/

PB97-916302

NTSB/RAR-97/02

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, DC 20594

RAILROAD ACCIDENT REPORT

COLLISION AND DERAILMENT

OF MARYLAND RAIL COMMUTER MARC TRAIN 286 AND

NATIONAL RAILROAD PASSENGER CORPORATION

AMTRAK TRAIN 29

NEAR SILVER SPRING, MARYLAND

ON FEBRUARY 16,1996

6664C

\ U.S. GOVERNMENT PRINTING OFFICE: 1989 0-942-865
Abstract: On February 16, 1996, Maryland Rail Commuter (MARC) train 286 collided with National Railroad

Passenger Corporation (Amtrak) passenger train 29 near Silver Spring, Maryland. All 3 CSXT operating

crewmembers and 8 of the 20 passengers on MARC train 286 were killed in the derailment and subsequent fire.

Eleven passengers on MARC train 286 and 15 of the 182 crewmembers and passengers on Amtrak train 29 were

injured.

The major safety issues discussed in this report are the performance and responsibility of the MARC train

286 crewmembers, the oversight of CSXT signal system modifications, the Federal oversight of commuter rail

operations, the lack of positive train separation control systems, and the adequacy of passenger car safety

standards and emergency preparedness. In addition, the Safety Board examined the use of the reverser during

an emergency brake application, the effectiveness of the computer-aided train dispatching recordkeeping, the

crashworthiness of locomotive fuel tanks, and the contents of the CSXT and MARC operating agreement.

As a result of its investigation, the Safety Board issued recommendations to the FRA, the FTA, the CSXT,

the MTA/MARC, the U.S. Department of Transportation, the Federal Emergency Management Agency, the

Governor and the General Assembly of Maryland, the Association of American Railroads, the Montgomery

County Emergency Management Agency, the Baltimore County Emergency Management Agency, the

Baltimore City Emergency Management Agency, the Metropolitan Washington Council of Governments, the

Jefferson County Commissioners, the Berkeley County Commissioners, the American Short Line Railroad

Association, the Brotherhood of Locomotive Engineers, the United Transportation Union, the International

Brotherhood of Teamsters, and the American Public Transit Association. In addition, the Safety Board

reiterated safety recommendations to the FRA, the General Electric Company, and the Electro-Motive Division

of General Motors.

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) 314-6551

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) 605-6000
COLLISION AND DERAILMENT

OF MARYLAND RAIL COMMUTER

MARC TRAIN 286

AND NATIONAL RAILROAD PASSENGER CORPORATION

AMTRAK TRAIN 29

NEAR SILVER SPRING, MARYLAND

FEBRUARY 16, 1996

RAILROAD ACCIDENT REPORT

Adopted: July 3, 1997

Notation 6664C

NATIONAL

TRANSPORTATION

SAFETY BOARD

Washington, DC 20594

iii

CONTENTS

EXECUTIVE SUMMARY.........................................................................................................vii

INVESTIGATION

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

Injuries..........................................................................................................................................................7

Damages........................................................................................................................................................7

Track and Signals ...................................................................................................................................8

MARC Train 286....................................................................................................................................8

Amtrak Train 29 .....................................................................................................................................8

MARC Train 286 Crew Information.............................................................................................................8

Engineer..................................................................................................................................................8

Conductor ...............................................................................................................................................9

Assistant Conductor..............................................................................................................................10

Amtrak Train 29 Crew Information ............................................................................................................11

Engineer................................................................................................................................................11

Assistant Engineer ................................................................................................................................11

Train Information........................................................................................................................................12

MARC Train 286..................................................................................................................................12

Amtrak Train 29 ...................................................................................................................................14

Postcollision Train Information ..................................................................................................................14

MARC Train 286..................................................................................................................................14

Amtrak Train 29 ...................................................................................................................................17

Track and Signal Information .....................................................................................................................17

Tracks ...................................................................................................................................................17

Signals ..................................................................................................................................................20

Operations Information ...............................................................................................................................22

CSXT Train Operations........................................................................................................................22

Operational Efficiency Testing.............................................................................................................24

MARC Train Radio Communication....................................................................................................24

MARC Train 286 Passenger Load Data...............................................................................................25

CSXT and MARC Operating Agreement.............................................................................................25

Meteorological Information ........................................................................................................................26

Medical and Pathological Information........................................................................................................26

MARC Train 286..................................................................................................................................26

Amtrak Train 29 ...................................................................................................................................26

Toxicological Information ..........................................................................................................................28

Emergency Response ..................................................................................................................................28

Montgomery County Fire and Rescue Services ...................................................................................28

Montgomery County Disaster Plan ......................................................................................................29

Amtrak, MARC, and CSXT .................................................................................................................29

Survival Aspects..........................................................................................................................................30

MARC Train 286 Occupant Evacuation ..............................................................................................30

Firefighter Evacuation Action ..............................................................................................................32
iv

Tests and Research......................................................................................................................................32

Locomotive Event Recorders ...............................................................................................................32

MARC Train 286 and Amtrak Train 29 Movement.............................................................................32

Sight Distance.......................................................................................................................................33

Signals ..................................................................................................................................................34

Stopping Distance.................................................................................................................................34

Passenger Train Air Brakes ..................................................................................................................35

Cab Control Car 7752 Doors................................................................................................................35

MARC Passenger Coach Car Interior Materials ..................................................................................35

Fuel Oil Presence..................................................................................................................................36

Postaccident Actions...................................................................................................................................36

National Transportation Safety Board..................................................................................................36

Federal Railroad Administration ..........................................................................................................37

Maryland Mass Transit Administration and Maryland Rail Commuter ..............................................38

CSX Transportation Inc........................................................................................................................38

National Railroad Passenger Corporation ............................................................................................39

Cooperative Organization Activities ....................................................................................................39

Other Information........................................................................................................................................39

Maryland Mass Transit Administration................................................................................................39

MARC Train Accidents........................................................................................................................40

Maryland Department of Labor and Industry.......................................................................................40

Brunswick Line Signal Modifications..................................................................................................41

Federal-Grant-Requested Signal Project ..............................................................................................41

CSXT Signal System Modification Design..........................................................................................43

CSXT Traincrew Roster Consolidation ...............................................................................................44

Locomotive Fuel Tanks ........................................................................................................................45

Cellular Service Communication..........................................................................................................45

ANALYSIS

General Factors ...........................................................................................................................................46

Accident Narrative Review.........................................................................................................................46

MARC Train 286 Engineer Performance ...................................................................................................47

MARC Train 286 Crewmember Responsibility .........................................................................................49

Traincrew Voice Recording........................................................................................................................51

CSXT Signal System Modification Oversight............................................................................................52

Federal Commuter Rail Operations Oversight............................................................................................54

Positive Train Separation Control Systems ................................................................................................55

Passenger Car Safety Standards..................................................................................................................58

Emergency Lighting .............................................................................................................................61

Emergency Windows............................................................................................................................62

Exterior Emergency Door Release .......................................................................................................62

Interior Materials ..................................................................................................................................63

Cab Control Car Structural Crashworthiness .......................................................................................64

Emergency Preparedness.............................................................................................................................66

Reverser Use during Emergency Braking...................................................................................................69

Computer-Aided Recordkeeping.................................................................................................................70

Locomotive Fuel Tank Crashworthiness ....................................................................................................70

CSXT and MARC Operating Agreement ...................................................................................................72
v

FINDINGS................................................................................................................................................73

Conclusions.................................................................................................................................................73

Probable Cause............................................................................................................................................75

RECOMMENDATIONS.............................................................................................................75

APPENDIXES

Appendix A--Investigation and Hearing .....................................................................................................81

Appendix B--Chronology of Signal Sequence............................................................................................83

Appendix C--Chronology of Accident........................................................................................................87

Appendix D--Excerpts from CSXT Operating Rules .................................................................................89

Appendix E--Organization Charts of CSXT and MDOT/MTA/MARC.....................................................97

Appendix F--Signal Incidents, Complaints, and False Proceed Indications.............................................103

Appendix G--Fire Testing Results of MARC Car Interior Materials .......................................................105

Appendix H--Issuance of Urgent Safety Recommendations.....................................................................109

Appendix I-- Federal Railroad Administration Emergency Order No. 20................................................115

Appendix J--MARC Train Service Schedule for Brunswick and Camden Lines.....................................135

Appendix K--FRA Correspondence on Regulatory Authority of Commuter Railroad Operations..........137

Appendix L--National Transportation Safety Board and Positive Train Control Systems.......................143

Appendix M--Acronyms and Abbreviations.............................................................................................145

vii

EXECUTIVE SUMMARY

About 5:39 p.m. on February 16, 1996,

Maryland Rail Commuter (MARC) train 286

collided with National Railroad Passenger

Corporation (Amtrak) passenger train 29 near

Silver Spring, Maryland. En route from

Brunswick, Maryland, to Union Station in

Washington, DC, MARC train 286 was

traveling under CSX Transportation Inc.

(CSXT) operation and control on CSXT tracks.

MARC train 286 passed an APPROACH signal

before making a station stop at Kensington,

Maryland; proceeded as if the signal had been

CLEAR; and, then, could not stop for the STOP

signal at Georgetown Junction, where it

collided with Amtrak train 29. All 3 CSXT

operating crewmembers and 8 of the 20

passengers on MARC train 286 were killed in

the derailment and subsequent fire. Eleven

passengers on MARC train 286 and 15 of the

182 crewmembers and passengers on Amtrak

train 29 were injured. Estimated damages

exceeded $7.5 million.

The National Transportation Safety Board

determines that the probable cause of this accident was the apparent failure of the engineer

and the traincrew because of multiple distractions to operate MARC train 286 according to

signal indications and the failure of the Federal

Railroad Administration (FRA), the Federal

Transit Administration (FTA), the Maryland

Mass Transit Administration (MTA), and the

CSXT to ensure that a comprehensive human

factors analysis for the Brunswick Line signal

modifications was conducted to identify potential sources of human error and to provide a

redundant safety system that could compensate

for human error.

Contributing to the accident was the lack

of comprehensive safety oversight on the

CSXT/MARC system to ensure the safety of

the commuting public. Contributing to the severity of the accident and the loss of life was

the lack of appropriate regulations to ensure

adequate emergency egress features on the

railroad passenger cars.

The major safety issues discussed in this report are the performance and responsibility of

the MARC train 286 crewmembers, the oversight of CSXT signal system modifications,

the Federal oversight of commuter rail operations, the lack of positive train separation control systems, and the adequacy of passenger

car safety standards and emergency preparedness. In addition, the Safety Board examined

the use of the reverser during an emergency

brake application, the effectiveness of the

computer-aided train dispatching recordkeeping, the crashworthiness of locomotive fuel

tanks, and the contents of the CSXT and

MARC operating agreement.

On March 12 

 

Emergency Management Agency, the

Metropolitan Washington Council of

Governments, the Jefferson County

Commissioners, the Berkeley County

Commissioners, the American Short Line

Railroad Association, the Brotherhood of

Locomotive Engineers, the United

Transportation Union, the International

Brotherhood of Teamsters, and the American

Public Transit Association. In addition, the

Safety Board reiterates safety

recommendations to the FRA, the General

Electric Company, and the Electro-Motive

Division of General Motors.

INVESTIGATION

Accident Narrative

On Friday, February 16, 1996, at 5:39 p.m.,

an eastbound Maryland Rail Commuter

(MARC) train 286, operated by the CSX Transportation Inc. (CSXT) for the Maryland Mass

Transit Administration (MTA) collided with the

westbound National Railroad Passenger Corporation (Amtrak) passenger train 29, Capitol

Limited. (See figure 1.) The accident occurred

during a blowing snowfall near milepost (MP)

BA 8.49

 at a railroad location, referred to as

Georgetown Junction, about 1 mile west of Silver Spring, Maryland. (See figure 2.) The snow

accumulation on the ground at the accident site

was 5 inches. (See figure 3.) Both trains were

operating on the double main tracks owned and

maintained by the CSXT.

The MARC train 286 was a “push-pull”

commuter train consisting of a locomotive unit

on the rear end, two passenger cars, and a passenger coach cab control car in the lead. The

engineer was operating the train from the cab

control car in the push mode at the time of the

collision. The MARC train 286 was in scheduled commuter service proceeding eastward on

track 2 between Brunswick, Maryland, and Union Station, Washington, DC. The train departed

Brunswick at 4:30 p.m. eastbound for a scheduled

5:30 p.m. arrival at Union Station with three

CSXT operating crewmembers

 (an engineer, a

 

1

The prefix BA stands for the Baltimore Division,

Metropolitan Subdivision. All MP designations in

this report are for that subdivision; henceforth the BA

will not be shown. 2

Train arrangement in which the motive power is

at one end and a control cab car is at the other end,

permitting the engineer to operate from either end of

the train. The power is at the rear of the train when

the train is configured for the push mode and at the

front of the train when it is configured for the pull

mode. 3

Traincrews are employed and contracted by the

CSXT to operate MARC commuter trains between

conductor, and an assistant conductor) on board.

MARC train 286 had to make a “flag” station

stop

 at the Kensington, Maryland, station to

board two waiting passengers. The train carried

20 passengers at the time of the collision. Before MARC train 286 stopped at Kensington,

the engineer on the westbound MARC train 279

stated that as the two trains passed each other on

adjacent tracks, he had heard a portion of the

radio communication of the MARC train 286

engineer acknowledging the wayside signal

1124-2,

 located about 1,000 feet west of Kensington station.

The westbound Amtrak train 29, with a 2-

unit locomotive and 15 cars, departed Union

Station about 5:25 p.m. en route to Chicago, Illinois. The Amtrak operating crew consisted of an

engineer, an assistant engineer, a conductor, and

an assistant conductor. Thirteen on-board service employees, a mechanical rider who was in

the second unit, and 164 passengers were also

on board the Amtrak train. The Amtrak train 29

had been routed onto track 2 from Union Station

to Georgetown Junction to pass a stopped westbound CSXT freight train that occupied track 1

east of Georgetown Junction. The engineer of

Amtrak train 29 stated he was operating on a

 

Washington and Brunswick. 4

The station is not a regularly scheduled stop. A

train makes a flag stop to pick up passengers who are

standing on the platform and are visible to the engineer. A train also makes a flag stop to discharge passengers who have requested the stop and notified the

conductor when boarding. 5

The signal would have been displaying an APPROACH indication, logically related to the STOP

indication being displayed at Georgetown Junction

because the crossover at the interlocking was aligned

for a train movement from track 2 to track 1 for the

westbound Amtrak train 29.
2

Figure 1--View of trains at point of impact.

MEDIUM CLEAR signal (see table 1) and was

beginning to negotiate the crossover from track

2 to 1 at Georgetown Junction when the

collision occurred. (See appendix B for the

signal sequence chronology.)

The locomotive event recorder of MARC train

286 indicated that the train accelerated upon departing the Kensington station, slowed for a

posted speed restriction, and then accelerated

again. The engineer of MARC train 286 placed

the train brakes in emergency about 2.18 miles

from the Kensington station at a speed of approximately 66 mph. About 11 seconds after the

emergency brake application and 7 seconds before impact, the train control lever (reverser) was

recorded as being moved from reverse to forward.

(The locomotive had been operating in the reverse position as a pusher locomotive before

this.) The impact speed with Amtrak train 29 was

about 38 mph.

The collision between the lead Amtrak unit

and the MARC cab control car tore away the

front left quadrant of the cab control car. The fuel

tank on the lead unit was ruptured in the collision

and sprayed fuel on the cab control car. All three

MARC cars and the MARC locomotive derailed

in the accident. Both Amtrak units and the first

eight cars of train 29 derailed. The derailed Amtrak equipment consisted of six material handling

cars, one baggage car, and a transition-sleeper

car, which was the only occupied Amtrak car to

derail. (See figure 4.)
3

Table 1.--Key to CSXT signal indications

CLEAR MEDIUM CLEAR APPROACH STOP

Rule C-281 Rule C-283 Rule C-285 Rule C-292

Proceed. Medium speed

(30 mph) through turnouts, crossovers, sidings, and over power

operated switches; then

proceed.

Proceed prepared to stop

at the next signal. Trains

exceeding medium speed

must immediately begin

reduction to medium

speed as the engine

passes the APPROACH

signal.

Stop.

Ten survivors from cab control car 7752 escaped after the accident through an opening

between the diaphragms of the first and second

car interior passageway of train 286. Two other

survivors from the MARC train exited through

an emergency window in the second car.

The CSXT AU

 dispatcher was contacted

about 5:41 p.m. by the traincrew of CSXT train

K951, which was stopped on the adjacent track

east of Georgetown Junction, that Amtrak train

29 had derailed while crossing over at Georgetown Junction. Also about 5:41 p.m., the Montgomery County [Maryland] Fire and Rescue

Services (MCFRS) 911 dispatcher received approximately 12 telephone calls reporting the derailment and fire. At 5:44 p.m. the AU dispatcher

 

6

The CSXT designates the train dispatcher that

controls train movements on the Brunswick Line as

the AU train dispatcher.

contacted the MCFRS to notify it of the accident

and was informed that it was already aware of the

derailment. About 5:46 p.m. the first units arrived

on scene.

During the emergency response activities,

CSXT freight train Q401 and MARC train 281

had been operating, respectively, behind MARC

train 286 and Amtrak train 29. These two trains

had been stopped from approaching the accident

scene by railroad wayside signal indication. Upon

request to the CSXT AU dispatcher, the engineer

of CSXT train Q401 received authorization from

the dispatcher to separate the locomotive units

from his train and to approach the accident site

prepared to stop because of the emergency response personnel in the area. The locomotive

from CSXT Q401 stopped about 775 feet west of

the derailed locomotive of MARC train 286 about

6:20 p.m. The MARC train 281 engineer had also

made a similar request to pull up behind



7

Amtrak train 29 and lend assistance. Approval

was not received until about 6:56 p.m. but not

from the dispatcher; instructions were received

from the CSXT/MARC manager of passenger

operations to move as close as possible to Amtrak

train 29. Neither train movement was coordinated

with the MCFRS incident commander (IC). The

IC stated that when a citizen reported that a train

was approaching the accident site, he had his staff

activate radio tones and air horns to warn emergency responders to evacuate the accident site.

(See appendix C for the accident chronology.)

The first firefighters to reach cab control car

7752 reported that the car was fully involved in

fire and that they did not observe any survivors.

They made several attempts to enter the cab control car. The fire was extinguished within 10

minutes, after which the firefighters were able to

enter cab control car 7752. They were later assisted by members of the Montgomery County

Police Department (MCPD) in the recovery of 11

victims for coordinating the identification and

notification process with the Maryland medical

examiner. At 3:50 a.m. on Saturday, February 17,

1996, the last victim was recovered, and the IC

turned over the accident to the MCPD. At 4 a.m.

the recovery operations were secured.

In the collision and subsequent fire, all 3

CSXT crewmembers and 8 passengers on

MARC train 286 were fatally injured; 11 of the

12 MARC train survivors sustained from serious

to minor injuries. The Amtrak engineer, assistant engineer, and mechanical rider sustained

serious injuries; the conductor, the assistant

conductor, two on-board service crewmembers,

and eight passengers sustained minor injuries.

Injuries*

Table 2.--Injuries sustained in Silver Spring railroad accident

Type MARC

Train 286

Operating Crew

MARC

Train 286

Passengers

Amtrak

Train 29

Operating Crew

Amtrak

Train 29

Employees

Amtrak

Train 29

Passengers

Total

FATAL 3 8 0 0 0 11

SERIOUS 0 3 2 1 0 6

MINOR 0 8 2 2 8 20

NONE 0 1 0 11 156 168

TOTAL 3 20 4 14 164 205

*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.

Damages

The CSXT, the MTA/MARC, and Amtrak estimated the damages, and the MTA/MARC and

National Transportation Safety Board estimated

replacement costs, as follows:

Cars $4,963,624

 (includes replacement cost for MARC equipment)

Locomotives 2,350,000

 (includes replacement cost for Amtrak lead unit)

Track/signals 200,000

Total $7,513,624
8

Track and Signals--Three turnouts,

 including

their signal operating components, were destroyed. The turnout leading to the Georgetown

industrial track and the westernmost crossover

from track 1 to 2 were replaced and repositioned. A total of about 663 feet of track was

replaced in main tracks 1 and 2. The track work

was completed on April 12, 1996. Because of

the turnout and track repositioning for the

Georgetown industrial track, the eastbound absolute signal (EAS) for track 2 was replaced and

relocated adjacent to track 2.

MARC Train 286--The locomotive of train 286

had minimal damage. The three MARC passenger cars, including cab control car 7752, sustained heavy damage and were considered totally

destroyed by MARC.

Amtrak Train 29--The collision and derailment

affected only the two locomotive units and the

first eight cars of the Amtrak train, with the remaining cars in the consist sustaining no reported

structural damage. The left rear side of the lead

unit car body exterior, truck assembly, and fuel

tank received substantial fire damage. The leading truck assembly of this unit was detached from

the unit. Amtrak considered the unit totally destroyed. The second unit and the derailed passenger cars sustained minimal damage; they were to

be repaired and returned to service.

MARC Train 286 Crew Information

Engineer--The 43-year-old engineer began

working for the Baltimore & Ohio (B&O) Railroad on September 3, 1970, in the signal department but became a brakeman on February

16, 1971. He was promoted to engineer on April

15, 1974, and qualified over the territory that

included Baltimore, Maryland, to Washington

and Washington to Brunswick shortly thereafter.

He operated freight trains and some passenger

 

7

An arrangement of switch point rails, crossover

rails (frog), and closure rails that permit trains to be

diverted from one track to another.

trains (from the extra board) before working as a

yard engineer in Baltimore. In 1980, he became

a CSXT employee through a merger.

In August 1994, he requalified over the territory in passenger service after leaving the yard

engineer position and worked several different

job assignments that included Washington to

Brunswick trips. He became the regular engineer on the assignment that included MARC

train 286 on January 1, 1996. The CSXT manager of passenger operations, who was his supervisor, testified that he was “one of the most

professional engineers that we had out here. He

did a real good job in everything that he did. He

was consistent, he was concise.”

His most recent CSXT operating rules class

was completed on February 25, 1995. His most

recent engineer certification was December 31,

1995; the class designation was Train Service

Engineer with no restrictions noted. His service

record showed five instances of discipline; however, none were for operational failure. Seventy

CSXT operational efficiency tests had been performed on the engineer during the previous 12

months; he had no reports of failure.

The most recent railroad physical for the engineer of MARC train 286 was conducted on

October 21, 1995, and it found him medically

qualified. His distant vision was 20/20 uncorrected; his near vision was 20/35, although he

had no difficulty reading and did not wear

glasses nor was he required to do so to operate

trains. His color perception was normal, and he

had no hearing loss. The engineer’s father noted

his son showed no signs of illness when he last

saw him on February 14, and did not complain

of any illness when they last spoke on February

15. In addition, the engineer expressed no concerns or health complaints when he spoke to a

female acquaintance from Brunswick about 4

p.m. on February 16.

For each weekday since his most recent assignment began on January 1, 1996, the engineer kept essentially the same work schedule.

According to CSXT records he also kept this
9

same schedule during the week before the accident. (See table 3.) His work schedule was 11

hours 35 minutes on duty and 12 hours 25 minutes off duty. He worked on four train runs each

day with a break between each run. These

breaks were scheduled to be 45 minutes, then 1

hour 15 minutes, and finally 2 hours, although

these could vary depending on train delays.

On Friday, February 16, the day of the accident, the engineer reported for duty at 10:10

a.m. and departed from Camden Station with

MARC train 251 as scheduled at 11 a.m. The

train arrived 45 minutes late in Washington at

12:55 p.m. because of weather-related switch

problems at Savage, Maryland. The next train he

operated, MARC train 273 to Brunswick, departed 24 minutes late at 1:24 p.m. Snow delayed that run and he arrived 33 minutes late in

Brunswick at 2:53 p.m. He departed Brunswick

with MARC train 286 at 4:30 p.m.

Conductor--The 48-year-old conductor was

hired by the B&O on October 27, 1969. He became a CSXT employee through a merger in

1980. He was regularly assigned to a yard job in

Baltimore. According to his wife, he has always

worked in the Baltimore rail yards (Curtis Bay

or Locust Point) and not in regular freight service. His seniority was sufficiently high that

when he worked in the yards, he was always off

on weekends. During the last 2 years, he had

also worked in passenger service on MARC

trains when called. His passenger service assignments also provided weekends off, except

for an occasional weekend train to the baseball

stadium in Baltimore.

Table 3.--MARC train 286 engineer’s daily work schedule

Time Activity

10:10 a.m. Report for duty at CSXT Riverside yard in Baltimore.

Drive to Camden Station to operate MARC train 251.

 11 a.m. Depart with train 251 en route to Union Station.

12:10 p.m. Arrive at Union Station.

Stay in station until his next run.

 1 p.m. Depart station with MARC train 273 en route to Brunswick.

 2:20 p.m. Arrive at Brunswick terminal.

Remain at Brunswick until time to operate return train 286 to Union Station.

Telephone and talk to friend usually each day during this time.

 4:30 p.m. Depart Brunswick with train 286 en route to Union Station.

 5:50 p.m. Arrive at Union Station.

Remain at terminal until time to operate (fourth) train 260.

 8 p.m. Depart with train 260 from Union Station to Baltimore.

 9:13 p.m. Arrive at Baltimore.

 9:30 p.m. Off duty.

 9:45 p.m. Arrive home after 15-minute drive.
10

He was promoted to freight conductor on

January 1, 1992, and to passenger conductor on

November 19, 1993. He successfully completed

his most recent operating rules class on February

13, 1995. His service record showed three instances of discipline, two of which were for operating rules infractions. The first operating rules

infraction was on May 11, 1981, for violation of

rules 104-C and 105 by fouling a track before

switches connected with the train movement were

lined and not being properly prepared to stop

within half the range of vision. A 5-day overhead

suspension

 was given. The second recorded instance was on July 27, 1981, when the employee

was cited for a violation of rule 103-G, which

resulted in a derailment and in a formal reprimand. (See Appendix D, Excerpts from CSXT

Operating Rules.) Twelve CSXT operational efficiency tests had been performed on the conductor

during the previous 12 months; no failures were

reported.

The most recent railroad physical for the conductor of MARC train 286 was on June 17, 1993,

which showed that he was medically qualified

for his job; his visual acuity, degree of visual

field, color sense, and hearing were all within

acceptable ranges. His wife stated that he always slept well at night and had done so the

night before the accident. She reported she did

not know whether her husband had taken any

medication on Friday, February 16, but he had

not reported any illness to her. He did not have

any medical conditions or take any medication

on a regular basis.

During the 4 days before the accident, the

conductor worked a daylight “yard job” at Curtis

Bay. He awoke about 6 a.m. daily; worked at the

rail yard until about 1:30 p.m. on Wednesday,

February 14, and until 3 p.m. on Thursday, February 15; and retired about 10 p.m. on both days.

Between 9 and 10 p.m. on Thursday, he was notified by the CSXT that he would be in passenger

 

8

Punishment that is held in abeyance provided the

employee has no other infractions.

service the next day. On Friday, February 16, he

awoke at 8 a.m. and left for work about 9 a.m.

Assistant Conductor--The 53-year-old assistant

conductor went to work for the B&O on September 1, 1965. He remained with that same

organization, which ultimately became a part of

the CSXT. He worked first as a brakeman and

later as a conductor in both yard and road

freight service. His last assignment before entering passenger service was as a brakeman at

the Jessup Yard.

The assistant conductor completed his most

recent operating rules training class on June 18,

1995. His service record showed two instances of

disciplinary action. He received a 10-day overhead suspension on September 27, 1969, for violation of rule 804 (approaching a hazardous materials derailment). The second incident occurred

on May 30, 1986, and entailed violation of rules

106 (safe train operation) and 450 (radio usage),

which resulted in a 10-day overhead suspension.

Both occurred while the assistant conductor was

in yard service. Twenty-nine CSXT operational

efficiency tests had been performed on the assistant conductor during the previous 12 months; no

failures were reported.

The most recent railroad physical for the assistant conductor of MARC train 286 was on

September 12, 1994, and showed him medically

qualified for his job. His distant vision was

20/70 in each eye but improved to 20/20 with

glasses, and his near visual acuity, degree of

visual field, color sense, and hearing were all

within acceptable ranges. His wife reported he

was wearing his glasses when he went to work

on February 16. She said that her husband had

slept well at night during the week before the

accident and that he took a daily capsule of the

medication Prilosec for an ulcer.

His wife characterized the relationship of her

husband and the engineer of MARC train 286 as

friendship. They had worked together previously

at the Curtis Bay rail yard. She said that on

many previous occasions her husband had

described him as one of the best engineers, that
11

her husband liked all of his coworkers, and that

they worked well together. She reported he had

also worked with the conductor previously and

considered him a good conductor, although he

had not really talked much about the conductor.

For the last 4 months he had worked the same

weekday assignment on MARC passenger trains.

On Wednesday, February 14, and Thursday, February 15, the assistant conductor awoke about

7:30 a.m. and arrived at work about 10 a.m.

During the day, his assignment allowed him free

time between trains while in Brunswick, and he

generally called his wife between 2:30 and 3:30

p.m. He returned home each night about 10:15

p.m. and retired at 11:30 p.m. On Friday, February 16, he awoke and arrived at work at his

usual times, and according to his wife, he called

her at 3:20 p.m. She described the conversation

as typical and said that he had expressed no

particular concerns when they talked.

Amtrak Train 29 Crew Information

The operating crewmembers were employed

by Amtrak.

Engineer--The 49-year-old engineer began his

railroad employment with the B&O on June 14,

1977. He was originally hired as a brakeman

and worked in Pittsburgh, Pennsylvania. He

went into engine service on June 8, 1978, when

he became a fireman and was promoted to engineer on May 20, 1979. He operated Amtrak passenger trains at times as a B&O employee. On

August 20, 1986, he transferred to Amtrak and

operated its passenger trains full time.

As a B&O engineer, he was qualified over

the territory from Cumberland, Maryland, to

Pittsburgh; as an Amtrak engineer, he became

qualified over the entire territory from Washington to Pittsburgh in 1986. From 1986 until

1993, he operated over various routes, often as

the relief engineer from Washington to Pittsburgh, and that route became his regular assignment in 1993.

The engineer successfully completed his last

locomotive engineer’s certification examination

on February 1, 1996, with no restrictions. He was

last examined on the CSXT operating rules on

October 3, 1995. His service record shows one

instance of discipline for violating CSXT operating rule 292 in Halifax, South Carolina, on

August 27, 1992. The incident occurred when his

assistant engineer, who was operating the train,

violated a STOP signal. He received a 30-day

suspension from Amtrak and was barred from

operating over the CSXT until March 1993. In

the 3 years before the accident, the engineer was

subject to 20 efficiency tests and was found to

be in compliance in each instance.

By happenstance, the engineer’s supervisor

conducted an efficiency test of the engineer at

1:04 p.m. on the day before the accident. The

supervisor observed the engineer cross over

from track 1 to 2 at Georgetown Junction (eastbound) on a MEDIUM CLEAR signal. Such a

crossover has a speed limit of 30 mph; and the

supervisor determined with a radar gun that the

engineer crossed over at 27.9 mph.

The engineer of Amtrak train 29 reported he

was in good health and was not ill on the day of

the accident. He stated he takes three medications each day: Procardia (30 mg) and one aspirin, since a heart attack in 1990, and Mevacor, a

cholesterol reduction medication. He passed his

last railroad physical on November 1, 1995. His

vision and hearing capabilities were found to be

within acceptable range without any restrictions.

He wore reading glasses but was not required to

wear them while operating the train, and he was

not wearing them at the time of the accident. He

was wearing railroad-supplied clear safety

glasses.

Assistant Engineer--The 38-year-old assistant

engineer of Amtrak train 29 was hired by the

B&O as part of a track gang in June 1977. In

August 1977 he began working as a conductor

and remained as a conductor with the B&O until

August 1986. He transferred to Amtrak in

August 1986 and continued to work as a conductor until 1989 when he went into engine
12

service as a fireman. He was promoted to engineer on May 27, 1992, and his most recent certification was February 9, 1996, which had a vision restriction requiring corrective lenses. He

was qualified on the CSXT railroad operating

rules, had been qualified over the territory for 4

years, and had worked with the engineer previously. His last CSXT operating rules exam was

October 3, 1995, and he had no recorded instances of discipline.

The assistant engineer of Amtrak train 29

had his most recent physical examination on

April 25, 1995, and was found medically qualified for his job. He reported that he was in good

health, had no long term illnesses, was not sick

on the day of the accident, took no medication,

and was wearing his prescription glasses at the

time of the accident.

Train Information

MARC Train 286--The train consisted of passenger coach cab control car 7752, passenger

coaches 7709 and 7720, and diesel electric locomotive (GP39-H2) unit 73. These cars were designated by MARC as MARC II type cars.	

 (See

figure 5a.) Neoprene diaphragms were attached

to both ends of the cars, which provided a

weather-resistant barrier between two coupled

cars. All cars were equipped with a safety bar on

both ends of the cars. The safety bar latched in

both the horizontal and the stored vertical position.

MARC train 286 was configured to operate in

the push mode with locomotive unit 73 at the rear

of the train. Passenger coach cab control car 7752

was very similar in arrangement to the other

passenger coaches in train 286 except that the

leading "F" end had an operating cab with controls in the front right corner of the car. (See

figure 5b.) This enabled the engineer to operate

 

9

Manufactured by Nippon Sharyo Seizo Kaisha

Ltd., of Toyokawa, Japan, and delivered under State of

Maryland contract SRA 2108-003 and subsequent

change orders.

from the front of the train in the push mode as

the locomotive unit pushed from the rear of the

train. This was the configuration at the time of

the accident.

Required Federal Railroad Administration

(FRA) scheduled maintenance of MARC passenger coaches and cab control cars is performed under contract by Amtrak personnel at

their Washington Ivy City maintenance facility.

Required FRA scheduled maintenance of the

MARC locomotives is performed under contract

by the CSXT mechanical personnel at the Riverside yard near Baltimore. CSXT and Amtrak

personnel may also perform daily inspection,

servicing, and running repair of MARC equipment depending on where the equipment is

stored or turned around.
 The CSXT also performs inspection, servicing, and running repair

at its Brunswick facility.

The night of February 15, 1996, at the CSXT

Riverside yard, locomotive unit 73 received a

daily inspection. It received a locomotive air

brake test as well as a train air brake test with

the three passenger coaches as MARC train 243

the next morning. The unit and the cars were

then designated as MARC train 271, and Amtrak performed another train air brake test in

Washington before the train departed for

Brunswick. The inspection records showed no

anomalies. That train departed Brunswick designated as MARC train 286 and was the consist

in the collision.

The CSXT inspection records for cab control

car 7752 showed that the speed indicator was

accurate at 70 mph and that no exceptions were

taken on the air brake inspection tests. The two

predeparture inspection sheets on the day of the

accident both indicated that the radio of cab

control car 7752 was “good,” and no previous

radio malfunction had been reported. The radio

was destroyed in the collision.

 

10The three MARC cars involved in this accident

had been continuously together since October 3,

1995.

14

Amtrak Train 29--The train consisted of a twounit (F40PH-255 and P40-811) locomotive followed by six material handling cars, a baggage

car, a transition-sleeper (from one level to

bilevel), two sleeping cars, a dining car, a lounge

car, two coaches, and a coach-dormitory car. The

radios and antennas from both Amtrak units 255

and 811 were tested at the accident site and then

bench tested. All radios and antennas were

found in good working order. The throttle on the

lead unit was found in the eighth notch position.

Postcollision Train Information

MARC Train 286--The cars and locomotive of

the train remained coupled and were situated approximately in a linear orientation, derailed but

upright, resting parallel to track 2 on the ballast

and the displaced track of the siding. The cars

were displaced laterally to the south between 6

and 20 feet from the track 2 centerline. Both the

front and rear sanders of locomotive unit 73

were 3/4 full. The sand box on the front left side

of cab control car 7752 had been sheared away,

and the sand box on the right (engineer's) side

had been crushed but still contained sand. Because the running gear and batteries of the

coaches were damaged in the derailment, the

emergency lighting and public address system

were inoperable.

After colliding with Amtrak train 29, cab

control car 7752 derailed and came to rest tilted

approximately 10 degrees clockwise. (See figure

6.) The leading truck assembly of the car had

separated from its mounting and was found upside down and lodged under the car midsection to

the right of centerline. The car body plymetal

floor above where the truck assembly came to

rest was indented about 2 feet in depth. The leftside front anchor bracket assembly of the truck

had fractured and was torn from its attachment to

the car.

The interior of cab control car 7752 (see figure 7) was gutted by fire, leaving the charred

metal shell, internal fittings, and combustion residue. Damaged remnants of insulation remained

in the ceiling and side walls. The rubber diaphragm at the rear passageway door was burned

near the roof. The rear safety bar was horizontally positioned. A 50-pound portable fire extinguisher, normally secured by a metal strap on

the front bulkhead of a vestibule, was missing

and later discovered in the debris. The glass

cover of the emergency toolbox was shattered,

and the tools were missing.

The rear interior door of the car was open

and slid within the wall pocket between the vestibule and the lavatory. The fire destroyed the

controls for the left- and right-side rear doors

and burned the position indicator lenses. The

right-side rear door was open 0.5 inch, and its

window was missing. The door contacted the

front of the car body shell, into which it slides,

12 inches above the vestibule floor. Its interior

emergency release handle was in a secured

cabinet in the lavatory. (During an inspection of

the car on March 14, 1996, at the Middle River,

Maryland, MARC facility, the door did not open

when this handle was pulled fully down.) The

right-side rear "T" handle (exterior emergency

door release mechanism) was missing from its

cable, which, when pulled downward by pliers,

moved the inside emergency release handle

downward; however, the door did not open. The

left-side rear door was open 1 inch, and its window was damaged by the fire and outwardly

displaced at the top. The door contacted the

front of the car body shell, into which it slides, 8

inches above the vestibule floor. Its interior

emergency release handle was damaged by the

fire and could not be pulled down or operate the

door. The cover to its cabinet was missing. The

left-side rear T-handle was also missing from its

cable, which, when pulled downward by pliers,

did not move, and the door did not open.

The second car in the consist, passenger

coach 7720, derailed and tilted approximately

30 degrees clockwise with its front end lodged

against the rear end of cab control car 7752. The

left-side front corner of the coach, which included

the bulkhead, the vestibule door, and a


17

4.5-foot-long section of sidewall, was pressed

inward resulting in a breach of the car body end

and corner structure. Fire damage was limited to

the front diaphragm, which contacted the adjacent cab control car. The left-side front door was

destroyed, and the T-handle was imbedded in

the damage. The right-side front door was

closed and could not be opened using the Thandle. The front interior door of the coach was

displaced rearward and closed; the rear interior

door remained intact. The left- and right-side

rear doors, respectively, were operable and

closed. Its emergency toolbox was empty, its

first aid kit was intact, and its fire extinguisher

was found in the debris.

The last car in the consist, passenger coach

7709, derailed and tilted approximately 30 degrees clockwise. Its corner was depressed near

the frame of the left-side rear door, which was

closed. The front end of the passenger coach

7709 was lodged against the rear end of the passenger coach 7720. The truck assembly on the

rear end, which was lodged against locomotive

unit 73 and Amtrak locomotive unit 811, was

damaged. Passenger coach 7709 had no fire

damage. No emergency window exit decals

were found on or near the windows. On February 29, 1996, with MARC officials present, a

Safety Board investigator took several minutes,

applying physical exertion, to remove the leftside front emergency exit window of passenger

coach 7709. Then on March 14, a Safety Board

investigator attempted unsuccessfully to remove

the right-side rear emergency exit window,

which was later removed by another investigator

after about 3 minutes of physical exertion. (A

lubricant used to install these particular emergency windows was later found to have hardened over time.)

Amtrak Train 29--The locomotive units, the

first, and the fourth through eighth cars were all

derailed (either one or both axles) but remained

upright. With the exception of the leading unit

(ATK 255) and the fifth and sixth (material handling) cars, the equipment was found to be coupled and approximately in a linear orientation.

The equipment was displaced laterally to both

sides of track 2 and the crossover or resting on

track 1 and its displaced ballast.

Lead unit ATK 255 derailed and received

damage to the hood, fuel tank, and running gear.

(See figure 8.) The left side of the unit superstructure received fire damage behind the control compartment, which remained intact. The

lavatory was destroyed. The right-side windshield was shattered, and the left-side windshield was not present. The side windows were

shattered. Unit ATK 811 derailed and received

substantial damage to its superstructure and

running gear.

Of the six material handling cars, the first

through sixth in the consist positioning, only the

second car remained on the rail. The baggage

car, the seventh car in the consist, and the front

trucks of the eighth car, a transition/dormitory

car, derailed. The passenger-occupied 9th

through 15th cars remained on the track and were

not damaged. All Amtrak cars in the consist remained upright and parallel to the track, except

for the fifth and sixth cars. No damage was

noted to passenger compartments.

All emergency lighting had been illuminated

immediately after the collision according to the

conductor. The emergency lights were illuminated in all cars, except in the 15th car, when

Safety Board investigators arrived on scene

about 1 hour after the collision. The public address system remained operable after the collision and was used by the conductor for emergency broadcasts. All emergency tools and

equipment remained in place.

Track and Signal Information

Tracks--The collision occurred on the CSXT

Baltimore Division, Metropolitan Subdivision,

which was double main track territory. The

tracks were designated as track 1 and 2, and they

were spaced on 12.5-foot centers at the collision

point. The point of collision was in a turnout on

track 2 about MP 8.49, where the track crossed

over to track 1, about 180 feet east of the EAS

for track 2. (See figure 9.)


20

The MPs were in decreasing numerical order

in the timetable eastward direction. The tracks

pass through a residential area. An unpaved railroad maintenance road is adjacent to track 1. The

right-of-way closest to the point of collision is

elevated above the adjacent topography. A steep

slope about 45 feet wide is on the south side, and

a far lesser slope about 80 feet wide is on the

north side. Both slopes had a dense cover of trees

and shrubbery. Open parking lots for large residential buildings are near the bottom of the slopes

on both sides of the right-of-way adjacent to the

collision site. Highway overpass bridges are

about 1,000 and 800 feet, respectively, to the west

and the east of the collision site.

Approaching the accident site at MP 8.49

from the west, track 2 between MPs 8.95 and

8.68 curves to the left through a 1°

 and 36' curve

on a 0.43-percent ascending grade eastward. The

track alignment and the gradient between MPs

8.68 and 8.27 are, respectively, straight and on a

0.18-percent descending grade in the eastward

direction.

The track and turnouts were 140-pound continuous welded rail. Both tracks 1 and 2 and the

turnouts making up the interlocking were inspected and maintained by the CSXT to FRA

class 4 track standards, which provide specific

minimum track geometry requirements for

freight and passenger train operations at maximum allowable speeds of 60 and 80 mph, respectively. The before and after accident track

geometry measurements for gage, alignment,

and cross level and all other track inspection and

maintenance records were reviewed and indicated no anomalies. Postaccident inspection

found the westernmost crossover switch rails on

track 2 and the switch rails on track 1 were lined

properly for a crossover movement by Amtrak

train 29.

About 8 to 10 “snow pots” (oil burning

switch heaters) were in place and lit at all four

switches of the Georgetown interlocking crossovers. The snow pots, which were in the spaces

between the switch and under the switch point

rails, were burning to keep snow from accumulating behind the switch points.

An adjacent track, the former Georgetown

branch track, is parallel to and intersects with

track 2 east of the collision site. The siding was

not involved in the collision but was skewed out

of alignment by the derailment and lateral displacement of the MARC equipment.

Signals--Train movements through the accident area, including Georgetown Junction, are

controlled by a traffic control signal (TCS) system on the two main tracks that is arranged for

train movement in both directions with color

position light signalsand the General Railway

Signal model 5H electric switch machines controlled from the operations center in Jacksonville, Florida. The AU dispatcher controls the

power-operated switches at Georgetown Junction

for crossover movements between tracks 1 and 2

remotely from Jacksonville by leased telephone

lines. East and west of Georgetown Junction the

system consists of a TCS on two main tracks

arranged for train movement in both directions

with color position light signals and electronic

track circuits.

The EAS at Georgetown Junction controls

eastbound train movements on track 2, and it as

well as the eastbound signal 1124-2 at Kensington are mast-mounted color position light

signals. (See figure 10.) Their method of operation is by timetable, direct traffic control (DTC)

block system, and signal indication of a TCS.

A defect detector is at MP 11.7, about 0.5

mile west of signal 1124-2 at Kensington, and

after the accident, it provided a paper tape printout for train movements on track 2. (See table

4.) The clock on the defect detector, measuring

 

11Train movements are authorized by block signals whose indications supersede the superiority of

trains for both opposing and following train movements on the same track. 12Fixed signals that display aspects by the color

and position of two or more lights. 13Governed by the verbal authority of the train

dispatcher, or a series of consecutive DTC blocks

activated by train movement on the track circuit.
21

in hours and minutes, is not synchronized with

either the event recorder at Georgetown Junction or the system log in Jacksonville. The defect detector is approximately 16 minutes ahead

of the Georgetown Junction event recorder and

14 minutes ahead of the system log in Jacksonville. The detector noted no defects on the three

passing trains.

The defect detector broadcasts an arrival and

a trailing message, respectively, as a train approaches and shortly after the last car passes.

The arrival message is preceded by a 1/4 second

tone to alert the engineer, which is followed by

an approximately 5-second message that identifies the defect detector MP location and track

number for an engineer to determine whether

the message applies to him. If no defects are

detected (none were for either train in this accident), the approximately 10-second trailing message repeats the arrival message and then adds

“no defects,” one of four brief safety messages,

and a concluding “end of transmission.”

The Georgetown Junction interlocking is

equipped with a signal event recorder to record

specific events and signal relay changes corresponding to the dispatcher’s requests, train

movements, signal indications, and interlocking

conditions. Following the accident the signal

event recorder was secured and obtained information indicating that the last time the EAS was

cleared for a train movement from track 1 to 1

was at 3:14 p.m. for the eastbound MARC train

284. About 4:05 p.m. the EAS recorded a STOP

signal and displayed this signal about 1 hour 33

minutes until the accident at 5:39 p.m.

Figure 10--Signal 1124-2. The “D” was added after the accident.
22

Table 4.--MP 11.7 defect detector printout for track 2 train movements

Train Date Time Direction Axles Cars Speed Length

 (not recorded) (mph) (ft)

MARC 284-16 2/16 16:19 East 40 10 61 744

MARC 286-16 2/16 17:50 East 16 4 49 279

CSXT Q401-16 2/16 18:23 East 22 5 15 280

Operations Information

Train movements on the CSXT Baltimore

Division, Metropolitan Subdivision, are governed

by CSXT operating rules in the Operating Procedures Manual, effective January 1, 1995. Instructions for the movement of trains or equipment

and related essential information are in Baltimore

Division Timetable No. 5, issued on January 1,

1996. Superintendent’s bulletins containing written special instructions about the movement and

safety of trains and employees are issued periodically. The Metropolitan Subdivision is called the

Brunswick Line for the MARC commuter train

operations between Brunswick and Washington,

approximately 50 miles. Eastbound MARC

trains on the Brunswick Line are normally operated in the push mode and westbound MARC

trains in the pull mode.

Train movements through the accident area

are controlled by the CSXT AU train dispatcher

from the operations center in Jacksonville. The

AU train dispatcher controls the movement of

approximately 80 trains daily over three lines:

Brunswick (Washington to Brunswick, which

includes the Georgetown Junction crossover);

Camden (Washington to Baltimore); and Penn

(Baltimore to Brunswick). (See figure 11.) About

28 unscheduled CSXT freight trains and 2

scheduled Amtrak passenger trains as well as

the 18 weekday-scheduled MARC commuter

trains on the Brunswick Line operate daily

through the Georgetown Junction interlocking.

The Safety Board investigation of this accident involved the activities of seven trains: Amtrak train 29, CSXT freight trains K951 and

Q401, and MARC trains 279, 281, 284, and 286.

About 4:05 p.m. MARC train 284 was the last

eastbound train to operate on track 2 through the

crossover switch at Georgetown Junction with the

switches lined in the “normal” or through position. MARC train 279 was the last westbound

train to operate before the accident through the

crossover switch at Georgetown Junction, crossing from track 2 to 1 about 5:15 p.m. The CSXT

train K951 was operating westbound toward

Georgetown Junction on track 1 and had stopped

east of the Georgetown Junction (near the highway overpass bridge) about 5:28 p.m. Amtrak

train 29 was operating westbound on track 2 proceeding to make the same crossover as MARC

train 279 had made and had been operating behind MARC train 279 before being struck by

MARC train 286. The CSXT train Q401 and

MARC train 281 had been operating, respectively, behind MARC train 286 and Amtrak train

29 also before the collision.

CSXT Train Operations--Trains through the

accident area operate under the authority of block

signal indications of a TCS system. Authority for

movement is governed by the CSXT operating

rules 265 through 271 for the TCS system rules.

Passenger-specific operating rules are contained

in the CSXT operating rules 620 through 635.

The Baltimore Division Timetable No. 5 specifies

the maximum authorized speed for the Metropolitan Subdivision as 79 mph for passenger and

55 mph for freight trains. Trains can operate in

either direction on either track by signal

 

14The MARC trains began push/pull operations in

1985 with the delivery of the MARC II cab control

cars.
23

Figure 11--Map of MARC operations for Brunswick, Camden, and Penn Lines.

indication. Between MP 11.0 at Kensington and

MP 8.3 at Georgetown Junction, the maximum

authorized passenger train speed is 70 mph, except for a timetable speed restriction between

MPs 10.6 and 9.5 for a reduction to 55 mph for

passenger trains.

The Safety Board reviewed event recordings

maintained by the CSXT in three formats: computerized train sheets (FRA records of train

movements),signal event logs, and train dis-

 

15Dispatcher records of train movements are

maintained by the CSXT in compliance with 49 CFR

Part 228 and are required to identify the timetable, the

train and engine, the traincrew with duty time, the

patcher voice communication recordings

(including telephone). Train-to-train radio communications are indicated on the dispatcher’s

voice recording only if the dispatcher is using the

radio channel. All event records, with the exception of the computerized train sheets, were voluntarily maintained by CSXT. The Safety Board

 

dispatcher with duty time, the station and office, the

location and date, the weather conditions in 6-hour

intervals, the distances between stations, the direction

of train movement, the time when the train passes each

reporting station, the train arrival and departure times at

each reporting station, and unusual events affecting

train movement.
24

reviewed the train sheets for the previous 90 days

and found that the sheets significantly lacked the

recording of unusual occurrences, such as this

accident, and weather information, which are

elements the FRA regulations require to be

maintained.

Operational Efficiency Testing--The CSXT

maintains an operational test and observation

program in compliance with 49 CFR Part 217 to

determine the extent of compliance with its operating rules, timetables, and timetable special instructions. The stated objectives of the program

are to eliminate human error accidents and to improve employee compliance with and knowledge

of the operating rules and special instructions.

CSXT operating officers, following procedures and instructions contained in the CSXT

Efficiency Test Manual dated April 1, 1993, test

CSXT and Amtrak crews who operate over

CSXT property. Of the 43,566 efficiency tests

performed on the Baltimore Division during the

calendar 1995, 1,334 test failures were recorded.

The Metropolitan Subdivision had 2,357 of those

efficiency tests and recorded 95 test failures. The

majority of the failures involved radio (37) and

safety rule (31) tests.

To comply with 49 CFR Part 240, the CSXT

maintains a Qualification and Certification Program of Locomotive Engineers. For 1995 the

CSXT revoked 66 engineer certifications, which

ranged from 30-day suspensions to permanent

revocations. Thirty-two, 14, and 6 suspensions

involved track authority, signal, and disarming a

safety device violations, respectively.

The MTA/MARC neither has operating rules

for its commuter trains nor performs operational

efficiency tests on traincrews because its trains

are operated by CSXT employees in accordance

with the CSXT operating rules or Amtrak employees in accordance with the Amtrak operating

rules. Amtrak conducts operational efficiency

tests on Amtrak traincrews operating on the

CSXT for observance of the CSXT operating

rules as well as the Amtrak operating rules.

MARC Train Radio Communication--Shortly before the accident, MARC trains 286 and 279

passed each other just west of the Kensington

station, and a radio transmission took place between the engineers of the two trains. The engineer of MARC train 279 provided information

about that interchange, which is contained in the

following synopsis:

The MARC train 279 conductor called his

engineer by radio when they were in Silver

Spring to determine whether he had heard from

MARC train 286 yet. The engineer had not. The

conductor wanted the engineer to notify train

286 that a passenger had boarded train 279 by

mistake. The passenger wanted to go to Baltimore, not Brunswick. Since MARC train 286

had not yet passed Silver Spring, the conductor

said that train 286 could return the passenger to

Washington from the Silver Spring station to

catch the proper train to Baltimore. The train

279 engineer did not transmit that information to

train 286 at that time because the train was still

too far away to contact. He said that the two

trains usually passed each other around Kensington. Around Georgetown Junction, the

MARC train 279 conductor called his engineer

and again asked whether he had heard from

MARC train 286, and again, the engineer had

not. The conductor reported that another passenger had also boarded the wrong train. He said

that if they had not passed train 286 by the time

they arrived at Kensington station, he would let

the passenger off at that station for train 286 to

pick up and return to Washington.

Shortly thereafter, the MARC train 286 engineer contacted the MARC train 279 engineer

and warned him about children in the Garret

Park area who were throwing snowballs near the

track. The train 279 engineer said that at first he

had not quite heard the other engineer and had

to ask him to repeat his message. The train 279

engineer asked the children’s location, and the

train 286 engineer responded that the children

were near the east end of the station platform.

The train 279 engineer at that time began

watching for the children or something on his

track. The train 279 engineer next told the train
25

286 engineer about the passengers at Kensington and at Silver Spring waiting for train 286;

the train 286 engineer had replied that that was

all right. The train 279 engineer, however, had

not told the train 286 engineer on which side of

the tracks the passengers had gotten off.

The MARC train 279 engineer stated that the

radio communications took place near the defect

detector at MP 11.7 between Kensington (MP

11.0) and Garrett Park (MP 12.4). He thought

that the two trains had passed each other near

MP 11.7 and that the rear of his train had possibly cleared the defect detector by four or five

car lengths before the head end of his train

reached the head end of MARC train 286. Between the radio communications of the two engineers, the defect detector was transmitting

messages to the trains over the same radio frequency. The train 279 engineer said that because

of the defect detector broadcast, which is still

conveyed when engineers speak, he and the train

286 engineer were not hearing each other’s

every word. Nevertheless, he believed that they

managed to get across their messages. The

communications began before the trains met and

continued as they passed each other. At the end

of the communications, the train 279 engineer

told the train 286 engineer that everything was

all right behind him, which meant that no snowball-throwing children were behind his train.

The engineer of MARC train 279 said he again

heard the engineer of MARC train 286 use the

radio to call out what he thought was the signal

aspect at Kensington; however, he could not

understand what signal aspect was called because the defect detector radio was broadcasting

its message at the same time.

MARC Train 286 Passenger Load Data--MARC

provided the January and February 1996 passenger load information for MARC train 286. Inclement weather during January forced the cancellation of 6 days of the train 286 scheduled

service. It operated 15 days and had a total ridership count for the month of 72 passengers. The

highest single-day (Friday, January 26) total was

21 passengers. Train 286 had operated 11 days

through Thursday, February 15, and had a total

ridership count of 79 passengers. The highest single-day (Friday, February 9) total was 25 passengers.

CSXT and MARC Operating Agreement--An operating agreement was first effected between the

B&O, now the CSXT operations, and the Maryland State Railroad Administration, now the

MTA/MARC. Their last contracted agreement,

dated November 1, 1985, was renewable for five

additional 5-year periods. The October 1990 operating agreement, in effect at the time of the

accident, has been under negotiation since 1995

for its second 5-year term. The contract provides

that the CSXT service will be “safe and efficient”

and that the CSXT will maintain equipment to

comply with all applicable safety regulations of

regulatory bodies and manufacturers’ standards.

The MTA owns the railroad equipment used for

the MARC service. The MTA/MARC has the

right to review and audit equipment shop orders

and maintenance. The operating contract has no

provision regarding the delineation of responsibility for passenger handling. The CSXT director

of passenger services explained in an August

1996 letter to the Safety Board that the contract

obligates the:

CSXT to handle MARC’s commuter

trains in a manner consistent with safe

operating rules and practices, to operate

them on schedule subject to operating

conditions and overriding safety considerations, and to operate them in a

cost efficient manner.

 

16The 1990 operating contract provides for limited

liability of the CSXT in the event of an accident in passenger service and affords that the MTA indemnify the

CSXT for the first $150 million of exposure per accident. The CSXT is not indemnified for any damages

payable to its employees from an accident; however,

the compensation terms of the contract include a 20-

percent additive to incurred labor costs intended to

reimburse the CSXT for the risk of insuring its own

employees.
26

He continued that the CSXT, as a freight railroad,

does not have special expertise in the handling of

passengers and “is responsible for matters associated with train handling and MARC is responsible for matters relating to the passengers themselves.” The CSXT indicated that its crews were

not specifically trained in emergency procedures

for passenger handling and that MARC, at its

choice, did not supply on-board train personnel.

However, MARC informed Safety Board investigators that it believed that for MARC to provide

its own on-board personnel would have been a

“contradiction to CSXT’s labor agreements.”

(See Appendix E, Organization Charts of the

CSXT and the MDOT/MTA/MARC.)

Meteorological Information

A strong low-pressure system, which was off

the central Atlantic coast on the morning of February 16, moved northeast during the day. Accumulated snow, reduced visibility due to the

snow and fog, and strong winds were associated

with the storm system.

The National Weather Service issued the

following short term forecast at 5:30 p.m. for

Montgomery County:

Winter storm warning continues....

Snow will continue this evening accumulating 1 to 3 inches before tapering to flurries by 7 p.m.... Temperatures will drop into the lower 20s

by 11 p.m. Winds will be north 15 to

25 miles per hour and gusty. There

will be blowing and drifting of snow

as wind chills below zero.

Pathological and Medical Information

MARC Train 286--On February 17, 1996,

autopsies were performed in Baltimore on the

three MARC operating crewmembers and the

eight MARC passengers who were fatally injured in the collision. The Maryland medical

examiner recorded the postmortem examination

reports.

The engineer, who was found on the exterior

left side of cab control car 7752, received fatal

multiple injuries and generalized body burns.

The conductor, who was recovered from the

aisle floor at row 10, sustained fatal multiple

injuries. The assistant conductor, who was discovered lying over a right side seat of row 9,

received fatal smoke and soot inhalation and

generalized body burns. The eight passenger

fatalities were also in cab control car 7752: two

sustained fatal smoke and soot inhalation injuries, three received fatal smoke and soot inhalation injuries plus general body burns, one sustained fatal generalized body burns, another received fatal soot inhalation injuries and generalized body burns, and the final victim sustained

fatal multiple injuries with generalized body

burns. (See figure 12 for the postaccident

placement of fatalities, which was based on information obtained from the MARC train survivors, the MCPD, and the Maryland medical examiner report.)

Amtrak Train 29--The engineer had remained in

the locomotive control compartment and received blunt torso injuries and multiple contusions. The assistant engineer, who jumped from

the locomotive unit before the collision, sustained pulmonary contusions and multiple facial

lacerations. The mechanical rider, who was in

the control compartment of the second locomotive unit, received blunt torso injuries and a

closed head injury. He said that he had been

thrown against the back wall of the locomotive.

He and the two operating crewmembers were

admitted to a local hospital. The conductor in

the midsection of the train sustained a facial

abrasion and stated that he had struck a table.

The assistant conductor in the last car also received a facial abrasion but from striking a seat.

Two on-board service crewmembers sustained

minor injuries. All four employees were treated

at and released from local hospitals. Eight Amtrak passengers received bruises and abrasions

and were taken to area hospitals, treated in the

emergency rooms, and released.

28

Toxicological Information

The postaccident specimens, which were

acquired from the three deceased crewmembers

of MARC train 286, consisted of blood for all

three and tissue and other body fluids, as obtainable under the circumstances. Postaccident

blood and urine specimens were also acquired

from the Amtrak engineer, assistant engineer,

conductor and assistant conductor. The federally

approved laboratory, Northwest Toxicology,

Inc., in Salt Lake City, Utah, conducted the tests

for marijuana, cocaine, phencylidine (PCP),

opiates (morphine and codeine), and amphetamines (amphetamine and methamphetamine)

and for alcohol in accordance with the FRA

postaccident testing program. No drugs or alcohol were identified in either traincrew’s specimens.

The Maryland medical examiner during the

autopsy process conducted a more comprehensive drug screening than the FRA-required testing. Neither other drugs nor alcohol were found

for the engineer and assistant conductor. However, acetaminophen, orphenadrine, and antipyrine were detected in the conductor’s bile and

antipyrine also in his blood. The nonprescription-analgesic acetaminophen relieves pain and

reduces fever. Orphenadrine is a prescription

muscle relaxant. The prescription-analgesicanesthetic antipyrine, applied within the ear,

relieves the pain and swelling of some ear infections and additionally removes ear wax.

At the request of the Safety Board, further

testing on the available specimens was conducted by the Center for Human Toxicology in

Salt Lake City. The test results confirmed the

FRA and medical examiner’s test results.

No postaccident toxicological testing specimens were obtained from the CSXT train dispatcher who was on duty at the time of the accident. FRA regulations require specimens be

provided by the dispatcher following an accident and their testing to occur only should the

dispatcher be “directly and contemporaneously

involved in the circumstances of the accident/incident.” To determine whether the dispatcher should be tested, the CSXT division

manager of operations reviewed the signal log

for the involved railroad line and the audio tapes

of the dispatcher’s conversations before the accident, interviewed the dispatcher, and conferred with the CSXT director of operating

practices. The two CSXT officials noted that the

audio tapes indicated the dispatcher had not

conversed with either traincrew or anyone else

in the area during the relevant timeframe before

the accident. They also determined that the dispatcher had lined the involved signal apparatus

well in advance of the accident and its position

had remained unchanged. As a result of these

observations, the CSXT officials found the dispatcher not “directly and contemporaneously

involved” in the accident and, thus, excluded the

dispatcher from postaccident testing.

Emergency Response

Montgomery County Fire and Rescue Services--

About 5:41 p.m. the MCFRS 911 dispatcher

received at least 12 telephone calls from citizens

who reported the train collision and fire. At 5:42

p.m. the MCFRS dispatcher notified fire and

rescue personnel through a computer activated

dispatch system. Also at 5:42 p.m., the Montgomery County 911 emergency operator received a cellular phone call from the conductor

on Amtrak train 29.

At 5:46 p.m., the first firefighter arriving on

scene reported a fully engulfed passenger car

which he was unable to enter or open the doors.

By 6:15 p.m., an emergency medical services

(EMS) command was established as well as the

fire sectors situated for the management of the

level two incident.

 

17This level of command is appropriate for use on

serious, involved, or extended incidents in which five

or more units are used. It is established at the

direction of the IC and requires a formal command

post and the use of command communications and

incident position designations.
29

The IC said that at 6:30 p.m. his communication center advised him that another train was

approaching the accident site from the direction

of Kensington. The IC staff activated radio

tones and air horns to warn emergency responders to evacuate the scene, and it was cleared for

about 10 minutes until the IC determined that

the approaching CSXT train Q401 was not a

hazard to the emergency responders.

The last victim was removed from the

wreckage by 3:50 a.m. on February 17 and

emergency operations were suspended. During

the rescue operations, five on-scene triage sites

were available for the injured victims, who were

later transported to five area hospitals for treatment.

Under Montgomery County Emergency Operations Center (EOC) direction, two nearby

schools were used to provide victims with shelter, crisis counseling, and staging for transportation. County, emergency management, and

volunteer agencies’ officials and members

staffed the EOC; however, MARC, Amtrak, and

the CSXT were not represented at the EOC.

State, county, and volunteer organizations supplied services at both the accident site and shelters.

Montgomery County Disaster Plan--

Montgomery County has a disaster plan to ensure maximum preparedness for response to and

recovery from any disaster that occurred within

the county. The on-scene IC decided not to fully

implement the disaster plan for this accident

based on the information developed during the

initial response. The disaster command system

(DCS), a part of the plan that provides for multiagency response and integrates the incident

command system used in the field, was activated. The DCS established a standardized operational system with unified command, comprehensive resource management and inter-

 

18Approved by the Governor in 1988 and certified

by the county executive and the county chief administrative officer in November 1995.

agency coordination, and cooperation from the

EOC. The Fire and Rescue Disaster Plan annex

O was also activated. The plan outlines how an

incident will be managed in the field and how

the IC will coordinate with the disaster manager

in the EOC. Additionally, the Greater Metropolitan Washington Area Police and

Fire/Rescue Services Mutual Aid Operational

Plan	 was implemented between Montgomery,

Prince George's, and Howard Counties in

Maryland, Fairfax County in Virginia, and

Washington, DC.

Montgomery County simulated a Washington Metropolitan Area Transit Authority

(WMATA) train derailment in Rockville in February 1995 during which at least 24 people were

transported to hospitals and shelters were established with county agencies' participation. A

hazardous materials incident was also included

in the derailment exercise. In October 1995 another WMATA train derailment was simulated

with casualties during a 30-inch snowfall.

MCFRS units responded on January 6, 1996, to

an actual WMATA train derailment during a

snowstorm, which involved one fatality, at the

Shady Grove station in Gaithersburg, Maryland. The MCFRS had not participated in any

disaster drills that involved MARC, Amtrak, or

the CSXT and in any disaster training or familiarization training with any freight or passenger

railroad that provides service in Montgomery

County.

Amtrak, MARC, and CSXT--Amtrak reported to

Safety Board investigators that about 6:15 p.m.

one of its officers made four attempts within 10

minutes to provide the passenger list and other

information to the MCFRS personnel at the

 

19Part of the Metropolitan Washington Council of

Governments plan and last revised in September

1990. 20Railroad Accident Report--Collision of Washington Metropolitan Area Transit Authority Train T111 with Standing Train at Shady Grove Passenger

Station, Gaithersburg, Maryland, January 6, 1996

(NTSB/RAR-96/04).
30

command center in the adjacent parking lot. He

was finally told that the information was not

needed and he should wait. Later he asked

MCFRS personnel at this command center to

which hospital the traincrew had been taken,

and they told him that they did not know. Amtrak did not locate the traincrew in the hospital

until 10:30 p.m.

The assistant superintendent of the CSXT

Baltimore Division told the Safety Board that on

two occasions at the MCFRS command post and

on one occasion at the accident site, he identified himself and asked to assist. He was told that

his assistance was not needed but to stand by, in

case he would be needed. Another CSXT official was later asked to participate in a media

interview with the MCFRS public relations officer.

Neither MARC nor the CSXT either had an

action plan for accidents or emergencies, in coordination with each other or Amtrak, or had

performed, in conjunction with each other or

Amtrak, any emergency disaster drills or exercises that involved the CSXT operation of

MARC passenger train equipment. In addition,

neither MARC nor CSXT personnel had attended any classroom instructions or hands-on

exercises that included the use of emergency fire

and rescue equipment or procedures.

According to the MARC Interim System

Safety Plan of April 5, 1995, MARC had made

its passenger equipment available in 1995 to the

Brunswick Volunteer Fire Department and to

the Maryland Fire and Rescue Institute for

emergency response training. On April 18,

1995, the Amtrak manager of emergency preparedness had conducted 4 hours of classroom

training and 2 hours of hands-on training at a

MARC facility to members of the Baltimore

County Fire Department and the Cowenton

[Maryland] Volunteer Fire Department. On

October 18, 1995, the Maryland Fire and Rescue

Institute provided a 3-hour class, which included classroom discussion, a photographic

slide presentation, and a tour of MARC passenger equipment at the Brunswick CSXT railroad

yard, for several fire and rescue departments of

Frederick County, Maryland. MARC reported

that it participated in this training by providing

the equipment.

Survival Aspects

MARC Train 286 Occupant Evacuation--Two passengers had occupied the second car, passenger

coach 7720, and exited it through an emergency

window. One of these passengers was injured

and needed assistance. The other passenger lost

his eye glasses after being thrown from his seat

on the left side of the car in the fourth or fifth

row. He said that he had been waiting to buy a

ticket from the conductor when he heard an explosion, the lights went out, and no emergency

lights came on. As he was starting for the rear

exit because displaced seats obstructed the exit

at the forward end of the car, the injured passenger pointed out the right-side emergency

window near the center of the car. He reported

that he pulled the rubber molding around the

emergency window and “then pulled on the

window handle and nothing happened.” He decided to then put one foot on the seat and to

place his other foot on the wall beside the window. He said:

Just so I can get better leverage and I

pull and then it starts coming unstuck,

and the top comes unstuck. So I grab

the top of the actual window with my

hands and pry the rest of it off and

then put that down.

He stated that removing the emergency window

took about 3 minutes and that helping the injured passenger to exit and his own exit required

about 7 minutes more.

 

21Part of the 45-hour Rescue Specialist Training

course that has been offered throughout the State to

full-time and volunteer emergency responders since

1991.
31

Ten of the 18 passengers on board cab control car 7752 survived the accident. The passengers were unsuccessful in opening the left and

right rear exterior doors after the accident. The

ten surviving passengers had exited the train

through an opening created by the misalignment

of the passageway between cab control car 7752

and passenger coach 7720. The longitudinal

misalignment of both cars was about 15 degrees.

Cab control car 7752 came to rest upright and

had rotated vertically clockwise about 10 degrees; passenger coach 7720 had also rotated

vertically clockwise, but about 30 degrees.

Nine surviving passengers were U.S. Department of Labor Job Corps students, and they

stated they had known nothing about the operation of the emergency doors or windows. Some

stated that they did not see any emergency placards explaining the use of emergency exits and

that no crewmember had given any emergency

announcements before the accident. One student

remarked that he had seen the emergency placards but had paid no attention to them. The survivors noted that about half of the students were

asleep before the collision. One stated that he

had been seated in the rear section of cab control car 7752 when the conductor ran from the

front of the car shouting, “Brace yourself! Get

on the floor!” The student dropped to the floor

and held onto the seat on which he had been

sitting. He said that windows had shattered

during the collision, that the car was on fire afterwards, and that he could feel the heat from

the fire on his back. He reported that he crawled

to the rear of the car and tried unsuccessfully to

open both side doors. He saw light through an

opening between the cars and climbed through

the space.

One student, who was sitting next to an

emergency window on the last seat in the rightrear section of control cab car 7752, described

the smoke as extending from about 2 feet above

the floor to the car ceiling. This student said that

he did not have time to open the window and

that he believed he could escape faster by using

the door through which he had entered the car.

Another student stated that the conductor

with another person came from the front of the

car shouting, "everybody run to the back" and

the conductor had reached the midpoint of the

car when the collision occurred. The student

reported that after the collision, he was thrown

between the seats, the lights went out, smoke

came into the car, and that other students were

screaming and running to the rear of the car. He

saw students unsuccessfully attempting to open

the rear side doors, and he explained that because of the fire, no one attempted to open the

emergency windows. He slid to the floor because he could not see or breathe with the

smoke. He observed that while he was on the

floor, one person exited “off the train through a

hole or crack in the train.” He followed another

person through that opening and ran down a hill

to a large residential building. He estimated that

he escaped within 5 minutes.

One student, who had been standing and

talking to another student, stated that he had

seen two crewmembers running rearward

through the car from the control compartment

and had heard them shouting, what he understood to be, “aboard, aboard.” He noted that the

two crewmembers appeared to be expressing

shock and disbelief that another train was approaching on the same track. He said that he saw

the conductor jump behind one of the seats and

that he himself crouched behind and held onto

the last seat on the left side of the car in anticipation of the collision. He recounted that he

proceeded immediately after the crash to the

rear door exits, that he felt the heat from the fire

on his back, and that smoke quickly filled the

car. He reported that he looked “high and low”

for “handles or gadgets or something to open the

doors” but smoke obscured his vision and that

he could find nothing to open the doors. He

added that he pounded with this hands on the

door windows but the glass would not break.

Other students were running toward him,

coughing from the smoke, and yelling for someone to open the doors. He also heard banging

and kicking noises that suggested other passengers were attempting to open or break windows.
32

Firefighter Evacuation Action--The first firefighters to reach cab control car 7752 observed

the car fully engulfed by fire and found no survivors. The firefighters said that they attempted

to open the right-rear door of the car with an ax,

a halligan tool, and a 10,000 psi hand-pumped

hydraulic tool. The door had opened about the

width (0.5 foot) of the ax head, could not be

opened any farther, and closed when the tools

were removed. One firefighter reported that he

had observed two victims within 0.5 foot of the

right-rear vestibule door of cab control car 7752.

He stated that he then endeavored to find another entrance into the car because the door

could not be opened.

Subsequently, the firefighters broke the first

right-side window on passenger coach 7720 and

entered that car through the broken window.

They exited passenger coach 7720 through the

damaged left-front door and crawled down to

the ballast on the north side of the train. Two

firefighters crawled up on the couplers and entered cab control car 7752 through the diaphragm opening that had been used as an escape

route by the surviving passengers from the car.

After the two entered the cab control car 7752, a

third firefighter passed a hand line through a

small opening between the two cars. (Because

of the angle at which the cars came to rest, no

person could pass through the vestibules from

one car to the other car.) The firefighters in cab

control car 7752 proceeded to suppress the fire

and search for victims.

The firefighters stated that they had not observed either any exterior instructions detailing

how to open the emergency windows or the location of the emergency door release handles on

the car exterior.

Tests and Research

Locomotive Event Recorders--MARC unit 73

was equipped with a Pulse MTR magnetic tape

event recorder and Amtrak units ATK 255 and

811 were equipped with Pulse Train Trax®

solid state event recorders. The Pulse solid state

event recorders on Amtrak units ATK 255 and

811, respectively, used a FAK PAK® removable recording media and a nonremovable memory module with battery-backed SRAM memory.

The event recorders were removed from

MARC unit 73 and the Amtrak lead unit ATK

255 under Safety Board supervision between 9

and 10:30 p.m. on February 16, 1996. The event

recorder from the Amtrak second unit ATK 811

was not removed but was downloaded the next

morning. The readouts of the three event recorders were successfully performed between 1

and 10 a.m. on February 17. A subsequent review of the raw electrical wave forms from the

MARC unit 73 event recorder data was performed on March 26 and 27, 1996, using Safety

Board laboratory hardware and WAVES software, which was required to establish more accurate timing of events than possible with the

manufacturer readout software.

MARC Train 286 and Amtrak Train 29 Movement--At 4:45 p.m., shortly after its eastbound

departure from Brunswick on track 2, MARC

train 286 was stopped behind the eastbound

CSXT freight train Q401, which had been disabled beyond Point of Rocks, Maryland. The

MARC train 286 engineer radioed the AU dispatcher, who directed him to make a reverse

(westbound) move on track 2 to Point of Rocks

and to cross over there onto track 1. MARC train

286 departed Point of Rocks eastbound on track 1

at 4:55 p.m., traveled eastward for 12 miles

around the disabled train, and returned at 5:11

p.m. to track 2 at MP 30. The event recorder data

indicated that the train stopped at the Rockville

station, accelerated to 74 mph, maintained for

about 1 minute a speed of between 72 and 74

mph, and 3 minutes 15 seconds and 2.9 miles

from that station initiated dynamic braking near

the signal at MP 13.78. The train then decelerated under dynamic braking for 1 minute 33

seconds and 1.33 miles until attaining a speed of

20 mph near the Garret Park station (MP 12.4)

and subsequently accelerated for 1 minute 13

seconds and 0.8 mile until reaching 53 mph near
33

the defect detector at MP 11.7. Westbound

MARC train 279, operating on track 1, passed

eastbound MARC train 286, still operating on

track 2 at 53 mph, near a dragging equipment detector 0.7 mile west of the Kensington station.

The train 279 engineer then advised the train 286

engineer that passengers were to be picked up at

the Kensington and Silver Spring stations.

MARC train 286 at this time decelerated at

idle throttle for 26 seconds and 0.36 mile, then

its engineer initiated dynamic braking at a speed

of 46 mph, and 6 seconds later the train passed

signal 1124-2 at 44 mph. It stopped 42 seconds

and 0.2 mile later at the Kensington station and

remained there about 50 seconds. The event recorder data indicated that it had traveled about

2.18 miles after leaving the station when an

emergency brake application was made at 66

mph. Dynamic and independent braking began

about 6 seconds and 540 feet after the emergency brake application, and the traction motor

current for dynamic braking increased to 375

amps. The train was traveling approximately 49

mph when, about 6 seconds and 460 feet later

(1,000 feet after the emergency brake application), the reverser on MARC unit 73 was moved

from reverse to forward. The traction motor current decreased to 0 amps when the direction of

travel changed, and the axle generator drive

wheel of MARC unit 73 stopped rotating about

13 seconds and 500 feet later (1,500 feet after

emergency brake application). Rapid deceleration at a speed of about 38 mph, consistent with

impact with Amtrak train 29, occurred during

this time.

Amtrak train 29 departed Union Station 1

hour 20 minutes late (about 5:25 p.m.) because of

electrical problems with Amtrak unit ATK 811.

The train was routed westbound on track 2 behind MARC train 279, which had departed 9

minutes earlier. The engineer of Amtrak train 29

stated that at MP 6.5 he received an APPROACH

MEDIUM signal indication, which limited the

train speed to 30 mph approaching the next signal, and he began reducing the train speed in the

Silver Spring area. He noted that he neither had

radio communications nor overheard any transmissions during that time. The engineer said that

he received a MEDIUM CLEAR indication from

westbound absolute signal (WAS)-2 for Amtrak

train 29 and looked again at the signal to confirm

the indication and, also, that CSXT train K951

was stopped at WAS-1 on track 1 east of the

Georgetown Junction.

According to the event recorder data from

Amtrak units 255 and 811, Amtrak train 29 had

traveled about 7.7 miles since its last stop and

had been moving for about 1 minute between 27

and 32 mph when data variations, consistent

with impact, occurred at 32 mph. Eight seconds

before the data ended, the throttle had been

moved from position three to four; about 5 seconds and 250 feet before the data ended, a 10

psi automatic brake pressure reduction had been

made. The engineer stated that when he saw

MARC train 286 moving toward his train, he decided that a collision was imminent and, thus, to

remain at his operating position and to accelerate

the train in an attempt to prevent a head-on collision. However, the postaccident investigation

found no recorded change in speed.

Sight Distance--Tests were conducted on February 19, 1996, between 5 and 6 p.m. to determine the optimum sight distance to the wayside

signals as they would have been observed by the

MARC train 286 crew at Kensington and

Georgetown Junction. A similarly configured

MARC train was used in the push mode on eastbound track 2. The weather conditions could not

be replicated; however, the MARC train 279,

CSXT train K951, and Amtrak train 29 engineers

had reported no difficulties seeing signal indications during the intermittent snow showers on

February 16. The eastbound signal 1124-2 at

Kensington, 885 feet west of the station, was displaying an APPROACH signal aspect (see table

1). The optimum sight distance to this signal was

4,299 feet. EAS-2, the next signal, was 13,786

feet east of eastbound signal 1124-2, and a STOP

signal aspect (see table 1) was visible at 1,737

feet.
34

Signals--After being notified of the accident,

the Safety Board had requested that all signal

instrument houses be sealed. A preliminary investigation, which entailed a visual inspection

of all signals, began about 8:15 p.m. at the

Georgetown Junction control station and continued until all involved signal cases were unsealed, including the signal cases east and west

of Georgetown Junction and Kensington. The

investigation documented the position of vital

relays and tested for grounds or combinations of

grounds at the energy bus. No grounds as well

as no evidence of tampering were found at any

signal instrument house.

Other tests performed to determine that circuits were effective and functioning properly

included battery voltage readings; route, time,

and switch indication locking; time release relays; and cable meggering.All test results indicated compliance with FRA regulations. Voltages of 9.8 and 10 volts d.c. were recorded at

eastbound signal 1124-2, respectively, for the

top marker lamp and the APPROACH indication (see table 1). No signal lamps were burnedout.

Operational tests pertaining to the involved

routes were conducted, and switch and track

circuit relays were manipulated because of the

track structure absence. A route was established

at Georgetown Junction for a westbound move

from track 2 to 1 with switches 1 reverse and 3

and 5 normal. WAS-2 was cleared and a MEDIUM CLEAR indication was observed (see

table 1), and EAS-2 at Georgetown Junction

displayed a STOP indication (see table 1). As

the two simulated trains proceeded toward each

other, EAS-2 was repeatedly requested for a

PROCEED indication and never displayed other

than a STOP indication. The Kensington eastbound signal 1124-2 never displayed other than

an APPROACH indication.

 

22Testing for the electrical resistance of wire and

cable insulation.

During the time-locking tests, the time element relay on tracks 1 and 2 was, respectively, 8

minutes 9 seconds and 8 minutes 13 seconds.

The November 3, 1994, CSXT test records

showed that tracks 1 and 2 were 8 minutes 10

seconds and 8 minutes 5 seconds, respectively.

The Georgetown Junction signal event recorder

data and the Jacksonville system log were compared. The event recorder data indicated that

MARC train 286 passed eastbound signal 1124-

2 about 5:34 p.m. and that the collision occurred

about 5:39 p.m. (total elapsed time of 4 minutes

44 seconds). The system log recorded that the

train passed the signal about 5:36 p.m. and that

the collision occurred about 5:41 p.m. (total

elapsed time of 4 minutes 46 seconds). The collision occurrence was based on the Georgetown

industrial track switch being “out of correspondence” (not in proper position).

After the on-site investigation, a meeting was

held at the CSXT headquarters in Baltimore to

document complaints about the signal system

operation. (See appendix F.) The Safety Board

proposed at this meeting that further testing be

performed at Georgetown Junction and specifically requested the presence of the involved

parties for the investigation. After the damaged

track and turnouts were replaced, additional

testing for route and time locking were performed on May 28, 1996. During these tests,

EAS-2 displayed only a STOP indication, and

eastbound signal 1124-2 remained at an APPROACH indication until the track circuit east

of the signal was shunted and then displayed a

STOP and PROCEED indication.

Stopping Distance--The Safety Board conducted these tests on November 23, 1996, using

train equipment similar to MARC train 286, to

determine whether differences were in the stopping distances between the push and pull modes

of train operation and from moving the reverser

from the reverse to forward position during

emergency braking. The tests were performed

on relatively flat straight tracks on the Amtrak

northeast corridor near Bowie, Maryland. The

weather was clear with the temperature at 40 o

F.
35

Five tests were done each in the push and the

pull modes with speeds ranging from 59 to 66

mph. The stopping distances extended from

about 1,200 feet at 59 mph with dynamic and

emergency braking to about 1,900 feet at 66

mph with only emergency braking. The test results indicated no significant differences in

stopping distance between the push and the pull

modes of operation; however, use of the reverser did eliminate dynamic braking and, thus,

increase stopping distance. MARC train 286 at

66 mph (recorded speed before emergency brake

application), according to the test data, would

have required approximately 1,650 feet of stopping distance after an emergency brake application with dynamic braking until stopped compared with approximately 1,900 feet of stopping

distance after an emergency brake application

using the reverser with no dynamic braking after

49 mph. The test data also demonstrated that

retaining dynamic braking until impact, MARC

train 286 would have collided with Amtrak train

29 at 34 mph (recorded collision speed of 38

mph), resulting in an additional 0.3 second of

elapsed time and in Amtrak train 29 advancing

about 14 feet farther into the crossover before

impact.

Passenger Train Air Brakes--Some locomotives, such as those operated on Amtrak, automatically combine dynamic and pneumatic

braking, which is called blended braking, for

greater efficiency and less mechanical wear.

MARC locomotives, such as the one involved in

the accident, are designed to apply the dynamic

brakes automatically during emergency braking,

and the dynamic brakes supplement the pneumatic braking. The dynamic brakes continue to

apply in emergency until a wheel slip occurs, or

the reverser is moved, at which time the dynamic braking discontinues and the braking is

fully pneumatic. Moving the reverser during

emergency braking resets the electrical contacts,

which interrupts the dynamic braking circuits,

drops the electrical load, and eliminates the dynamic braking; thus, moving the reverser during

emergency braking causes a loss of the additional braking effort that the supplemental dynamic braking provided.

The CSXT engineer training in place at the

time of the accident had advised that reverser

use on a locomotive in motion was inappropriate

unless “the brakes fail when a locomotive is

being moved at low speed without any cars attached” and other operational use would “increase braking distance due to wheel slide.” The

training material did not indicate that using the

reverser would eliminate dynamic braking. The

CSXT training and mechanical officials stated

that they were unfamiliar with the automatic

dynamic braking feature that occurred during

emergency braking on the MARC locomotives.

Cab Control Car 7752 Doors--The tests and

disassembly of the rear interior door performed

by the Safety Board on May 2, 1996, revealed

that the debris within the door wall pocket and

floor track had prevented the door from closing.

The right-side rear door interior emergency handle and T-handle were pulled downward and

were functional. The right-side rear door was

manually opened and slid into its car body

pocket. The left-side rear door contacted a loose

sheet metal panel in its car body pocket when

the door was manually opened and, therefore,

could be opened only about 12 inches.

The left-side door opening mechanism was

removed and tested in the Washington, DC,

Safety Board laboratory. Test results showed no

mechanical damage but all electrical components had thermal damage. Sealant melting and

then hardening on the pinion and ball bearing, as

a result of the fire, caused the resistance to rotation of the motor shaft and to movement of the

pinion bearing and the fused toggle spring and

self-aligning spherical bearing, which contributed to the inoperable emergency handle on the

left-side rear door.

MARC Passenger Coach Car Interior Materials--

The Maryland Department of Transportation

(MDOT) purchase contract for 11 passenger

cars, including cab control car 7752, contained

the following smoke and flammability specifications:
36

All materials used in the interior of the

car (that is, all materials inboard of the

structural shell and including, but not

limited to, liners, floor panels, thermal

and acoustic insulation, seats and

cushions, floor covering materials,

wainscots, carpeting, glazing materials, and light fixture lenses) shall have

the highest degree of fire resistance

and lowest smoke emission consistent

with the other qualities required. As a

minimum, all materials used in the interior of the car shall meet the requirements of the U.S. Department of

Transportation’s [DOT] “Proposed

Guidelines for Flammability and

Smoke Emission Specifications.”

To determine the compliance of the MARC

car interior materials with the flammability and

smoke requirements, tests were conducted on

materials from an exemplar MARC passenger

car by the University of Maryland Department

of Fire Protection Engineering at College Park,

Maryland. (See appendix G.) These tests were

governed by the FRA recommendations for

testing the flammability and smoke emission

characteristics for commuter and intercity rail

vehicle materials.

The tested materials, consisting of the major

combustible items in the car, included the upholstered portion, but not the rigid plastic siderail and back components, of the seats (see figure 13); the ceiling lining, which was similar, if

not identical, to the other wall lining and partition materials; and the window mask material.

The pad cushion materials of the seat passed the

 

23Developed by the DOT in 1979 and used by the

transit industry in general on a voluntary basis, these

guidelines were superseded by the “Recommended

Fire Safety Practices for Rail Transit Materials Selection,” published in 1984 by the Urban Mass

Transportation Administration, now the Federal Transit Administration. The recommended practices

formed the basis for the FRA recommendations for

testing the flammability and smoke emissions characteristics of commuter and intercity rail vehicle materials, published in January 1989.

smoke criterion but failed the flammability criterion. The fabric upholstery seat covering

passed the flammability test but failed the

smoke test in the flaming mode. The vinyl seat

coverings passed the flammability test but failed

the smoke test in the nonflaming mode. The

ceiling panel passed both the smoke and flammability criteria; however, the window mask

material failed both criteria. Floor materials

were not included in the tests because the cab

control car 7752 floor was not destroyed by the

fire.

Fuel Oil Presence--On March 18, 1996, fire

debris samples were collected from MARC cab

control car 7752 and second car 7720 to document the presence of diesel fuel. The chromatographic results from three samples from cab

control car 7752 revealed weathered diesel fuel

mixed with heavier unknown petroleum hydrocarbon.

Postaccident Actions

National Transportation Safety Board--On

March 12, 1996, during its investigation of this

accident, the Safety Board issued the following

four urgent safety recommendations (see appendix H) to improve the safety of the rail commuting public:

--to the Maryland Mass Transit Administration:

Install removable windows or kick

panels for emergency exits in interior

and exterior passageway doors. (R-96-

4)

Install an easily accessible interior

emergency quick-release mechanism

adjacent to all exterior doors. (R-96-5)

Install retro-reflective signage on car

interiors and exteriors at emergency

exits that contains easily understood

instructions and clearly marks all

emergency exits (doors and windows).

(R-96-6)
37

Figure 13--Photograph of typical seats in MARC passenger cars.

--and to the Federal Railroad Administration:

Inspect all commuter rail equipment to

determine whether it has: (1) easily accessible interior emergency quickrelease mechanisms adjacent to exterior

passageway doors; (2) removable windows or kick panels in interior and exterior passageway doors; and, (3)

prominently displayed retro-reflective

signage marking all interior and exterior emergency exits. If any commuter

equipment lacks one or more of these

features, take appropriate emergency

measures to ensure corrective action

until these measures are incorporated

into minimum passenger car safety

standards. (R-96-7)

Federal Railroad Administration--The FRA

stated that because this and the recent train accident in Secaucus, New Jersey,had caused serious concerns about certain aspects of the safety of

passengers and railroad employees, it issued on

February 20, 1996, emergency order (EO) 20 to

all railroads. (See appendix I.) The MARC operations were covered by EO 20, which required

the CSXT to modify operating rules covering

delays in block and crew communications and

MARC to address the operation and inspection of

and the instructions on emergency exits as well as

to provide interim system safety plans.

 

24Railroad Accident Report--Near head-on Collision and Derailment of Two New Jersey Commuter

Trains near Secaucus, New Jersey, on February 9,

1996 (NTSB/RAR-97/01).
38

Maryland Transportation Administration and

Maryland Rail Commuter--Either the AU dispatcher or the chief dispatcher at the CSXT operations center in Jacksonville relays nonemergency information to MARC and Amtrak through

a passenger coordinator desk, which provides this

information to the MARC operations center

 at

Baltimore Washington International (BWI) airport, Maryland. To manage emergency situations

that require immediate attention, the dispatcher

and the MARC operations center use a direct line.

When the CSXT dispatcher became aware of

the collision between MARC train 286 and Amtrak train 29, the CSXT manager of operations

support (MOS) in Jacksonville tried telephoning

the MARC BWI operations center about 5:45

p.m., but the phone line was busy. While trying to

reach the MARC operations center, the MOS did

inform the CSXT passenger services director in

Jacksonville and both CSXT managers of passenger operations in Baltimore. The MOS stated that

he was unable to get through by telephone to the

MARC operations center until 6 p.m., at which

time he was informed that “they knew” about the

collision and were very busy. Some MARC officials who had the Amtrak alphanumeric pagers

were made aware of a MARC train involvement

in the accident only by reading messages meant

for the Amtrak personnel. Since the accident, the

CSXT and MARC have established direct communication procedures to be followed in the

event of an emergency situation and have available a dedicated phone line for emergency notification. In addition, the CSXT has access to the

MARC officers’ alphanumeric pagers.

CSX Transportation Inc.--In response to the

FRA EO 20, the CSXT installed D markers (see

figure 9) for use in passenger train operations to

 

25Its consoles mirror the CSXT AU dispatcher display screens and monitor the AU dispatcher radio

communications on channels only in use by the dispatcher. From this information, the commuter train

passengers are advised by a station public address system of train arrivals and delays and passenger boarding

directions.

remind train operators of the requirements in the

revised CSXT operating rule 269 (TCS system),

which states:

When a train has passed a signal permitting it to proceed (other than a Restricting, a Stop and Proceed at Restricted Speed, or Grade aspect) and is

stopped in the block, the train must

proceed prepared to stop at the next

signal. This must be done until it can

be seen that the next signal permits the

train to proceed.

Exceptions:

A. This rule does not apply to

passenger trains, making station

stops, this includes push-pull, or

MU [multiple-unit] passenger

trains:

1. Equipped with automatic train control/cab

signal apparatus

or

2. Operating immediately preceding an intermediate signal, however, rule 98-G does

apply.

Passenger trains in push-pull, or MU

service not equipped with automatic

train control/cab signal apparatus, or

operating immediately preceding an

absolute signal be governed by exception (B) below.

B. If a passenger train in pushpull, or MU service has passed

a block signal that permitted it

to proceed, (other than an approach, a restricting, a stop and

proceed at restricted speed or

grade aspect), and

1. Is stopped in the

block

or
39

2. The train speed is reduced below 10 mph.

The train must proceed prepared

to stop at the next signal not exceeding 40 mph. The train must

not exceed the indication permitted by the previous signal.

This must be done until,

a. The next signal

is clearly visible,

b. That signal displays a proceed indication, and

c. The track to that

signal is clear.

National Railroad Passenger Corporation--In

October 1996 as the first of 20 planned installations, Amtrak made the OREIS

 software available to the Montgomery County fire department

and rescue communications center to assist first

responders to train accidents. The software provides schematics of Amtrak cars and locomotives with layout information about the seating

configuration, the emergency exit doors and

windows, and the electric and fuel sources.

Cooperative Organization Activities--Also

since the accident, MARC, in cooperation with

the CSXT and Amtrak, has developed and distributed video training material for emergency

responders. The MTA safety department, in

conjunction with MARC, the CSXT, Amtrak,

and the Maryland Fire and Rescue Institute, has

effected a training course for emergency responders and scheduled several training dates.

MARC and the MCFRS have initiated a training

program to become familiar with emergency

equipment on the MARC passenger trains.

 

26Operation Respond Emergency Information System,

developed by the Operation Respond Institute, Inc.,

of Washington, DC.

Other Information

Maryland Mass Transit Administration--As the

modal administration of the MDOT, the MTA

operates the MARC train service as well as the

light rail, subway, and bus services for approximately 370,000 passengers each day. The MARC

train service averages 20,000 passenger trips

daily compared with 50,000 and 20,000 passenger trips daily, respectively, for the subway and

light rail operations.

Regularly scheduled daily (Monday through

Friday) MARC commuter rail service is provided

on the Camden and Penn Lines between Baltimore and Washington and on the Brunswick Line

between Martinsburg, West Virginia, and Washington. The CSXT and Amtrak, under contract,

operate daily 40 and 39 trains, respectively. The

MARC weekday schedule for the Brunswick and

Camden Lines was last revised on December 11,

1995. (See appendix J.) Nine scheduled MARC

passenger trains are provided daily in each direction on the Brunswick Line. Two morning

MARC trains originate and three evening MARC

trains terminate in Martinsburg, and Brunswick is

an intermediate stop for these trains. The remaining MARC trains originate or terminate in

Brunswick.

In addition to a chief transportation officer,

the MARC operating staff consists of three

trainmasters, who address the station operations,

such as the condition of the platforms and walkways, and ten staff personnel, who act as ticket

agents, operations clerks, and customer service

representatives. The MARC trainmasters also

respond to passenger complaints and resolve passenger operational issues with the CSXT; they

have no responsibility for or authority over train

handling.

The CSXT and Amtrak supply and supervise

the traincrews, control the train movement dispatching, and provide the equipment maintenance, depending on whose property is being

used. The CSXT, under its contractual agreement,

allocates two managers of passenger operations,
40

who supervise the CSXT traincrews. MARC pays

the cost of these positions. The on-duty CSXT

conductors and assistant conductors are required

to wear MARC uniforms, which MARC supplies,

to assist passengers in identifying the traincrew.

The CSXT engineers are not required to wear

the MARC uniforms because they do not have

direct contact with the passengers.

The CSXT, sometimes in coordination with

MARC, issues Passenger Service Bulletins to

cover unique circumstances that occur during the

operation of MARC trains. These bulletins include passenger safety alerts, schedule change

notices, and general guidance. The CSXT and

MARC were developing a passenger conductor’s

guidance manual that incorporated the Passenger

Service Bulletins, which MARC had been reviewing at the time of the accident and is still

reviewing now.

MARC Train Accidents--During the previous 5

years, the CSXT reported two train accidents that

involved MARC trains operating on the CSXT.

Both accidents involved nonrail equipment fouling the track on the Camden Line between

Washington and Baltimore. In one accident,

MARC train 244 collided with a backhoe that

was fouling the track near Hanover, Maryland, in

December 1992. Neither a derailment nor injuries

were reported, and the equipment damages were

$15,000. The second MARC accident occurred

when an empty MARC train, being moved in the

push mode to Washington by a CSXT crew, collided with a concrete pouring boom fouling the

track near College Park, Maryland, in November

1993. The cab control car derailed and the engineer and two private-contractor personnel sustained injuries; the damages were estimated at

$475,000.

Maryland Department of Labor and Industry--

The Maryland Department of Labor and Industry (MDLI) is accountable for occupational

safety and health in the State of Maryland. It is

responsible for boiler, amusement ride, and elevator as well as railroad safety. The MDLI has

an agreement with the FRA to conduct inspections, and three MDLI railroad safety inspectors

work, under the FRA state participation program, in the track, operating practices, and motive power equipment disciplines by reporting

through the FRA and its reporting system. The

MDLI is unable to perform independent inspections, must conform to the FRA inspection

regulations, and must channel all activities

through the FRA; consequently, the MDLI is not

permitted to have an independent inspection

program.

The MDLI has jurisdiction over some areas

where the FRA would not be involved, such as

private yards where it inspects the tracks, but it

has no jurisdiction over rapid rail systems,

which include the two metro systems and the

light rail system in Baltimore. However, it does

inspect some of the track in the light rail system

because freight operations are on some of that

track. It has little direct relationship with the

MTA regarding railroad issues, but it does all

MARC inspection activity (operations, mechanical, and track) that would be done with the

operating carriers such as Amtrak and CSXT.

According to the MDLI, its inspection reports

are sent directly from Amtrak or the CSXT to

MARC, and it does not work directly with

MARC, unless specific issues arise that put

them in contact from the inspector level to the

operating level.

The MDLI has no signal inspector and had

no responsibility for oversight of the design and

installation of the CSXT signal system modifications on the Brunswick Line, and it stated that

it believed the FRA had the oversight responsibility. As recently as 1989, the MDLI had about

eight inspectors; currently they have only three,

even though the number of passenger and commuter trains has increased. The MDLI informed

the Safety Board that it is considered the monitor of carriers in the State and not the safety

system for the State. The MDLI was aware of

the FRA EO 20 but had not participated in the

development of that order and had not seen it.

Also the MDLI had not participated in the development of the MARC interim system safety

plan submission to the FRA.
41

Brunswick Line Signal Modifications--About

1985, MARC requested the CSXT to allow

more commuter trains on both the Camden and

Brunswick Lines. (MARC wanted to add 22

trains on a daily basis between 5 and 10 a.m.

and between 4 and 9 p.m. in addition to the

January 1, 1990, schedule.) The CSXT provided

cost estimates in 1986 after which an agreement

was signed. The development of a joint project

to increase the service capacity of the corridor

from Baltimore to Washington to Brunswick

was begun in August 1988. The project was designed to permit signaled, dispatcher-controlled

movement between main tracks in either direction. In April 1990, the Board of Public Works

awarded a project contract of $13.085 million to

the CSXT. The areas covered were the 40 miles

from Camden Station to Union Station and the

50 miles from Brunswick Station to Union Station. The Federal Transit Administration

(FTA), formerly the Urban Mass Transit Administration (UMTA), the CSXT, and the

MDOT were to pay, respectively, 75, 12.5, and

12.5 percent. The MTA and the CSXT would

divide any cost overruns of the modifications by

87.5 and 12.5 percent, respectively.

The signal modification project was designed

in 12 phases, and plans were subsequently issued in October 1991. Construction began south

of Baltimore and proceeded towards Brunswick.

Track changes during construction necessitated

changes in signal design, which were approved

by MDOT. New crossovers were proposed for

several locations which included MP 19.7 at

Derwood, Maryland. The crossover installation

at Derwood added a new control point (CP),

which required respacing the signals between

Georgetown Junction and Derwood. As a result,

additional safe braking distance for mixed

freight and passenger operation was achieved by

reducing from four to three the number of intermediate signals between Georgetown Junction and Derwood.

 

27Established in 1968, under the Urban Mass

Transportation Act of 1964, to administer Federal

grants to urban mass transit projects for new acquisition, construction, and operations and for the improvement of existing facilities and equipment.

The project was completed in July 1993 at a

final total cost of $17.085 million. The MTA

paid the cost overrun of $3.9 million plus $0.10

million for the final inspection. The Federal and

State interest in the fixed assets of the signal

system will be 87.5 percent for the 15-year life

of the improvements. At the end of this 15

years, July 2006, the CSXT assumes full ownership.

Federal-Grant-Requested Signal Project--In

accordance with the FTA act under which Federal assistance is allocated, the FTA provides

grants through section programs of discretionary

and formula funds. Discretionary funds are allocated at the discretion of the FTA administrator,

and the formula funds are apportioned by a

statutory formula based on population, population density, and various transportation data.

The FTA obligated, for example in 1995, approximately $2.6 billion of discretionary funds

and about $3.1 billion of formula funds. According to the FTA, local organizations and

transit systems submit grant applications to the

appropriate FTA regional office. The grantees

self-certify that they have the legal, financial,

and technical capacity to engage in the project

for which they are applying for FTA funding.

In May 1987 the MDOT applied to the FTA

for a rail modernization grant of approximately

$9.8 million to assist in the financing of a fiscalyear 1987 capital project, generally described as

the “installation of centralized traffic control

system on MARC/CSXT Lines.” The MDOT

State Railroad Administration (now the MTA)

was delegated to administer this project. In addition to the Federal funds, the MDOT and the

CSXT would each provide about $1.6 million

for the project. The grant application included

the excerpted project justification:

 

28The MTA indicated that for a $940-million 6-

year-period (1996 through 2001) capital program,

approximately $667 million of Federal funds were

anticipated. MARC would account for $390 million,

of which $294 million would be Federal funds, of this

$940 million.
42

The centralized traffic control (CTC)

system on the CSXT lines will modify

the method and efficiency of train

control and operations, thus providing

increased system capacity, and consequently allowing expanded use of the

CSXT lines for commuter rail operations. More specifically, the CTC will

permit:

the addition of trains in bidirectional service during peak periods: head-ways could be reduced

to twenty minutes in each direction. This would provide the capacity to double service levels on

the Brunswick Line and triple

service on the WashingtonBaltimore Line.

the addition of bi-directional service in off peak periods: Midday,

evening, weekend, and special

event service will be possible, enhancing commuter as well as shopper, tourist, and non-work related

trips by providing increased flexibility in scheduling trips.

continued safe, combined movements of freight and passenger

trains on the CSXT lines. By

minimizing the possibility of conflict between freight and passenger

traffic through computerized

monitoring and control of movements, the CTC will enhance the

safety of MARC and CSXT operations.

When questioned whether it would conduct a

safety analysis of the project, given the above

statements in the project justification, the FTA

indicated that a safety analysis, or at least a preliminary safety analysis, would be done at the

local level as the entities develop their transportation improvement programs. Under those

auspices FTA employees would not review the

grant application because the grantee has certified the technical capacity to undertake the project. For this particular grant, according to the

FTA, the budget included $450,000 for engineering, which would be the design of the signal

system upgrade, and that would be conducted by

the grantee or the grantee contractor, in this case

the CSXT. Because this grant application involved an upgrade to the signal system, Safety

Board investigators questioned whether the FTA

had in-house signal expertise or would look to

the FRA for any guidance on the benefits or

shortcomings of the MDOT proposed signal

project. According to the FTA, it had no inhouse signal expertise and no communication

with the FRA regarding this project because it

was not required to have the FRA involved. The

FTA has indicated that subsequent to the Silver

Spring accident, the FTA administrator has requested that the FRA become more involved in

reviewing operational plans and safety proposals

for grantees, including commuter railroads.

The MDOT grant project (exhibit A) description included:

The improvements envisioned in this

program provide the foundation for the

next “generation” of train control systems: advanced train control system

(ATCS). This system will permit discrete train identification and provide

remote override operation of the train

itself. The technology for ATCS is

progressing with significant commercial applications starting in 5-10 years.

The FTA or the MTA did not follow up the

MDOT pursuit of this technology. According to

MARC officials, the industry had no consensus

on ATCS or commercial applications at the

time.

Following the approval of the grant, the

CSXT and the MDOT/MTA signed an agreement in March 1990 regarding the installation of

the CTC system on CSXT lines. The signal

system, according to the agreement, would be

designed in compliance with all applicable Fed-
43

eral and State requirements and installed by the

CSXT. The MTA would have the right to review and comment on the design and construction plans. However, the CSXT, according to

this agreement, would have exclusive control

over the design, installation, and operation of

the signal system. The agreement stated that “at

the end of 15 years, which is calculated from

July 1, 1991, or the operational start date,

whichever comes first, CSXT will assume full

ownership of the fixed assets and UMTA’s and

SRA’s [State Railroad Administration] net salvage credit shall be reduced to zero.”

CSXT Signal System Modification Design--The

CSXT uses several equal factors in the determination of signal spacing and traffic density.

First, if it is necessary to run trains on short

headway,	 the signals will need to be spaced

close enough to allow the trains to move safely

behind one another. The aspects displayed by

the signals must inform the train engineer what

actions need to be taken to safely advance the

train. Another factor is the train braking distance

required to stop or slow a train to the prescribed

speed, conforming to the signal indication with

respect to the operating rules. The CSXT standard braking distance for freight trains is 11,000

feet for 55-mph operation or greater than 13,000

feet for 60-mph operation.

When signals must be spaced closer than

three-aspect breaking will allow, a fourth aspect

needs to be employed so that trains would be

operating at less than maximum authorized

speed should conditions require the train to stop.

In a two-block three-aspect signal system, a

normal signal progression would be CLEAR,

APPROACH, and STOP. As example of a threeblock four-aspect signal system, the normal signal progression would be CLEAR, APPROACH-MEDIUM, APPROACH, and STOP.

 

29Time separation between two trains traveling in

the same direction on the same track, which is measured from the instant the head end of the leading train

passes a given reference point until the head of the

train immediately following passes the same reference

point.

When freight and passenger trains both operate

on the same set of tracks, the more restrictive

braking data for freight trains is used.

The proposal to install the TCS operation on

the Brunswick and Camden Lines was conceived, designed, and constructed to increase the

capacity of these subdivisions to accommodate

additional traffic proposed by MARC. The operating headway to meet the MARC scheduling

request was a 15-minute headway during the

most dense scheduling periods and a significantly more-than-15-minute headway in other

nonpeak periods. To increase the capacity on the

Metropolitan Subdivision, the TCS operation

was proposed with crossovers at MPs 19.7 and

29.9 as well as a power turnout to access the

Potomac Electric Power Company plant at MP

37.

To accommodate the braking requirements

for freight trains, the intermediate signal spacing

needed to be no less that 11,000 feet. Automatic

signals 99 and 100 at MP 10 were part of a single direction, automatic block signal system in

service between CP Rocks at MP 42.8 and CP

Georgetown Junction at MP 8.5. The control

circuitry for these signals was inconsistent with

the controls required for TCS operation because

it had been designed for one direction operation.

The last automatic wayside signal before the

CSXT signal modification project had been signal 100, which had been east of the Kensington

station platform. Additionally, signal 100 was

less than the 11,000 feet minimum braking requirement from the EAS-2 signals at CP

Georgetown Junction. As a result of the signal

modifications, signal 100 was replaced by signal

1124-2, which was now the last automatic wayside signal before EAS-2 for Georgetown Junction and was west of the Kensington station

platform.

Neither the FRA nor the MDOT/MTA reviewed the CSXT design of the proposed signal

system modification before installation. The

CSXT did not have to apply to the FRA to review and approve the proposed CSXT signal

modifications on the Brunswick Line. The FRA
44

made changes in 1984 to the regulations (49

CFR Part 235). An extensive list of changes was

developed that the FRA believed should not require prior approval to implement a signal modification;
 therefore, the installation of the TCS

system to replace an automatic block signal

system did not require prior approval. The FRA

stated that the reason a railroad would change

from an automatic block signal to a TCS system

is safety and efficiency. In addition, the FRA

regional inspectors were aware of the signal

modifications through routine inspections, and

the signal installation on the Brunswick Line

was FRA-inspected on three separate occasions

with no exceptions taken. The FRA performed

normal inspections of the signal system modifications after installation for compliance with

Federal regulations and the CSXT signal plans.

CSXT Traincrew Roster Consolidation--CSXT

had consolidated its seniority rosters on January

30, 1996, which combined six rosters into one.

That change lowered the roster position of the

three crewmembers of MARC train 286 and was

reported to be a topic of conversation on the day

of the accident.

The roster change began in late 1993 when

the CSXT initiated an effort through the U.S.

Interstate Commerce Commission (ICC) to consolidate the train and engine service work forces

of the former B&O, Western Maryland, and

Richmond, Fredericksburg, and Potomac railroads. The approximately 1,300 employees who

were involved worked in the territory bounded

by Philadelphia, Pennsylvania; Richmond, Virginia; and Parkersburg, West Virginia. The labor unions objected to the consolidation, and an

arbitration hearing was held in March 1995,

with a decision rendered 1 month later. Neither

the CSXT nor the labor unions were satisfied

 

30The changes were made to clarify the meaning

of a material modification, a discontinuance, a catastrophic occurrence, and track change. These changes

were based on information acquired through the experience of investigating applications for signal changes

in signal and train control systems.

with the arbitrator’s decision, and both subsequently appealed it to the ICC, which decided in

favor of the consolidation in December 1995.

The labor unions then appealed to the courts,

and the U.S. Circuit Court in Washington refused to stay the ICC decision; therefore, the

CSXT went forward with its consolidation

plans. The labor unions then advised the CSXT

of their intention to strike over the issue, after

which the CSXT obtained a court-issued restraining order. The consolidation was subsequently implemented on January 30, 1996, although litigation has continued.

Before the consolidation, the MARC train

286 engineer had been the number 11 engineer

of 126 engineers on the Baltimore West End

Engineer Seniority Roster. After the consolidation, he was the number 50 engineer of 428 engineers. The MARC train 286 conductor and

assistant conductor had been on two prior rosters. As trainmen, they were on the Baltimore

West End Trainman Seniority Roster, and the

conductor and assistant conductor, respectively,

had been numbers 34 and 11 of 246 trainmen.

After the consolidation, the conductor and assistant conductor, respectively, became numbers

110 and 36 of 695 trainmen. On the Baltimore

West End Conductor Seniority Roster, the conductor and assistant conductor, respectively, had

been numbers 133 and 99 of 255 conductors.

After the consolidation, the conductor and assistant conductor, respectively, became numbers

328 and 273 of 664 conductors.

The regular conductor for MARC train 286

stated that the engineer did not show much

emotion about the roster change. However, he

said that the engineer was aware of and was

concerned about the possibility that as the lowest seniority engineer in passenger service, he

could be the first to be bumped from his assignment by a higher seniority engineer. The

regular conductor for MARC train 286 characterized the assistant conductor as “very distraught” and vocal over the seniority issue. On

the day before the accident, the topic was discussed at a safety meeting in Brunswick, which

the assistant conductor, the engineer, and he had
45

attended (the accident-day conductor was not at

the meeting). The regular conductor said, “It

upset him [the assistant conductor] enough that

on our run on the [MARC train] 286 going

from...Brunswick to Washington that he stood in

the cab and talked about it the whole way down

the road. So he was really upset about it.”

On the day of the accident, the assistant conductor again discussed his concerns with a fellow conductor and a United Transportation Union (UTU) representative. The conversation

took place at the Riverside Yard after the assistant conductor reported for work in the morning.

The UTU representative reported that the assistant conductor was “very upset” about the

meeting that had occurred the day before. The

engineer, the assistant conductor, and the conductor also all discussed the seniority change on

the day of the accident at the yard office in

Brunswick. They spoke to another engineer who

said, “nobody seemed to like it.” The assistant

conductor and the engineer of MARC train 286

also spoke to a fellow conductor about their

concerns during their lunch break about 3:30

p.m. MARC train 286 left Brunswick about 1

hour later.

The wife of the assistant conductor was

asked about his comments concerning the seniority change, and she said that they had discussed it previously in general terms. She indicated her husband was not too worried about his

job and had told her there was nothing he could

do about the seniority change anyway and that

he just had to go along with it. Still, no one had

bumped him from his assignment.

The wife of the conductor was asked about

her husband's comments concerning the recent

alteration in the seniority structure at work. She

said that they had discussed it, although not in

the last week. She said he did not know what his

seniority position would ultimately be, but he

was not worried about it because he was "still

working." He also told her that no changes were

likely before November because of the litigation

between the CSXT and the various labor unions.

She added that her husband told her that no

change would take place in the conductor or

engineer seniority rosters for passenger service

at all and that it would remain the same as before.

Locomotive Fuel Tanks--The postaccident inspection of the fuel tank of the MARC unit 73

indicated that it was not breached during the derailment. The fuel tank of the Amtrak lead locomotive unit ATK 255 was almost completely

separated from the unit and was found lodged

against and partially underneath the left side of

the unit, adjacent to its normally mounted location. The left side-plate of the tank was catastrophically ruptured open and showed substantial shredding deformation and impact striations.

The circumstances suggest that the fuel tank of

the lead Amtrak unit ATK 255 ruptured on impact with the MARC cab control car 7752 and

that the diesel fuel therein ignited and engulfed

the cab control car. There are no regulatory requirements or industry design specifications for

the locomotive fuel tanks involved in this collision; however, the Association of American Railroads (AAR) Recommended Practice (RP)-506,

Performance Requirements for Diesel Electric

Locomotive Fuel Tanks, effective September 1,

1995, is the current industry standard for all locomotives built after that date.

Cellular Service Communication--During the

emergency response activity of this accident, the

arriving fire and rescue personnel were unable

to communicate by cellular phone with off-site

accident support personnel because of an apparent saturation of the cellular phone network. The

on-scene news media quickly engaged and

would not release the existing cell sites in the

area. This situation prevented the rescue personnel from making any connections and hampered the rescue efforts according to several

rescuers, who stated that this problem had occurred previously during other high-visibility

accidents in which the news media were present.
46

ANALYSIS

General Factors

The witness statements, inspection reports,

and locomotive event recorder readouts provided no evidence of equipment failure. The

track inspections and measurements before and

after the accident indicated no defects or deviations from the FRA track safety standards. The

Safety Board investigation revealed that the

CSXT AU dispatcher conducted the dispatching

activities properly.

Results of the postaccident toxicological

tests found that the three MARC train 286

crewmembers and the two Amtrak train 29 locomotive crewmembers were not impaired by

alcohol or drugs. The investigation also examined the experience, sleep/wake cycle, and

health of the three MARC train 286 crewmembers and two Amtrak train 29 crewmembers to

determine whether those factors influenced the

accident. Except for the MARC engineer’s normal operational experience with MARC train

286, which will be discussed later, these factors

had no effect on the accident.

Therefore, the Safety Board concludes that the

train equipment and the track functioned as

designed and that the AU dispatcher conducted

the dispatching activities properly. Neither the

three MARC train 286 crewmembers nor the two

Amtrak train 29 locomotive crewmembers were

impaired by alcohol or drugs. All train

crewmembers were in good health, had no

evidence of fatigue, and were experienced in and

qualified for their duties.

Because of the reports of blowing snowfall

in the accident area, the Safety Board reviewed

the locomotive event recordings, AU dispatcher

voice recordings, and statements from other

traincrews for any negative impact that the

weather might have had on the visibility of

Kensington signal 1124-2. No traincrew operating in the accident area reported being unable

to distinguish signal indications. The MARC

train 279 engineer stated that he heard the radio

transmission from the MARC train 286 engineer

acknowledge signal 1124-2, as required by

CSXT operating rule 34-A; however, the wayside equipment defect detector had distorted that

transmission. The Safety Board concludes that

the weather conditions did not impair the ability

of the MARC train 286 crewmembers to distinguish the indication of Kensington signal 1124-

2.

The Safety Board staff conducted a postaccident signal examination that revealed the signal indications for MARC train 286 before the

collision would have been an APPROACH at

Kensington signal 1124-2 and a STOP at

Georgetown Junction signal EAS-2. Additionally, all postaccident signal tests indicated that

the proper codes were being transmitted to

Kensington from the electronic track circuit unit

at Georgetown Junction. The signal system

transmitted codes in a logical progression when

tested, and the signals displayed were not in

conflict with each other. All tests of signal

1124-2, EAS-2, and WAS-2 indicated that conflicting signals could not be displayed. Therefore, the Safety Board concludes that the signal

system functioned as designed.

Accident Narrative Review

The APPROACH indication of signal 1124-2

required the MARC train 286 engineer to slow

his train to not more than 30 mph after passing

the signal and to be prepared to stop at the

Georgetown Junction signal. The collision occurred because the engineer did not operate

MARC train 286 in conformity with the signal

indication when he stopped at Kensington station and then proceeded towards Georgetown

Junction, attaining a speed of about 66 mph. The

engineer’s actions after departing the Kensington station were appropriate had signal 1124-2

been CLEAR, but his actions were inappropriate

for an APPROACH aspect.
47

The Safety Board determined from the

stopped position of the MARC train 286 locomotive and its event recorder information that

the engineer placed the train into emergency

braking 1,407 feet before the collision at a speed

of about 66 mph. The engineer made the emergency brake application about 510 feet after

passing the optimum sight distance location,

about 1,227 feet from the EAS-2 or 5.27 seconds later. The delay is understandable and reasonable considering the engineer’s apparent belief that he was operating under a CLEAR signal

indication.

There is no reason to suppose that the

MARC train 286 engineer would be looking for

the Georgetown Junction signal as soon as it

was physically visible. If the engineer thought

that his last signal (1124-2) was CLEAR, none

of the signals he could have normally expected

at Georgetown Junction would have been so

restrictive as to demand his immediate action.

Hence, he had no reason to try to see the signal

as soon as possible. In addition, there was no

radio conversation between train engineers and

the dispatcher that could have provided the

MARC train 286 engineer with a clue on the

other trains operating in the area. Disbelief was

likely once he or the other crewmembers or both

observed the STOP signal at Georgetown Junction. The crew would have then consumed some

time trying to reconcile the restrictive STOP

indication with an expected CLEAR indication,

which had been the norm for them at Georgetown Junction. One of the passengers stated, “I

could see the look, like bend over and check to

see if something’s coming, then they jump back

like in shock, then they went forward again just

to double check,” which would attest to disbelief on the part of the traincrew.

About 407 feet before impact, the reverser of

MARC train 286 was moved when the train

speed was about 49 mph. The speeds at impact

were 38 mph and 32 mph, respectively, for

MARC train 286 and Amtrak train 29. After

colliding with Amtrak train 29, MARC train 286

came to rest with its cab control car 7752 about

93 feet beyond the point of impact.

The Safety Board identified the following

safety issues in its investigation of this accident:

the performance and responsibility of the

MARC train 286 crewmembers, the oversight of

CSXT signal system modifications, the Federal

oversight of commuter rail operations, the lack

of positive train separation control systems, and

the adequacy of passenger car safety standards

and emergency preparedness. In addition, the

Safety Board considered the use of a reverser

during an emergency brake application, the effectiveness of the computer-aided train dispatching recordkeeping, the crashworthiness of

locomotive fuel tanks, and the contents of the

CSXT and MARC operating agreement.

MARC Train 286 Engineer Performance

The actions of the MARC train engineer

prompted two questions that would need to be

answered to understand the accident events:

Why did he behave as he did? How could a

well-respected, experienced engineer forget a

signal?

Although it is possible that the engineer did

not see signal 1124-2, this does not appear to be

likely because the engineer of the passing

MARC train 279 overheard a partial radio

transmission that he believed was the MARC

train 286 engineer acknowledging the signal

indication as required by CSXT operating rules.

(The MARC train 279 engineer did not hear,

however, what signal aspect was acknowledged.) In addition, based on witness statements

and the normal operating practice of the assistant conductor to ride this trip segment from

Brunswick to Washington in the cab control car,

at least one other crewmember was, and perhaps

the other two were, in the cab control car during

the time that the signal was visible. The CSXT

operating rule 34 requires that crewmembers

call out the signal as it becomes visible. That at

least one other crewmember was present argues

against the signal not being seen.

Another possible explanation for the engineer’s behavior is that he saw the signal, forgot
48

the aspect after passing it, and realized he did

not remember the aspect. However, this is not

likely because the engineer could have simply

asked the other crewmember or crewmembers in

the cab control car about the aspect. If he or they

also did not know the aspect, the engineer

should have immediately slowed his train to the

restricted speed,as required by CSXT general

operating rule S, which states, “In case of doubt

or uncertainty, the safe course must be taken.”

However, it is more likely that the engineer

observed and correctly identified the signal and

correctly repeated its indication over the radio,

but he then forgot its aspect because other information interfered with its retention. The

specific information and tasks that demanded

the engineer’s attention and interfered with his

retention of the signal information came from

several sources, some routinely encountered and

some unique to the trip. These sources included

the important mental and physical tasks required

to stop the train at Kensington station, the various radio conversations with the engineer of

MARC train 279, the defect detector broadcasts

and disrupted radio conversations, and the presence of the crewmembers in the cab control car,

possibly discussing an important topic.

The physical and mental tasks associated

with stopping the train at Kensington station

provided the primary source of interference. The

attention demanding tasks included reducing the

throttle, applying the train brakes, and stopping

at the proper platform location at a station where

the engineer seldom stopped. He was also

probably watching through the snow to ensure

that the passenger waiting at the at-grade platform was clear of the path of the train.

 

31Defined by the CSXT operating rules as “A

speed that will permit stopping within one-half the

range of vision. It will also permit stopping short of a

train, a car, an obstruction, a stop signal, a derail or

an improperly lined switch. It must permit looking out

for broken rail. It will not exceed 15 MPH.” 32Psychological literature refers to the process as

retroactive interference: new information interfering

with the retention of previously learned or sensed

information.

Other sources of interference for the MARC

train 286 engineer included the various radio

conversations held with the MARC train 279

engineer and the defect detector broadcasts that

needed to be listened to but at the same time

disrupted the radio conversations. The defect

detector broadcasts caused both engineers to

repeat information back and forth to ultimately

attain it, which was a process that required increased attention for a longer period of time

than otherwise necessary. The radio conversations that had to be repeated between the two

engineers included the information about the

children throwing snowballs and their location.

As both trains continued, the engineers exchanged more information concerning the passenger at Kensington and the one at Silver

Spring to be picked up by MARC train 286,

which was important information because neither station is a regular station stop for the train.

As these conversations took place, both

trains passed over adjacent defect detectors,

which also provided information important to

the safe operation of the train. Indeed, “if/then”

CSXT operating rules 58A-G, 60, and 60A prescribe what an engineer must do under various

circumstances if a defect detector locates a defect. Many of the prescribed actions may involve immediately stopping and inspecting the

train and, thus, require the immediate attention

of the engineer. With the trains so close to each

other, the engineers needed to attend to both

messages, first to determine who the message

applied to and secondly because of its potential

safety implications. The MARC train 279 engineer stated that these conversations occurred

about MP 11.7, which is less than 0.5 mile from

signal 1124-2. Because the signal could have

been visible from about 0.8 mile, these communications had the potential to delay perception

of that signal or to interfere with the aspect retention or both.

In addition, the CSXT operating rules require

that when two trains pass each other, each engineer is required to conduct a visual inspection of

the other train as it passes, which would require

the engineer’s attention during the passing.
49

When a train passing event and a defect detector

broadcast occur concurrently, an engineer benefits by listening to the broadcast associated with

the other train to cue him where to look for specific problems. This is a practice of many engineers. The defect detector, however, broadcasts

on the same radio frequency used by engineers

to talk to each other or the dispatcher or both.

Consequently, when the defect detector began to

automatically broadcast, radio communication

between the two trains was disrupted. This disruption made understanding each other difficult

and required repetition and clarification of information as well as additional attention.

The last source of interference may have

come from the presence of a crewmember or

crewmembers in cab control car 7752 with the

engineer and the possible discussion of an important topic. The other crewmembers have essentially no function in the cab control car, but

they may have been talking to the engineer.

Their presence, however, can be beneficial

when they assist the engineer in observing the

track and signals and the conversation is limited

to essential operational exchanges. Listening to

or participating in a conversation with another

crewmember would further divide the engineer’s attention and interfere with his retention

of the signal aspect. A conversation between

crewmembers likely did occur in cab control car

7752 on the accident day because of the practice

of the assistant conductor to ride this segment of

the trip in the cab control car and to talk during

the trip. Conversation creates a potential for

distraction and interference with the engineer’s

retention of information, in this case the signal

information.

Although the information provided by the

signal 1124-2 aspect was critical for directing

the engineer’s actions after the station stop, it

had no relevance to the task immediately at

hand, which was stopping at Kensington station.

The locomotive event recorder showed that the

engineer started reducing speed about 0.5 mile

before the signal. The speed reduction is believed to have been in response to the stopping

for passengers and not to the APPROACH signal indication because compliance with the signal would not have required the engineer to reduce his speed as soon as he did.

Ample sources of competing information and

tasks were present and capable of interfering

with the engineer’s retention of the signal 1124-

2 information. One or more of those sources

interfered with his retention of that information,

which is believed to have caused the signal indication to be completely forgotten as if it had not

existed. Nevertheless, when the engineer left

Kensington station, he had to have some guidance, which is normally supplied by the signals,

on how to operate over the next block of track.

However, because signal 1124-2 was before the

station and his stop, the engineer needed to recall the signal aspect after intervening information and tasks. The regular conductor for MARC

train 286 could not recall ever having to stop at

Georgetown Junction, which would mean that

the engineer would not have normally observed

any other indication but CLEAR at signal 1124-

2. On the accident day, the engineer may have

recalled the expected CLEAR indication, rather

than what was actually there, and operated

MARC train 286 accordingly. The Safety Board

therefore concludes that the MARC train 286

engineer apparently forgot the signal aspect,

which required him to be prepared to stop at

Georgetown Junction, due to interference caused

by various events, including performing an unscheduled station stop, that occurred between the

presentation of the APPROACH aspect at signal

1124-2 and the STOP signal at Georgetown

Junction.

MARC Train 286 Crewmember

Responsibility

As MARC train 286 departed the Kensington

station, its engineer was required to comply with

the signal indication that had been displayed on

signal 1124-2. An APPROACH indication

required that the engineer limit the train speed to

30 mph or less and be prepared to stop at

Georgetown Junction. According to the event

recorder data, however, the engineer accelerated

the train speed to 59 mph in the next 1.15 miles,
50

gradually reduced the speed, and then accelerated

until an emergency brake application was made at

66 mph. The acceleration rate from the station

stop was constant for the first 0.8 mile, reaching a

speed of about 50 mph in just over 1 minute. The

engineer exceeded the 30 mph speed restriction

within the first minute of the departure. As a

result of this evidence, the Safety Board

examined why other crewmembers in the cab

control car apparently did not take action as

required by the CSXT operating rules.

The responsibilities of the various crewmembers in the operating cab control car are

quite different. The engineer’s role of physically

operating the train requires him to be in the locomotive or cab control car of the train. The job

responsibilities of conductors in passenger

service require them to be primarily in the passenger cars. Consequently, the nature of each

job generally separates crewmembers and keeps

them in different places on the train. (Neither

the CSXT nor MARC prohibits other crewmembers being in the operating cab control car.)

The CSXT recognizes that crewmembers other

than the engineer may have occasion to be in the

operating cab control car and has assigned responsibilities to them when they are. The CSXT

operating rules 34 and 34C basically require

other crewmembers to acknowledge signals and

to take action should the engineer fail to operate

his train in accordance with a signal indication.

Under the usual passenger train operations,

the conductor and assistant conductor would be in

the passenger cars performing the assigned duties

of collecting tickets, responding to passenger

queries, preparing for station stops, and

monitoring radio transmissions from the engineer.

However, because of the light passenger load

during this segment of the trip on MARC train

286, the conductor and assistant conductor

divided the work; one of them stayed in the cab

control compartment with the engineer while the

other performed the requisite duties and then

returned to the compartment. The CSXT

operating rules expect that when crewmembers

are in the operating compartment of the

controlling locomotive (in this case, the cab

control car) they have the responsibility for

calling and acknowledging the wayside signals

and for taking the appropriate action should the

engineer fail to operate the train according to the

signal indication.

The assistant conductor is believed to have

been in the cab control car with the engineer for

the entire trip from Brunswick to the accident

site, based on his normal habit of riding this trip

segment in the cab control car and, also, the

statements of surviving passengers. Consequently, he would have been in the cab control

car when the Kensington signal was visible and

when the engineer acknowledged it. Whether

the assistant conductor also acknowledged the

signal is unknown; however, he did have the

opportunity both to see and to hear what it was.

In addition, the conductor is believed to have

been in the cab control car during much of the

trip, and may have been in the cab control car

when the Kensington signal was visible and the

engineer acknowledged it. However, the witness

testimony is unclear on his exact activities at

that time. He could have been walking to or

waiting at the doors between cab control car

7752 and car 7720 to board passengers at

Kensington station and not have seen the signal;

although, he might have heard the engineer acknowledge the signal over his portable radio.

Still, the conductor may have neither seen the

signal indication nor heard the engineer acknowledge it and, therefore, not have known

what the signal indication was. However, had he

not heard the signal being called, the conductor

was in the cab control compartment with the

engineer later according to witnesses and could

have then questioned the signal indication that

should have been acknowledged.

Accident survivors who had been in the passenger compartment of the cab control car placed

all three crewmembers in the cab control car after

the Kensington station stop. Clearly, both crewmembers were in the cab control compartment

with the engineer for most, if not all, of the trip

segment after signal 1124-2 from Kensington to

Georgetown Junction. Additionally, the survivors
51

did not note any unusual activity from the crewmembers until the accident appeared imminent.

MARC train 286 had not been operated in accordance with the APPROACH indication during

that segment of the trip. The other crewmembers

apparently had not taken action when the engineer did not operate the train according to the

last signal indication.

The explanation for their behavior may be

found in the normal operating practice. Rule 34,

to acknowledge the signals, is a required activity

for crewmembers that occurs many times each

day. As such, the assistant conductor may have

acknowledged the signal when the engineer did,

and the conductor may also have done so. Once

the signal is called and acknowledged, however,

only the engineer has a physical activity to perform. The other crewmembers have only a passive oversight responsibility to do something

under rule 34C should the engineer fail in his

responsibility. Since adhering to signal indications is fundamental to safe rail operations, such

failures are rare. Personnel practices further

sanctify signal compliance, as engineers who

fail to adhere to signals are usually disciplined

or fired. The other crewmembers have the responsibility to be vigilant for a rare event and to

take corrective action. Actually taking a corrective action, such as using the emergency brake

handle, is even more rare and not likely to occur

in a crewmember’s entire career. Thus, because

the engineer has an active task to perform with

every signal and does so routinely, and the other

crewmembers have only a passive responsibility

that is rarely, if ever, exercised, it is not difficult

to conceive that the crewmembers in this accident deferred to the engineer and did not monitor his compliance with the signal indication

during the interval from the Kensington station

stop to the emergency brake application.

It is possible that one crewmember or both

told the engineer that he was not complying with

the APPROACH signal. However, they may

have deferred to the engineer’s recollection of

the signal aspect as CLEAR in the absence of an

independent source of information, such as cab

signals, to advise them otherwise. This is perhaps an unlikely possibility because a prudent

engineer would probably accept the most restrictive signal aspect and act accordingly. Nevertheless, no actions were taken by the conductor or assistant conductor to counteract the actions of the engineer as required by rule 34C.

This occurred even though the conductor and

assistant conductor were competent, experienced personnel, which calls into question

whether it is reasonable to rely on the vigilance

of a person to compensate for the error of another person in the same circumstances. The

Safety Board concludes, therefore, that neither

the conductor nor the assistant conductor while in

the cab control compartment appeared to have

effectively monitored the engineer’s operation of

MARC train 286 and taken action to ensure the

safety of the train. The Safety Board believes that

the CSXT should inform all operating train

crewmembers of the circumstances of this accident and emphasize the crew responsibility while

in the operating compartment for the safe operation of the train.

Traincrew Voice Recording

The 35-year experience using cockpit voice

recordings (CVRs) to assist in determining the

cause of commercial aviation accidents has

shown that evidence about the operating communications among crewmembers is frequently

important in accident investigations. Initially

installed on aircraft carrying 40 or more passengers, CVRs only recorded the last 30 minutes of

cockpit and radio conversation before an accident. In the early 1990’s a change was made to

establish design standards that increase the recording length from 30 minutes to 2 hours. Although required for all newly manufactured

transport aircraft registered in Europe after

1995, a 2-hour CVR is not required for any aircraft operating in the United States. However,

the Safety Board is of the opinion that a 2-hour

CVR should be required on all newly manufactured commercial aircraft registered in the

United States.
52

Over the years the CVR recordings have

been a key tool in documenting the circumstances leading up to an accident and a valuable

assistance to the Safety Board in determining

the probable cause of aviation accidents. The

CVR has been most useful in the type of accident that has not been caused by mechanical

failure onboard an aircraft. The CVR recording

has shown to be an almost necessary tool in

documenting the operational decisions or mistakes of the crew that lead up to the accident.

The Safety Board had repeatedly recommended

to the Federal Aviation Administration (FAA),

using this argument, that the FAA require CVRs

on smaller commuter aircraft, and the FAA has

now required that CVRs be installed on all

multi-engine turbine-powered aircraft having a

seating configuration of six or more and for

which two pilots are required by certification or

operating rules.

The Safety Board understands that appropriate protections of the privacy of such communications have been established in aviation and

could also be adopted by the railroad industry.

The communications that occurred from the

Garret Park station up to the collision at

Georgetown Junction would have been extremely valuable to this investigation. In particular, knowing the signal aspect acknowledged

by the MARC train 286 engineer at signal 1124-

2 would have facilitated investigative activities.

Although Safety Board investigators conducted

an exhaustive attempt to reconstruct traincrew

activities, they could not document the MARC

train 286 engineer's acknowledgment of the

Kensington signal or the communications, if

any, among crewmembers as the train approached Georgetown Junction.

Current locomotive event recorders have

great utility but only provide mechanical response data, which cannot answer some questions asked in an accident investigation about

the traincrew’s knowledge and actions. The

voice recordings maintained by the CSXT operations center included no communications

between trains or among MARC train 286

crewmembers. Had a voice recording from

MARC train 286 existed, the signal aspect acknowledged and the communications in the last

few minutes before the collision would have

been available to this investigation. A few years

ago the FRA contemplated issuing a rule requiring voice recorders in locomotive compartments but rejected the idea because it did not

consider them as a necessary safety measure.

The FRA could have included traincrew voice

recording requirements in the 1993 regulations

for locomotive event recorders as part of the

minimum parameters to be recorded. The Safety

Board, consequently, concludes that had the

FRA required the recording of the train crewmembers’ voice communications, the essential

details about the circumstances of this accident

could have been provided. Therefore, the Safety

Board believes that the FRA should amend 49

CFR Part 229 to require the recording of train

crewmembers’ voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of

such recordings.

CSXT Signal System Modification

Oversight

The CSXT and MARC had operational

reasons to modify the Brunswick Line signal

system: improve passenger safety and freight

train operations by changing the method that

CSXT dispatched and monitored trains, upgrade

the system capacity to operate more trains with

increased peak and midday service, increase the

MARC labor and equipment productivity, and

reduce the CSXT operating costs. Identifiable

improvements, such as total trains, traincrew

use, cost savings, and CTC operations, could be

quantified and measured; however, the signal

system modifications did not address the overall

safety of the signal system for traincrew use.

The adequacy of the system safety could only have

been addressed with a total system review that

included a human factors analysis of such issues as

human information processing capabilities.

A total system review examining human capabilities and limitations might have resulted in

the installation of a redundant system, such as an

automatic train control system or automatic cab

signals (ACS), which would have produced an
53

audible indication to alert the engineer and a

visible reference to identify when the cab signal

display changed to a more restrictive aspect.

The MTA application for FTA funding for the

project indicated that the funding approval for

the project would later address advanced train

control systems. Yet, when MTA and MARC

officials were queried about this subject, they

had no current plans.

The Safety Board investigators questioned

the removal of signal 100, which, located east of

the Kensington station, had been the last signal

on track 2 for eastbound trains traveling towards

Georgetown Junction. As a result of the modification and respacing of the signals, the last signal on track 2 for trains traveling towards

Georgetown Junction was now signal 1124-2,

which is west of Kensington station and about

1.25 miles west of the former signal 100 location. The spacing of signals is FRA regulated

under 49 CFR Part 236.24, which requires signals to be adequately spaced to provide proper

distances for reducing speeds or stopping by use

of other than an emergency brake application

before reaching the point where reduced speed

or stopping is required. The FRA determined

during routine signal inspections that the

Brunswick Line signal system complied with the

regulation for the spacing of roadway signals.

The CSXT signal system modification, however, did not adequately account for the operating characteristics of passenger trains stopping

at the Kensington station, as evidenced by this

accident. The removal of signal 100 relocated a

source of vital information for passenger train

engineers stopping at the Kensington station

from a position close to where it would be acted

upon to a position farther away. In this case, the

physical distance the signal was moved was not

the critical element; but rather, the relocation

created the potential for other information and

tasks to intervene and interfere with the retention of the signal indication, thus permitting it to

be forgotten before it was required to be used.

Of course, the potential for interference to lead

to an operational error did not necessarily exist

to the same degree for all trains, and the right

set of circumstances had to exist. Nevertheless,

the potential for an operational error to occur as

a result of the relocated signal could have been

foreseen. Had the design of the signal system

received input from knowledgeable human factors specialists, the potential pitfall of the relocation could have been addressed and redundancy provided for an engineer forgetting a signal. Such redundancy could have been accomplished through a delayed-in-block rule change,

as the FRA did with EO 20 issued following this

accident; with a repeater signal; with cab signals; or with a positive train separation (PTS)

control system, as the Safety Board has long

advocated.

The FRA EO 20 contained specific

information for all railroads on every push-pull

operation without benefit of cab signal,

automatic train stop, or automatic train control

and whose speed exceeds 30 mph. The new rule

required that all trains stopped or delayed in a

block immediately preceding interlockings and

controlled points must reduce their speed in

accordance with applicable operating rules, but,

in no case, may speed exceed 40 mph. In

addition, EO 20 added another measure that

required appropriate signs be installed at each

affected signal and at the departure end of

stations. The Safety Board concludes that had

the FRA and the FTA required the CSXT to

perform a total signal system review of the

proposed signal changes that included a human

factors analysis within a comprehensive failure

modes and effects analyses, this accident may

have been prevented.

The information obtained during the Safety

Board investigation of this accident, including

its public hearing, raised questions about the

oversight by Federal agencies of federally

funded transit projects and, specifically, the

FTA grant application and approval process.

Although Federal funding provided most of the

funds for the design and installation of the CTC

system on the CSXT Brunswick and Camden

Line signal modification, the Federal Government apparently did not perform an in-depth
54

analysis or evaluation of this project from a

safety standpoint primarily because the applying

agency self-certified that it had the technical

capacity to undertake the project. Furthermore,

the project justification statement indicated that

safety would be enhanced by the installation of

this upgraded signal system; however, the available evidence indicates that the project was undertaken for economic reasons and that a total

system safety review, including a human factors

analysis of the upgraded signal system, was not

considered at either the State or Federal Government level.

The Safety Board recognizes that the FTA

may not have the necessary expertise in all project areas for which transit agencies seek funding. In this particular instance, the FTA indicated that it did not have any in-house signal

expertise with which to judge the safety benefits

of the proposed signal modifications. However,

the FTA could have either requested assistance

from other modal administrations that have the

technical expertise or required a total system

safety analysis by an independent contractor, as

a condition for grant approval. Subsequent to

the Silver Spring accident, the FTA has requested that the FRA become more involved in

reviewing operational plans and safety proposals

for grantees, including commuter railroads. Although the FTA request for FRA involvement is

commendable, it does not formally address what

the FTA specifically expects from the FRA.

The Safety Board concludes that Federal

funds granted for the signal modifications on the

CSXT Brunswick Line to accommodate an increase in the number of MARC trains did not

ensure that the safety of the public was adequately addressed. Therefore, the Safety Board

believes that the FRA should require comprehensive failure modes and effects analyses, including a human factors analysis, for all signal

system modifications and that the FTA should

revise the grant application process to require

the same such analyses be provided for all federally funded transit projects that are directly

related to the transport of passengers.

Federal Commuter Rail Operations

Oversight

The Safety Board requested the FRA to respond to its concerns about commuter railroad

operations within FRA regulatory authority,

which included a 5-year reportable accident

listing for MARC and the Virginia Railway Express (VRE) and a 5-year accident, inspection,

and defect history for commuter railroad operations. The FRA responded that 17 commuter rail

operations are under its regulatory authority of

which six, including VRE, are operated by Amtrak; two, including MARC operations, are operated by Amtrak and CSXT together; seven are

operated by the commuter railroad, itself; two

are operated by a freight railroad; and one is

operated by a contractor. The FRA reported that

it does not have a 5-year accident, inspection,

defect, or violation record database for individual commuter railroads and that before 1996,

any data regarding accidents/incidents was reported as it related to the railroad operating the

commuter service. This data could not be readily separated because it was commingled with

the freight and intercity rail reporting data. The

FRA advised that it is currently working with

those railroads to ensure that commuter rail operations data will be reported separately in the

future. (See appendix K.)

The Safety Board, consequently, concludes

that without a separate collection database specific to commuter rail inspections and accident/incidents, it is difficult for the Federal Railroad Administration to evaluate its own effectiveness of inspections and to identify problematic trends. Records should include reporting on

inspections and accident/incidents to determine

the effectiveness of its own as well as that of

participating state organizations and to identify,

and to take corrective action in, those areas inadequate to public safety. Therefore, the Safety

Board believes that the FRA should develop and

maintain separate identifiable data records for

commuter and intercity rail passenger operations.
55

Positive Train Separation

 Control Systems

The Safety Board has long advocated a PTS

control system and since 1970 has issued

safety recommendations concerning train collision prevention. (See appendix L.) A PTS control system can prevent trains from colliding by

automatically interceding in the operation of a

train when an engineer does not comply with the

requirements of the signal indication.

Following its investigation of a head-on collision on the Burlington Northern Railroad near

Ledger, Montana, the Safety Board issued in

July 1993 the following safety recommendation

to the FRA:

In conjunction with the Association of

American Railroads and the Railway Progress Institute, establish a firm timetable

that includes at a minimum, dates for final development of required advanced

train control system hardware, dates for

an implementation of a fully developed

advanced train control system, and a

commitment to a date for having the advanced train control system ready for installation on the general railroad system.

(R-93-12)

The Safety Board additionally issued a similar

recommendation to the AAR and to the Railway

Progress Institute (RPI), respectively, in Safety

Recommendations R-93-13 and -15.

The Safety Board classified Safety Recommendation R-93-12 “Open--Acceptable Response” after the FRA took the measure to seek

the “final system definition, migration path, and

timetable” for a PTS control system by Decem-

 

33Railroad Accident Report--Head-on Collision

between Penn Central Trains N-48 and N-49 at

Darien, Connecticut, August 20, 1969 (NTSB/RAR70/03). 34Railroad Accident Report--Head-on Collision

between Burlington Northern Freight Trains 602 and

603 near Ledger, Montana, on August 29, 1991

(NTSB/RAR-93/01).

ber 1994. The Safety Board also classified

Safety Recommendations R-93-13 and -15, respectively, to the AAR and the RPI “OpenAcceptable Response” based on their responses.

Because of the AAR and the RPI participation

and support in current test projects of the Union

Pacific/Burlington Northern Santa Fe Railroad

(UP/BNSF) in the Pacific Northwest and of

Amtrak tests in Michigan, the Safety Board reclassifies R-93-13 and -15, respectively, as

“Closed--Superseded” and “Closed--Acceptable

Alternate Action.” Neither the AAR nor the RPI

is in a position to either establish timetables or

to implement a PTS control system for the railroad industry. The FRA and the railroad industry share the responsibility for the development

and implementation of a PTS control system.

Under its regulatory authority, the FRA can order a railroad to install a PTS control system,

and the FRA can issue emergency orders, as it

did following this accident, where an unsafe

condition or practice causes an emergency

situation involving a hazardous death or injury.

The Safety Board, however, believes that the

AAR can assist the railroad industry with the

development of PTS control systems through a

continuing review of nonrailroad technology

and assess its adaptability to railroad communication-based control systems. In addition, the

Safety Board believes that the AAR can assist

the railroad industry with the development of

PTS control systems by acting as a clearinghouse for information on the status and results

of pilot projects and by disseminating that information to the railroad industry and the Federal and participating State transportation organizations. Finally, the Safety Board believes

that the AAR can assist the railroad industry

with the installation and operation of PTS control systems by maintaining industry standards

to ensure interoperability of equipment and an

open architecture for train control systems.

Citing the recent train accidents in Secaucus

and Silver Spring, the FRA stated in EO 20 that

it had a particular concern for operations that

involve lead cars carrying passengers on track
56

segments that have neither cab signals nor an

automatic train stop or automatic train control.

EO 20 required that commuter and intercity passenger railroads modify services operating

above 30 mph that lack cab signals or automatic

train stop or automatic train control protections

and that permit passengers to occupy the lead

car, either cab control cars in the forward position push-pull mode or self-propelled locomotives with passenger seating (MU [multiple-unit]

locomotives). The FRA also exercised its oversight responsibility for operating rules by concluding that certain current conditions and practices on commuter and intercity passenger railroads posed an imminent and unacceptable

threat to public and employee safety. The EO 20

specifically addressed the delayed-in-block rule

and the exclusion granted to passenger trains

under certain conditions. The FRA recognized

that unacceptable threats to public and employee

safety exist where protection is not provided by

cab signal or automatic train stop or automatic

train control systems. The FRA addressed several public safety issues that required immediate

attention in EO 20; however, it did not address

the other critical risks posed by reliance on crew

alertness in complying with operating rules.

The Safety Board has investigated numerous

train collisions in which the probable cause or

contributing cause was the inattention of the

traincrew to wayside signals. In its investigation

of the head-on collision of two freight trains

near Kelso, Washington, the Safety Board attempted to determine again why one traincrew

did not comply with the signal indication of an

intermediate signal. The Safety Board reported

its concerns about a systemic safety issue: the

adequacy of passive wayside signals to reliably

capture traincrews’ attention when competing

sources of attention are present, and it urged the

railroad industry to recognize that human vigilance has limits and that wayside signals do not

 

35Railroad Accident Report--Head-on Collision

and Derailment of Burlington Northern Freight Train

with Union Pacific Freight Train, Kelso, Washington,

on November 11, 1993 (NTSB/RAR-94/02).

ensure safe train operations. The FRA EO 20,

notice no. 2, concluded that “certain current

conditions and practices on commuter and intercity passenger railroads pose an imminent and

unacceptable threat to public and employee

safety. Of greatest concern are push-pull and

MU operations lacking the protection provided

by cab signal, automatic train stop, or automatic

train control systems.” After its investigation of

the Thedford, Nebraska, accident, the Safety

Board stated that had a PTS control system been

in place it could have detected that the engineer

was not responding appropriately to the signal

indications and could have slowed and stopped

the train, thus preventing the collision.

The FRA newly required rule for calling signals has basically the same instructions as the

existing CSXT operating rule 34. The signal

calling that the FRA requires likely occurred in

the Silver Spring accident, and at least one

crewmember was in the cab control car with the

engineer and is believed also to have seen the

signal. The accident still happened because such

a rule does not adequately compensate for human capabilities and crew interaction, as noted

earlier in this report. Therefore, the Safety

Board concludes that the FRA reliance on the

need for increased vigilance of wayside signals

and special actions in operating rules, such as

the crew communication rule of EO 20, does not

adequately safeguard the public.

The full development of a PTS control system is still underway; however, current technology exists for cab signal, automatic train stop, or

automatic train control systems. At the Safety

Board public hearing for this accident also, a

commuter railroad official from METRA explained an alternate system that METRA has

 

36Railroad Accident Report--Collision and Derailment Involving Three Burlington Northern

Freight Trains near Thedford, Nebraska on June 8,

1994 (NTSB/RAR-95/03). 37Chicago Commuter Rail Service Board, formerly Northeast Illinois Railroad Corporation, operates its own suburban services and controls commuter

trains, operated by freight railroads, such as

UP/BNSF, in the Chicago area.
57

designed, in cooperation with the operating carrier and labor unions, to caution the engineer of

his last signal indication, which METRA believes may not require FRA approval. The

Safety Board concurs with the FRA EO 20, notice no. 1, that:

Since most train collisions on the railroad

result from human factors, the most effective preventive measure is a highly effective train control system. Cab signal

systems serve an important safety purpose

because they provide a constant display

of the governing signal indication. This

provides a corrective measure should an

engineer fail to note, forget, or misread a

restrictive wayside signal indication.

Even greater security is provided by a

train control system capable of intervening should the engineer fail to observe

signals and operating rules for whatever

reason....Such systems are referred to as

automatic train control or automatic train

stop.

Although all MARC locomotives and cab control cars have cab signal equipment, the Brunswick Line was not equipped with a train control

system to implement those devices. A train control system, which would have been recognized

by the MARC cab control car cab signal

equipment, could have provided the engineer

with a visual reminder of the 1124-2 signal aspect, required him to acknowledge and comply

with the APPROACH signal indication, or enforced the requirements of the signal indication

by stopping the train. The Safety Board concludes that had a train control system that could

utilize the cab signal equipment on the MARC

cab control car been a part of the signal system

on the Brunswick Line, this accident may not

have occurred. Therefore, the Safety Board believes that the FRA should require, in the interim of a PTS control system being available,

the installation of cab signals, automatic train

stop, automatic train control, or other similar

redundant systems for all trains where commuter

and intercity passenger railroads operate.

In addition, the Safety Board believes that the

FTA should cooperate with the FRA for requiring, in the interim of a positive train separation

control system being available, the installation of

cab signals, automatic train stop, automatic train

control, or other similar redundant systems for

all trains where commuter and intercity passenger railroads operate.

The 1987 MDOT grant application to the

FTA for the CSXT signal system modification

on the Brunswick Line stated that the improvements envisioned in this program provide the

foundation for the next “generation” of train

control systems: ATCS. However, neither the

FTA nor the MTA followed up on the MDOT

pursuit of this technology. In the MTA/MARC

grant application to the FTA, the future installation of an ATCS, such as cab signals, was part

of the justification for awarding the grant for the

signal modifications being proposed. At the time

of this accident, no advanced train control had

been installed.

Since the collision at Georgetown Junction,

MARC has undertaken a project, for which the

MTA has hired a consultant and provided

funding, to develop and evaluate an intermittent

cab signaling system (ICSS) that features both

civil speed enforcement and positive train stop

technology. In addition, the supplier of track

circuit equipment is estimating the cost for upgrading the equipment to continuously inductive

ACS that will be compatible with the automatic

train control equipment currently installed on

MARC locomotives and cab control cars. The

CSXT is also involved in the project because its

wayside signal equipment and locomotives will

be directly affected by the installation of any

changes proposed to the current signal system.

The Safety Board is encouraged by the efforts of the MTA/MARC project to develop and

evaluate an ICSS; however, ICSS should only

be an interim solution until a PTS control system can be fully implemented. A PTS control

system is a major step for the railroad industry

to provide a redundant system where an unacceptable threat to public and employee safety

exists. Pending the FRA issuance of regulations
58

that require a PTS control system installation,

railroads remain responsible for a PTS control

system development and installation. Consequently, the Safety Board believes that the

CSXT should develop and install a PTS control

system on its track segments that have commuter and intercity passenger trains. The Safety

Board also believes that the FTA and the MTA

should cooperate with the CSXT in the development and installation of a PTS control system

where MARC equipment operates on CSXT

tracks.

In the FRA July 1994 report to Congress regarding advanced train control, the FRA

planned to begin a 2-year “Corridor Risk Assessment” study in 1995 to identify and evaluate

which conventional rail corridors would be

prime candidates for advanced train control implementation. The study was to contain a geographic information system (GIS) platform to

provide the analysis, which would include PTS

control system preventable accidents plotted on

the GIS. The initial results of the study are to be

presented to the FRA Railroad Safety Advisory

Committee in June 1997 for review and further

analysis.

An Amtrak project in Michigan is complete,

but another in Illinois has not started. The

Michigan project tested an incremental train

control system on the Amtrak line between

Kalamazoo and Green Beach. The Michigan

territory is similar to the Brunswick Line, in that

both passenger and freight trains operate.

The Silver Spring accident is the latest in a

series of collisions that could have been prevented had a PTS control system been in place.

A PTS control system could have detected that

 

38The DOT, Michigan DOT, Amtrak, and Harmon

Industries began a project in 1995 to implement a

high-speed positive train control system on a 71-mile

portion of the Detroit, Michigan, and Chicago, Illinois, corridor. Testing was done on the 20-mile segment between Dowagiac and Niles, Michigan. The

system works by allowing grade crossings, signals,

and locomotives to communicate with each other using data radio.

the MARC train 286 engineer was not responding appropriately to signal indications and then

slowed and stopped the train, thus, preventing

the collision. The Safety Board concludes that a

fully implemented PTS control system would

have prevented this accident by recognizing that

MARC train 286 was not being operated within

allowable parameters, based on other authorized

train operations, and would have stopped the

train before it could enter into the unauthorized

track area. The Safety Board therefore believes

that the FRA should require the implementation

of PTS control systems for all trains where

commuter and intercity passenger railroads operate. The Safety Board also believes that the

FTA should cooperate with the FRA for requiring the implementation of positive train separation control systems for all trains where commuter and intercity passenger railroads operate.

In addition, the Safety Board reiterates Safety

Recommendations R-87-16 and R-93-12 to the

FRA. The Safety Board intends to closely

monitor the progress made on this important

issue and to continue discussing the benefits of a

PTS control system in all reports of accidents

that such a control system could have prevented.

Passenger Car Safety Standards

During the investigation of this accident, the

Safety Board identified problems with emergency egress from the passenger cars that contributed to the number of fatalities. The Safety

Board concluded that the emergency egress of

passengers was impeded because the passenger

cars lacked readily accessible and identifiable

quick-release mechanisms for the exterior doors,

removable windows or kick panels in the side

doors, and adequate emergency instruction signage. The Safety Board further concluded that the

absence of comprehensive Federal passenger car

safety standards resulted in the inadequate

emergency egress conditions. Therefore, the

Safety Board issued four urgent safety recommendations on March 12, 1996. One was issued

to the FRA; three were issued to the MTA, as

follows:
59

Install removable windows or kick panels

for emergency exits in interior and exterior passageway doors. (R-96-4)

Install an easily accessible interior emergency quick-release mechanism adjacent

to all exterior doors. (R-96-5)

Install retroreflective signage on car interiors and exteriors at emergency exits that

contains easily understood instructions

and clearly marks all emergency exits

(doors and windows). (R-96-6)

The MTA responded in a November 7, 1996,

letter that it has: 1) entered into an engineering

contract for designing removable windows for

emergency exits in car end and side doors, but

the work will not be completed until the end of

1997; 2) completed the design of a quick-release

mechanism adjacent to all exterior doors with

the mechanism installation to be completed in

March 1997	 (see figure 14); and 3) installed

luminescent interior as well as enhanced retroreflective exterior signage on all MARC cars as of

August 30, 1996. Based on this MTA response,

the Safety Board classifies the urgent Safety

Recommendations R-96-5 and -6 “Closed--

Acceptable Action” and “Closed--Exceeds Recommended Action,” respectively. The Safety

Board also recognizes the complexity of redesigning and installing removable windows for

emergency exits in car end and side doors and

the MTA efforts to complete the work as

promptly as possible. Because this work cannot

be completed within the 1-year timeframe required for an urgent safety recommendation, the

Safety Board had reclassified Safety Recommendation R-96-4 to regular safety recommendation status “Open--Acceptable Action.”

Additionally, as a result of this accident investigation, the following urgent safety recommendation was issued to the FRA:

 

39MARC informed the Safety Board on March 3,

1997, that the installation was complete on February

28, 1997.

Inspect all commuter rail equipment to

determine whether it has: (1) easily accessible interior emergency quick-release

mechanisms adjacent to exterior passageway doors; (2) removable windows

or kick panels in interior and exterior passageway doors; and, (3) prominently displayed retro-reflective signage marking

all interior and exterior emergency exits.

If any commuter equipment lacks one or

more of these features, take appropriate

emergency measures to ensure corrective

action until these measures are incorporated into minimum passenger car safety

standards. (R-96-7)

After reviewing the FRA response of June 6,

1996, the Safety Board classified Safety Recommendation R-96-7 “Open--Acceptable Action” in March 1997. The FRA had stated in that

response that it had inspected 1,250 pieces of

railroad equipment on 16 commuter organizations, that any variation in the inspection results

was indicative of equipment age and of difference by commuter agencies, and that emergency

quick-release mechanisms were typically accessible to passengers; although, many were not

adjacent to exterior passageway doors. In addition, the FRA had stated that marking emergency exits inside cars with luminescent rather

than retroreflective materials may be better. The

FRA, however, has taken no immediate action to

make corrections. The Safety Board acknowledges the FRA efforts concerning its urgent

safety recommendation and recognizes the complexities of developing practical solutions

within the requested 1-year period; therefore,

the Safety Board classifies Safety Recommendation R-96-7 “Closed--Superseded” and is substituting it with three separate safety recommendations for longer-term action. Consequently,

the Safety Board believes that the FRA should:
60

Figure 14--Photograph showing quick-release mechanisms on MARC cars.

Require all passenger cars to have easily

accessible interior emergency quickrelease mechanisms adjacent to exterior

passageway doors and take appropriate

emergency measures to ensure corrective

action until these measures are incorporated into minimum passenger car safety

standards.

Require all passenger cars to have either

removable windows, kick panels, or other

suitable means for emergency exiting

through the interior and exterior passageway doors where the door could impede

passengers exiting in an emergency and

take appropriate emergency measures to

ensure corrective action until these measures are incorporated into minimum passenger car safety standards.

Issue interim standards for the use of luminescent or retroreflective material or

both to mark all interior and exterior

emergency exits in all passenger cars as

soon as possible and incorporate into

minimum passenger car safety standards.

The Safety Board first began addressing passenger car safety with the FRA after an accident

at the Botanical Gardens station in New York,

New York, in January 1975.The Safety Board

continued its efforts on passenger car crashworthiness following Amtrak accidents in

March 1980 near Glacier Park, Montana, and in

 

40Railroad Accident Report--Collision of Two

Penn Central Commuter Trains at Botanical Garden

Station, New York, New York, January 2, 1975

(NTSB/RAR-75/08).
61

June 1982 at Gibson, California. The Safety

Board issued the following safety recommendations, respectively, to the FRA:

Promulgate regulations to establish minimum standards for the interior of commuter cars so that adequate crash injury

protection and emergency equipment will

be provided passengers. (R-75-38)

Promulgate regulations to establish minimum safety standards for the inspection

and maintenance of railroad passenger

cars. (R-80-31)

Expedite the development of passenger

car safety standards which were mandated

by Congress in October 1980 (reiterated

January 14, 1983) including in the standards: (A) Criteria for the location and

intensity of emergency lights within the

cars to ensure adequate visibility for escape from smoke filled cars; (B) Requirements for emergency evacuation

plans, for training of personnel for emergencies, and for emergency systems, such

as emergency exits and doors, smoke detector systems, etc., specifying the numbers, type, location, and markings; (C)

Acceptable levels of flame spread rate,

smoke emissions, and toxic fumes for interior materials, and (D) Requirements for

the installation of a sprinkler system to

which water can be supplied by emergency equipment through externally

mounted standard standpipes. (R-83-76)

Safety Recommendation R-75-38 was classified

in April 1984 “Closed--Superseded” by Safety

Recommendation R-84-46, which was subsequently classified “Closed--No Longer Applicable” in August 1991, when Amtrak informed the

 

41Railroad Accident Reports--Derailment of Amtrak Train No. 7 the Empire Builder on Burlington

Northern Track, Glacier Park, Montana, March 14,

1980 (NTSB/RAR-80/06) and Fire Onboard Amtrak

Passenger Train No. 11, Coast Starlight, Gibson,

California, June 23, 1982 (NTSB/RAR-83/03).

Safety Board of research in progress which

eliminated the need for FRA studies. Safety

Recommendations R-80-31 and R-83-76 were

both classified “Closed--Unacceptable Action,”

based on FRA responses, in January 1986. In

June 1996, the FRA finally reacted to the concerns raised by the Safety Board, the General

Accounting Office, and others and issued a notice of initiation for rulemaking on rail passenger equipment safety standards to comply with

the Federal Railroad Safety Authorization Act

of 1994.

Current FRA regulations for passenger car

safety standards are inadequate. They do not

address passenger car safety standards for selfcontained emergency lighting; inspection, removal, and maintenance of emergency windows;

exterior emergency door releases; interior

flammability and smoke standards; and structural crashworthiness. The Safety Board is encouraged by the current FRA position in developing rulemaking and expects that the passenger

car safety standards will not only address the

safety of passengers in newly built passenger

cars but also in existing passenger cars. The

FRA indicated that the group working on the

development of passenger car safety standards

completed their work in December 1996, and a

notice of proposed rulemaking (NPRM) is expected by the end of 1997.

In addition during the investigation of this

accident, the Safety Board identified several

areas of safety deficiencies that should be addressed by passenger car safety standards for

improved passenger safety. The identified areas

are the power source of emergency lighting, the

difficulty in removing emergency windows, the

missing or inaccessible exterior emergency door

release handles, the failure of interior materials

to meet flammability and smoke standards, and

the structural crashworthiness of cab control

cars.

Emergency Lighting--The two passengers

in coach car 7720 stated that no emergency

lighting was available after the accident. One

passenger's injuries and the other's loss of eye
62

glasses compounded the reported difficulty in

moving in the darkness. Additionally, the tilted

position of the car contributed to their disorientation and hindered their mobility. Postaccident

inspection of the car revealed that batteries supplying power to the emergency lighting system,

located below the floor level, had been damaged

in the derailment. After Safety Board investigators alerted MARC to the failure of the emergency lighting system, MARC projected plans

to complete by late 1997 the fleetwide installation of battery pack ballasts, designed to provide

power should head-end or car battery power be

lost, in selected fluorescent lighting fixtures.

The MARC passenger cars are not unique in

the location of the battery supplying power to

the emergency lighting system being below the

car floor, which makes them susceptible in a

derailment to damage from contact with the car

trucks, the rails, or the ground. The installation

of battery pack ballasts or other self-contained

independent power sources in the car interior

would provide reliable power to emergency

lighting in derailments when the batteries under

the car are most likely to be damaged. The

Safety Board concludes that a need exists for

Federal standards requiring passenger cars be

equipped with reliable emergency lighting fixtures with a self-contained independent power

source when the main power supply has been

disrupted to ensure passengers can egress safely.

Therefore, the Safety Board believes that the

FRA should require all passenger cars to contain

reliable emergency lighting fixtures that are

each fitted with a self-contained independent

power source and incorporate the requirements

into minimum passenger car safety standards.

Emergency Windows--One passenger in

coach car 7720 stated that he exerted much effort to open an emergency window in that car.

Postaccident inspection of the car emergency

windows revealed that much effort was also

necessary to open two other emergency windows in the same car because the window lubricant had hardened. The Safety Board determined that no periodic preventive maintenance

had been performed on the emergency windows

of the MARC passenger equipment and that

none had been required.

The FRA EO 20 requires all passenger railroads to inspect emergency window exits for

proper operation, marking, and instructions as

part of routine equipment maintenance. The

FRA informed the Safety Board in October

1996 that changes to the regulatory text of the

draft NPRM on Passenger Train Emergency

Preparedness were being made because the inspection cycle requirements of EO 20 were

vague. The February 24, 1997, FRA-issued

NPRM proposes that a railroad test a representative sample of emergency window exits on its

cars a least once every 180 days to verify proper

operation and that it repair a defective unit before returning the car to service. As a result of

the Safety Board urgent recommendations and

the FRA EO 20, MARC has performed functional tests on all existing emergency exit windows and initiated a program to install additional emergency exit windows in all their passenger equipment. The Safety Board, however,

is concerned that the FRA EO 20, pertaining to

the inspection cycle, does not require a prescribed test cycle and that until the proposed

rulemaking becomes effective, emergency windows on other passenger rail carriers may not be

adequately inspected. The Safety Board concludes that prescribed inspection and maintenance test cycles are needed to ensure reliable

operation of emergency windows in all longdistance and commuter rail passenger cars.

Therefore, the Safety Board believes, pending

the issuance of the final rule on passenger car

safety standards, that the FRA should promptly

provide a prescribed inspection and maintenance

test cycle to ensure the proper operation of all

emergency exit windows as well as provide that

the 180-day inspection and maintenance test

cycle is prescribed in the final rule.

Exterior Emergency Door Release--

The MARC II passenger cars have provisions

for a T-handle, which is used to disconnect the

interior release mechanism allowing the exterior

side doors to be opened from the outside, at

each of the four exterior doors. During postacci-
63

dent inspection of cab control car 7752, investigators found that the exterior emergency door

release T-handles were missing. In addition,

when MARC last performed general servicing

of cab control car 7752, the T-handles were

noted as missing. MARC mechanical officers

explained that because of the difficulty in receiving replacements from the original equipment supplier, they needed time to manufacture

and install substitute T-handles, but MARC did

not restrict the car from being placed back into

passenger service.

The postaccident inspection of the passenger

coach 7720, immediately behind cab control car

7752, revealed that the exterior emergency door

release T-handles on the right side were buried

in ballast when the car derailed and were, therefore, inaccessible to emergency responders. The

T-handles were designed to be below the floor

line of the car and about 3 inches inboard. The

original design plans for the MARC II passenger

cars showed the emergency door release Thandles above the bottom of the car body and in

a glass-covered recessed pocket adjacent to each

vestibule door. However, the T-handles had not

been installed there because of an approved design change during car building. Emergency responders may have been able to quickly locate

the T-handles and gain access to passenger

coach interior had the handles been located

where planned.

The Safety Board concludes that the exterior

emergency door release T-handles for the

MARC cars were not either in place or accessible to firefighters because no requirements for

their maintenance or accessibility exist. Therefore, the Safety Board believes that the FRA

should require that all exterior emergency door

release mechanisms on passenger cars be functional before a passenger car is placed in revenue service, that the emergency door release

mechanism be placed in a readily accessible position and marked for easy identification in

emergencies and derailments, and that these requirements be incorporated into minimum passenger car safety standards.

Interior Materials--The analysis of fire

debris indicated that diesel fuel from the

breached fuel tank of Amtrak unit 255 sprayed

into the breached opening of the MARC 286 cab

control car. Positive residues were found on

some passenger seats and on a sheetmetal panel

near the opening. The analysis revealed that the

diesel fuel played a significant role in the early

fire growth within the car, and within 3 to 5

minutes after the collision based on witness testimony, flashover developed in the cab control

car with the fire accelerating over the breached

area because of that sprayed diesel fuel. Had

diesel fuel not sprayed into the cab control car,

the fire likely would not have spread as quickly

as it did. For the passengers to quickly exit the

car became even more critical because of the

rapid growth of fire. Except for those passengers

who died from blunt trauma injuries, others may

have survived the accident, albeit with thermal

injuries, had proper and immediate egress from

the car been available. The Safety Board concludes that the catastrophic rupture of the Amtrak unit 255 fuel tank in the collision with the

MARC cab control car 7752 released fuel,

which sprayed into the interior of the cab control car, and resulted in the fire and at least 8 of

the 11 fatalities.

The Safety Board recognizes that the materials taken from an exemplar MARC car may not

have been identical to the materials that were

installed on cab control car 7752 and that other

factors, such as wear, can affect the performance of the car materials; nevertheless, the materials taken from the exemplar car were significantly similar to the materials in the accident

car. Some of the interior materials from the exemplar MARC car failed current flammability

and smoke emissions testing criteria, and the

materials in the cab control car 7752 also most

likely would have failed. Had the materials met

current performance criteria, however, the outcome would not have been any different because

of the presence of diesel fuel as an ignition

source. The fire would have spread quickly

whether the interior materials of the MARC

passenger cars had met current performance

criteria regarding flammability and smoke emis-
64

sions characteristics; still, the Safety Board is

concerned that the interior materials in the

MARC passenger cars did not meet existing performance criteria for flammability and smoke

emissions characteristics.

Performance criteria is based on guidelines

developed by the FRA and the FTA, and the

passenger commuter rail industry could reference them with or without modification when

ordering new equipment. The Safety Board concludes that because other commuter passenger

cars may also have interior materials that may

not meet specified performance criteria for

flammability and smoke emission characteristics, the safety of passengers in those cars could

be at risk. Therefore, the Safety Board believes

that the FRA should require that a comprehensive inspection of all commuter passenger cars

be performed to independently verify that the

interior materials in these cars meet the expected performance requirements for flammability and smoke emissions characteristics.

The current FRA information on the flammability and smoke emissions characteristics

and the testing of commuter and intercity rail

vehicle materials is based on guidelines that

have not changed significantly in the past 30

years. Consequently, the Safety Board concludes that the Federal guidelines on the flammability and smoke emissions characteristics

and the testing of interior materials do not provide for the integrated use of passenger car interior materials and, as a result, are not useful in

predicting the safety of the interior environment

of a passenger car in a fire. Therefore, the

Safety Board believes that the DOT should review the testing protocols within the various

modal administrations regarding the flammability and the smoke emissions characteristics of

interior materials and coordinate the development and implementation of standards for material performance and testing with the FRA and

the FTA.

Cab Control Car Structural Crashworthiness--The left side of cab control car 7752

was ripped open in the collision from its front to

midsection. (See figure 15.) The cab control car

was equipped, as required by FRA standards,

with structural components serving as collision

posts at each end doorway; however, the magnitude of the impact and collision forces were

more than the collision posts could resist. The

Safety Board first addressed structural crashworthiness of passenger cab control cars after its

investigation of the August 1981 head-on collision between a Boston & Maine Corporation

freight train and a Massachusetts Bay Transportation Authority commuter train in Beverly,

Massachusetts, urging the FRA to:

Expedite implementation of Safety Board

recommendations to study structural protection for occupants of control cars and

locomotive operating compartments. (R82-34)

Safety Recommendation R-82-34 was classified

“Closed-Acceptable” based on the FRA response that it had completed the study, Analysis

of Locomotive Cabs.

The Safety Board investigation of the January 1993 collision between two MU-locomotive

passenger trains in Gary, Indiana, resulted in a

safety recommendation asking the FRA to address the collision protection afforded by the

corner post structures of passenger cars:

In cooperation with the Federal Transit

Administration and the American Public

Transit Association, study the feasibility

of providing car body corner post struc-

 

Railroad Accident Report--Head-on Collision of

Boston & Maine Corporation Extra 1731 East and

Massachusetts Bay Transportation Authority Train

No. 570, Beverly, Massachusetts, August 11, 1981

(NTSB/RAR-82/01). Railroad Accident Report--Collision Between

Northern Indiana Commuter Transportation District

Eastbound Train 7 and Westbound Train 12 near

Gary, Indiana, on January 18, 1993 (NTSB/RAR93/03).

66

tures on all self-propelled passenger cars

and control cab locomotives to afford occupant protection during corner collision.

If feasible, amend the locomotive safety

standards accordingly. (R-93-24)

Similar Safety Recommendations R-93-25 and -

26, respectively, were issued to the FTA and the

American Public Transit Association. Since

April 1994, Safety Recommendations R-93-24

through -26 have been classified “Open--

Acceptable Action.”

The car body design of the trains involved in

the Gary accident was a lightweight monocoque

structure and almost identical to the design of

the MARC II cars involved in this accident. The

damage to the cars in the Gary collision was not

as extensive as to cab control car 7752 in the

Silver Spring collision, and no fire was involved. The Silver Spring accident serves to

underscore the vulnerability of certain passenger

car and cab control car designs in major collisions and the importance of addressing occupant

collision protection in car body design.

The FRA, which is principally responsible

for oversight of the passenger rail transportation

industry, initiated a formal study of the crashworthiness issue in response to the Rail Safety

Enforcement and Review Act. That study resulted in the comprehensive Locomotive Crashworthiness and Cab Working Conditions-Report

to Congress in September 1996, which included

an engineering evaluation of cab control cars.

The findings identified several crashworthiness

safety features, such as implementation of

stronger collision posts and full height corner

posts, that merited further FRA action in cooperation with private industry.

 

Metal structure in which the covering absorbs a

large part of the stresses to which the body is subjected.

Emergency Preparedness

The CSXT, as well as a local resident, contacted the MCFRS 911 dispatcher about the

collision at 5:41 p.m. Within 1 minute, the first

fire engine company was notified, and it arrived

on scene within 5 minutes of notification. All

MCFRS commands had been established by

6:15 p.m. Therefore, the Safety Board concludes

that even though the MCFRS personnel responded promptly to the emergency, they could

do nothing to save any of the accident victims

because passenger coach cab control car 7752

was already completely engulfed in flames when

the first firefighter arrived on scene. The investigation identified problems with the MCFRS

preparedness for railroad passenger train accidents; the CSXT, the MTA/MARC, and the

MCFRS contingency planning; and the interaction between these three agencies.

The MCFRS activated the fire annex section

of the Montgomery County Emergency Management Agency (MCEMA) disaster plan; however, the fire annex section did not provide for

interchange with the CSXT or MARC, which

was evident when interactions were not consistently maintained between the supervisors or

dispatchers or both of the MCFRS, the CSXT,

and MARC. The MCFRS personnel were not

receptive to the CSXT offers for assistance. The

fire annex section did not provide for railroad

representatives to respond to strategic locations

to contribute their expertise and assistance.

The CSXT attempted to assist in evacuating

passengers by moving trains closer to the accident site and only complicated the emergency

response efforts. Although this attempt was consistent with the CSXT practice for controlling

train movements and providing assistance, the

MCFRS was not familiar with railroad operations because no procedures had been coordinated between the CSXT and the MCFRS. As a

result, the accident scene was evacuated about

6:30 p.m. by emergency responders who feared

that another train was entering the accident site.
67

The MCEMA disaster plan did not contain procedures for responding to railroad passenger

train accidents. The Safety Board concludes that

the MCEMA disaster plan lacked procedures for

responding to railroad passenger train accidents,

such as simulating the accident response with

coordinated management, which could have

emphasized the importance of being familiar

with passenger cars and of coordinating activities between the MCFRS, the MTA/MARC, and

the CSXT. To be familiar with the means of

emergency egress from a passenger train and to

coordinate activities with the railroads are extremely essential procedures needed for emergency response. Therefore, the Safety Board

believes that the MCEMA should develop comprehensive procedures for responding to railroad

passenger train accidents and include these procedures in its disaster plan.

Although MARC knew of the train accident,

it was not immediately aware that the collision

involved one of its commuter trains. The MARC

chief transportation officer said that for 45 minutes after the accident, the MARC operations

center had been in a state of confusion. In addition, the CSXT operations center in Jacksonville

was unable to contact the MARC operation

center by telephone from 5:45 until 6 p.m. because the telephone line was busy and no backup communications was available. Some MARC

officials who had the Amtrak alphanumeric

pagers were only made aware of the MARC

train involvement in the collision by reading the

messages that were meant for Amtrak personnel.

Since the accident, a dedicated emergency

phone line between the MARC operations center and the CSXT operations center has been

installed, and the CSXT has been provided with

the alphanumeric pager numbers of MARC supervisors.

The confusion between the CSXT and the

MCFRS at the accident site and the untimely

notifications between the CSXT and MARC of

the collision resulted because neither the CSXT

nor MARC had a formal emergency management plan available that contained procedures

for dispatchers and traincrews to notify emergency responders of train movements near an

accident site. When the AU dispatcher authorized the engineer of CSXT train Q401 to move

his locomotive closer to assist in evacuating

passengers, the MCFRS IC was not advised that

the train would be approaching the accident site.

The movement of trains toward an accident area

should have been addressed by the CSXT and

MCRFS dispatchers. The Safety Board concludes that the confusion during the initial

emergency response resulted because the CSXT

and MARC lacked a formal emergency management plan to follow. The implementation of

an emergency management plan that addressed

communications and training would have eliminated the confusion between the CSXT and

MARC. Therefore, the Safety Board believes

that CSXT should develop and implement a

formal emergency management plan that contains procedures specific to employee responsibilities and interaction with emergency response

agencies and other transportation entities. The

Safety Board also believes that the

MTA/MARC should develop an emergency plan

that will provide a detailed description of emergency response procedures as well as a protocol

to coordinate activities with the emergency response organizations and other transportation

entities when an accident occurs.

The CSXT traincrews of MARC passenger

trains had minimal guidance, compared with the

Amtrak manual of on-train instructions for conductors and assistant conductors, to properly

perform passenger train functions. Since the

CSXT operation in 1985 of the MARC passenger service, the CSXT had not maintained a

comprehensive passenger program that would

provide guidance to traincrews for passenger

train functions. The CSXT produced Passenger

Service Bulletins as needed, but it offered little

guidance on responding to passenger train

emergencies. The CSXT passenger traincrews

reported that they had not received any emergency training in passenger train operations and

in passenger responsibility in emergencies. The

Safety Board concludes that the CSXT personnel operating MARC passenger trains are not

adequately trained to understand and therefore
68

execute their responsibilities for passengers in

emergencies. The CSXT and MARC have

been working since 1993 to complete the Passenger Conductor’s Manual, which was unfinished at the time of the accident. A review of

this unfinished manual shows that it is much

less comprehensive than the Amtrak manual of

on-train instructions for conductors and assistant

conductors. The Safety Board believes that the

CSXT and MARC should develop and implement, in cooperation, a complete training agenda

for all CSXT passenger traincrews that provides

experience in the correct use of emergency

equipment, in emergency communications procedures, and in passenger evacuation and assistance in an emergency and also includes the

distribution of a comprehensive employee guidance manual.

Since the accident MARC has informed the

Safety Board that it, in cooperation with Amtrak

and the CSXT, has developed video materials

for training emergency responders and the Amtrak and CSXT traincrews who operate MARC

commuter trains. However, such passive

training may not be as effective as training that

requires traincrews to actively participate and

practice what is being demonstrated. To achieve

the protocols and procedures described in any

emergency management plan, emergency drills

should be performed in conjunction with local

emergency management agencies and with the

railroad to reinforce training, to test communications, and to determine whether procedural

changes are needed. Therefore, the Safety Board

believes that the CSXT and the MTA/MARC, in

cooperation with the emergency management

agencies of Baltimore County, of the city of

Baltimore, of the Metropolitan Washington

Council of Governments, and of Jefferson and

Berkeley Counties in West Virginia, should

conduct periodic disaster drills to assess their

emergency management plans, to reinforce and

 

45Before the accident, Amtrak was providing

training for MARC traincrews on the Penn Line and

hands-on as well as audio-visual training for

emergency responders in areas near the Penn Line.

evaluate their emergency training, and to test the

communications with the organizations.

The Safety Board has found in other accident

investigations that emergency responders can

be hampered in their search and rescue, as well

as extrication, efforts because of the lack of

emergency plans, inaccessible terrain along railroad property, accounting for number of passengers, difficult extrication caused by rescue tools

inadequate for the construction of and materials

in passenger equipment, coordination and communication with railroads and emergency responders, and infrequent disaster drills for

emergency responders. With the exception of

the nationwide Amtrak service, only certain localities have commuter passenger railroad service. Many rural emergency response agencies

may never have had the opportunity to respond

to a rail disaster involving fire. With the advent

of high-speed passenger rail service, increased

development of commuter railroad systems, and

widespread rail transportation of hazardous

materials, however, the likelihood of more

communities being involved in a railroad emergency of this type has increased. The Safety

Board therefore concludes that the lack of appropriate training for emergency responders in

the areas of emergency planning, coordination

and communications, rescue methods, inaccessible terrain along railroad property, familiarity

with railroad equipment, and disaster drills

may become a recurrent problem for other

 

46Railroad Accident Reports--Rear-end Collision of

Amtrak Passenger Train 94, the Colonial, and Consolidated Rail Corp. Freight Train ENS-121 on the

Northeast Corridor, Chase, Maryland, January 4,

1987 (NTSB/RAR-88/01); Head-on Collision of National Railroad Passenger Corporation (Amtrak) Passenger Trains Nos. 151 and 168, Astoria, Queens, New

York, New York, July 23, 1984 (NTSB/RAR-85/09);

Derailment and Subsequent Collision of Amtrak Train

82 with Rail Cars on Dupont Siding of CSX Transportation Inc. at Lugoff, South Carolina, on July 31,

1991 (NTSB/RAR-93/02); and Derailment of Amtrak

Train No. 2 on the CSXT Big Bayou Canot Bridge near

Mobile, Alabama, on September 22, 1993

(NTSB/RAR-94/01).
69

emergency response organizations unless a national effort is made to address emergency response training for railroad accidents. Consequently, the Safety Board believes that the Federal Emergency Management Agency should

include in its training at the U.S. Fire Administration National Fire Academy a curriculum

that addresses the needs of State and local

emergency management agencies to respond to a

major railroad accident and that familiarizes

emergency response organizations with railroad

equipment and appropriate rescue methods for

railroad accidents.

In December 1993, the FRA published its

report Recommended Emergency Preparedness

Guidelines for Passenger Trains, in which it

stated that it

has recognized the need for intercity and

commuter passenger train system operators to engage in careful advance planning

to respond effectively to emergencies.

This advance planning should address

emergency response procedures, training

of system operating and other emergency

response organization personnel, and provision and use of emergency equipment.

The report also noted that "This document is

advisory in nature. The recommended guidelines

contained herein do not have the force and effect of law or regulation."

On February 24, 1997, the FRA published

the NPRM Passenger Train Emergency Preparedness, which proposes requiring minimum

Federal safety standards for the preparation,

adoption, and implementation of emergency

preparedness plans by railroads connected with

the operation of passenger trains, including

 



Prepared for the FRA by the DOT, Research and

Special Programs Administration, John A. Volpe

National Transportation Systems Center, Final Report

No. DOT/FRA/ORD-93/24 November 1993.

freight railroads hosting the operations of rail

passenger service. The proposed rule also requires each affected railroad to instruct its employees on the provisions of the plan. The

Safety Board encourages the FRA to move forward in the rulemaking process for the development of comprehensive emergency management plans that affect the safety and well being

of passengers, railroad employees, and the

community in an emergency.

Reverser Use During Emergency

Braking

The Safety Board stopping distance tests indicated that had the MARC train 286 engineer

not used the reverser, thereby retaining dynamic

braking until impact, MARC train 286 would

have impacted Amtrak train 29 at a speed of

about 34 mph as opposed to the actual impact

speed of about 38 mph. The additional deceleration of MARC train 286 would have resulted

in an additional 0.3 seconds of elapsed time before impact, which in turn would have resulted

in Amtrak train 29 moving approximately 14

feet farther into the crossover before impact.

Thus, with MARC train 286 operating at the

speed of 66 mph and going into emergency

braking 1,407 feet before impact, a collision was

inevitable regardless of the reverser use by the

MARC train 286 engineer.

Despite the CSXT instructions that the reverser only has limited utility and its intentions that

the reverser be used only under specific conditions, the use of the reverser having a retarding

effect is implied in the instructions. The MARC

train 286 engineer may have drawn from that

implication and used the reverser about 1,000

feet into his emergency braking sequence out of

desperation when he realized emergency braking

would not prevent the impending collision.

Nevertheless, because the reverser use eliminated the additional braking provided by the

locomotive dynamic brakes, the Safety Board

concludes that the MARC train 286 engineer’s

use of the reverser during the emergency brake

application resulted in a marginally increased

stopping distance for MARC train 286.
70

Therefore, the Safety Board believes that the

CSXT should inform its engineers, and the

AAR, the American Short Line Railroad Association, the Brotherhood of Locomotive Engineers, the UTU, the International Brotherhood

of Teamsters, and the American Public Transit

Association should inform its membership, of

the circumstances of this accident and caution

them not to use the reverser during emergency

brake applications for those trains on which the

use of reverser will eliminate the dynamic

braking, thus increasing stopping distance.

Computer-Aided Recordkeeping

Federal regulations under 49 CFR Part

228.17 require that each carrier keep records of

train movements that are made under the direction and control of a dispatcher who uses a telephone, radio, or any other electrical or mechanical device to dispatch, report, transmit, receive,

or deliver orders pertaining to train movements.

These records are to contain such important information as the identification of the timetable

in effect; the train location and the date; the dispatcher identification and duty time; the weather

conditions at 6-hour intervals; the identification

of the trains and the traincrews and their duty

times; the station names and the office designations; the distances between stations; the direction of train travel and the times of arrival, departing, and passing all reporting stations; and

any unusual events affecting the movement of

trains and the identity of affected trains. Before

the computerization of dispatching offices, these

records were recorded manually and retained on

file for review by railroad operating officers,

Federal regulators, and accident investigators.

The CSXT operates its CTC system with a

computed-aided dispatching (CAD) system, as

do many major railroads in the country. The

CAD generates “computerized train sheets” (a

computer file that can print out the requested

information), which was designed by the CSXT

for the recordkeeping of each train (about 3,000

per month). The Safety Board examined train

sheets covering about 90 days, with particular

attention given to the accident trains, and found

that the train sheets were incomplete in so far as

recording the information delineated under 49

CFR Part 228.17. For example, the computergenerated train sheet for MARC train 286 did

not show the train activity after its departure

from Point of Rocks, when it was required to

make a reverse movement to crossover and go

around a disabled freight train; the weather that

day; and the accident occurrence. The Safety

Board investigation revealed that the train sheets

being maintained by CSXT lacked the information required by FRA regulation and, therefore,

were of little value in determining unusual

events the day of the accident. The Safety Board

concludes that the FRA has not addressed the

use of CAD system records to provide information for the identification and evaluation of potential safety-related trends for corrective action.

The FRA must consider, when alternative methods of recordkeeping are employed, that the current minimum data requirements are critical to

good event recording and that alternative should

be comparable or better. Consequently, the

Safety Board believes that the FRA should update 49 CFR Part 228.17, Train Dispatcher’s

Record of Train Movements, to include the

same parameters for electronic recordkeeping of

the dispatcher’s record of train movements.

Locomotive Fuel Tank

 Crashworthiness

In 1992 the Safety Board conducted comprehensive Safety Study (NTSB/SS-92/04), Locomotive Fuel Tank Integrity, which addressed,

among other issues, the potential in railroad accidents for diesel fuel fires to fatally injure the

trapped crewmembers. The report primarily

covered the risk in freight locomotive operations, although a passenger train collision case

study was cited. However, the risk of collision

damage is effectively the same for both types of

operations because fuel tanks for freight locomotives are configured essentially the same as

passenger locomotives, such as the one involved

in this accident. Specific safety issues discussed

in the study were the adequacy of current fuel

tank design, factors that affect fuel tank design,
71

and the sufficiency of research to improve fuel

tank integrity or fuel containment. The study

findings concluded that the evaluation of the

extent of locomotive fuel tank damage and spills

on an annual basis is difficult because of the

limited data available. Furthermore, although

the railroad industry has explored changes in

fuel tank design, no evidence was found that the

industry has performed a systematic engineering

analysis to determine the feasibility of providing

better crash protection for fuel tank systems.

As a result of this safety study, the Safety

Board issued Safety Recommendation R-92-10

to the FRA:

Conduct, in conjunction with the Association of American Railroads, the General Electric Company, and the ElectroMotive Division of General Motors, research to determine if the locomotive fuel

tank can be improved to withstand forces

encountered in the more severe locomotive derailment accidents or if fuel containment can be improved to reduce the

rate of fuel leakage and fuel ignition.

Consideration should be given to crash or

simulated testing and evaluation of recent

and proposed design modifications to the

locomotive fuel tank, including increasing

the structural strength of end and side

wall plates, raising the tank higher above

the rail, and using internal tank bladders

and foam inserts.

The Safety Board also issued the similar Safety

Recommendations R-92-14, -16, and -17, respectively, to the AAR, the General Electric

Company (GE), and the Electro-Motive Division of General Motors (EMD). The Safety

Board classified Safety Recommendations R-92-

10, -16, and -17 to the FRA, GE, and the EMD,

respectively, “Open--Acceptable Response” after noting the industry efforts to address the issue. However, the crash or simulation testing

and evaluation of recent and proposed design

modifications has not yet been addressed.

Therefore, the Safety Board reiterates to the

FRA, GE, and the EMD, respectively, Safety

Recommendations R-92-10, -16, and -17. In addition the Safety Board has classified Safety

Recommendation R-92-14 “Closed--Acceptable

Action” to the AAR after it reported the adoption of RP-506 for all locomotive units built after September 1, 1995. RP-506 addressed structural and puncture resistance properties of the

fuel tank to reduce the risk of spillage under

derailment or minor collision conditions.

Also as a result of the safety study, the

Safety Board issued Safety Recommendation R92-11 to the FRA:

Establish, if warranted, minimum performance standards for locomotive fuel

tanks based on the research called for in

Safety Recommendation R-92-10.

Because the Safety Board believed that AAR

RP-506 was an adequate direction to take and, at

the time, realized no need for Federal regulations, Safety Recommendation R-92-11 was

classified “Closed--No Longer Applicable.”

The locomotive in the Silver Spring accident,

Amtrak unit ATK 255, was built in 1977 and

was under the FRA standard in 49 CFR Part

229.71, stipulating the minimum clearance from

the top of the rail. The current FRA regulations

do not address the design, size, locations, or performance of locomotive fuel tanks, and do not

require a regularly scheduled or periodic inspection of fuel tanks to ensure no safety hazards are present. In this collision, substantial

compressive forces bearing on the lead truck of

Amtrak unit ATK 255 caused it to be displaced

into the front plate of the fuel tank, located immediately behind the lead truck. The front of the

fuel tank compressed inward substantially damaging the fuel tank. The left side of the fuel tank

subsequently was ruptured catastrophically by

the raking action of the body bolster of the

MARC cab control car 7752 as both trains continued to move forward. The fuel tank provided

little impact resistance to the compressive forces

of the lead truck and the shearing action of the

projecting body bolster of cab control car 7752.

The released fuel sprayed into the exposed inte-
72

rior of cab control car 7752, and with multiple

sources of ignition, the fuel quickly ignited and

engulfed the car.

The Safety Board has previously expressed

its concern to the FRA about locomotives built

before the effective date of September 1, 1995,

noting that many of these locomotives will remain in service for several years, and this accident only reinforces that concern about this issue. The Safety Board will continue to address

the crashworthiness issue in future accident investigations and to monitor the FRA progress

for improving locomotive fuel tank crashworthiness.

CSXT and MARC Operating Agreement

The FTA grant process and FRA/MDLI operations oversight suggest areas of needed improvement for the involved government agencies; however, the CSXT is inevitably the most

important agent in safe, or unsafe, operations. In

this regard, the indemnification arrangement for

CSXT/MARC service is a significant, but not

likely uncommon, issue: the actual operator of

the service in question was well-insulated

against damages that might arise from both its

employees and the passengers on the line. Risk

of liability from injury to its employees was

compensated by a substantial surcharge to the

CSXT billings for labor expense, and the State

of Maryland assumed the risk, through selfinsurance and the purchase of commercial coverage, for the first $150 million of passengerrelated liabilities.

The exposure to liability may induce cautious behavior; however, in the absence of this

exposure, it is not so obvious that one will be

readily able to identify the precautions that were

forsworn when the financial risks were eliminated, particularly in a regime, like railroading,

where so much of the activity is required and

inspected under regulatory authority. Nevertheless, the manner in which the protection of

MARC passengers was approached, and subsequently explained, almost assuredly reflects a

disconnect between activity and responsibility.

The CSXT manager for these commuter services

indicated that at the request of MARC, the

CSXT crews wore MARC uniforms in the passenger cars. The CSXT crews were not trained

by MARC or by the CSXT in emergency procedures. Indeed, no specific carrier-initiated safety

assessment of the emergency passenger equipment or its operation had been undertaken, and

no emergency preparedness plan had been developed. In postaccident questioning, CSXT

personnel allowed that passenger safety, as opposed to train handling safety, was an issue for

MARC. The CSXT was, of course, aware that

MARC had done little in this regard and had no

on-train personnel. But when asked whether the

matter had ever been discussed between the two

principals, the CSXT indicated that MARC had

never broached the subject. It appears that the

CSXT had not raised the issue as well. The

Safety Board concludes that the CSXT/MARC

system lacked comprehensive safety oversight to

ensure the safety of the commuting public. The

Safety Board is concerned by this apparent

hands-off approach and is convinced that it cannot be divorced from the environment of diminished liability in which it arose. Therefore, the

Safety Board believes that the Governor and the

General Assembly of the State of Maryland

should instruct and empower an appropriate

State agency to provide continual, effective, and

independent safety oversight of all aspects of

the MARC operations.
73

FINDINGS

Conclusions

 1. The train equipment and the track functioned

as designed and the AU dispatcher conducted the

dispatching activities properly. Neither the three

MARC train 286 crewmembers nor the two Amtrak train 29 locomotive crewmembers were impaired by alcohol or drugs. All train crewmembers were in good health, had no evidence of fatigue, and were experienced in and qualified for

their duties.

 2. The weather conditions did not impair the

ability of the MARC train 286 crewmembers to

distinguish the indication of Kensington signal

1124-2.

 3. The signal system functioned as designed.

 4. The MARC train 286 engineer apparently forgot the signal aspect, which required him to be

prepared to stop at Georgetown Junction, due to

interference caused by various events, including

performing an unscheduled station stop, that occurred between the presentation of the

APPROACH aspect at signal 1124-2 and the

STOP signal at Georgetown Junction.

 5. Neither the conductor nor the assistant conductor while in the cab control compartment appeared to have effectively monitored the engineer’s operation of MARC train 286 and taken

action to ensure the safety of the train.

 6. Had the Federal Railroad Administration required the recording of the train crewmembers’

voice communications, the essential details

about the circumstances of this accident could

have been provided.

 7. Had the Federal Railroad Administration and

the Federal Transit Administration required the

CSX Transportation Inc. to perform a total signal system review of the proposed signal

changes that included a human factors analysis

within a comprehensive failure modes and effects analyses, this accident may have been prevented.

 8. Federal funds granted for the signal modifications on the CSXT Brunswick Line to accommodate an increase in the number of Maryland Rail Commuter trains did not ensure that

the safety of the public was adequately addressed.

 9. Without a separate collection database specific to commuter rail inspections and accident/incidents, it is difficult for the Federal Railroad Administration to evaluate its own effectiveness of inspections and to identify problematic trends.

10. The Federal Railroad Administration reliance on the need for increased vigilance of wayside signals and special actions in operating

rules, such as the crew communication rule of

emergency order 20, does not adequately safeguard the public.

11. Had a train control system that could utilize

the cab signal equipment on the Maryland Rail

Commuter cab control car been a part of the

signal system on the Brunswick Line, this accident may not have occurred.

12. A fully implemented positive train separation control system would have prevented this

accident by recognizing that MARC train 286

was not being operated within allowable parameters, based on other authorized train operations, and would have stopped the train before it

could enter into the unauthorized track area.

13. The emergency egress of passengers was

impeded because the passenger cars lacked

readily accessible and identifiable quick-release

mechanisms for the exterior doors, removable

windows or kick panels in the side doors, and

adequate emergency instruction signage.

14. The absence of comprehensive Federal passenger car safety standards resulted in the inadequate emergency egress conditions.
74

15. A need exists for Federal standards requiring

passenger cars be equipped with reliable emergency lighting fixtures with a self-contained

independent power source when the main power

supply has been disrupted to ensure passengers

can safely egress.

16. Prescribed inspection and maintenance test

cycles are needed to ensure reliable operation of

emergency windows in all long-distance and

commuter rail passenger cars.

17. The exterior emergency door release Thandles for the MARC cars were not either in

place or accessible to firefighters because no

requirements for their maintenance or accessibility exist.

18. The catastrophic rupture of the Amtrak unit

255 fuel tank in the collision with the MARC

cab control car 7752 released fuel, which

sprayed into the interior of the cab control car,

and resulted in the fire and at least 8 of the 11

fatalities.

19. Because other commuter passenger cars may

also have interior materials that may not meet

specified performance criteria for flammability

and smoke emission characteristics, the safety of

passengers in those cars could be at risk.

20. The Federal guidelines on the flammability

and smoke emissions characteristics and the

testing of interior materials do not provide for

the integrated use of passenger car interior materials and, as a result, are not useful in predicting the safety of the interior environment of a

passenger car in a fire.

21. Even though the Montgomery County Fire

and Rescue Services personnel responded

promptly to the emergency, they could do nothing to save any of the accident victims because

passenger coach cab control car 7752 was already completely engulfed in flames when the

first firefighter arrived on scene.

22. The Montgomery County Emergency Management Agency disaster plan lacked procedures

for responding to railroad passenger train accidents, such as simulating the accident response

with coordinated management, which could

have emphasized the importance of being familiar with passenger cars and of coordinating

activities between the Montgomery County Fire

and Rescue Services, the Maryland Rail Commuter, and the CSX Transportation Inc.

23. The confusion during the initial emergency

response resulted because the CSX Transportation Inc. and Maryland Rail Commuter lacked a

formal emergency management plan to follow.

24. The CSX Transportation Inc. personnel operating Maryland Rail Commuter passenger trains

are not adequately trained to understand and,

therefore, execute their responsibilities for passengers in emergencies.

25. The lack of appropriate training for emergency responders in the areas of emergency

planning, coordination and communications,

rescue methods, inaccessible terrain along railroad property, familiarity with railroad equipment, and disaster drills may become a recurrent

problem for other emergency response organizations unless a national effort is made to address emergency response training for railroad

accidents.

26. The MARC train 286 engineer’s use of the

reverser during the emergency brake application

resulted in a marginally increased stopping distance for MARC train 286.

27. The Federal Railroad Administration has not

addressed the use of computer-aided dispatching

system records to provide information for the

identification and evaluation of potential safetyrelated trends for corrective action.

28. The CSX Transportation Inc./Maryland Rail

Commuter system lacked comprehensive safety

oversight to ensure the safety of the commuting

public.
75

Probable Cause

The National Transportation Safety Board

determines that the probable cause of this accident was the apparent failure of the engineer and

the traincrew because of multiple distractions to

operate MARC train 286 according to signal

indications and the failure of the Federal Railroad Administration, the Federal Transit Administration, the Maryland Mass Transit Administration, and the CSX Transportation Inc. to

ensure that a comprehensive human factors

analysis for the Brunswick Line signal modifications was conducted to identify potential

sources of human error and to provide a redundant safety system that could compensate for

human error.

Contributing to the accident was the lack of

comprehensive safety oversight on the CSX

Transportation Inc./Maryland Rail Commuter

system to ensure the safety of the commuting

public. Contributing to the severity of the accident and the loss of life was the lack of appropriate regulations to ensure adequate emergency

egress features on the railroad passenger cars.

RECOMMENDATIONS

As a result of its investigation, the National

Transportation Safety Board makes the following

recommendations:

--to the Federal Railroad Administration:

Amend 49 Code of Federal Regulations

Part 229 to require the recording of train

crewmembers’ voice communications for

exclusive use in accident investigations

and with appropriate limitations on the

public release of such recordings. (R-97-

9)

Require comprehensive failure modes and

effects analyses, including a human factors analysis, for all signal system modifications. (R-97-10)

Develop and maintain separate identifiable data records for commuter and intercity rail passenger operations. (R-97-11)

Require, in the interim of a positive train

separation control system being available,

the installation of cab signals, automatic

train stop, automatic train control, or

other similar redundant systems for all

trains where commuter and intercity passenger railroads operate. (R-97-12)

Require the implementation of positive

train separation control systems for all

trains where commuter and intercity passenger railroads operate. (R-97-13)

Require all passenger cars to have easily

accessible interior emergency quickrelease mechanisms adjacent to exterior

passageway doors and take appropriate

emergency measures to ensure corrective

action until these measures are incorporated into minimum passenger car safety

standards. (R-97-14)

Require all passenger cars to have either

removable windows, kick panels, or other

suitable means for emergency exiting

through the interior and exterior passageway doors where the door could impede

passengers exiting in an emergency and

take appropriate emergency measures to

ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (R-97-15)

Issue interim standards for the use of luminescent or retroreflective material or

both to mark all interior and exterior

emergency exits in all passenger cars as

soon as possible and incorporate the in-
75

terim standards into minimum passenger

car safety standards. (R-97-16)

Require all passenger cars to contain reliable emergency lighting fixtures that are

each fitted with a self-contained independent power source and incorporate the

requirements into minimum passenger car

safety standards. (R-97-17)

Provide promptly a prescribed inspection

and maintenance test cycle to ensure the

proper operation of all emergency exit

windows as well as provide that the 180-

day inspection and maintenance test cycle

is prescribed in the final rule. (R-97-18)

Require that all exterior emergency door

release mechanisms on passenger cars be

functional before a passenger car is

placed in revenue service, that the emergency door release mechanism be placed

in a readily accessible position and

marked for easy identification in emergencies and derailments, and that these

requirements be incorporated into minimum passenger car safety standards. (R97-19)

Require that a comprehensive inspection of

all commuter passenger cars be performed

to independently verify that the interior

materials in these cars meet the expected

performance requirements for flammability and smoke emissions characteristics.

(R-97-20)

Update 49 Code of Federal Regulations

Part 228.17, Train Dispatcher’s Record of

Train Movements, to include the same parameters for electronic recordkeeping of

the dispatcher’s record of train movements. (R-97-21)

--to the Federal Transit Administration:

Revise the grant application process to

require a comprehensive failure modes

and effects analyses, including a human factors analysis, be provided for

all federally funded transit projects

that are directly related to the transport

of passengers. (R-97-22)

Cooperate with the Federal Railroad

Administration for requiring, in the

interim of a positive train separation

control system being available, the installation of cab signals, automatic

train stop, automatic train control, or

other similar redundant systems for all

trains where commuter and intercity

passenger railroads operate. (R-97-23)

Cooperate with the Federal Railroad

Administration for requiring the implementation of positive train separation control systems for all trains

where commuter and intercity passenger railroads operate. (R-97-24)

Cooperate with CSX Transportation

Inc. in the development and installation of a positive train separation control system where Maryland Rail

Commuter equipment operates on

CSX Transportation Inc. tracks. (R-97-

25)

--to the CSX Transportation Inc.:

Develop and install a positive train

separation control system on track

segments that have commuter and intercity passenger trains. (R-97-26)

Develop and implement a formal

emergency management plan that

contains procedures specific to employee responsibilities and interaction

with emergency response agencies and

other transportation entities. (R-97-27)

Develop and implement, in cooperation with Maryland Mass Transit Administration/Maryland Rail Commuter, a complete training agenda for

all CSX Transportation Inc. passenger

traincrews that provides experience in

the correct use of emergency equip-
76

ment, in emergency communications

procedures, and in passenger evacuation and assistance in an emergency

and also includes the distribution of a

comprehensive employee guidance

manual. (R-97-28)

Conduct, in cooperation with Maryland Mass Transit Administration/Maryland Rail Commuter, the

Baltimore County Emergency Management Agency, the City of Baltimore Emergency Management

Agency, the Metropolitan Washington

Council of Governments, the Jefferson

County Commissioners, and the Berkeley County Commissioners, periodic

disaster drills to assess their emergency management plans, to reinforce

and evaluate their emergency training,

and to test the communication with the

organizations. (R-97-29)

Inform all operating train crewmembers

of the circumstances of this accident

and emphasize the crew responsibility

while in the operating compartment for

the safe operation of the train. (R-97-

30)

Inform your engineers of the circumstances of this accident and caution

them not to use the reverser during

emergency brake applications for

those trains on which the use of the

reverser will eliminate the dynamic

braking, thus increasing stopping distance. (R-97-31)

--to the Maryland Mass Transit Administration:

Cooperate with CSX Transportation

Inc. in the development and installation of a positive train separation control system where Maryland Rail

Commuter equipment operates on

CSX Transportation Inc. tracks. (R-97-

32)

Develop an emergency plan that will

provide a detailed description of

emergency response procedures as

well as a protocol to coordinate activities with the emergency response

organizations and other transportation

entities when an accident occurs. (R97-33)

Develop and implement, in cooperation with CSX Transportation Inc., a

complete training agenda for all CSX

Transportation Inc. passenger traincrews that provides experience in the

correct use of emergency equipment,

in emergency communications procedures, and in passenger evacuation and

assistance in an emergency and also

includes the distribution of a comprehensive employee guidance manual.

(R-97-34)

Conduct, in cooperation with the CSX

Transportation Inc., the Baltimore

County Emergency Management

Agency, the City of Baltimore Emergency Management Agency, the Metropolitan Washington Council of Governments, the Jefferson County Commissioners, and the Berkeley County

Commissioners, periodic disaster drills

to assess their emergency management

plans, to reinforce and evaluate their

emergency training, and to test the

communication with the organizations.

(R-97-35)

--to the U.S. Department of Transportation:

Review the testing protocols within

the various modal administrations regarding the flammability and the

smoke emissions characteristics of interior materials and coordinate the development and implementation of

standards for material performance

and testing with the Federal Railroad

Administration and the Federal Transit

Administration. (R-97-36)
77

--to the Federal Emergency Management Agency:

Include in your training at the U.S.

Fire Administration National Fire

Academy a curriculum that addresses

the needs of State and local emergency

management agencies to respond to a

major railroad accident and that familiarizes emergency response organizations with railroad equipment and

appropriate rescue methods for railroad accidents. (R-97-37)

--to the Governor and the General Assembly of the State of Maryland:

Instruct and empower an appropriate

State agency to provide continual, effective, and independent safety oversight of all aspects of the Maryland

Rail Commuter operations. (R-97-38)

--to the Association of American Railroads:

Assist the railroad industry with the

development of positive train separation control systems through a continuing review of nonrailroad technology and assess its adaptability to railroad communication-based control

systems. (R-97-39)

Assist the railroad industry with the

development of positive train separation control systems by acting as a

clearinghouse for information on the

status and results of pilot projects and

by disseminating that information to

the railroad industry and the Federal

and participating State transportation

organizations. (R-97-40)

Assist the railroad industry with the

installation and operation of positive

train separation control systems by

maintaining industry standards to ensure open architecture and an

interoperability of equipment for train

control systems. (R-97-41)

Inform your membership of the circumstances of this accident and caution them not to use the reverser during emergency brake applications for

those trains on which the use of the

reverser will eliminate the dynamic

braking, thus increasing stopping distance. (R-97-42)

--to the Montgomery County Emergency Management Agency:

Develop comprehensive procedures

for responding to railroad passenger

train accidents and include these procedures in your disaster plan. (R-97-

43)

--to the Baltimore County Emergency Management Agency, the Baltimore City Emergency

Management Agency, the Metropolitan Washington Council of Governments, the Jefferson

County Commissioners, and the Berkeley

County Commissioners:

Conduct, in cooperation with the CSX

Transportation Inc. and the Maryland

Mass Transit Administration/Maryland Rail Commuter, periodic disaster drills to assess their

emergency management plans, to reinforce and evaluate their emergency

training, and to test the communication with the organizations. (R-97-44)

--to the American Short Line Railroad Association, the Brotherhood of Locomotive Engineers,

the United Transportation Union, the International Brotherhood of Teamsters, and the

American Public Transit Association:

Inform your membership of the circumstances of this accident and caution them not to use the reverser during emergency brake applications for

those trains on which the use of the

reverser will eliminate the dynamic

braking, thus increasing stopping distance. (R-97-45)
78

Also, as a result of its investigation, the National Transportation Safety Board reiterates the

following recommendations:

--to the Federal Railroad Administration:

Promulgate Federal standards to require

the installation and operation of a train

control system on main line tracks that

will provide for positive separation of

all trains. (R-87-16)

Conduct, in conjunction with the Association of American Railroads, the

General Electric Company, and the

Electro-Motive Division of General

Motors, research to determine if the

locomotive fuel tank can be improved

to withstand forces encountered in the

more severe locomotive derailment

accidents or if fuel containment can be

improved to reduce the rate of fuel

leakage and fuel ignition. Consideration should be given to crash or simulated testing and evaluation of recent

and proposed design modifications to

the locomotive fuel tank, including increasing the structural strength of end

and side wall plates, raising the tank

higher above the rail, and using internal tank bladders and foam inserts. (R92-10)

In conjunction with the Association of

American Railroads and the Railway

Progress Institute, establish a firm

timetable that includes at a minimum,

dates for final development of required

advanced train control system hardware, dates for an implementation of a

fully developed advanced train control

system, and a commitment to a date for

having the advanced train control system ready for installation on the general

railroad system. (R-93-12)

--to the General Electric Company:

Conduct, in conjunction with the Federal Railroad Administration, the Association of American Railroads, and

the Electro-Motive Division of General Motors, research to determine if

the locomotive fuel tank can be improved to withstand forces encountered in the more severe locomotive

derailment accidents or if fuel containment can be improved to reduce

the rate of fuel leakage and fuel ignition. Consideration should be given to

crash or simulated testing and evaluation of recent and proposed design

modifications to the locomotive fuel

tank, including increasing the structural strength of end and side wall

plates, raising the tank higher above

the rail, and using internal tank bladders and foam inserts. (R-92-16)

--to the Electro-Motive Division of General

Motors:

Conduct, in conjunction with the Federal Railroad Administration, the Association of American Railroads, and

the General Electric Company, the research to determine if the locomotive

fuel tank can be improved to withstand

forces encountered in the more severe

locomotive derailment accidents or if

fuel containment can be improved to

reduce the rate of fuel leakage and fuel

ignition. Consideration should be

given to crash or simulated testing and

evaluation of recent and proposed design modifications to the locomotive

fuel tank, including increasing the

structural strength of end and side wall

plates, raising the tank higher above

the rail, and using internal tank bladders and foam inserts. (R-92-17)
79

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

July 3, 1997
81

APPENDIX A

INVESTIGATION AND HEARING

The Safety Board was notified of the collision at 6 p.m. on February 16, 1996, and dispatched a major

railroad accident investigation team. Investigative groups studied the operations, track, signals, mechanical,

survival factors, and human performance aspects of the accident.

The CSX Transportation Inc., the National Railroad Passenger Corporation, the Maryland Mass

Transit Administration, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers,

the United Transportation Union, and the Montgomery County Department of Fire and Rescue Services

assisted in the Safety Board investigation.

As part of its investigation, the Safety Board held a 3-day public hearing in Rockville, Maryland,

between June 26 and 28, 1996, at which 27 witnesses testified. Parties to the hearing included the CSX

Transportation Inc., the National Railroad Passenger Corporation, the Maryland Mass Transit

Administration, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, the

United Transportation Union, and the Montgomery County Department of Fire and Rescue Services.

APPENDIX B

CHRONOLOGY OF SIGNAL SEQUENCE

The times recorded at Georgetown Junction differ about 2 minutes from the Jacksonville

system log. The discrepancy results from the delay that occurs in the order the information is

received from field locations and the actual setting of the clock. The following information was

recorded at Georgetown Junction:

1. Train No. K951-16: “Rock Runner” - a westbound ballast train.

2. Train No. P279-16: Westbound MARC passenger train ahead of Amtrak passenger train.

3. Train No. P28 4-16: Eastbound MARC passenger train ahead of MARC passenger train.

4. Train No. P029-16: Westbound Amtrak passenger train involved in accident.

5. Train No. P286-16: Eastbound MARC passenger train involved in accident.

P is the CSXT designation for a passenger train.

Signal Identification corresponding to report:

Signal No. 2 Eastbound Absolute Signal track 1 (EAS-1)

Signal No. 4 Westbound Absolute Signal track 1 (WAS-1)

Signal No. 6 Eastbound Absolute Signal track 2 (EAS-2)

Signal No. 8 Westbound Absolute Signal track 2 (WAS-2)

Present Conditions at 1500:

Switch No. 1 - Normal

Switch No. 3 - Normal

Switch No. 5 - Normal

Signal No. 4 Clear

Signal No. 2 at Stop

Signal No. 8 at Stop

Signal No. 6 at Stop

Track 1 Interlocking Track Circuit Energized

Track 2 Interlocking Track Circuit Energized

Track Circuit West of Interlocking - Track No. 1 Energized

Track Circuit West of Interlocking - Track No. 2 Energized

Track Circuit East of Interlocking - Track No. 1 Energized

Track Circuit East of Interlocking - Track No. 2 Energized

Track Circuit West of Interlocking - From Georgetown Branch Energized

83
,,

APPENDIX B

Time Train Track Direction Event

15:14:04 P284-16 2 East Signal 6 Clear

Last time signal No. 6 is cleared at Georgetown Junction on track No. 2 for an eastbound

move.

15:21:38

15:26:04

15:26:04

15:26:32

15:27:38

15:28:16

15:32:18

16:02:10

16:05:39

16:05:39

E107-16

E107-16

E107-16

E107-16

E107-16

E107-16

E107-16

P284-16

P284-16

P284-16

1

1

1

2

2

2

West

West

West

West

West

West

West

East

Occupies track cast of Georgetown

Occupies Georgetown interlocking

switches 1N, 3N, 5N

Signal 4 at Stop

Occupies track west of Georgetown

Unoccupied track east of Georgetown

Unoccupied Georgetown interlocking

switches 1N, 3N, 5N

Unoccupied track west of Georgetown

Occupies track west of Georgetown

Occupies Georgetown interlocking

switches 1N, 3N, 5N

Signal 6 at stop

Signal No. 6 remains at stop up to and beyond the time of the accident,

about 1 hour and 33 minutes.

16:05:50

16:05:55

16:06:14

16:08:06

16:32:51

16:33:08

16:33:23

16:40:37

16:05:39

16:46:45

16:47:05

16:47:079

16:47:15

16:47:37

16:47:45

16:50:20

16:50:36

16:54:10

17:03:48

17:04:04

17:04:09

P284-16

P284-16

P284-16

P284-16

P275-16

P275-16

P275-16

P275-16

P275-16

P275-16

P275-16

P275-16

P275-16

P277-16

17:04:04 P277-16

2

2

2

2

l&2

l&2

2

2

2

2

2

1

1

2

1

l&2

l&2

1

l&2

l&2

2

East

East

West

West

West

West

West

West

West

West

West

West

West

Unoccupied track west of Georgetown

Occupies track east of Georgetown

Unoccupied Georgetown interlocking

Unoccupied track cast of Georgetown

Switch 1 out of correspondence

Switch 1 reverse

Signal 8 Clear

Occupies track cast of Georgetown

Occupies Georgetown interlocking

switches 1R, 3N, 5N

Signal 8 at Stop

Unoccupied track east of Georgetown

occupies Georgetown interlocking

switches 1R 3N, 5N

Occupies track west of Georgetown

Unoccupied Georgetown interlocking

switches lR, 3N, 5N

Unoccupied Georgetown interlocking

switches 1R, 3N, 5N

switch 1 out of correspondence

Switch 1 normal

Unoccupied track west of Georgetown

Switch 1 out of correspondence

Switch 1 Reverse

Signal 8 at Clear
17:09:51

17:14:45

17:14:45

17:15:03

17:15:03

17:15:11

17:15:38

17:15:42

17:16:49

17:18:31

17:21:16

17:25:25

17:25:25

17:25:41

17:25:50

17:25:59

17:26:18

17:26:22

17:26:59

17:28:07

17:31:38

17:33:57

17:35:46

17:38:22

17:38:22

1738:41

17:38:42

17:38:45

17:38:47

17:38:48

P277-16

P277-16 West

P277-16

P277-16

P277-16 West

P277-I 6

P277-16

P277-16 West

P279-16

P279-I 6

P279-16

P279-16

P279-16

P279-16

P279-16

P279-16

P279-16

P279-16

P029-16

K951-16

P279-16

P286-16

P029-16

P029-16

P029-16

P029-16

P286-16

P029-16

P286-16

P029-16

P029-16

P286-16

P029-16

P286-16

2

2

2

1

2

1

2

1

2

2

2

2

2

2

1

1

2

1

2

1

2

2

2

2

2

2

2

2

2

2

2

2

2

2

West

West

West

West

West

West

West

West

West

West

West

West

West

west

West

West

West

West

East

West

West

West

East

West

East

West

Occupies track cast of Georgetown

Occupies Georgetown interlocking

switches 1R,3N, 5N

Signal 8 at Stop

Occupies Georgetown interlocking

Unoccupied track cast of Georgetown

Occupies track west of Georgetown

Unoccupied Georgetown interlocking

switches 1R, 3N, 5N

Unoccupied Georgetown interlocking

switches 1R, 3N, 5N

Signal 8 at Clear

Unoccupied track west of Georgetown

Occupies track east of Georgetown

Occupies Georgetown interlocking

switches 1R,3N, 5N

Signal 8 at Stop

Unoccupied track east of Georgetown

Occupies Georgetown interlocking

switches 1R, 3N, 5N

Occupies track west of Georgetown

Unoccupied Georgetown interlocking

switches 1R, 3N, 5N

Unoccupied Georgetown interlocking

switches 1R, 3N, 5N

Signal 8 at Clear

Occupies track east of Georgetown

Unoccupied track west of Georgetown

Occupies track west of Georgetown

Occupies track East of Georgetown

Occupies Georgetown interlocking

switches 1R, 3N, 5N

Signal 8 at Stop

Switch 3 out of correspondence

switch 5 out of correspondence

Switch 5 Normal

switch 5 out of correspondence

*****Switches out of correspondence due to derailment*****

85

APPENDIX C

CHRONOLOGY OF ACCIDENT

Times indicated with (j) are from the Jacksonville signal log and are about 2 minutes ahead

of time shown. All other times are from the Jacksonville AU dispatcher tape, published time

tables, or the reporting agency.

Time

10:10 a.m.

11:00 a.m.

12:59 p.m.

1:24 p.m.

1:34 p.m.(j)

2:50 p.m.

2:53 p.m.

4:05 p.m.

4:05 p.m.(j)

4:27 p.m.

4:30 p.m.

4:33 p.m.(j)

4:47 p.m.(j)

5:15 p.m.(j)

5:18 p.m.

5:25 p.m.

5:27 p.m.

5:28 p.m.(j)

5:30 p.m.(j)

5:30(j) to

5:34 p.m.(j)

(approx.)

5:32 p.m.(j)

5:34 p.m.(j)

5:36 p.m.(j)

Event

CSXT/MARC engineer reports to work in Baltimore.

CSXT/MARC crew began first trip (train 251) from Camden station to

Washington.

MARC train 251 arrives in Washington 49 minutes behind schedule.

CSXT/MARC crew began second trip (train 273) from Washington to

Brunswick 24 minutes late.

MARC train 273 travels westbound (WB) through Georgetown Jct. from track

2 to 1.

Amtrak train 29 crew reports to work.

MARC train 273 arrives in Brunswick 33 minutes late.

Scheduled departure time for Amtrak train 29 from Union Station.

MARC train 284 travels eastbound (EB) through Georgetown Junction from

track 2 to 2.

Scheduled departure time for Amtrak train 29 from Rockville station.

CSXT/MARC crew began third trip (train 286) from Brunswick to

Washington.

AU Jacksonville dispatcher makes request and crossovers at Georgetown

Junction are lined for WB movements from track 2 to 1.

MARC train 275 travels WB through Georgetown Juntion from track 2 to 1.

MARC train 277 travels WB through Georgetown Junction from track 2 to 1.

Scheduled time for MARC train 286 to depart (flag stop) from Rockville

station.

Amtrak train 29 departs Union Station 1 hour 20 minutes late.

MARC train 279 travels WB through Georgetown Junction from track 2 to 1.

MARC train 286 recorded by Rockville intermediate wayside signal on track 2.

CSXT train K951, WB, stops for Georgetown Junction STOP signal on track 1.

Engineers of MARC train 279 and MARC train 286 communicate over radio

near equipment defect detector at MP 11.7. Engineer of MARC train 279 hears

engineer of MARC train 286 acknowledge the wayside signal before

Kensington but did not hear what signal showed.

MARC train 279 WB by Kensington signal on track 1.

MARC train 286 EB by Kensington signal on track 2. MARC train 286 stops

(approx. 50 seconds) at Kensington station (flag stop) and departs.

Amtrak train 29 passes Takoma Park signal on track 2.

87
APPENDIX C

Time Event

5:38:41 p.m.

5:41 p.m.

5:44 p.m.

5:45 p.m.

5:46 p.m.

5:47 p.m.

5:48 p.m.

5:51 p.m.

5:53 p.m.

6:00 p.m.

6:02 p.m.

6:08 p.m.

6:15 p.m

.

6:20 p.m.

6:30 p.m

6:56 p.m.

Accident occurred: Train 286 (MARC) collided with train 29 Amtrak

First communication with CSXT AU dispatcher from CSXT traincrew K951.

reporting accident. Reports fire and derailment of Amtrak train 29.

CSXT AU dispatcher notifies MCFRS, which is already aware of accident.

CSXT AU dispatcher attempts to call MARC operations center, but line

is busy.

First MCFRS emergency responders on scene.

CSXT train Q401 passes Rockville signal EB on track 2.

CSXT AU dispatcher notifies WMATA operations center.

Second call from CSXT train K951 to inform AU dispatcher of fire and

evacuation, emergency personnel on scene.

Amtrak train 29 conductor contacts AU dispatcher that Amtrak train 29 had

had a MEDIUM CLEAR signal indication and about Amtrak crew condition.

CSXT AU dispatcher contacted MARC operations center, which was already

aware of accident.

AU dispatcher contacts CSXT manager of passenger operations in Baltimore,

who already knew about accident.

CSXT train 401 (following MARC train 286) with a CSXT road foreman on

board contacts AU dispatcher requesting permission to cut away and close up

behind MARC train 286. AU dispatcher authorizes CSXT train 401 to go

ahead and to be prepared to atop, looking out for emergency personnel.

MARC train 281 (following Amtrak train 29) contacts AU dispatcher asking

permission to come up behind Amtrak train 29 and assist in passenger

evacuation AU dispatcher gives OK.

MCFRS command sectors established for level two incident.

CSXT train Q401 stops near bridge.

MCFRS IC receives message from his communications center about train

approaching accident scene from Kensington and orders evacuation of site.

MARC train 281 (following Amtrak train 29) instructed to move west of Silver

Sprint station to allow MARC train 285 into station to unload passengers.

88
APPENDIX D

EXCERPTS FROM CSXT OPERATING RULES

Rule 27

A signal imperfectly displayed must be regarded as the most restrictive indication

that can be conveyed by that signal.

Exceptions:

1. When the arms of a semaphore signal can be seen, they will govern.

2. When one colored light is displayed in the cluster of lights of a color position

light signal, it will mean the same as two lights in the cluster; or

3. when one or more lower units of a color light signal aspect is dark, the aspect

will be observed as though the lights that should be displayed were displaying red.

This does not apply to Rule C-290(a).

A signal imperfectly displayed must be reported promptly to the dispatcher.

Rule 34 (IN PART)

Crew members must maintain a lookout for signals or conditions along the track

that affect the movement of their train. Crew members located in the operating

cab of an engine must clearly communicated the following information to each

other:

1. Concerning signals:

a) The name of each block and interlocking signal governing the

movement of their train;

b) The number of the track to which the signal applies if in multiple track

territory;

Rule 34-A

A crew member located in the operating cab of a radio-equipped engine must

announce by radio the following conditions that affect the movement of the

train:

1. The name and location of each block and interlocking signal.

2. The train entry into each DTC Block when entering the block.

3. In multiple track territory, a crew member must announce the number of the

track.

On radio-equipped freight trains, each of these announcements must be

acknowledged by a crew member if located on the rear of the train, or by any

crew member who may be in a trailing unit of the traim.

89
APPENDIX D

Rule 34-C

Should the engineer fail to control the train in accordance with a signal indication

or a restriction imposed upon his train, other members of the crew must:

1. Caution the engineer and, if necessary,

2. Take action to ensure the safety of the train, (including stopping the

movement).

Rule 98-G

When a train is stopped or its speed is reduced to 15 mph or less after passing a

signal governing either the approach to a railroad crossing at grade, or the

beginning of TCS territory, the train must approach the next signal prepared to

stop. It must do so until it can be seen that the indication of the signal permits the

train to proceed.

Exception: This does not apply where special instructions specify and govern

the approach to locations with time-out features.

Rule C-292

Block, interlocking, and other fixed signal aspects and indications. STOP AND

PROCEED; stop then proceed at restricted speed.

Rule 103-G

When humping operations are being conducted in a hump yard equipped with

remotely controlled switches, train or engine service employee may be required to

couple an air hose or adjust a coupling device. When this requires the employee to

place himself between rolling equipment located on a bowl track, the following

protection must be provided against cars being released from the hump into the

track involved.

1. The employee controlling any remotely controlled switch that provides access

from the apex of the bump to the track on which the rolling equipment is located

must be notified.

2. Upon such notification, the operator of such remotely controlled switch must

line the switch against movement to the affected bowl track. The operator must

ply, or must have applied a locking or blocking device to the control for that

switch, and

3. The operator must then notify the employee that the required protection has

been provided. The operator will remove the locking or blocking device only after

he has been notified by the employee that the protection is no longer required on

that track.
APPENDIX D

Rule 104-C

Employees lining switches must ascertain that: 1. The route is lined for the

movement. 2. The switch points fit properly. And 3. The switch lever is secured.

A main track switch must not be lined for a diverging movement of an approaching

train until the employee attending the switch is assured by the affected train that the

movement is to use the turnout or crossover.

Employees must ascertain that the switches that they are to use are in proper

position. When such switches are being changed ahead of an approaching

movement, they must know that the movement is under control to prevent operating

over or through an improperly lined switch.

When kicking cars, a switch must not be lined for a following car going to another

track, until it is known that the preceding car will clear the route.

Rule 105

Trains may use tracks, other than main tracks, signaled tracks or sidings, without

permission. (see rule 46.)

Rule 106 (from Chessie System Operating Rules, effective September 1, 1985.)

Both the conductor and engineer are responsible for the safe and efficient

operation of their train and the observance of the rides. Train crew members must

comply with the instructions of the conductor. When there is no conductor, or the

conductor is not available to directly supervise, crew members will comply with

the instructions of the engineer. The train dispatcher must be advised as promptly

as practicable, by the engineer or conductor, of any condition that will delay the

train or prevent it from making the usual speed. The conductor and engineer must

see that members of their crew are familiar with their duties and instruct them

when necessary in the observance of the rules and safe performance of their work.

Rule 450 (from Chessie System Operating Rules, effective September 1, 1985.)

Radio communications must not be used instead of hand signals when conditions

exist for continuous direct visual contact between the engineer and the signal of

the employee(s) directing the movement. Radio communication and hand signals,

except stop signals, must not be used simultaneously by a crew to direct train or

engine movements. When changing from one mode of signaling to another, all

crew members involved must be notified and acknowledge their under-standing

before the change is made.

Rule 804 (from Chessie System Operating Rules, effective September 1, 1985.)

When trying to determine the extent of damage in a derailment involving a

hazardous material or a car leaking a hazardous material, the employees should

always approach the incident from up-wind in order to avoid any fumes. If fumes

arc detected, the employees should withdraw to a safe distance until qualified

people have arrived and determined the extent of the danger.

91











APPENDIX F

SIGNAL INCIDENTS, COMPLAINTS, AND FALSE PROCEED INDICATIONS

A review of CSXT signal incident reports for the period between August 1995 and February

1996 indicated approximately 134 signal and 21 highway/rail grade crossing incidents between

Washington and Brunswick on the Metropolitan Subdivision. The majority of the signal

incidents were weather-related (snow/lightning/rain), A.C. power interference by Amtrak at “F”

Tower, commercial power outages, and burned-out signal lamps. All reported incidents were in

the fail safe mode.

During the public hearing, the FRA indicated that it had one signal complaint filed in 1994

and none in 1995 on the CSXT. To follow up on reported traincrew complaints about the

operation of the signal system, the Safety Board provided a survey form to the Brotherhood of

Locomotive Engineers (BLE) and the UTU requesting a description of any unusual signal

occurrences. A total of 95 complaints were received from both organizations dating from

February 1993; 3 of the 95 reports were at Kensington.

One of the complaints for March 13, 1996, involved multiple complaints. Three trains

reported the eastbound signal at Kensington “pumping” from CLEAR to STOP and PROCEED.

The FRA had repros of the same condition. According to the FRA and the CSXT, the failure

was caused by one of the lamps in the green aspect being burned-out, and the filament in the

other green aspect was broken and intermittently touching. The signal system is designed that

when both filaments in the yellow or green aspect burn out, the signal will go to STOP and

illuminate the red aspect. This will prevent a train from passing a CLEAR signal to a dark signal.

The signal should have displayed a CLEAR signal, but because of the condition of the signal

lamps, intermittently displayed a STOP and PROCEED signal. The signal was considered to

have failed in a fail-safe mode as designed. The FRA continues to investigate other BLE and

UTU complaints on the Brunswick and Camden Lines. To date, no signals have failed in a more

favorable state, which would cause a false proceed signal indications1 on these lines.

In 1994, the CSXT had 13 false proceed signal indications. In 1995, the CSXT reported

seven confirmed false proceed signal indications, and one reported to May 1996. For 1995 and

1996 these were attributed to vandalism (4), defective pole line (2), wiring short (l), and sunlight

reflection (1).

By May 15, 1996, at a meeting held at CSXT headquarters in Baltimore, the FRA had

received over 30 complaints, which were under investigation. All complaints were reports of

signal malfunctions which resulted in a more restrictive aspect than should have been displayed.

The majority of the complaints were stated by one labor union as a lack of understanding on how

the signal system operates. Suggestions were made that during the employees annual operating

rules test, an overview of the signal system be presented. The FRA is in the process of finalizing

its report and is to have a follow-up meeting with the parties.

1A more favorable aspect than intended or other condition hazardous to the movement of a train.

103

APPENDIX G

FIRE TESTING RESULTS OF MARC CAR INTERIOR MATERIALS

Table 1. Test Results for Cushion Materials

Material Test

Cushions: ASTM D 3675

(flammability)

3b. Seat

4c. Pad

4b. Pad

cover

3b. or 4c. ASTM 662

(smoke)

4b.

~

Parameter

Ds(l.5)1

Ds(4.0)1

Ds(l.5)1

Ds(4.0)1

9.6

4.6

1498

54

105

43

92

2

6.6

5.3

1105

54

122

50

109

1. he maximum value under flaming or non-flaming is given.

6.5

5.9

833

50

117

51

109

Average

8

5

1145

115

48

103

ri?i!r

criterion

2

25

2

1002

2

2002

0 0 2

22002

2. The 1979 Guidelines excepted cushions, we list the 1982 criteria for reference.

105
. . . .,

APPENDIX G

Table 2. Results for Upholstery Coverings

Material

Upholstery

covering

3a. Fabric

4a. Vinyl

3a. Fabric

4a. Vinyl

Test

FAR 28.853

(flammability)

ASTM E 662

(smoke)

Parameter

Flame time

Burn

length

Flaming

drips

Flame time

Burn

length

Flaming

drips

D,(4.0)’

1. The maximum value under flaming or non-fl

1

1

1.75

0

1

2.2

0

254

359

ming is 

4

2

0

0

2.6

0

245

351

iven.

2

1.5

0

0

1.9

0

205

321

Average

2.3

1.8

0

0.33

2.2

0

235

344

-

criterion

210s

‘6 in.

0s

2

10 s

26 in.

0s

2

100
APPENDIX G

Table 3. Results for Wall and Ceiling Linings

Material

Walls/Ceilings:

1. Ceiling panel

2. Window

mask

1. Ceiling panel

2. Window mask

. - .

Test

ASTM E 162

(flammability)

ASTM E 662

(smoke)

Parameter

Is

Ds (1 .5)1

Ds (4.0)1

Ds(l.5)1

Ds (4.0)1

r

5.8

51

23

79

92

234

2

2.5

57

1

51

73

278

3

63.5

79

30

109

105

373

Average

24

62

18

80

90

295

1979

criterion

2

3 5

2

100

2

200

2

100

2

200

1. The maximum value under flaming or non-flaming is given. For large continuous sheets used

in applications, such as the passenger rail car, the edge effects should be different and, likely,

less. The edge effect is very likely responsible for the Is value of 63.5 for the ceiling material.

This is very likely attributed to the way that the cut sample responded in its metal frame holder

of the apparatus.

107

APPENDIX H

ISSUANCE OF URGENT SAFETY RECOMMENDATIONS

National Transportation Safety Board

Washington, D.C. 20594

Safety Recommendation

Date: March 12, 1996

In Reply Refer To: R-96-4 through -6

Mr. John A. Agro, Jr.

Administrator

Mass Transit Administration

William Donald Schafer Tower

6 Saint Paul Street

Baltimore, Maryland 21202-1614

About 5:38 p.m. on February 16, 1996, eastbound Maryland Rail Commuter (MARC)

train 286 collided with westbound National Railroad Passenger Corporation (Amtrak) train 29,

the Capitol Limited, at milepost 8.55 on CSX main track near Silver Spring, Maryland. The

MARC train was operating in the push mode in revenue service between Brunswick, Maryland,

and Washington, D. C.; it consisted of a locomotive and three commuter cars. The Amtrak train,

operating in revenue service between Washington, D. C., and Chicago, Illinois, consisted of 2

locomotives and 15 cars.

The left front quadrant of the MARC cab car (the leading passenger car) separated and

was destroyed as a result of the collision. The fuel tank of the Amtrak lead locomotive ruptured

on impact and the diesel fuel ignited. Fire engulfed the rear superstructure of the locomotive.

Fuel spilled onto the MARC cab car, ignited, and destroyed the car.

One hundred sixty-four passengers, 13 on-board service personnel, 4 operating crew, and

1 mechanical rider were aboard the Amtrak train. The engineer, assistant engineer, and conductor

received minor-to-moderate injuries.

Three operating crewmembers and 20 passengers were on board the MARC train. Two

crewmembers and 7 passengers died of smoke inhalation, and 1 crewmember and 1 passenger

died as a result of impact injuries; 11 of the 12 survivors were injured.
APPENDIX H

2

Safety Board investigators interviewed six U.S. Department of Labor Job Corps students

who were passengers in the MARC cab car and two individuals who were passengers in the

second MARC car.

The students stated that after the impact, the car quickly filled with smoke, making it very

difficult to see. One student, who said he was sitting in the last seat on the right rear of the first

car next to an emergency window, described the smoke as extending from the ceiling of the car

to 2 feet above the floor. The student also stated that he did not have time to open the window

and that he believed it would be faster to exit using the door through which he had entered.

Another student said that he had to crawl to the rear of the car on his hands and knees because

of the smoke. Two other students, seated near the rear of the first car, proceeded through the

rear end interior door and made several unsuccessful attempts to open the left and right exterior

side doors. They stated that no instructions were provided concerning the operation of the door

handle in an emergency.

These two students made their way into the vestibule of the second car and escaped

through an opening in the damaged left front corner of the second car. All surviving students,

as well as a 26-year-old passenger who was also seated in the cab car, followed.

The upper half of the side exterior doors on the MARC Sumitomo cars are fitted with

freed polycarbonate windows. When opened, the single-panel exterior side doors slide into a

pocket in the car body sidewall. Construction of the interior end doors, which have upper-half

freed windows, is similar to that of the exterior doors. These doors also slide into a wail pocket

when opened; they are not equipped with emergency release mechanisms. The four exterior side

doors are electrically operated and may be opened manually in an emergency by pulling an

emergency handle located in one of four secured cabinets (two at each end of the passenger

compartment). Each cabinet door is secured by two fasteners, which require a screwdriver or

coin to open. Instructions for opening the cabinet doors are on the door’s exterior. Instructions

for operating the emergency handles to release the exterior doors are inside the cabinet.

The Safety Board is concerned that emergency quick-release mechanisms for the exterior

doors are located in a secured cabinet some distance from the door they control. Emergency

controls for each door should be readily accessible and identifiable. Therefore, the Safety Board

believes that well-marked emergency quick-release mechanisms for exterior doors on MARC cars

should be relocated so that they are immediately adjacent to the door they control and readily

accessible for emergency escape purposes.

Examination of the first and second cars revealed that the left and right rear exterior side

doors of the former, as well as the front interior end door and the right front exterior door of

the latter, were jammed. None of the doors had removable windows or pop-out emergency

escape panels (kick panels) for use in an emergency. The left front exterior door of the second

car was destroyed. Thus, if the opening in the damaged car body of the second car had not

provided an escape route for the surviving passengers of the cab control car, the loss of life in

this accident could have been far greater.
APPENDIX H

3

Several students stated that they were unaware of the locations of the emergency exits,

and none knew how to operate them. The Safety Board found that the interior emergency

window decals were not prominently displayed and that one car had no interior emergency

window decals. The Safety Board noted that the exterior emergency decals were often faded or

obliterated and that the information on them, when legible, directed emergency responders to

another sign at the end of the car for instructions on how to open emergency exits, which is a

time-consuming process. The Safety Board believes that all emergency exits should be clearly

identified and provided at the exit with easily understood operating instructions. These

instructions should be prominently located on the car interior for use by passengers and on the

exterior for use by emergency responders.

Therefore, the National Transportation Safety Board recommends that the Mass Transit

Administration of the Maryland Department of Transportation

Install removable windows or kick panels for emergency exits in interior and

exterior passageway doors. (Class I, Urgent Action) (R-96-4)

Install an easily accessible interior emergency quick-release mechanism adjacent

to all exterior doors. (Class I, Urgent Action) (R-96-5)

Install retroreflective signage on car interiors and exteriors at emergency exits that

contains easily understood instructions and clearly marks all emergency exits

(doors and windows). (Class I, Urgent Action) (R-96-6)

The National Transportation Safety Board is an independent Federal agency with the

statutory responsibility “to promote transportation safety by conducting independent accident

investigations and by formulating safety improvement recommendations” (Public Law 93-633).

The Safety Board’s investigation of the MARC accident is continuing. The Safety Board is

interested in any action taken as a result of its safety recommendations. Therefore, it would

appreciate a response from you regarding action taken or contemplated with respect to the

recommendations in this letter. Please refer to Safety Recommendations R-96-4 through -6 in

your reply. If you need additional information, you may call (202) 382-6840.

Chairman HALL, Vice Chairman FRANCIS, and Members HAMMERSCHMIDT,

GOGLIA, and BLACK concurred in these recommendations.

&u●

By Jim H
APPENDIX H

Transportation Safety

Washington, D. C. 20594

Safety Recommendation

Board

Date March 12, 1996

In Reply Refer To: R-96-7

Honorable Jolene M. Molitoris

Administrator

Federal Railroad Administration

Washington, D.C. 20590

About 5:38 p.m. on February 16, 1996, eastbound Maryland Rail Commuter (MARC)

train 286 collided with westbound National Railroad Passenger Corporation (Amtrak) train 29,

the Capitol Limited, at milepost 8.55 on CSX main track near Silver Spring, Maryland. The

MARC train was operating in the push mode in revenue service between Brunswick, Maryland,

and Washington, D. C.; it consisted of a locomotive and three commuter cars. The Amtrak train,

operating in revenue service between Washington, D. C., and Chicago, Illinois, consisted of 2

locomotives and 15 cars.

The left front quadrant of the MARC cab car (the leading passenger car) separated and

was destroyed as a result of the collision. The fuel tank of the Amtrak lead locomotive ruptured

on impact and the diesel fuel ignited. Fire engulfed the rear superstructure of the locomotive.

Fuel spilled onto the MARC cab car, ignited, and destroyed the car.

One hundred sixty-four passengers, 13 on-board service personnel, 4 operating crew, and

1 mechanical rider were aboard the Amtrak train. The engineer, assistant engineer, and conductor

received minor-to-moderate injuries.

Three operating crewmembers and 20 passengers were on board the MARC train. Two

crewmembers and 7 passengers died of smoke inhalation, and 1 crewmember and 1 passenger

died as a result of impact injuries; 11 of the 12 survivors were injured.
APPENDIX H

2

Safety Board investigators interviewed six U.S. Department of Labor Job Corps students

who were passengers in the MARC cab car and two individuals who were passengers in the

second MARC car.

The students stated that after the impact, the car quickly filled with smoke, making it very

difficult to see. One student, who said he was sitting in the last seat on the right rear of the first

car next to an emergency window, described the smoke as extending from the ceiling of the car

to 2 feet above the floor. The student also stated that he did not have time to open the window

and that he believed it would be faster to exit using the door through which he had entered.

Another student said that he had to crawl to the rear of the car on his hands and knees because

of the smoke. Two other students, seated near the rear of the first car, proceeded through the

rear end interior door and made several unsuccessful attempts to open the left and right exterior

side doors. They stated that no instructions were provided concerning the operation of the door

handle in an emergency.

These two students made their way into the vestibule of the second car and escaped

through an opening in the damaged left front comer of the second car. All surviving students,

as well as a 26-year-old passenger who was also seated in the cab car, followed.

The upper half of the side exterior doors on the MARC Sumitomo cars are fitted with

fixed polycarbonate windows. When opened, the single-panel exterior side doors slide into a

pocket in the car body sidewall. Construction of the interior end doors, which have upper-half

freed windows, is similar to that of the exterior doors. These doors also slide into a wall pocket

when opened; they are not equipped with emergency release mechanisms. The four exterior side

doors are electrically operated and may be opened manually in an emergency by pulling an

emergency handle located in one of four secured cabinets (two at each end of the passenger

compartment). Each cabinet door is secured by two fasteners, which require a screwdriver or

coin to open. Instructions for opening the cabinet doors are on the door’s exterior. Instructions

for operating the emergency handles to release the exterior doors are inside the cabinet.

The Safety Board is concerned that emergency quick-release mechanisms for the exterior

doors are located in a secured cabinet some distance from the door they control. Emergency

controls for each door should be readily accissible and identifiable. Therefore, the Safety Board

believes that well-marked emergency quick-release mechanisms for exterior doors on MARC cars

should be relocated so that they are immediately adjacent to the door they control and readily

accessible for emergency escape purposes.

Examination of the first and second cars revealed that the left and right rear exterior side

doors of the former, as well as the front interior end door and the right front exterior door of

the latter, were jammed. None of the doors had removable windows or pop-out emergency

escape panels (kick panels) for use in an emergency. The left front exterior door of the second

car was destroyed. Thus, if the opening in the damaged car body of the second car had not

provided an escape route for the surviving passengers of the cab control car, the loss of life in

this accident could have been far greater.
APPENDIX H

3

Several students stated that they were unaware of the locations of the emergency exits,

and none knew how to operate them. The Safety Board found that the interior emergency

window decals were not prominently displayed and that one car had no interior emergency

window decals. The Safety Board noted that the exterior emergency decals were often faded or

obliterated and that the information on them, when legible, directed emergency responders to

another sign at the end of the car for instructions on how to open emergency exits, which is a

time-consuming process. The Safety Board believes that all emergency exits should be clearly

identified and provided at the exit with easily understood operating instructions. These

instructions should be prominently located on the car interior for use by passengers and on the

exterior for use by emergency responders.

The Safety Board’s investigation of the MARC accident is continuing. However, the

Board is concerned that the unsafe conditions identified on MARC’s Sumitomo cars may exist

on other commuter lines subject to Federal Railroad Administration (FRA) oversight. No

comprehensive passenger car safety standards are currently in place. Consequently, the Safety

Board believes that FRA safety inspection personnel should determine whether the unsafe

conditions identified on MARC’s Sumitomo cars exist on other lines. The Safety Board further

believes that the FRA should issue emergency orders to correct such unsafe conditions, as

necessary, and incorporate the emergency measures into minimum passenger car safety Standards.

Therefore, the National Transportation Safety Board recommends that the Federal

Railroad Administration:

Inspect all commuter rail equipment to determine whether it has: (1) easily

accessible interior emergency quick-release mechanisms adjacent to exterior

passageway doors; (2) removable windows or kick panels in interior and exterior

passageway doors; and (3) prominently displayed retroreflective signage marking

all interior and exterior emergency exits. If any commuter equipment lacks one

or more of these features, take appropriate emergency measures to ensure

corrective action until these measures are incorporated into minimum passenger

car safety standards. (Class 1, Urgent Action) (R-96-7)

Chairman HALL, Vice Chairman FRANCIS, and Members HAMMERSCHMIDT,

GOGLIA, and BLACK concurred in this recommendation.

W

*

By: imH






















APPENDIX K

FRA CORRESPONDENCE ON REGULATORY AUTHORITY

OF COMMUTER RAILROAD OPERATIONS

NATIONAL TRANSPORTATION SAFETY BOARD

w

(q Office of Surface Transportation Safety

‘%& Washington, D. C. 20594

Honorable Jolene M. Molitoris

400 Scvcnth Street S.W. Washington, D.C. 20590

Dear Ms. Molitoris:

The collision and derailment of the MARC commuter train with Amtrak train 29 at Silver

Spring on February 16, 1996 has focused attention on commuter railroad options. The Safety

Board needs to obtain accident and inspection statistics for commuter operations regulated by the Federal Railroad Administration (FRA) along with the inspection and compliance history for these

operations. This information will assist the Safety

(s) of 

Board in its investigation of the recent accident

at Silver Spring by identifying the operator commuter operations and the accident history of the those organizations and the commuter rail industry.

The Safety Board requests the following information:

● Listing of commuter railroad operations within FRA’s regulatory authority.

€ A five year accident history and rate per million train miles for commuter operations for those

commuter railroad operations under FRA's regulatory authority.

Thank you for FRA's cooperation in this investigation.

Ed DobranetskiP.E.

Chief Major Investigations

Railroad Division

137





APPENDIX L

NATIONAL TRANSPORTATION SAFETY BOARD

AND POSITIVE TRAIN CONTROL

Railroads rely on train crews to comply with operating rules to prevent collisions. The

operating rules explain the meaning of each signal, the proper response to a particular signal aspect,

the procedure for conveying track warrants, the individual duties of the train crew members, and

other vital information needed to safely operate trains. The operating rules provide all necessary

guidelines to prevent collisions providing crews understand and obey them.

An increasing majority of the train accidents investigated by the Safety Board have been the

result of human error. The best efforts by the railroads to train and test train crews for compliance

with operating rules has not guaranteed that individuals will take the correct action or that accidents

will not happen. Highly trained individuals still have accidents. A PTS control system provides the

back-up to the engineer that ensures a train is properly operated.

After its investigation of a May 1986 rear-end collision at Brighton, Massachusetts,2 the Safety

Board issued the following Safety Recommendation to the FRA:

R-87-16

Promulgate Federal standards to require the installation and operation of a train control

system on main line tracks that will provide for positive separation of all trains.

In June of 1993 the FRA responded that the 1992 “Rail Safety Enforcement and Review Act”

requires them to conduct a comprehensive review and safety inquiry into ATC. They reported that

several major railroads are beginning installation of the ATC communications platform or are

actively considering installation. In addition the FRA stated that they were to explore possible trial

applications on one or more corridors selected for funding under the President’s high speed rail

ground transportation initiative. The recommendation is still classified "Open--Acceptable

Response.” PTS control systems are still on the Safety Board’s list of most wanted transportation

safety improvements.

Following the accident involving the head-on collision between two trains in Kelso,

Washington on November 11, 1993, the Safety Board reiterated Safety Recommendations R-87-16

and R-93-12 to the FRA and issued the following safety recommendations to the FRA:

As part of your monitoring and oversight activities on the Burlington Northern and the

Union Pacific Railroad's train control demonstration project, identify and evaluate all

potential safety and business benefits of the train control system currently proposed for the

northwest region of the United States. Consider the value of these benefits in your overall

assessment of the system.

R-94-14

2 Railroad Accident Report--Rear End Collision Between Boston and Maine Corporation Commuter Train No.

5324 and Consolidated Rail Corporation Train TV-14, Brighton, Massachusetts, May 7, 1986 (NTSB/RAR-87/02).

143
APPENDIX L

In conjunction with the AAR, identify and evaluate all of the potential benefits of positive

train separation and include them in any cost benefit analysis conducted on positive train

separation control systems.

Based on the FRA's response and the awarding of a financial grant to the Washington State DOT to

develop high-speed train control technology, through the use of computer modeling, as an

assessment tool of the benefits of PTS, both recommendations were classified as “OpenAcceptable Response” in November of 1995.

From the same Kelso, Washington accident the Safety Board issued the following Safety

Recommendation to the AAR:

R-94-16

In conjunction with the FRA, identify and evaluate all of the potential benefits of positive

train separation and include them in any cost benefit analysis conducted on positive train

separation control systems.

The AAR responded in August of 1995 that its membership continue to believe that PTS must be

justified on the basis of safety benefits only. However, the Safety Board recognized the cooperative

efforts that were taking place on the UP/BNSF PTS pilot project and will revisit the

recommendation once the results of the project are released. The recommendation is classified as

“Open-Acceptable Response.”

144
AAR

ACS

Amtrak

ATCS

B &O

CAD

CFR

CP

CSXT

CTC

CVR

DCS

DTC

DOT

EAS

EMS

EO

EOC

FAA

FRA

FTA

GIS

IC

ICC

ICSS

MARC

APPENDIX M

ACRONYMS AND ABBREVIATIONS

Association of American Railroads

automatic cab signals

National Railroad Passenger

Corporation

advanced train control system

Baltimore and Ohio Railroad

computer-aided dispatching

Code of Federal Regulations

control point

CS X Transportation Inc.

centralized traffic control

cockpit voice recorder

disaster command system

direct traffic control

U.S. Department of Transportation

eastbound absolute signal

emergency medical services

emergency order

emergency operations center

Federal Aviation Administration

Federal Railroad Administration

Federal Transit Administration

geographic information system

incident commander

U.S. Interstate Commerce

Commission

intermittent cab signaling system

Maryland Rail Commuter

MCEMA

MCFRS

MCPD

MDLI

MDOT

MOS

MP

MTA

MU

NPRM

PTS

RP

RPI

TCS

UMTA

UTU

VRE

WAS

WMATA

Montgomery County Emergency

Management Agency

Montgomery County Fire and

Rescue Services

Montgomery County Police

Department

Maryland Department of Labor

and Industry

Maryland Department of

Transportation

manager of operations support

milepost

Mass Transit Administration

(Maryland)

multiple unit

notice of propose d rulemaking

positive train separation

recommended practice

Railway Progress Institute

traffic control signal

Urban Mass Transit

Administration

United Transportation Union

Virginia Railway Express

westbound absolute signal

Washington Metropolitan Area

Transit Authority

145