PB96-916302

NTSB/RAR-96/02

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, DC 20594

RAILROAD ACCIDENT REPORT

DERAILMENT OF AMTRAK TRAIN 49

ON CONRAIL TRACKAGE

NEAR BATAVIA, NEW YORK, ON AUGUST 3, 1994

6721
Abstract: On August 3, 1994, westbound Amtrak (National Railroad Passenger Corporation)

train 49 derailed on Conrail (Consolidated Rail Corporation) trackage at milepost 406.7 near

Batavia, New York. Ten crewmembers and 108 passengers sustained injuries.

The major safety issues included in this report are the lack of Federal and industry guidelines for

flattened rail head conditions and the integrity of passenger car seats. The report also discusses

the timeliness and adequacy of emergency response services.

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

recommendations to the Federal Railroad Administration, the National Railroad Passenger

Corporation, the Association of American Railroads, and the American Short Line Railroad

Association.

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

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

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

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

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

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

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

recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, SW

Washington, DC 20594

(202) 382-6735

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

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
DERAILMENT OF AMTRAK TRAIN 49

ON CONRAIL TRACKAGE

NEAR BATAVIA, NEW YORK

AUGUST 3, 1994

RAILROAD ACCIDENT REPORT

Adopted: July 11, 1996

Notation 6721

NATIONAL

TRANSPORTATION

SAFETY BOARD

	
 
 

iii

CONTENTS

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

INVESTIGATION

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

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

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

Personnel Information ..................................................................................................................... 7

Train Information ............................................................................................................................ 8

Operations ....................................................................................................................................... 8

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

Rail Defects................................................................................................................................... 10

Meteorological Information .......................................................................................................... 11

Pathological, Medical, and Toxicological Information................................................................. 11

Survival Aspects............................................................................................................................ 11

Disaster Preparedness.................................................................................................................... 13

Postaccident Tests ......................................................................................................................... 13

Rail Heads ............................................................................................................................... 13

Signals ..................................................................................................................................... 14

Material Handling Car 1500.................................................................................................... 14

Dynamic Interaction between Material Handling Car 1500 and Rail Head............................ 19

Metallurgical ........................................................................................................................... 23

ANALYSIS

General .......................................................................................................................................... 25

Accident ........................................................................................................................................ 25

Rail Structure................................................................................................................................. 25

Wheel and Rail Dynamics............................................................................................................. 26

Track and Rail Inspection.............................................................................................................. 27

Flattened Rail Definition Standards .............................................................................................. 28

Rail and Material Handling Car 1500 Dynamics .......................................................................... 30

Survival Aspects............................................................................................................................ 31
iv

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

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

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

APPENDIXES

Appendix A--Investigation and Hearing ................................................................................. 37

Appendix B--Material Handling Car Characteristics.............................................................. 39

Appendix C—Acronyms Used in this Report......................................................................... 41
v

About 3:44 a.m. on August 3, 1994,

Amtrak (National Railroad Passenger

Corporation) train 49, the Lake Shore

Limited, en route from New York, New

York, to Chicago, Illinois, was traveling

westbound about 79 mph on Conrail

(Consolidated Rail Corporation) trackage

when it derailed at milepost 406.7 near

Batavia, New York. No fatal injuries were

sustained; 108 passengers and 10 crewmembers were injured.

The National Transportation Safety

Board determines that the probable cause of

the derailment was the fact that Federal and

industry guidelines do not currently address

flattened rail head conditions, due to an

insufficient understanding of the risk that

flattened rail poses to train operation.

The major safety issues discussed in this

report are the lack of Federal and industry

guidelines for flattened rail head conditions

and the integrity of passenger car seats. The

report also discusses the timeliness and

adequacy of the emergency response

services.

As a result of its investigation of this

accident, the National Transportation Safety

Board makes recommendations to the

Federal Railroad Administration, the

National Railroad Passenger Corporation,

the Association of American Railroads, and

the American Short Line Railroad

Association.

EXECUTIVE SUMMARY

1

INVESTIGATION

The Accident

Amtrak (National Railroad Passenger

Corporation) passenger train 49, the

Lake Shore Limited, was a regularly

scheduled westbound train that traveled

from New York, New York, to Chicago,

Illinois. (See figure 1.) The train

consisted of 2 locomotive units, 2

material handling cars (MHCs), 1

baggage car, 12 passenger cars, and 1

baggage/dormitory car. Before the train

left Albany, New York, its operating

crew received a list of speed restrictions

for their trip. The crewmembers

inspected the locomotive unit consist,

reviewed the cab defect and inspection

cards, and checked the radio. They also

did a mandatory road air brake test, by

applying and releasing the train air

brakes. The crew found no problem with

the locomotive consist or the air brakes.

Train 49 left Albany at 10:46 p.m. on

August 2, 1994, and reached Rochester,

New York, by early morning on August

3. It left Rochester about 3:13 a.m.; and

at 3:27 a.m., it passed over a dragging

equipment and train defect detector,

which did not detect any defects. (See

figure 2.) About 3:42 a.m., it reached

milepost (MP) 403.7, the point where the

initial derailment1

 occurred. The train

 

1

At the initial derailment, two wheels of the

train left the track, but the train continued on.

The general derailment happened 3 miles and 2

minutes 15 seconds later, when several more

train cars derailed and the train could no longer

proceed. The initial derailment as it occurred was

not witnessed, nor was the train crew aware of it.

continued west and passed the head end

of a Conrail (Consolidated Rail Corporation) freight train at MP 406.45. The

freight train on the adjacent track, main

line track 1, was also moving west.

According to both the Conrail train

engineer and conductor, sparks and

gravel were coming from the underside

of either the second or third car behind

the locomotive units of train 49. The

crew of the freight train attempted to

alert the crew of train 49 by radio.

No response was received from the

initial attempt. Train 49 responded to the

second attempt, but the general

derailment at MP 406.7 occurred almost

simultaneously. At the time, train 49 had

a clear (proceed) signal indication and

was traveling, according to the event

recorder, about 79 mph. The event

recorder data strip also indicated that the

emergency brakes were initiated by a

train line separation after the general

derailment had occurred.

Fourteen cars of the 18-car consist

had derailed. The two locomotive units

and the first seven cars remained on the

right-of-way within the track structure

after the derailment. The locomotive

units and the second and third cars did

not derail, and only the lead trucks of the

first, fourth, and fifth cars derailed.
,“ ,/ iti (..,

2
Signal Bridge

/

i

f x Area where Conrail

train crew saw

train 49 i Track 1 fi

E

Destroyed switch Track 2

‘t- u

I I

14 3 miles

‘7”2mi’e+

M.P. 406.7 M.P. 403.7

General derailment Initial derailment M.P. 386.5

Defect detector

Not to scale

Figure 2 — Profile of defect detector and initial and general derailment sites.


:x .&$-i., .;=>: ~,z .& :% .,.+ ~ +<~,, AL,,%,., ~, ,,, -;” N#i?~~gii~gyf!;,:iw$g+j 4EnlfiNQ0;i ,::,q’;~~;f~Qn%tibnx*%&*: ~, ,g<<, *,&As.~.’&~.~,

,, ,., ,..> . s ,- ?-,, ~ ,, ,,, --., ,,

1

;%?.,..,. .n. $,.v~- .-,.

Engine 374 Upright

2 Engine 207 Upright

3 Material handling car 1500 Upright, lead truck off

4 Material handling car 1505 Upright

5 Baggage car 1162 Upright

6 Coach car 4705 Upright, lead truck off

7 Coach car 4602 Upright, lead truck off

8 Coach car 4728 Upright, both trucks off

9 Lounge car 28021 Upright, both trucks off

M.P. 407.36

10 Dome coach car 9411 On side, over bank

11 Diner car 8503 On side, over bank

12 \ Coach car 4007 On side, over bank

13 Coach car 4716 On side, over bank

14 Coach car 4640 On side, over bank

15 I Sleeper car 2430 I Upright, over bank

16 Sleeper car 2433 Upright, over bank

17 Sleeper car 2056 Upright, over bank

18 I Dormitory car BD1621 I Upright

A

‘Signal Bridge

)

Not to scale

.——. - .

Figure 5 – Location of cars after accident.

8

supervisory school, a 4-week foreman

school, and a 1-week track inspection

school.

Train Information

The Amtrak Lake Shore Limited was

a consolidation of trains 449 and 49,

which were combined at Albany for the

trip to Chicago. Trains 449 and 49 had

originated at the South Hampton Street

Yard in Boston, Massachusetts, and at

the Sunneyside Yard on Long Island,

New York, respectively. Train 449 had

consisted of the two locomotive units

and the first seven cars of the Lake Shore

Limited. These locomotives had their air

brakes tested and inspected on the day

before the derailment when still part of

train 449. Train 49 had included the cars

that became the last eight cars on the

Lake Shore Limited. Mechanical

personnel had tested and inspected the

air brakes on August 2 at 5:50 a.m.

When train 49 arrived at Albany, eight of

its cars and dome car 9411 were added

to the end of train 449 to form the

consist of the Lake Shore Limited. After

the two trains were combined, mechanical personnel, in accordance with 49

CFR 232.12(b), did a 1,000-mile

inspection, and no defects were noted.

Operations

The accident track was a section of

the Chicago line of the Albany division,

which was governed by the signal

indications of the traffic control signal

system, supplemented by bulletins,

timetable special instructions, NORAC

operating rules, and radio communications. Conrail owned the track, and

Amtrak had trackage rights to operate

passenger trains over it. Over 45-million

gross tons of freight were transported on

main line track 2 in 1993.

The train dispatcher for the Albany

division was in Selkirk, New York, and

operated the Chicago line territory

remotely under a traffic control system.

The trains were routed and controlled on

the main tracks by automatic and control

point signals. According to the timetable,

train 49 was limited at Batavia to a speed

of 79 mph. The engineer was operating

the train under Amtrak Air Brake and

Train Handling Rules and Instructions

for passenger train operations.

Track and Signals

The accident track was designated as

Federal Railroad Administration (FRA)

class 5 track, and the maximum speed

for a passenger train, under 49 CFR

213.9, was 90 mph. However, FRA

regulations do not allow any train to

operate at speeds greater than 80 mph

unless the train is equipped with

automatic cab signals or automatic train

stop or train control systems. Since the

Conrail Rochester to Buffalo main line

was not equipped with either of the

systems, the Conrail timetable limited

passenger trains to a maximum speed of

79 mph. No other operational speed

restrictions were in effect for main line

track 2 on the day of the derailment.

The derailment areas had two main

line tracks. Main line track 1 was north

of main line track 2. The tracks, spaced

13 to 13.5 feet apart, ran from east to

west. The numbering of the mileposts

increased also from east to west. The

track gradient between the initial point
9

of derailment (POD), MP 403.7, and MP

405.1 was 0.25 percent ascending,

followed by a 0.14-percent descending

grade to the general POD at MP 406.7.

The initial POD was in a 1o

 0' curve to

the right (westward) on main line track

2.

Main line track 2 was constructed of

140-pound RE (American Railroad

Engineering Association), control

cooled, continuous welded rail. Manufactured by United States Steel, it was

classified as an “A” rail,2 heat number

CH D 27080A26, and installed new in

1977. The rail at the initial POD was

fastened to wooden crossties with double

shoulder tie plates (1:40 cant) with two

plate-holding spikes and two rail-holding

spikes per tie plate.

According to 49 CFR 213.233, class

5 track must be inspected twice a week.

Between July 5 and the day before the

accident, the Conrail track inspector had

inspected the track between MPs 356

and 407 nine times from a high-rail

vehicle. He had noted the following

track defects: 24 bolt defects in joints, a

missing frog bolt, a wide-gage location,

and 2 cross level variations. Each defect

was reported as being corrected the same

 

2

“A” rails are rolled from the topmost

portions of ingots cast from the open hearth steelmaking process. During earlier times, railroads

generally restricted the use of “A” rail to yard or

side tracks because of a tendency for inclusions

and impurities to congregate in the top of an

ingot. Conrail had not restricted the placement of

“A” rails because in 1977, when the subject rail

was manufactured and installed, the clean steelmaking processes were in use. During the last 5

years, newly manufactured “A” rails have

disappeared entirely because rails are now manufactured using a continuous casting process.

day as noted, and not one of the noted

defects was in the area of MP 403.7.

Figure 7 — View of normal

and flattened rail heads.

FRA track inspectors randomly

accompany Conrail track inspectors to

observe track inspections. An FRA track

inspector had accompanied the Conrail

track inspector, riding a high-rail

vehicle, 9 days before the August 3

derailment. They found flattened rail

head3 (see figure 7) at MP 403.7. The

Conrail track inspector stated that they

thought the flattened rail head might

constitute a track geometry defect.4 After

measuring the track for compliance with

the track geometry requirements for class

5 track, the inspectors found that

 

3

The head is the running surface of the rail; a

flattened head is one that has acquired a

depression.

4

When an inspector finds a track defect, he

must take, according to CFR 213.9, one of two

immediate actions: either have the defect repaired or lower the track class number, thus lowering

the maximum operating speed of a train.
10

the track met the standards, and no other

exceptions were noted. They stopped at

other areas without noting any defects.

Sperry Rail Service conducted an

internal rail defect inspection for Conrail

on June 27, 1994. No rail defects were

noted in the initial POD area at MP

403.7.

Main line track 2 had its last track

geometry test 2 months before the

accident on June 6, 1994. One FRA

reportable defect was noted between

MPs 403 and 408. This defect at MP

405.72 consisted of a cross level

variation (height level between two rails)

of 1.37 inches on tangent track. The

FRA allowable tolerance for class 5

track cross level variation is 1.0 inch.

The defect was corrected on June 8,

when a section of rail was replaced

because of a flattened rail head.

The geometry test in the span

between MPs 403 and 408 revealed five

deviations from Conrail standards: four

cross level variations (from 0.78 to 0.87

inch, with 0.75 inch as the threshold for

class 5 variance) and one cross level

variation in a spiral to the curve (0.68

inch, with 0.5 inch as the threshold for

class 5 variance in a spiral). However,

the deviations were not FRA defects.

Conrail categorizes such deviations as

level 1, which do not require immediate

attention.

The most recent major maintenance

projects were tie replacement from MPs

401.6 to 405.8, track surfacing between

MPs 402.8 and 405.9, and rail grinding

from MPs 382.0 to 435.8 on July 21 and

26 and September 13, 1993, respectively.

No record of unscheduled maintenance

that was performed in the derailment

area was reported.

Signal test records before the

accident indicated no anomalies, and the

system was functioning as intended. All

required FRA signal tests were current

and complete.

Rail Defects

Rail defects are addressed in the

FRA track safety standards under 49

CFR 213.113. The standards identify

such rail defects as transverse fissures,

compound fissures, detail fractures,

engine burns, damaged rails, defective

welds, horizontal or vertical split heads,

split web or web separations, and cracks

or ordinary breaks. Inspectors find these

defects by either visual or electronic

inspection, and various remedial actions

are prescribed to reduce the effect of a

defect on the safety of train operations.

The FRA track safety standards define

damaged rail as rail that has sustained

damage from one of three causes: a

wreck; broken, flat, or unbalanced

wheels; or slipping wheels. No definition

addresses a flattened rail head.

Because a flattened rail is neither

defined as nor considered a rail defect,

no category was provided within the

Conrail track inspector’s form on which

to record the findings of his inspection.

The track inspector, according to his

statement, had recorded observed flattened rail head conditions on the other

side of his report forms as a reference for

subsequent inspections. He said that he

had first identified the flattened rail at

MP 403.7 as engine burn since it did not

fit any identified category.
11

The Sperry Rail Service Rail Defect

Manual, used as a reference by railroad

track departments, does not contain a

definition of a flattened rail head.

However, it states that a crushed rail

head is a "flattening of several inches of

the head usually accompanied by a

crushing down of the metal, but with no

cracking under the head." The origin is

usually a soft spot in the steel of the

head. The crushed rail head grows when

heavy loads go over it, and the faster that

the heavy load is traveling, the more the

depth of the crushing increases. The

manual goes on to state that a crushed

head is not a serious defect, but is

generally removed from high speed track

because it can cause rough riding of

equipment and concentrated load defects

(rail fracture) may develop from impact.

Conrail has a program for replacing

worn curve rail. The flattened rail near

the initial POD was not considered to be

worn rail and was not reported to the

supervisor as part of this worn rail

program.

Meteorological Information

At the time of the accident, the skies

were cloudy, visibility was about 5 miles

with some fog, winds were calm,

temperature was about 69 o

F, and dew

point was 67 oF with 90 percent

humidity.

Pathological, Medical, and

Toxicological Information

No fatal injuries were sustained in

the accident. The injured included 108

passengers and 10 crewmembers who

were either treated at and released from

or admitted to one of five local hospitals.

The 93 people who were treated and

released from hospitals sustained

bruises, abrasions, and small lacerations.

The 25 passengers who were admitted

sustained extremity and rib fractures,

back injuries, internal injuries, and

concussions.

FRA regulations required the

operating crewmembers of train 49 to

submit blood and urine specimens for

toxicological testing; the test results

were negative.

Survival Aspects

The Heritage class dome coach 9411

had seats that rotated and reclined (see

figure 8), which differed from all the

other seats in the train cars. Each back

frame was attached to its pan frame by

two 12-inch-long tapered metal braces.

During the derailment, the pan frames

remained attached to the pedestals, and

the pedestals remained anchored to the

floor tracks and sidewalls. However, 20

back frames, including the back cushions, separated from the pan frames,

exposing the metal braces. (See figure

9.) No car occupants reported being

injured by these braces.

Some passengers reported that they

had no difficulty in evacuating the cars;

others, however, said that the evacuation

was difficult. Several passengers in the

cars that had turned on their sides stated

that they had trouble reaching the exposed

side windows. Other passengers said that

they could not open the heavy car-end

doors. Darkness, the steep embankment,

and the awkward position of the cars were

other reasons attributed to a difficult

evacuation.

Disaster Preparedness

The GCEMC initiated the Genesee

County mass casualty incident plan for

this accident. The plan was to provide

guidelines for orderly and efficient

response procedures to incidents that tax

normal day-to-day response. The last

disaster drill, according to the GCEMC,

had been in September 1993 and simulated a hazardous material spill accident

in which five fatalities and two injuries

occurred at a rest stop on an interstate

highway.

In October 1994 at the New York

State Fire Academy, Amtrak presented

to emergency response agencies its 3-

hour training course, which includes

how emergency responders should

interact with Amtrak crewmembers,

what emergency responders should

know about Amtrak equipment, and how

to evacuate Amtrak trains. Genesee

County emergency response agencies

participated in this training. In April and

May 1995, Amtrak provided passenger

cars for use in disaster drills in five

communities near the site of the Batavia

derailment.

Postaccident Tests

Rail Heads — The south rail was the

high rail in the accident curve. The head

of the south rail at the initial POD was

flattened in several places (see figure

10), most significantly just to the east,

where the head was flattened for a length

of 38 inches for a maximum depth of

0.43 inch on the high side of the curve.

(See figure 11.) At the same spot was a

mark, which appeared to be a wheel

flange (see figure 12) mark on top of the

rail head, dropping off onto the crossties

and ballast and leading to the general

POD. (See figure 13.)

Figure 10 — Flattened rail head

at initial POD (looking east).

In the flattened rail head area, the top

of the head had flowed outward (mushroomed) toward both the gage and field

sides 5 of the rail head, resulting in an

increase in the width of the head and a

low spot in the running surface. The

head material spread a greater amount

toward the field side of the rail (a

maximum amount of more than 0.5 inch

5The gage side is between the running rails

and is adjacent to the wheel flange. The field

side is opposite the gage side.

13
The head of the south rail was also

flattened in about 12 other locations east

Figure 11 — Flattened rail head

after removal.

beyond the field side of the head) than

toward the gage side (about 0.15 inch).

The maximum width of the head in the

flattened area, as measured in the Safety

Board materials laboratory, was 3.695

inches. The typical maximum head

width of the rail was about 2.815 inches.

(The rail head width and height is 3.0

and 7.31 inches, respectively, for a new

140-pound RE rail section.) The following table lists the south rail field measurements from the initial POD to 15

feet 10 inches east of the POD:

Location

MP 403.7 (POD)

4 feet 6 inches

east*

9 feet O inches east

11 feet 8 inches

east

15 feet 10 inches

east

Rail Head

Width

(inches)

3.0

3.62

3.0

3.0

3.0

1

Corresponds with center of flattened rail

14

Rail

Height

(inches)

7.28

6.79

7.13

7.22

7.26

 section.

of the initial POD. One such location of

flattened rail head was at MP 402.79,

where the track alignment was in a 1028’

curve. The flattened rail head was on the

high side rail of the curve and appeared

to be marked by a wheel flange. The

following table lists the observed rail

head measurements:

Location

mark on rail head

flattened head

(maximum)

Rail Head

Width

(inches)

2.98

3.17

Rail

Height

(inches)

7,09

7.02

The Safety Board did track geometry

measurements with the track in the

loaded and static conditions. The cross

level variation at the flattened rail head

at the initial POD in the loaded condition

was 1.125 inches. The maximum allowable deviation for class 5 track is 1 inch

under 49 CFR 213.63.

Signals — Postaccident signal testing

was completed on August 8, 1994, in

accordance with FRA requirements. No

exceptions were noted.

Material Handling Car 1500 — The first

and second cars behind the locomotive

consist were the empty MHC 1500 and

the half-loaded MHC 1505, respectively.

(The car weight light and with maximum

cargo load is 76,700 and 177,000

pounds, respectively.) These cars were

painted steel gray with Amtrak striping

and logos.
P

.

Flange

Depth

T

~Gage Side

Side , +

Head Point of

Rail: Web Measurement

Bas Tie Plate of Gage

(Double-shoulder)+ I r % 4 1 ; I

!k ~~ ‘ I Track II

1,1 Spike ~~

Wood Crosstie

Figure 12 — Wheel/Rail interface.

Figure 14 — Material handling car of 1500-series.
1 Truck Frame 12 Friction Snubber

2 Equalizer Beams 13 Lateral Bumper

3 Equalizer Springs 14 Package Tread Brake

4 Pedestal Tie Bar 15 Disc Brakes

5 Roller Bearing Adapter 16 Bolster Anchor Assembly

6 Central Bearing 17 Locking Center Pin

7 Truck Bolster 18 Vertical Wear Sleeve

8 Secondary Coil Springs 19 Equalizer Spring Seat

9 Rubber Sandwich 20 Bolster Spring Seat Assembly

10 Vertical Shock Absorber 21 Insulation Pad

11 Lateral Shock Absorber 22 Wheel and Axle Assembly

Figure 15 — Truck of material handling car 1500.

18

20

final test was also organized by the

Safety Board and was conducted by the

Research and Test Department of the

AAR Transportation Test Center (TTC)

in Pueblo, Colorado, between November

7 and 10, 1995. This test physically

replicated the dynamics of the flattened

rail head being traversed by MHC 1500.7

According to the consulting firm,

MHC 1500 lost vertical wheel load near

the initial POD because of the flattened

rail head. The narrowing of track gage

due to flattened rail head resulted in an

increase of lateral wheel forces. The firm

concluded that these two factors in union

would be sufficient to cause the

derailment.

In addition, the consulting firm

conducted simulations comparing the

dynamic vehicle performance of an

empty MHC 1500 at 70 mph with the

following: an empty trailer-on-flat-car

(TOFC) at 50 and 70 mph, a loaded

TOFC at 50 and 70 mph, a loaded and an

empty hopper at 50 mph, and an

Amcoach car at 70 mph. The results

were preliminary in nature; however,

these results indicated that the empty

MHC and the empty TOFC were more

susceptible than the other cars to losing

vertical wheel load when the flattened

rail head was traversed.

In February 1995, a team of three

TTC vehicle/track interaction dynamics

engineers at the Amtrak Beech Grove

shop facility inspected MHC 1500 to

factor the condition of the car into the

computer model. Amtrak and repre-

 

7

The second and third tests were conducted in

partnership with Amtrak, Conrail, the AAR, and

the FRA.

sentatives of the truck manufacturer

were present while the team examined

the car. MHC 1500 was not in the same

condition as at the time of the

derailment, and the trucks inspected

were not the same trucks that were

installed at the time of the derailment.

The car had been released and returned

for service. AAR in its initial report

noted the following:

• The B-end left side bolster anchor rod

was misadjusted, causing the bolster to

rub on its keeper and to have a potential

for vertical and lateral suspension

binding.

• The car body leaned to the left.

• The bolster springs on both ends of the

car had more shims on the right side of

the car than on the left side.

• The B-end left side bearing gap was

almost completely closed up and showed

signs of frequent rubbing between the

bolster and truck frame. Wear surfaces at

the other three side bearings showed

little signs of rubbing.

• Fatigue cracks were developing where

some of the secondary vertical

suspension friction dampers were

mounted to the side sill. This condition

might be a sign of binding in the

dampers causing excess force

transmission into the body.

• Several axle journal boxes were

binding in the truck frame pedestal jaws.

• The B-end bolster was offset to the

right so that the right side lateral stop

was almost in contact and showed signs
21

of frequent rubbing. The left side stop

showed no sign of contact or rubbing.

• The wheel profile measurements from

the derailed axles showed a ridge in the

gage corner of both wheels of the second

axle.

Amtrak and the truck manufacturer

considered the conditions noted by the

TTC team to be still within design tolerances. The car had been in service

successfully for some months after the

accident.

The AAR, in participation with the

Safety Board and the parties to the

investigation, oversaw additional computer modeling in August 1995. The

TTC initial computer modeling verified

to a great extent the Amtrak consulting

firm’s results; however, the TTC did not

agree with all of the conclusions. The

Amtrak consultant concluded that the

lateral wheel force was sufficient to

cause derailment, but the TTC believed

that the lateral force predicted was not

sufficient to cause flange climb. The

TTC thought that an extreme component

failure, such as the truck failing to rotate

for the curve, would be necessary to

cause a derailment. An actual field test

was proposed to determine whether the

AAR NUCARS model reasonably

predicted the actual on-track performance of MHC 1500. Therefore, the

TTC installed the accident rail in its own

test tracks and secured MHC 1500 to

replicate the dynamics of the accident.

Then, the TTC conducted the following

tests between November 7 and 10, 1995:

• Twist and Roll: The TTC measured

the suspension dynamics of the test car

over known track perturbations and

compared the results with the computer

model parameters.

• Steady State Curving: The TTC

measured truck rotations and other

dynamic characteristics of MHC 1500 in

a 7.5- and 5-degree curve.

• Flattened Rail Head: The TTC

measured the response of MHC 1500

over the flattened rail from the accident

site.

• Balloon Track: The TTC measured

truck rotations and other dynamic

characteristics of the car on the curved

track.

These test results correlated relatively well with the NUCARS simulations.

During flattened rail head tests,

minor wheel unloading occurred at 50

mph in the lead axle, and a more

pronounced wheel unloading occurred at

55 mph. The trailing axle wheel seemed

in the video to be unloaded, but the

computer data indicated a positive

vertical force in the downward direction.

Further calculations revealed that the

maximum unloading occurred approximately 4 to 4.5 feet from the flattened

rail, corresponding with the Safety Board

POD measurement in Batavia. At that

point, the contact position sensor

indicated that the wheel flange was

forced away from the rail. The tests were

terminated at 55 mph.

The AAR engineer suggested that the

rail "fell away" from the wheel because

of the inertia of the wheel and

suspension, and when it came back in

contact with the wheel, it caused a
22

1. The wheel is in normal contact with the rail

2. The wheel is air borne as the rail “falls away” from the wheel.

3. The wheel strikes the rail at the far side of the flattened area.

4. The wheel is again air borne due to the rebounding effect.

5. The wheel is in normal contact with the rail.

Figure 17 — Movement of wheel on flattened rail head.

relatively large vertical force that created

a "bouncing" effect. Figure 17 illustrates

the sequence.

The AAR engineer had noticed in his

inspection of MHC 1500 that the car body

leaned to the left. A leaning car body can

decrease side bearing clearance and cause

increased turning friction in the truck as it

attempts to steer through a curve. To

simulate this condition at the test track, a

shim was welded onto the side bearing on

the low-rail side. The resulting side bearing clearance8

 on the modified truck was

 

8

A side bearing is intended to control the roll

dynamics of the car. Side bearing clearance

allows the truck of a rail car to swivel freely to

adjust to changes in the rail. Absence of side

bearing clearance increases friction force in the

approximately zero, which creates more

friction in the side bearing and makes it

more difficult for the truck to turn.

The results of the tests with the trucks

shimmed closely corresponded with the

results of the test without the shims. The

data from the second set of tests showed

greater wheel unloading and a greater

total moment around the center pin. The

trucks, however, did not lock.

During the second set of tests, at 60

mph, the video image of the trailing axle

showed the flange riding on the gage

corner of the rail. The tests were

terminated at this time because snow

 

side bearing and decreases the ability of the truck

to swivel.
23

began falling, which changed the friction

coefficients between rail and wheel.

Metallurgical — The Safety Board

materials laboratory examined the

flattened area and the adjacent section of

the rail before the TTC tests were conducted. An ultrasonic test of the rail

showed no identifiable internal defects.

After the TTC tests were performed,

the materials laboratory examined two

additional sections of the rail. One

section was from the center of the

flattened area, and the other, without

flattening, was from an area near the first

section. The shape of the base and web

of the rail on both sections appeared to

closely conform with the specified shape

of a new 140-pound RE rail. However,

the section without flattening contained

wear to the gage side and to the top of

the head, and the section from the center

of the flattened area was shown to have

substantial deformation, as previously

documented. Figure 7 shows an approximate outline of the shape of a new 140-

pound RE rail superimposed on the head

of the flattened rail section. Most of the

lateral deformation of the rail, as indicated in this figure, was toward the field

side. Also, more vertical (downward)

deformation was on the field side of the

head than on the gage side.

Approximately 60 hardness measurements were taken on a grid pattern

throughout the head portion of each rail

section. These measurements generally

ranged from 60 to 64 HRA (about 223 to

262 Brinell). Within about 0.375 inch of

the head surface of the section from the

flattened area, the hardness was higher,

up to a maximum measured value of

69.6 HRA (345 Brinell). A thinner layer

of increased hardness was also noted

adjacent to the head on the other section,

up to a maximum hardness of 66.6 HRA

(304 Brinell). Standard rail manufactured in the 1970s has a typical

hardness of 250 Brinell.

25

General

The investigation by the Safety Board

determined that the members of the

operating crew of train 49 were qualified

for their duties and were operating the

train properly. The crewmembers were

rested in accordance with applicable

regulations, and the on-board service

crewmembers performed their duties

correctly.

The signal system had been recently

inspected, and preaccident tests had not

revealed any defects. The signal event

recorder indicated that the signal system

had been interrupted at 03:43:58 a.m.,

when the train derailed and struck the

supporting structure of the signal bridge.

The investigation by the Safety Board

determined that the signal system had no

deficiencies, had functioned as intended

at the time of the derailment, and had

been clearly visible to the train crew.

Train 49 was operating on a clear signal

indication as intended. In addition, the

weather did not affect the visibility of

the signal aspects and was not a factor in

the derailment.

Therefore, the Safety Board

concludes that the operation of train 49,

the performance of the operating and onboard service crews, the signal system,

and the weather were not factors in the

derailment.

The 118 injured passengers and

crewmembers were removed from the

derailment site within 1 hour 16 minutes.

All severely injured people were given

priority attention. Therefore, the Safety

Board concludes that the local

emergency response personnel reacted

promptly and acted effectively at the

derailment site.

Accident

The track structure between the initial

and general PODs was marked by the

flange of a wheel, indicating that at least

one car was derailed. Other marks were

also found near other flattened rail

before the initial POD, indicating that

wheel lift or some degree of dynamic

instability between the track and a train

car may have occurred. To correlate the

marks with a particular car or with the

Amtrak train as a whole, however, was

not possible. The Safety Board also

determined that neither the equipment

nor the track deviated from the FRA and

design specifications. The investigation,

therefore, focused on the interaction

between the flattened rail head at the

initial POD, MP 403.7, and MHC 1500.

Rail Structure

The determination that the initial

POD was at MP 403.7 was based on the

two wheel flange marks on the gage side

of the rail head that began about 22 feet

east of the POD and continued westward

on the rail head for about 34.8 feet

before leading to the field side. The

marks indicate that at this point, the

ANALYSIS
26

wheel dropped off the rail and struck the

tie plates 42.4 feet later. The same marks

continued for about 3 miles until they

reached the general POD at MP 406.7.

The rail head was flattened for

approximately 38 inches, starting about

4.6 feet east of the POD, and the

depression was 0.43 inch at its deepest

point. The Safety Board concentrated its

investigation on this depression and the

series of other flattened rail heads and

wheel/flange marks east of the initial

POD to determine what part, if any, the

rail and track structure had in the

accident.

Wheel and Rail Dynamics

The TTC of the AAR replicated the

wheel/rail dynamics between MHC 1500

and a segment of the flattened rail

removed from the accident track. These

tests were electronically monitored for

vertical/horizontal loads and real-time

video recording of the wheel/rail

interface at various speeds. The TTC

installed the flattened rail in its high

speed test track in a 0' 50" curve.

Safety Board investigators observed

the video monitor showing the wheel/rail

interface at various running speeds with

MHC 1500 in a nominally modified

condition, as well as in its increased side

bearing friction condition. Investigators

noted that when the car was traveling

between 55 and 60 mph, a space was

between the trailing wheel of the lead

truck and the rail surface when the car

went over the depression. The wheel

then dropped to the rail surface and

rebounded for a short time before

returning to the running surface of the

rail. The contact position sensors of the

instrumented wheels indicated that a

flange had been in contact with the rail

for between 2 and 2.5 feet at the

flattened rail head. The sensors also

showed that the flange had had two very

brief periods of rail contact in the 10 feet

past the flattened rail head. The sensors,

thus, validated the importance of the

marks that the Safety Board had noted

on the gage face of the rail after the

testing. What the investigators saw on

the video monitor was generally

consistent with what the Safety Board

had found at the initial POD and with the

results of the computer simulations

performed by Amtrak and the AAR.

In addition, the Safety Board found an

area further east of the initial POD where

the rail head was flattened and the

running surface was marked by a wheel

flange. The rail head was not flattened as

severely as it was at the POD; but it still

evidenced wheel lift.

Safety Board investigators analyzed

all of the evidence available in this

derailment. The results of the various

computer simulations and field tests do

not conclusively predict that a flange

climb derailment would take place at the

POD that was identified at the accident

scene. However, the test results do

indicate that extreme wheel unloading

and flange contact was at the flattened

rail just before the POD, which are two

conditions that must be present for a

flange climb derailment to occur.

Therefore, the Safety Board concludes

that the simulations and field tests

corroborate the location of the initial

POD and confirm that the flattened rail

head allowed the wheel to lose contact

with the rail.
27

Track and Rail Inspection

Title 49 CFR 213.233 required that

main line track 2 be inspected twice

weekly. The Safety Board investigation

determined that two inspections of the

track in the Batavia area had been done

by the Conrail track inspector within the

6 days before the derailment. On July 29,

1994, the Conrail track inspector

performed his last inspection of the track

before the August 3 derailment and

noted no exceptions on his inspection

report.

The FRA randomly assigned an

inspector to observe the Conrail track

inspector's practices during an

inspection. On July 25, 1994, during a

routine joint track inspection, an FRA

track inspector and the Conrail track

inspector rode together on a high-rail

vehicle. The inspectors stopped at

several locations, including the section

of track near MP 403.7. They found the

flattened rail condition at what was to

become the initial POD. They examined

the rails at that location and found the

condition to be within track geometry

specifications.

The Safety Board investigation

determined that both the carrier and the

FRA inspectors were experienced and

had knowledge of the existing standards

for track defects. The Safety Board,

therefore, concludes that the track

inspections were being performed as

intended by the carrier and by the FRA

and that the flattened rail condition at

MP 403.7 had been detected before the

derailment occurred.

Under FRA track safety standards a

flattened rail head is neither defined as

nor considered a rail defect. The Conrail

track inspector had recorded the

observed flattened rail head on the other

side of his report forms because no

category was provided within the form to

record these observations. He used this

record as a reference for subsequent

inspections. As he told Safety Board

investigators, he had first identified the

flattened rail at MP 403.7 as engine burn

since it did not fit any identification

category. Because flattened rail head was

not defined as or considered an FRA rail

defect and because the industry had no

identification for flattened rail head, the

FRA and Conrail track inspectors, when

they noted the flattened rail condition

during their joint inspection, had no

guidance to follow for a potentially

dangerous situation. The Safety Board

concludes that the FRA has not provided

the guidance on what size or type of

flattened rail head is potentially hazardous

to train operations that would allow track

inspectors to take corrective action.

Consequently, the inspectors could only

examine the area of the flattened rail

head for a track gage or cross level

violation of the track geometry

standards. The Safety Board, therefore,

concludes that the flattened rail head at

the initial POD was not considered a

defect because it did not meet the

definition of an existing rail defect and

the track geometry did not meet defect

specifications.

During the postaccident investigation,

the cross level variation of the track at

the center of the flattened rail head near

the initial POD was 1.125 inches, which

would have been considered a track

geometry defect requiring repair or the

reclassification of the track to FRA class

4. Had the track been repaired by

leveling the geometry defect, the
28

flattened rail condition would have

remained in the track. The flattened rail

still being in the track would have

caused the geometry to vary again from

the wheel pounding over the rail

irregularity and would have caused a

potential for wheel lift. Had the track

been reclassified, the maximum speed

for a passenger train on the track would

have been lowered to 80 mph.

Nevertheless, the speed of train 49

would not have been affected because

the train was governed by the Conrail

maximum allowable timetable speed of

79 mph for passenger trains.

Consequently, the Safety Board

concludes that the track geometry defect

found after the derailment at the initial

POD was not a contributing factor in the

derailment.

Flattened Rail Definition

Standards

The Conrail division engineer who

after the accident had accumulated data

about flattened rail estimated that 30.72

miles of the 300 miles of rail between

Selkirk (near Albany) and Bay View,

New York, (near Buffalo, New York) is

“A” rail, which is the type of rail that

seems to be subject to flattening.

The flattened rail head found in this

accident is not unique to Conrail. The

AAR examined rail in 1994 from the

Chicago & North Western (CNW) and

from the Canadian National (CN)

railroads that exhibited physical and

chemical properties that were similar to

the properties of the flattened rail head

from the Batavia derailment. These rails

were manufactured in the 1970s; the

CNW rail was an “A” rail. (A CNW and

CN review of other rails suggested “A”

rails were more likely to have this

flattened head condition.) Rolling load

tests on the CN rail, performed by the

AAR, disclosed that after 2 million

cycles of impact simulation, no internal

fatigue defects developed. The AAR

concluded that these flattened rail

conditions tended not to be structurally

destructive. As a remedy for the rail

condition, the CNW placed a speed

restriction on its track, and the CN

attempted to weld and grind the affected

areas. The industry, however, has not

determined the best long-term remedial

action.

The chief engineer of Conrail, who

also was the president of the American

Railway Engineering Association,1

 told

the Safety Board that flattened rail heads

had not been discussed to any extent

with other railroads, other than being

reported on at various committees, with

the CNW experience being the

predominant incident.

The Safety Board is concerned about

the incidents of flattened rail on Conrail,

CNW, and CN tracks because they

indicate that this condition may occur

elsewhere and, thus, threaten the safety

of train operations. The Safety Board

recognizes that some time would be

required to collect and analyze data to

ascertain the cause of flattened rail and

the extent of the potential hazard. Safetyenhancing steps, however, could be

 

1

 The engineering body of the North

American railroad industry, which presents a

forum for discussion and development of

standards of recommended practices for railroad

maintenance and design. Its members are railroad

engineers and other qualified individuals who

serve on various organization committees.
29

taken in the interim. The FRA could

issue technical bulletins for its inspectors

that provide them with an interim aide in

determining the hazard posed by

flattened rail conditions. A bulletin could

explain the circumstances of this

accident and offer guidelines based on

such information as the speed and type

of a train and its operating area.

Therefore, the Safety Board believes that

the FRA should develop, not later than

December 31, 1996, an interim technical

bulletin authorizing track inspectors to

take corrective action to prevent the

potential hazard of flattened rail head

conditions to train operations.

The Conrail division engineer

accumulated data on removed flattened

rail to determine whether he could

establish any correlation between the

likelihood of rail being flattened and its

weight, curvature, or classification. He

found that “A” rails had the highest

percentage of flattening, with the highest

number of occurrences in curves of 1

degree or less. (The flattened rail head in

this accident was no exception to his

findings; the “A” rail was in a 1-degree

curve.)

The Safety Board materials laboratory

did not find any metallurgical defects in

the flattened rail head from the POD.

Although the reason for the flattening

cannot be conclusively determined, the

rail seemed to have much in common

with other rail that has developed

flattened rail head: it was an “A” rail

manufactured in the 1970s that had been

heavily used in terms of tonnage and

high axle loads. Additional research is

needed on flattened rail head to

determine the type of rail that is likely to

flatten, the conditions that will cause it

to flatten, and the risk posed by the

flattening. The Safety Board believes

that the FRA should conduct appropriate

research and develop a data base that can

be used to assess the risk posed by

flattened rail heads. In addition, the

Safety Board believes that the AAR and

the American Short Line Railroad

Association, in conjunction, should

assist the FRA in developing the data

base.

As a result of the Safety Board’s

investigation, Conrail devised a working

definition of flattened rail head when

considering flattened rail replacement.

Conrail defined it as rail head that has a

depression that is at least 12 inches long

and 0.25 inch deep. The chief engineer

stated that this definition is arbitrary and

had been chosen as a starting point. The

definition would be more valuable if it

were based on an understanding of the

correlation between risk and degree of

flattening. However, both the FRA and

the industry lack the necessary data. The

Safety Board concludes that the FRA

track safety standards fail to address

flattened rail head condition risks such

as found in this accident. Therefore, the

Safety Board believes that the FRA

should develop guidelines, using the data

compiled about the risk of flattened rail

heads, for track inspectors to use to

identify rail head that may be hazardous

to train operations and also regulations

to ensure that corrective action is taken

when such flattened rail head conditions

have been identified.
30

Rail and Material Handling Car

1500 Dynamics

The TTC as part of its on-track

simulation tests of the dynamic

interaction between the track and MHC

1500 noted several irregularities;

however, none were serious enough to

be considered defects. The irregularities

indicated normal wear and tear, and they

were used to devise a more accurate

representation of the car for the

computer simulation. MHC 1500 had

been repaired and released back into

service up to that time. However, these

anomalous conditions had not been

previously reported and might have been

of some significance to the performance

of the car in its dynamic interaction with

the rail.

The detailed inspection of the car by

the Safety Board, both at the site of the

accident and at the Amtrak shop before

the car was repaired, did not reveal any

conditions that either caused or

contributed to the accident. On October

13, 1994, the trucks were disassembled

and measured at the Amtrak Beech

Grove shop, and the car truck frames and

parts were found to be within

specification.

During testing at the TTC, a 0.025-

inch shim was tack welded into the lead

left side bearing gap, completely filling

the gap. As a consequence, some of the

weight of the car shifted from the center

bowl to the side bearing, causing a

friction increase when the trucks slewed.

The attempt to modify the behavior of

the car during the dynamic testing at the

TTC had no significant effect on the

performance of the car.

MHC 1500 had no history of

performance, maintenance, or repair

problems, either before or after the

accident, and the car had accumulated

about 200,000 miles annually without

incident. Consequently, the Safety Board

concludes that even though the rail in the

flattened area met FRA requirements

when inspected before the accident and

MHC 1500 had no design deficiencies,

the dynamic interaction of the car with

the flattened rail head initiated the

derailment sequence.

The analysis of the engineering

consulting firm contracted by Amtrak

indicated that lightly loaded or shorter

wheel base cars, such as MHCs or empty

TOFCs, have a greater tendency to initiate

wheel lift as they transverse over flattened

rail head than do longer wheel base or

heavier cars. Flattened rail may be a

hazard to all trains and could cause cars in

both freight and passenger trains to derail.

The materials laboratory of the Safety

Board examined both broken brake discs

from MHC 1500. Not all of the fracture

surface could be examined because some

of the fracture surface was obliterated

and other pieces of the fracture surface

were missing. The remaining material on

both discs exhibited typical features of

overstress separations. No indications of

preexisting cracks were in any of the

pieces examined.

Investigators examined the truck,

brake cylinders, and brake calipers for

any indication of strike damage from a

loose brake disc. No marks were found

on these components that would be

consistent with a loose brake disc. Thus,

no evidence was found to support the
31

theory of a broken brake disc occurring

before the accident. The Safety Board,

therefore, concludes that the brake discs

of MHC 1500 broke as a result of the

forces of derailment and were not causal

to the derailment.

Survival Aspects

No occupant of the Heritage dome car

reported being injured by the 12-inchlong metal seat back braces that were

exposed when the frames of the car seats

separated. The Safety Board concludes,

however, that these exposed metal seat

back braces in dome coach car 9411

were a potential hazard for passengers

when that car overturned. Therefore, the

Safety Board believes that Amtrak

should install, in all Heritage coach

dome cars in its possession, a positive

locking feature that will prevent the

separation of the car seat backs from the

seat back braces.
32

CONCLUSIONS

1. The operation of train 49, the

performance of the operating and

on-board service crews, the

signal system, and the weather

were not factors in the

derailment.

2. The local emergency response

personnel reacted promptly and

acted effectively at the derailment site.

3. The simulations and field tests

corroborate the location of the

initial point of derailment and

confirm that the flattened rail

head allowed the wheel to lose

contact with the rail.

4. The track inspections were being

performed as intended by the

carrier and by the Federal

Railroad Administration, and the

flattened rail condition at

milepost 403.7 had been detected

before the derailment occurred.

5. The FRA has not provided the

guidance on what size or type of

flattened rail head is potentially

hazardous to train operations that

would allow track inspectors to

take corrective action.

6. The flattened rail head at the

initial point of derailment was

not considered a defect because it

did not meet the definition of an

existing rail defect and the track

geometry did not meet defect

specifications.

7. The track geometry defect found

after the derailment at the initial

point of derailment was not a

contributing factor in the

derailment.

8. The Federal Railroad Administration track safety standards

fail to address flattened rail head

condition risks, such as found in

this accident.

9. The rail in the flattened area met

the Federal Railroad Administration requirements when inspected

before the accident, and material

handling car 1500 had no design

deficiencies.

10. The derailment occurred because

of the dynamic interaction of

material handling car 1500 and

the flattened rail head.
33

11. The brake discs of material

handling car 1500 broke as a

result of the forces of derailment

and were not causal to the

derailment.

12. The exposed metal seat back

braces in dome coach car 9411

were a potential hazard for

passengers when that car

overturned.

PROBABLE CAUSE

The National Transportation Safety

Board determines that the probable cause

of the derailment was the fact that

Federal and industry guidelines do not

currently address flattened rail head

conditions, due to an insufficient understanding of the risk that flattened rail

poses to train operations.

RECOMMENDATIONS

As a result of its investigation, the

National Transportation Safety Board

makes the following recommendations:

--to the Federal Railroad Administration:

Develop not later than December

31, 1996, an interim technical

bulletin authorizing track inspectors to take corrective action

to prevent the potential hazard of

flattened rail head conditions to

train operations. (Class II, Priority

Action)(R-96-12)

Conduct appropriate research and

develop a data base that can be

used to assess the risk posed by

flattened rail heads. (Class II,

Priority Action)(R-96-13)

Develop guidelines, using the data

compiled about the risk of

flattened rail heads, for track inspectors to use in identifying rail

head that may be hazardous to

train operations and also regulations to ensure that corrective

action is taken when such flattened

rail head conditions have been

identified. (Class II, Priority

Action)(R-96-14)
34

--to the National Railroad Passenger

Corporation:

Install, in all Heritage coach dome

cars in its possession, a positive

locking feature that will prevent

the separation of the car seat backs

from the seat back braces. (Class

II, Priority Action)(R-96-15)

--to the Association of American

Railroads:

Inform its membership of the

circumstances of this accident.

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

16)

Assist the Federal Railroad

Administration, in conjunction

with the American Short Line

Railroad Association, in developing

a data base that can be used to

assess the risk posed by flattened

rail heads. (Class II, Priority

Action)(R-96-17)

--to the American Short Line Railroad

Association:

Inform its membership of the

circumstances of this accident.

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

18)

Assist the Federal Railroad

Administration, in conjunction

with the Association of American

Railroads, in developing a data

base that can be used to assess the

risk posed by flattened rail heads.

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

19)
35

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 11, 1996

37

APPENDIX A

Investigation and Hearing

The National Transportation Safety Board was notified at 5:21 a.m. on August 3, 1994, of

the derailment of Amtrak (National Railroad Passenger Corporation) train 49, the Lake Shore

Limited, on Conrail (Consolidated Rail Corporation) trackage near Batavia, New York. The

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

from the headquarters in Washington, DC. Investigative groups studied operations, track, signals,

mechanical, survival factors, and human performance.

The Association of American Railroads, Brotherhood of Locomotive Engineers,

Consolidated Rail Corporation, National Railroad Passenger Corporation, New York State

Department of Transportation, and U.S. Department of Transportation Federal Railroad

Administration assisted in the Safety Board investigation.

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

December 14, 1995, at which six witnesses testified.

39

APPENDIX B

Material Handling Car Characteristics

The following are the general characteristics of an MHC:

Length between Pulling Face of Coupler 64 feet 03.50 inches

Maximum Width over Grab Irons 8 feet 10.25 inches

Maximum Height 13 feet 06.25 inches

Distance between Truck Centers 41 feet 03.00 inches

Truck Wheel base 8 feet 06.00 inches

Distance Centerline of Trucks to Coupler 11 feet 06.25 inches

Car Construction Material carbon steel

Minimum Turning Radii 250 feet (22.7 degrees)

Coupler Type H tightlock

Draft Gear dresser type WM-6-DPB

Wheel Size and Type 36-inch diameter class B

41

APPENDIX C

Acronyms Used in this Publication

AAR Association of American Railroads

Amtrak National Railroad Passenger Corporation

Conrail Consolidated Rail Corporation

CN Canadian National Railroad

CNW Chicago & North Western Railroad

FRA Federal Railroad Administration

GCECC Genessee Country Emergency Communication Center

GCEMC Genessee County Emergency Management Coordinator

MHC material handling car

MP milepost

NORAC Northeast Operating Rules Advisory Committee

NYS New York State

POD point of derailment

TOFC trailer on flat car

TTC Transportation Test Center