2-532 is

not equipped with a lunar white light. The

Safety Board therefore concludes that

because the operator was able to key by

signal D2-532, he had slowed his train

eventually to less than 5 mph and passed the

stop marker.

The difference between GT signals that

are and are not equipped with a lunar white

light may account for the operator

misidentifying signal D2-532. An

illuminated lunar white light indicates that a

GT signal invariably will clear on time if

approached at the allowable speed. A light

train operator can therefore enter a station

with confidence that he will not be stopped

in that station. GT signals not equipped with
25

lunar white lights, however, provide

ambiguous information because the signal

may or may not clear on time, depending on

track occupancy. The NYCT system has 213

one-shot GT signals similar to signal D2-

532 without a lunar aspect. The electrical

systems manager told Safety Board

investigators that although new installations

provide lunar white lights at any signal that

has a one-shot GT control, the NYCT had no

plans to retrofit the 213 existing signals with

lunar white lights. To eliminate any

ambiguous information about whether a

signal will clear on time, the Safety Board

believes that the NYCT should ensure that

each existing one-shot GT signal is equipped

with a lunar white light.

The M train operator told Safety Board

investigators that as his train neared signal

D2-532, he remembered looking at the stop

arm but not the signal and that he saw the

stop arm go down and continued to proceed.

The stop arm being outside of the left rail

opposite signal D2-532 may explain, in part,

the M train operator's assertion that he did

not remember viewing the signal when he

observed the stop arm go down. In the keyby feature test conducted after the collision,

the test M train operator slowly passed the IJ

(stop marker) to key by the signal. When she

observed the stop arm move down, the test

train was stopped, and the operating

compartment was directly across from the

signal. The test operator could not see the

signal aspect from the normal sitting or

standing positions. In addition, the stop arm

and the signal have a 10-foot separation

horizontally and vertically. When the M

train crossed the IJ about 9.75 feet in

approach of the signal, the arm and signal, as

viewed from the operator's position, were

separated visually by a 45o

 angle, which

made it difficult to keep the arm and the

signal both in focus at the same time. The

visual angle increased as the train

approached. Therefore, the Safety Board

concludes that had the M train operator seen

the stop arm go down, as stated, he would

have been unable to readily determine the

signal aspect from the normal standing or

sitting positions of an operator in the control

compartment, even had he looked.

Safety Board investigators next

considered whether the operator's

unauthorized key-by action was deliberate.

The operator had no history of operating

rules violations. He described the provisions

of the operating rules applicable to light

train operation during the investigative

interviews. When he passed signal D2-532

at 2:38 p.m., he was less than 2 minutes

away from the Ninth Avenue station

traveling at the allowable 15-mph speed.

Because the M train he was relaying was not

scheduled to depart the Ninth Avenue

station until 2:46 p.m., he unlikely

considered himself pressed for time. He had

three additional scheduled trips to make that

day and, therefore, likely would not be

rushing to an off-duty activity. Finally, had

he deliberately keyed by, he would have

known that the signal was red and a train

was ahead and would not conceivably have

accelerated the speed of his train as he did.

The Safety Board concludes that the M train

operator keyed by signal D2-532 when he

erroneously assumed the stop arm had gone

down because the signal had cleared.

Whether the operator deliberately or

unintentionally keyed by the signal, the stop

arm design that enabled an operator without

authorization to key by a red (stop) signal

was a significant factor in this collision. The

Safety Board further concludes that had the
26

operator not been able to key by the stop

signal, the collision would have probably not

occurred.

The Safety Board investigation identified

two major safety issues: the effectiveness of

automatic stop arms to ensure compliance

with stop signals and the adequacy of NYCT

oversight to ensure compliance with

operating rules. The analysis will discuss

those issues as well as safety issues relating

to speedometers, radios, positive train

separation, crashworthiness and occupant

survivability, and emergency response.

Effectiveness of Automatic Stop

Arms to Ensure Compliance

with Stop Signals

Because the M train operator was easily

able to key by the stop arm at signal D2-532

and to bypass an important safety device, the

NYCT may be placing undue reliance on the

operation of stop arms as currently

implemented. The 1971 NYCT Standard

Procedures Manual No.7.71.011 describes

the following purpose of stop arms:

The train stop is used to ensure

observance of and compliance with

the stop indication of the signal.

Failure of the motorman to comply

with the rules regarding STOP

signal indications results in

stopping the train. Brake

application on the train is

completely automatic and entirely

independent of any action on the

part of the motorman.

The failure to comply with the rules

regarding stop signal indications, as asserted

in the manual, does not invariably result in

stopping the train, as demonstrated in this

collision. The stop arm can be bypassed as

currently implemented, and it can be done

by an operator who passes the stop marker at

less than 5 mph approaching the signal,

which causes the stop arm to go down while

the signal remains red.

Excluding either an electrical or a

mechanical malfunction, a stop arm is in a

raised position for only two reasons: the

track ahead is occupied by another train; and

at GT signals, the striking train has

approached and passed the signal at

excessive speed. Each strike mark therefore

is evidence that a train has been operated at

risk of collision or derailment. The Safety

Board is concerned, as the NYCT L line

survey found, that 17 percent of the

inspected stop arms had been struck at least

once within the past 30 days, which averages

1.4 strikes a day. Because GT signals

enforce a predetermined speed on

descending grades or at other safety critical

locations, the Safety Board has an even

greater concern that nearly half of GT signal

stop arms had been struck. The percentage

of stop arm strikes (45 percent) at GT

signals was five times greater than the

percentage of strikes (9 percent) at other

automatic signals, indicating a

disproportionately greater frequency of

strikes at GT signals. The disproportion may

be caused by display differences since stop

arms at GT signals and at other automatic

signals, respectively, are normally up until a

train approaches at a predetermined speed

and down unless the track ahead is occupied.

However, the disproportion is more likely

because the operators have acquired, with

experience on the transit system, certain

expectancies and habits. The 88.7-percent
27

on-time train performance reported by the

RTO as of February 1995 indicates that

trains are moving without delay most of the

time, and presumably operators become

accustomed to that flow of traffic. The GT

signals usually clear on time as operators

approach, and trains proceed without delay;

however, the operators' routine expectancies

occasionally are not met, and the signal does

not clear on time because of track

occupancy. The strike arm survey indicates

that on some of those occasions, the

operators do not stop the train before

striking stop arms and passing stop signals,

particularly the safety-critical GT signals.

The NYCT has issued a series of

directives and bulletins since 1990, each

after a rear-end collision, reminding

operators to obtain permission before keying

by signals. Six rear-end collisions between

July 1990 and February 1995 have been

attributed to operators keying by signals

without permission. The continuation of

rear-end collisions demonstrates a lack of

compliance with published operating rules.

Therefore, the Safety Board concludes that

the NYCT directives and bulletins were

inadequately administered to ensure operator

compliance with stop signals to prevent

subsequent collisions.

A few days after the collision, the NYCT

deactivated the automatic key-by feature at

signal D2-532. The NYCT reported that

since the deactivation, no strike marks have

been detected on the stop arm at signal D2-

532 and no delay in service on the B line has

occurred. Therefore, the Safety Board

concludes that the safety of operations at

signal D2-532 has been enhanced by the

deactivation of its automatic key-by feature.

Consequently, the Safety Board believes that

the NYCT should deactivate the automatic

key-by feature at every one-shot GT signal.

Adequacy of NYCT Oversight

to Ensure Compliance

with Operating Rules

The principal duty of the NYCT

management to guarantee the safety of its

3.4 million daily passengers is to ensure

operating crew compliance with the NYCT

published operating rules. The management

oversight procedures, considering this and

past collisions on the NYCT lines, have

been examined. The Safety Board reviewed

the July 26, 1990, NYCT rear-end collision

that involved keying by without permission

and in which the track, signal, and trains

were the same as addressed in this report.

One employee and 37 passengers were

injured, and equipment damage was

estimated at $63,735. The RTO was

informed by memorandum after the NYCT

investigation that the collision was caused

“by the failure of the operator, operating the

M train, to adhere to the operating rules

relative to passing red signals, and failing to

pay proper attention to the operation of the

train” and was issued a safety

recommendation by the OSS to “instruct

local supervisors to increase their

observation of operator's performance in

their areas of responsibility as a deterrent to

improper train operation.” In addition, the

Safety Board is investigating the June 5,

1995, NYCT collision on the Williamsburg

Bridge in New York City, New York, which

will further detail operational oversight.

According to the M train operator, he

could not remember the aspect of signal D2-

532 when he passed it without stopping.
28

Signal D2-532 will display a red (stop)

signal when a train is ahead in the block.

The signal worked properly during the

stopping distance tests conducted with the

test train after the collision, which indicated

that signal D2-532 was working as designed.

The Safety Board, therefore, concludes that

the M train operator failed to comply with

published operating rules that require

stopping at a red signal and requesting and

obtaining RTO permission to proceed.

The M train was not equipped with a

speedometer; however, its operator was

required to comply with different speed

restrictions. The south end to the north end

of Fort Hamilton station and the curve

before the collision site were restricted to 20

and 15 mph, respectively. When asked how

he determined the train speed, the operator

replied that he used the controller positions

to estimate the speeds. The RTO operations

support and review senior director affirmed

that without a speedometer, an operator is

“guesstimating” his speed and relying on

experience.

Three postcollision stopping distance

tests, using a full-service brake application

at speeds of 15, 20, and 25 mph, resulted in

the train stopping short of the POI. In two

other stopping distance tests, the test

operator placed the train at 25 mph in

emergency braking, and the test M train

passed the POI. The Safety Board concludes

that based on these stopping distance tests

and the 10-foot forward movement of the B

train after impact, the operator had

accelerated the M train to at least 25 mph

before he placed the train in emergency

braking. Had the train been traveling at the

posted 15-mph speed restriction, the

collision might not have occurred.

The Safety Board investigated a rear-end

collision on March 10, 1989, between two

NYCT trains at the 103rd Street station15 in

which 3 crewmembers and 38 passengers

were injured. The estimated damage was

$360,000. After its investigation, the Safety

Board determined that contributing to the

severity of the accident was the operation of

train 428 into the 103rd Street station at a

speed in excess of the posted speed, in part,

as a result of the failure of the NYCT

management to furnish a reasonable means

for operators to determine speed. The Safety

Board issued Safety Recommendation R-90-

2 urging the NYCT to provide speed

indicators on each car in service on the

system to allow operators the ability to

properly determine speed. The NYCT

responded in April 1991 that a speed

indicator test program was being conducted

and that it would retrofit the R-44 fleet (280

cars) beginning in 1992. Additional car

classes would be retrofitted following a 1-

year evaluation of the R-44 fleet. In May

1993, the NYCT announced that the

installation of speedometers on the car fleet

was in its proposed budget between 1992

and 1998. The Safety Board classified Safety

Recommendation R-90-2 “Open--

Acceptable Response” in August 1993.

The NYCT assistant chief mechanical

officer in April 1995 advised the Safety

Board that all new cars will be equipped

with speedometers and that the NYCT is

retrofitting its entire fleet of cars, except the

1,400 oldest, with speedometers. The older

cars will be removed from service when new

 15Railroad Accident Report--Rear-End Collision of

Two New York City Transit Authority Trains, 103rd

Street Station, New York, New York, March 10, 1989

(NTSB/RAR-90/01).
29

cars begin arriving in 2000. The remaining

4,379 cars are scheduled for retrofit

completion in 1996; however, 2,246 cars

have been retrofitted as of January 14, 1996.

The Safety Board recognizes the efforts of

the NYCT and will monitor the progress of

this project to enhance the safety of the

NYCT system.

Also after the March 10, 1989, rear-end

collision at the 103rd Street station, the

Safety Board asked the NYCT in Safety

Recommendation R-90-4 to conduct random

testing, using radar guns, of train speed, with

special emphasis given to those locations

where speed restrictions are in effect. The

NYCT responded that “operators are

regularly monitored for their adherence to

posted speed limits; we will, manpower

permitting, intensify our efforts to ensure

that speed restrictions are strictly obeyed.”

The Safety Board classified Safety

Recommendation R-90-4 “Closed--

Acceptable Action” in December 1990.

In the April 1995 interviews with NYCT

line superintendents, only the superintendent

of the L line stated that he conducted

unannounced testing. The NYCT also has no

oversight compliance program that includes

either speed checks with radar guns or

formal written efficiency testing. NYCT

operators are passing stop signals without

permission and not adhering to the speed

restrictions. The NYCT has no

unannounced, oral or written, operating rule

compliance testing program. Therefore, the

Safety Board concludes that the NYCT lacks

an adequate oversight testing program to

ensure operator compliance with critical

speed and signal operating rules. An NYCT

operational testing program that includes

frequent unannounced speed and signal tests

as well as radio communication procedure

testing to monitor operator performance

would not only detect violations but also

instruct operators.

The NYCT TSSs use the B-Form check

list to document operator performance. The

NYCT provides no written standardized

instruction to them for either filling out or

grading the 18 items found on the form,

which allows possible subjective

performance evaluations. An overall rating

is filed on the computer data base and may

not adequately reflect the operator's

compliance with critical speed and signal

rules. The Safety Board believes that the

NYCT should revise the Operating

Employee Evaluation Check List to

effectively determine compliance with

operating rules and instructions and include,

at a minimum, unannounced speed and

signal tests and radio communication

procedures. The NYCT should also provide

standardized written instructions for

administering and grading the evaluation

check list.

Radio Procedures

Rule 20 (b) of the Rules and Regulations

Governing Employees Engaged in the

Operation of the New York City Transit

System requires that each train must be

equipped with an operable train-to-wayside

radio. Additionally, NYCT rule 40 (m)

requires operators to obtain radio permission

to key by and pass a stop signal. However,

the M train in the collision was not outfitted

with a permanent radio. The M train

operator stated during a Safety Board

interview that he neither had been issued nor

possessed a radio at the time of the collision.
30

He, consequently, could not request

permission to key by and pass a stop signal

as required by the NYCT rules. The NYCT

lacked any documentation that would

confirm it had provided a radio to the M

train operator. Therefore, the Safety Board

concludes that the NYCT failed to have

procedures for radio accountability at the

Ninth Avenue station to document

compliance with rule 20 (b) of its published

operating rules to ensure the M train

operator was provided with a radio during

his tour of duty.

Since the collision, according to the

senior director of Operations Support and

Review for the RTO, the relay operator now

uses the radio of the train operator who

controls the train to the Ninth Avenue

station. After the train is relayed, he returns

the radio to the train operator who provided

it.

Positive Train Separation

The Safety Board has long been an

advocate of train control systems that

provide positive train separation (PTS) and

has included PTS on its list of “Most

Wanted Transportation Safety

Improvements.” The PTS system provides

an automatic means of backing up the

actions of the train operator by monitoring

the performance of operator and train when

approaching the limits of a signal or speed

restriction. Should the operator or the train

fail to apply the proper brake action, the PTS

system will assume control, automatically

apply the brakes, and stop the train. The

newer transit agencies in San Francisco,

California; Atlanta, Georgia; and

Washington, DC, use PTS systems to

control train speed and separation.

The NYCT relies on the stop arm to

prevent collisions as well as on the

operator's understanding of and compliance

with operating rules. The collision just south

of the Ninth Avenue station demonstrates

the limitations of this NYCT control system.

The Safety Board concludes that the track

section on which the collision occurred

lacked a true PTS system because the

automatic stop arm did not prevent the M

train from passing signal D2-532. Therefore,

the Safety Board believes that the NYCT

should include overspeed protection and

PTS in the modernization of its signal

system.

Crashworthiness and

Occupant Survivability

Municipal subway systems are not

subject to the Federal Railroad

Administration (FRA), and the subway cars

are constructed according to municipalityprepared specifications. Consequently, the

car construction is not obliged to comply

with FRA crashworthiness design

requirements at 49 CFR 229.141, which

address the minimum performance standards

of structural components, such as collision

posts, anticlimbers, and truck securements.

The NYCT now follows a design philosophy

in which equipment crashworthiness is

considered. Its R-68 type car procurement

specification stipulates that carbodies be

constructed to include engineered primary

and secondary collision posts, progressive

crush resistance, carbody stress analysis, and

truck securing devices. Incorporation of

these design features places the NYCT in
31

voluntary compliance with the current FRA

crashworthiness design requirements.

However, the economics of construction and

operation in the late 1950s resulted in a

lightweight stainless steel carbody design of

which the R-40 and R-42 type cars were

typical. The refurbishment by Sumitomo

Corporation of America included the

running gear, the air conditioning, and

carbody cosmetics but not a retrofit of

crashworthiness structural features.

The R-40 and R-42 cars did provide

reasonable protection to the occupants in

this collision. A postrecovery analysis of the

damage indicated that the end and corner

posts of both type cars, being secured to the

floor and roof structure, successfully

minimized carbody telescoping as the posts

pulled the roof and floor structures together

in an inward folding action. Given the

estimated collision speed and the amount of

telescoping damage observed, the

effectiveness of the carbody-end structure

post is not unreasonable. The anticlimber

effectiveness may have been exceeded

because the collision occurred on curved

track and the forces of impact may have

caused one of the cars to lift. An impact

occurring at such an angle may result in one

car end being slightly elevated above the

other corresponding car end. Because of the

curved track, the impact was off center and

biased to the side opposite the operator

control compartment. Such a bias, in which

collision forces are partially directed in a

lateral direction, causes the cars to pivot and

skew at the coupler connections. This lateral

component of force dissipated the kinetic

energy of the collision in a transverse

direction. Collision forces on tangent track

are substantially linear and normally

absorbed into the carbody-end structures,

which results in compressive collapse and

crush zone intrusion.

The B train held 153 occupants, of whom

only 14 people sustained minor injuries, and

none of the occupants were in the intrusion

“crush zone.” The injuries described by

emergency responders are consistent with

those typically sustained when standing

occupants are thrown to the floor and seated

occupants are pitched rearward against hard

obstacles during a low-speed, nonintrusion,

rear-impact collision. The M train was not

occupied except for the operator, who was in

the control compartment and sustained only

minor injuries. Given the amount of

collision crush that was observed, the

operator apparently benefited by being

positioned within a small “survival space”

cavity that was created during the collapse of

the carbody-end structure.

Emergency Response

The collision was reported, the FDNY

units were dispatched, these first units

arrived on scene, and the train was

evacuated at 2:39, 2:41, 2:45, and 3:15 p.m.,

respectively. Five emergency response

agencies, municipal and private, responded

with equipment and manpower to the

collision site. The 15 reported injuries were

minor. The Safety Board concludes that the

local emergency response personnel reacted

promptly to and acted effectively at the

collision site.
32

CONCLUSIONS

1. Neither the weather, the train equipment,

nor the track either caused or contributed

to the collision. No crewmember fatigue

was indicated, crewmembers had the

necessary initial training to competently

perform their duties, and neither alcohol

nor drug use was a factor in the collision.

2. Because the operator was able to key by

signal D2-532, he had slowed his train

eventually to less than 5 mph and passed

the stop marker.

3. Had the M train operator seen the stop

arm go down, as stated, he would have

been unable to readily determine the

signal aspect from the normal standing

or sitting positions of an operator in the

control compartment, even had he

looked.

4. The M train operator keyed by signal

D2-532 when he erroneously assumed

the stop arm had gone down because the

signal had cleared.

5. Had the operator not been able to key by

the stop signal, the collision would have

probably not occurred.

6. The Metropolitan Transportation

Authority/New York City Transit

directives and bulletins were

inadequately administered to ensure

operator compliance with stop signals to

prevent subsequent collisions.

7. The safety of operations at signal D2-

532 has been enhanced by the

deactivation of its automatic key-by

feature.

8. The M train operator failed to comply

with published operating rules that

require stopping at a red signal and

requesting and obtaining Rapid Transit

Operations permission to proceed.

9. Based on the postcollision stopping

distance tests and the 10-foot forward

movement of the B train after impact,

the operator had accelerated the M train

to at least 25 mph before he placed the

train in emergency braking. Had the train

been traveling at the posted 15-mph

speed restriction, the collision might not

have occurred.

10. The Metropolitan Transportation

Authority/New York City Transit lacks

an adequate oversight testing program to

ensure operator compliance with critical

speed and signal operating rules.

11. The Metropolitan Transportation

Authority/New York City Transit failed

to have procedures for radio

accountability at the Ninth Avenue

station to document compliance with

rule 20 (b) of its published operating

rules to ensure the M train operator was

provided with a radio during his tour of

duty.
33

12. The track section on which the collision

occurred lacked a true positive train

separation system because the automatic

stop arm did not prevent the M train

from passing signal D2-532.

13. The local emergency response personnel

reacted promptly to and acted effectively

at the collision site.

PROBABLE CAUSE

The National Transportation Safety

Board determines that the probable cause of

the rear-end collision between the two

subway trains was the inadequate oversight

and compliance program of the Metropolitan

Transportation Authority/New York City

Transit to ensure that train operators comply

with the published operating rules.

Contributing to the collision was the design

modification to the automatic key-by feature

of the automatic stop arm that enabled the

operator of the M train to pass a stop signal

contrary to the published operating rules that

require stopping at a red signal unless

permission to pass is granted by Rapid

Transit Operations.

RECOMMENDATIONS

As a result of its investigation, the

National Transportation Safety Board makes

the following recommendations:

--to the Metropolitan Transportation

Authority/New York City Transit:

Ensure that each existing one-shot

grade time signal is equipped with

a lunar white light. (Class II,

Priority Action)(R-96-8)

Deactivate the automatic key-by

feature at every one-shot grade time

signal. (Class II, Priority

Action)(R-96-9)

Revise the Operating Employee

Evaluation Check List to

effectively determine compliance

with operating rules and

instructions and include, at a

minimum, unannounced speed and

signal tests and radio

communication procedures.

Provide standardized written

instructions for administering and

grading the evaluation check list.

(Class II, Priority Action)(R-96-10)

Include overspeed protection and

positive train separation in the

modernization of the signal system.

(Class II, Priority Action)(R-96-11)
34

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR

Member

March 19, 1996
35

APPENDIXES

APPENDIX A

INVESTIGATION AND HEARING

The National Transportation Safety Board was notified at 3 p.m. on February 9, 1995, of

a rear-end collision between two New York City Transit subway trains in Brooklyn, New York.

The investigator-in-charge and other members of the Safety Board investigative team were

dispatched from the headquarters in Washington, D. C., and the regional offices in Chicago,

Illinois, and Los Angeles, California. Investigative groups studied operations, track, signals,

mechanical, survival factors, and human performance.

The Office of the Inspector General (MTA), New York State Public Transportation Safety

Board, New York City Transit, New York City Transit Police, New York City Fire Department,

New York City Police Department, and New York City Emergency Medical Service assisted in

the Safety Board investigation.

Safety Board staff conducted a deposition hearing as part of its investigation on April 4,

1995, at which 10 witnesses testified.

37

APPENDIX B

B TRAIN PERSONNEL INFORMATION

The train operator was employed as a cleaner by the NYCT on March 11, 1985. He was

promoted to train operator on September 6, 1987. His regular assignment was on the B line

working the 1405 to 2200 tour of duty. After being off on February 4 and 5, 1995, he worked his

regular tour on the subsequent days leading up to the collision.

The operator passed his last periodic medical examination on June 14, 1993. During the

year preceding the collision, he received six operating employee evaluations: the check list items

were rated "good" or "acceptable" on a rating scale of good, acceptable, unacceptable. He had no

records in the Rapid Transit Operations "Disciplinary Action History" data base.

The train conductor was employed as a cleaner by the NYCT on December 30, 1987. He

began working as a conductor in subdivision B on July 5, 1988. He worked the 1405 to 2200 tour

on the B line as his regular assignment. He was out sick on February 5 and 6, 1995, and then

resumed his regular tour of duty up to the collision.

The conductor had his last periodic medical examination on November 15, 1994, and was

assessed fit for full work. He received three operating employee evaluations during the year

preceding the collision. His most recent evaluation on January 15, 1995, rated him "good" on all

check list items. The conductor's personnel file contained eight disciplinary action cases, which

were for administrative violations (undocumented emergency absence, AWOL, and late

submission of sick forms).

39

APPENDIX C

NYCT RULES APPLICABLE TO REPORT

Rule 20

(b) Each train must be equipped with an operable Train-to-Wayside Radio. Train

Crews must test their radios, prior to leaving a terminal or yard for operation on

the mainline, by transmitting their call sign to the Train Dispatcher or Yard

Dispatcher; the reception of his/her response will indicate that the radio

equipment is functioning properly. Any train having a defective radio and/or radio

bracket must have that equipment exchanged; the train crew must have an

operable radio before proceeding on an over the road movement.

Rule 39

(b) A Train Operator is prohibited from passing a STOP SIGN OR STOP SIGNAL or

going over a switch that is set the wrong way.

(i) The train will enter the stations being bypassed at the normal speed for the area;

the Train Operator will then begin to decelerate gradually, ensuring that the train

does not go faster than fifteen (15) miles per hour as it leaves the station. The

Train Operator must blow the horn or whistle at the entering and leaving end of

the station.

Unless ordered by the Command Center or an RTO Supervisor, Train Operators

operating LIGHT trains must not enter stations, unless they can get their whole

train beyond the station platform without making a stop. On stations that have

grade time signals, either within the station, or at the leaving end, the Train

Operator must regulate the speed of his or her train so that the signals will clear

without the train coming to a stop. In no event must speed exceed 15 miles per

hour.

The only exception for LIGHT trains shall be in those stations that require the

Train Operator to punch in to indicate the requested route or train identification

and where this can not be done prior to entering the station.
40

APPENDIX C

Rule 40

NOTE: effective with NYCTA RTO Bulletin No. 17:93 Red Automatic Signals

dated March 4, 1993, the last paragraph of rule 40(m) is changed and reads as

follows.

(m) A Train Operator must STOP for a RED AUTOMATIC SIGNAL.

He/she must stop fifteen (15) feet short of the signal, or at the yellow joint marker

plate on the contact rail protection board. He/she must NOT MOVE until the light

turns to YELLOW or GREEN, UNLESS:

1. The signal has an "AK" sign; or

2. The signal is on a storage track or in a yard; or

3. An employee whom the Train Operator KNOWS is an authorized RTO 

or Electrical (Signal) employee gives a signal to go ahead which the 

Train Operator KNOWS is meant for him/her; or

4. The Train Operator calls the Command Center Desk Superintendent by 

radio and is told to proceed with RESTRICTED SPEED AND 

EXTREME CAUTION.

The Train Operator must call the Command Center Desk Superintendent

immediately via radio. If Command Center does not acknowledge the

transmission and there is no train visible ahead, he/she must wait two (2) minutes

before using the wayside telephone. If after ten (10) minutes and there is a train

visible ahead and Command Center still has not acknowledged the radio

transmission, the Train Operator must then use the nearest wayside telephone.

(n) When he/she is permitted to move past a RED Automatic Signal, the Train

Operator must pull up to the signal, Stop and make sure that the Automatic Stop

Arm goes down. If the signal has a "K" sign, the Train Operator must use the

Automatic Stop Arm Manual Release lever, button or special key to make the

Automatic Stop Arm go down. The Train Operator must then proceed with

RESTRICTED SPEED AND EXTREME CAUTION to the next signal.
41

 APPENDIX C

Rule 59

Signal colors have the following meanings:

(a) RED STOP.

(b) YELLOW (including PROCEED WITH CAUTION, BE

flashing lights) PREPARED TO STOP.

(c) GREEN PROCEED.

(d) BLUE Indicates the location of an Emergency 

Alarm Box, Emergency Telephone and Fire 

Extinguisher, or an Emergency Telephone

only.

(e) LUNAR WHITE Indicates that the fixed signal on which it is 

displayed may be cleared by a train

operating at a predetermined speed. Also

used for train orders. Two horizontal white

lights means no orders to be received.

Rule 66

(a) TIME-CONTROLLED SIGNAL

A fixed signal having a time element in its control which requires the passage of

time for a change in aspect.

(b) GRADE TIME CONTROL OF SIGNALS

Is intended to cause a train to run through grade time territory at a predetermined

speed. Trains exceeding such speed are automatically stopped.

(d) TIME CONTROL "T" SIGN

A fixed signal bearing the letter "T" located at the point of entrance to timecontrolled territory.
42

APPENDIX C

(e) GRADE TIME "GT" SIGNAL

A fixed signal used to enforce a predetermined speed on descending grades or at

other locations; this signal is always preceded by a Time Control "T" Sign and a

sign designating the allowable speed in miles per hour or by a "GT" Sign.

(h) LUNAR WHITE SIGNAL

A fixed signal bearing a lunar white aspect which when illuminated together with

a STOP indication, indicates that the signal may be cleared by a train approaching

said signal at a predetermined speed.

Rule 68

(a) AUTOMATIC STOP

A device used in conjunction with a fixed signal to cause an emergency

application of the air brakes of a train passing that signal when it indicates STOP.

Some Automatic Stops are operated as "BLIND" stops without any signal being

opposite. In this case the Automatic Stop is cleared by the train passing at a

predetermined speed. (Used on both Subdivisions A and B; Williamsburg Bridge,

reverse running.)

(b) AUTOMATIC STOP ARM

The part of an Automatic Stop which engages a device on a car to apply the train

air brakes in emergency. It is located outside the running rails.

Rule 70

(b) SPEED LIMIT SIGN

A fixed signal located at the entrance to a section of track on which trains are

required to run at a reduced speed; it indicates the maximum speed at which trains

may be operated on said section of track. (PROCEED AT SPEED INDICATED

"10" DENOTES MILES PER HOUR.)
MEMORANDUM AND SPEED CALCULATIONS

FROM NYCT BRAKE SYSTEMS ENGINEERING MANAGER

@New York City Transit Authority

Metropolitin Transportation Authority

Memorandum

Date: February 16, 1995

To: Keith Falk, Director Car Systems Engineering

From: George Feinstein, Manager Brake Systems Engineering m’

Re: COLLISION OF FEBRUARY 9, 1995 N/O 9TH AVE. (BMT)

Following the subject collision I was requested to inspect the accident site and

determine the speed of the moving train at the instant of impact based on the physical

evidence

A light, moving eight car R42 train (M service) with brakes applied collided with a

stationary ten car R4C train (B service) with brakes applied. The R40 train had an

unknown number of passengers.

Skid marks indicated that the last car (4259) of the R40 train was moved forward

10.5 ft. The first car (4351) of the R40 train was moved 1.5 ft. The cars in between

were moved various distances between 1.5 and 10.5 ft. There were approximately

100 ft. of intermittent skid marks on the running rails behind the last car (4914) of the

R42 train.

There was extensive damage to the two cars (4259 & 4918) directly involved in the

collision. The two cars telescoped into each other approximately 5.5 ft. Heavy

damage, including broken drawbass and cars leaving the center castings of the truck,

was observed on several cars in each of the trains.

Considering the motion of the individual cars, and the damage to the various cars it

was taken that the total energy absorbed by the two trains after the collision is

represented by an average motion of the two trains of 10.5 ft. after the collision.

Based on the above considerations, the calculated speed of the R42 train just before

the collision was 13 to 17 mph. The calculated speed of the train at the start of the

skid marks was 21 to 26 mph. See attached sheets for the calculations.

Attachment

43


46
APPENDIX E

NYCT B FORM

EMPLOYEE EVALUATION CHECK LIST

OPERATING EMPLOYEE EVALUATION CHECK LIST

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

47

APPENDIX F

NYCT BULLETIN NO. 15-95

DEACTIVATION OF KEY-BY FEATURE - SIGNAL D2-532

BULLETIN

BULLETIN NO.: 15-9 5

TO: ALL EMPLOYEES February 14, 1995

SUBJECT: : DEACTIVATION OF KEY-BYFEATURE - SIGNAL D2-532

An subdivision "B" Train Operators are advised that effective Sunday, February 12, 1995, you

arc no longer able to key-by Automatic Signal D2-532, located at the north end of the

northbound platform (Track D-2) at the Fort Hamilton Parkway Station, in the manner

prescribed in Rule 40(n). The automatic key-by feature associated with Automatic Signal D2-

532 has been deactivated. Should it be necessary for a train Operator to move past this signal

when it is at danger (RED), they MUST proceed as follows:

o The Train Operator will call the Command Center via wayside radio or telephone and

ask for permission to proceed past the red signal according to Rule 40(n).

o When given permission by the Command Center to proceed past the red automatic signal,

the Train Operator must pull up to the signal and stop. Any further movement will

result in an emergency application of the air brakes

o After stopping, the train Operator must descend to the roadbed and step on the stop arm

and make sure that it retains

NOTE: If the stop arm does not retain Use Train Operator must inform the

Command Center immediately and be governed by their

instructions.

o Having done this, the train operator will board the train and proceed with

RESTRICTED SPEED AND EXTREME CAUTION to the next signal.

Line Managers and Train Service Supervisors will ensure that all train Operators are aware of

and strictly comply with this directive.

Chief Transportation Officer

Rapid Transit Operations

BULLETIN NO.: 15-95

49