PB97-917002

NTSB/SIR-97/01

WASHINGTON, D.C. 20594

RAILROAD SPECIAL INVESTIGATION

REPORT

DERAILMENT OF AMTRAK TRAIN NO. 12 AND

SIDESWIPE OF AMTRAK TRAIN NO. 79 ON PORTAL

BRIDGE NEAR SECAUCUS, NEW JERSEY,

NOVEMBER 23, 1996

6813B
Abstract: On November 23, 1996, the National Railroad Passenger Corporation (Amtrak) train

No. 12 derailed while crossing Portal Bridge, a swing bridge spanning the Hackensack River in

Secaucus, New Jersey. When the train derailed, it sideswiped Amtrak train No. 79, which was

crossing the bridge in the opposite direction on an adjacent track. No fatalities resulted, but 42

passengers and crewmembers aboard train No. 12 were injured, as was 1 passenger aboard train

No. 79. Estimated cost of the damaged train, track, and signal equipment and site cleanup

exceeded $3.6 million.

The safety issues discussed in this report are (1) Amtrak management oversight of the

inspection, maintenance, and repair of the miter rail assemblies on Portal Bridge; and (2) the

effectiveness of Amtrak’s emergency notification procedures. The report also examines the

effectiveness of Amtrak locomotive event recorders in capturing critical operational data.

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

recommendations to Amtrak, the Federal Railroad Administration, 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, S.W.

Washington, D.C. 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) 487-4600
	

	

	





	

	



	










RAILROAD SPECIAL INVESTIGATION REPORT

Adopted: December 18, 1997

Notation 6813B

NATIONAL

TRANSPORTATION

SAFETY BOARD

Washington, D.C. 20594

iii

CONTENTS

CONTENTS ..............................................................................................................................iii

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

INVESTIGATION......................................................................................................................1

Synopsis......................................................................................................................................1

Preaccident Events ......................................................................................................................1

The Accident ...............................................................................................................................4

Survival Factors...........................................................................................................................6

Emergency Response............................................................................................................6

Emergency Preparedness ......................................................................................................7

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

Damages .....................................................................................................................................8

Personnel Information..................................................................................................................8

Traincrews............................................................................................................................8

Portal Bridge Operator .........................................................................................................8

Bridge and Building Electrician.............................................................................................8

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

Train No. 12.........................................................................................................................8

Train No. 79.........................................................................................................................8

Signal Information.......................................................................................................................8

Site Description...........................................................................................................................9

Portal Bridge ........................................................................................................................9

Track and Special Trackwork ...............................................................................................9

Postaccident Inspection .............................................................................................................12

Preaccident Bridge Inspections..................................................................................................13

Operations Information..............................................................................................................13

Meteorological Information .......................................................................................................15

Toxicological Information..........................................................................................................15

Tests and Research....................................................................................................................15

Bridge Tests .......................................................................................................................15

Signal Tests........................................................................................................................15

Bridge Event Recorder Information ....................................................................................16

Signal System Event Recorder Information.........................................................................16

Locomotive Event Recorder Information............................................................................16

Metallurgical Information ...................................................................................................18

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

Portal Bridge Miter Rail Configuration History...................................................................20

Previous Defects In and Problems With the Miter Rail System............................................21

Amtrak Postaccident Actions..............................................................................................23

Amtrak Locomotive Event Recorders.................................................................................25
iv

Throttle Position Recording.........................................................................................25

Cab Signal Aspect Recording.......................................................................................26

Event Recorder Tests and Inspections..........................................................................27

Federal Oversight of Special Trackwork .............................................................................28

ANALYSIS...............................................................................................................................29

General......................................................................................................................................29

The Accident .............................................................................................................................29

Design of Portal Bridge Miter Rail System.................................................................................30

Maintenance of the Miter Rail System........................................................................................30

Inspection of the Miter Rail System ...........................................................................................31

Removal of the Miter Rail Position Detection Circuits ...............................................................32

Emergency Response.................................................................................................................33

Locomotive Event Recorders.....................................................................................................34

Using Traction Motor Current to Indicate Throttle Position................................................34

Cab Signal Multiplexer and Current Module .......................................................................34

Event Recorder Inspections ................................................................................................35

Amtrak Management Oversight of Safety Issues ........................................................................36

Federal Oversight of Special Trackwork ....................................................................................37

FRA Bridge Survey ...................................................................................................................37

FINDINGS................................................................................................................................38

Conclusions...............................................................................................................................38

Probable Cause..........................................................................................................................39

RECOMMENDATIONS...........................................................................................................40

APPENDIX — Investigation.....................................................................................................43
v

About 6:28 a.m. on Saturday, November 23,

1996, eastbound National Railroad Passenger

Corporation (Amtrak) train No. 12 derailed while

crossing Portal Bridge, a swing bridge spanning

the Hackensack River in Secaucus, New Jersey.

When the train derailed, it sideswiped Amtrak

train No. 79, which was crossing the bridge in

the opposite direction on an adjacent track. All

12 cars of train No. 12 derailed, with both

locomotives, 1 material handling car, and the 3

head passenger coaches coming to rest at the

bottom of an embankment at the east end of the

bridge. Train No. 79 sustained damage but was

able to stop with the entire train intact and on the

rails some distance west of Portal Bridge. No

fatalities resulted from the accident, but 42

passengers and crewmembers aboard train No.

12 were injured, as was 1 passenger aboard train

No. 79. Estimated cost of the damaged train,

track, and signal equipment and site cleanup

exceeded $3.6 million.

The National Transportation Safety Board

determines that the probable cause of the

accident was the failure of Amtrak management

to foster an environment that promoted adequate

inspection, maintenance, and repair of the miter

rail assemblies on Portal Bridge and to

permanently correct defects in the miter rail side

bars that were discovered 10 months before the

accident. Contributing to the accident were (1)

the failure of the Federal Railroad Administration

to develop track inspection standards for special

trackwork and to periodically inspect such track

as part of its oversight responsibilities and (2)

Amtrak’s removal of the miter rail position

detection circuitry without installing replacement

circuitry or implementing procedures to

compensate for the loss of this safety-critical

system.

The two primary safety issues discussed in

this report are: (1) Amtrak management oversight

of the inspection, maintenance, and repair of the

miter rail assemblies on Portal Bridge; and (2)

the effectiveness of Amtrak’s emergency

notification procedures. The Safety Board also

examined the effectiveness of Amtrak locomotive

event recorders in capturing critical operational

data.

As a result of its investigation of this

accident, the Safety Board makes safety

recommendations to Amtrak, to the Federal

Railroad Administration, to the Association of

American Railroads, and to the American Short

Line Railroad Association.

EXECUTIVE SUMMARY

1

Synopsis

About 6:28 a.m. on Saturday, November 23,

1996, eastbound National Railroad Passenger

Corporation (Amtrak) train No. 12 derailed while

crossing Portal Bridge, a swing bridge1

 spanning

the Hackensack River in Secaucus, New Jersey.

(See figure 1.) When the train derailed, it

sideswiped Amtrak train No. 79, which was

crossing the bridge in the opposite direction on an

adjacent track. All 12 cars of train No. 12

derailed, with both locomotives, 1 material

handling car, and the 3 head passenger coaches

coming to rest at the bottom of an embankment at

the east end of the bridge. Train No. 79 sustained

damage but was able to stop with the entire train

intact and on the rails some distance west of

Portal Bridge. No fatalities resulted from the

accident, but 42 passengers and crewmembers

aboard train No. 12 were injured, as was 1

passenger aboard train No. 79.

Preaccident Events

Amtrak train No. 12 departed Washington,

D.C., at 3:00 a.m. on November 23, 1996, en

route to Boston. The train consisted of two

locomotives, seven passenger coaches, and five

material handling cars loaded with mail. The

train changed crews (an engineer, conductor, and

assistant conductor) in Philadelphia, departing

that station at 5:10 a.m.

Also early in the morning of November 23,

Amtrak train No. 79 was made up in Sunnyside

Yard, Queens, New York, with one locomotive

and nine passenger coaches. A baggage car was

added to the rear of the train at Pennsylvania

Station in New York, and at 6:15 a.m. the train

departed Penn Station en route to Charlotte,

North Carolina. The crew consisted of an

engineer, a conductor, and two assistant

conductors.

At 4:00 a.m. on November 23, the bridge

operator on duty at Portal Bridge received a radio

 

1

The center portion of the bridge could be rotated up

to 90° to permit the passage of river traffic.

call from a tugboat asking that the bridge be

opened to allow the vessel to proceed north up

the Hackensack River. At 4:03 a.m., according to

the bridge event recorder, the bridge operator

received the “unlock” from the on-duty Amtrak

train dispatcher in New York City.2

The bridge operator stated that the bridge

unlocking function sequenced normally, but that

when he attempted to open the bridge by rotating

its center section counterclockwise, he was

unable to do so. The bridge operator noted the

problem in the bridge log book. The log book

indicated that the bridge was electrically locked

at 4:10 a.m. According to telephone transcripts,

the bridge operator called the train dispatcher at

4:15 a.m.3

 and told him

It’s locked up now. I had a real hard time

lining it up.... [T]his thing [was] rocking

like it never rocked before, and...I just

don’t want to take any chances. It’s all

locked up now.... It’s all closed; you

should be able to lock it up.

The bridge event recorder indicated that the

train dispatcher reassumed electrical control of

the bridge at 4:17 a.m. After his call to the onduty train dispatcher, the bridge operator called

the Amtrak bridge and building (B&B)

department electrical foreman4

 and then, at 4:20

a.m., the assistant chief train dispatcher. He told

the assistant chief dispatcher

 

2

The bridge operator could operate the bridge only

after the authority and the means had been provided by the

train dispatcher. By sending an “unlock” signal, the train

dispatcher made electrical power available so that the

bridge operator could open and close the bridge.

3

The bridge event recorder and telephone transcripts

are not synchronized and vary by a few minutes.

4

The bridge operator stated that he called an

electrician because about 1 week earlier, the bridge had

experienced a problem with the swing brakes, and he

assumed that this latest malfunction was brake-related.

INVESTIGATION
Figure 1- Looking south over Amtrak’s Portal Bridge spanning the Hackensack River near Secaucus, New Jersey
3

I can’t even describe it. I never had

this...happen before. I’m giving the

release, and I’ve got all my indications

that everything is fine on the board

[control panel] as far as my brakes and

my swing go, but as soon as I swing, the

thing goofs up on me.... This bridge is

really rocking...back and forth—it

almost seems like the thing is going to

crack....

At 4:22 a.m., the assistant chief train

dispatcher relayed this information via

telephone to the Amtrak communication and

signal (C&S) department trouble desk.

In response to the bridge operator’s call to

the B&B department electrical foreman, a B&B

electrician arrived at the bridge about 5:40 a.m.

to troubleshoot the bridge’s brakes and control

circuits and determine why the bridge would not

open. He approached the bridge from the west

end and walked on the north side of track 2. He

stated that the west end of the bridge was fully

illuminated and that he did not see anything

unusual. In the meantime, at 5:50 a.m., the

bridge operator called the train dispatcher and

requested a bridge unlock so that he could make

a test. The electrician said that he went up to the

bridge operator’s control room to check the

bridge swing brakes electrically. When he

learned that the bridge had been unlocked, he

asked the bridge operator to call the train

dispatcher to request that the bridge be locked

again so that he (the electrician) could

physically inspect the brakes below the bridge

before another opening was attempted. The train

dispatcher responded by

Neither the bridge operator nor the B&B

technician was aware that, during the aborted

bridge opening, a 10-foot 6-inch movable

section of the north rail of track 1 became

improperly aligned. While the west-facing

portion of the rail section mated properly with

the rail on the approach to the bridge, the

trailing end was elevated 5 inches above the

track with which it was supposed to align. (See

figure 2.) As a result, the right lead truck of any

westbound train crossing Portal Bridge on track

1 would have struck the elevated butt end of the

misaligned rail, and the left lead truck of any

eastbound train would ride up the “ramp”

created by the rail and then drop off the elevated

end. Because the mitered end of the rail was

positioned properly and electrical continuity

was maintained throughout the misaligned rail,

the signals governing train movements along

track 1 over the bridge continued to display a

clear aspect.

Figure 2 — Looking west at the west end of track 1. The heel of the miter rail is elevated about 5 inches

above the running rail, creating a ramp for the left side trucks of any eastbound train.

(Photograph taken on the day of the accident after removal of the derailed equipment.)
4

The Accident

At 6:19 a.m., the train dispatcher called to

notify the Portal Bridge operator that a train

(train No. 79) was leaving Penn Station

westbound (toward the bridge) on track 2. At

6:24 a.m., the dispatcher called to advise the

bridge operator that an eastbound train (train No.

12) was approaching the bridge on track 1.

Meanwhile, although it was dark, the B&B

electrician had visually inspected the bridge

swing brakes and, judging them to be normal,

went back to the bridge operator’s control room

to make a second electrical brake check.

Locomotive event recorder data indicated

that as eastbound train No. 12 approached the

Portal Interlocking5

 on track 1, the engineer

reduced the train’s speed from 90 mph to 62

mph, which was below the 70 mph permanent

timetable speed restriction in force for

movements through the interlocking on both main

tracks. Event recorder data indicated that as

westbound train No. 79 approached Portal

Interlocking on track 2, its engineer reduced the

train’s speed from 90 mph to 67 mph.

At about 6:28 a.m., the lead locomotive of

eastbound train No. 12 rolled onto the “ramp”

created by the misaligned rail section. Both

locomotives and all 12 following cars derailed

and, with emergency train brakes having been

applied by the engineer, the train continued

eastward about 1,060 feet. The engineer of

approaching train No. 79 observed “extreme

wheel sparking” as train No. 12 moved east, at

which time train No. 12’s engineer radioed,

“Emergency! Everything east and west of Portal!

All Stop! All Stop!” Train No. 79’s engineer also

reported that his train had initiated emergency

braking. Train No. 79 was struck along its south

side by equipment of the still-moving train No.

12 as the trains passed on the bridge. The impact

caused some of the air brake hoses between the

cars on train No. 79 to separate, initiating an

automatic emergency brake application.

 

5

An interlocking is an arrangement of signals and

control apparatus so interconnected that functions must

succeed each other in a predetermined sequence, thus

permitting train movements along routes only if safe

conditions exist. Portal Bridge was located within the

confines of the Portal Interlocking.

Train No. 79 sustained sideswipe damage

but stopped with the entire train intact and on the

rails west of Portal Bridge. Train No. 12 came to

rest with both locomotives, one material handling

car, and the three head passenger coaches entirely

derailed and located in various positions to the

south of track 1 and down the embankment at the

east end of the bridge. (See figure 3.) The

remaining eight cars of train No. 12 remained

upright and in line, but they were all or partially

derailed.

At the time of the derailment, the B&B

electrician was in the bridge control room talking

on the telephone with someone from the C&S

trouble desk who had called to determine if the

problem with the bridge had been identified. A

C&S signal maintainer was on duty in a work

trailer just west of Portal Bridge when the

derailment occurred. He said he heard what

sounded like a “rough ride” on the bridge.

According to telephone transcripts, at 6:35 a.m.,

the C&S maintainer contacted the C&S trouble

desk and reported trouble at the bridge. He was

told that train No. 12 had reported derailing and

that train No. 79 may have derailed also. The

C&S maintainer asked if the bridge had been

opened. He was told about the failed attempt to

open the bridge earlier that morning and was told

that the bridge had been reported locked again

after the attempt, but that no one had visually

confirmed that it was, in fact, properly aligned

and locked.

After the C&S maintainer inspected the

bridge, he reported back to the C&S trouble desk

that

The heel of the miter rail6

 is driven up in

the air. Now, the front part of it, where

we [get] our [signal] indication, that’s

down...so [our signals] indicate that the

rail is down. But the back part of [the

rail]...is in the air.

 

6

One of the eight (two for each track on each end of

the bridge) movable rails located at the junction of the

fixed and movable spans of the bridge. During bridge

opening, the miter rails were mechanically raised, freeing

the center bridge span to rotate.
Figure 3 – Wreckage of train No. 12 at the east end of Portal Bridge
6

Survival Factors

Emergency Response -- According to

telephone tape transcriptions, at about 6:36 a.m.,

Amtrak’s assistant chief train dispatcher notified

Amtrak’s National Police Dispatching Center

(NPDC) in Philadelphia that train No. 12 had

derailed on Portal Bridge over the Hackensack

River. The train dispatcher stated that police and

emergency personnel would be needed at the

scene.

Amtrak’s computerized geographical data

base indicated that the derailment fell within the

Secaucus police area and that the closest access

roads east and west of the site were County Road

and Belleville Road. The NPDC dispatcher called

the Secaucus Police Department at 6:40 a.m. and

said that an Amtrak train had derailed at “Portal

Tunnel” between County Road and Belleville

Road. The Secaucus police officer told the

Amtrak police dispatcher that Portal Tunnel was

located at the Bergen Interlocking (which is

about 3 miles east of Portal Bridge) in North

Bergen, New Jersey, and was outside Secaucus

police jurisdiction.

At 6:42 a.m., the Amtrak police dispatcher

called the North Bergen Police Department,

reported the derailment, and described the

accident location as being between County Road

and Belleville Road at the “Portal Tunnel

Bridge.” The North Bergen police told the

Amtrak police dispatcher that that location was

in Jersey City in Secaucus jurisdiction and not in

the North Bergen area.

At 6:44 a.m., the Amtrak police dispatcher

called the Secaucus police again and related his

conversation with the North Bergen police. The

Amtrak dispatcher and the Secaucus police

discussed the fact that the Portal Bridge spans

the Hackensack River and that the Amtrak data

base showed the closest access roads as County

and Belleville. At 6:47 a.m., a Secaucus police

unit was dispatched to check bridges in the area,

but Portal Bridge was not checked.7

 At about

6:54 a.m., a construction worker from a

construction site near the bridge flagged down a

Secaucus police patrol car and directed its two

officers to the accident location. A short time

 

7

Secaucus police officials told the Safety Board they

were not familiar with Portal Bridge.

later, another patrol car with two more police

officers was dispatched to the scene.

Shortly after the initial identification of the

accident location, the Secaucus police called the

NPDC and said that the Secaucus police had

located the accident site. The caller told the

NPDC how access had been gained to the site

and provided a preliminary assessment of

injuries. About 18 minutes elapsed between the

time the NPDC was notified of the accident and

the time the first police officers arrived on the

scene. The first ambulance arrived on the scene

about 47 minutes after the initial notification.

Once at the bridge location, emergency

responders had difficulty accessing the actual

accident site. Some of the emergency vehicles

approached the bridge from the west, but because

the wreckage was on the east end of the bridge,

they had to be rerouted to the other side.

Responding to the accident were the

Secaucus and Jersey City Fire Departments; the

Secaucus, Jersey City, and Amtrak Police

Departments; the Secaucus Emergency

Management Agency; and Jersey City Medical

Center Emergency Medical Services.

The Secaucus Fire Department received a

call about 6:57 a.m. to respond to a train

derailment and assist in opening passenger

windows on the derailed cars. The department

dispatched one engine company, one truck

company, one rescue company, the fire chief, and

two assistant fire chiefs. The firefighters were

directed to the accident site by a police official

and arrived about 7:04 a.m. Upon arrival, the fire

units established a mobile incident command post

and surveyed the scene. The fire chief later stated

that he was advised by a railroad employee that

no one was on board the train, but that he

ordered a search of all the cars.

At about 7:05 a.m., the Jersey City Fire

Department arrived. The Jersey City and

Secaucus fire chiefs communicated on different

radio frequencies, but they were able to

establish a unified command post after several

minutes. The Jersey City Office of Emergency

Management dispatched 12 units and 27

personnel at 7:02 a.m. All units began arriving at

the accident scene at 7:08 a.m. The Jersey City

Fire Department was dispatched to the accident
7

scene at 7:18 a.m., and all 34 personnel arrived

at 7:28 a.m. Four engines, two trucks, one rescue

unit, one squad unit, one car, the division chief,

and the battalion chief responded to the accident.

While on patrol, a Jersey City police car

heard a report of the derailment on the radio with

the possible location being on the Jersey City and

Secaucus border. The police officer arrived and

found seven cars derailed on the east side of the

bridge. The officer saw that many, if not most, of

the passengers had gotten off the train, and he

was told that one person was still on the train

being treated by train personnel. The officer

located that person, who was being ministered to

by train personnel and a unit from the Jersey City

Medical Center. The officer advised his

department of the best way to access the accident

site and requested help from the emergency

services unit to check the remainder of the train

for additional injuries. A sergeant from

emergency services arrived and took control of

securing and removing injured passengers. A

police lieutenant of the Jersey City Police

Department was in charge of all police personnel

on the scene.

The Jersey City Police Department

dispatched six patrol cars, one K-9 unit, one

motorcycle unit, five emergency medical services

units, the tour commander, the city captain, and

the deputy police director. About 20 police

department personnel responded to the accident.

Units were dispatched to the accident scene

starting at 7:16 a.m., with all units arriving by

7:29 a.m.

Emergency Preparedness -- The Hudson

County Emergency Operating Center was opened

and the staff maintained communications with the

accident scene coordinator and disseminated

information about the accident to State and

county officials and the press. Hudson County

implemented the emergency response plan that

had been prepared by the Hudson County Office

of Emergency Management and approved by the

New Jersey State Police Office of Emergency

Management in December 1995.

Local officials told the Safety Board that

full-scale disaster drills and simulated “table top”

exercises (without the use of train equipment or

mock evacuations) are regularly held in Hudson

County and all of its municipalities. Before this

accident, the most recent exercise had been held

on November 9, 1994, simulating a hazardous

materials accident.

Injuries

Table 1 is 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. The number of

reported injuries reflects only the crewmembers

of train 12 and those individuals transported to a

medical facility.

Table 1. — Injuries resulting from the Portal Bridge derailment

Injury Type Train

12

Crew

Train

79

Crew

Passengers

Train 12

Passengers

Train 79

Deadhead

Employees1

(Train 12)

Total

FATAL 0 0 0 0 0 0

SERIOUS 0 0 0 0 2 2

MINOR 2 0 17 1 22 42

NONE 1 4 732 161 0 239

TOTAL 3 4 90 162 24 283

1

Railroad employees traveling from one terminal to another in nonrevenue service.

2

Two people traveling in train No. 12 in unknown capacities refused treatment.
8

Damages

From information provided by Amtrak, the

Safety Board estimated the cost of the damaged

train, track, and signal equipment and site

cleanup to exceed $3.6 million. Damages to train

No. 12 included both locomotives, seven

passenger cars, and five material handling cars.

Damages to train No. 79 were limited to the

locomotive, three passenger cars, and a baggage

car.

Personnel Information

Traincrews -- The investigation determined

that the engineer, conductor, and assistant

conductor of train No. 12 and the engineer,

conductor, and both assistant conductors of train

No. 79 were rested in accordance with the

Federal Hours of Service Law. Additionally, all

were qualified on the operating rules and physical

characteristics of the territory.

Portal Bridge Operator -- The 38-year-old

bridge operator was hired by Amtrak as a

trackman on April 3, 1980. He was rated

qualified as a bridge operator in 1985 and had

been the bridge operator at Portal Bridge for

about 4 years prior to the accident. He was not

designated by Amtrak as an employee

responsible for supervising track maintenance or

renewals or for inspecting track. He therefore

was not, and was not required to be, qualified on

Amtrak’s maintenance of way (MW) 1000,

Specifications for Inspection, Construction and

Maintenance of Track; nor was he qualified, or

required to be qualified, for track inspection and

maintenance supervision duties under 49 CFR

213.7, “Designation of qualified persons to

supervise certain renewals and inspect track.”

According to Amtrak officials, all bridge

operators are given cursory training on inspection

of bridge fender systems, wedges, and miter rail

systems.

The bridge operator had been off duty for 2

days before reporting for work at 11:00 p.m. on

November 22, 1996. At the time of the

derailment, he had been on duty for about 7

hours and 28 minutes.

Bridge and Building Electrician -- The 52-

year-old electrician was hired by Amtrak on

November 3, 1980. His regular duty hours were

7:00 a.m. to 3:30 p.m., Monday through Friday.

He received a trouble call from the electrical

foreman about 4:50 a.m. on November 23, 1996,

and had therefore been on duty for almost 1 hour

and 40 minutes when the derailment occurred. He

had been off duty for 13 hours and 20 minutes

prior to this call to service. He was not

designated by Amtrak as a person responsible for

supervising track maintenance and renewals or

for inspecting track under the provisions of 49

CFR 213.7, and he was not, nor was he required

to be, qualified on Amtrak’s MW 1000.

Train Information

Both accident trains used AEM-7 electric

locomotives built by General Motors ElectroMotive Division in 1980. Each locomotive was

equipped with multiple traction motors totaling

7,000 horsepower. The traction motors received

power from overhead electric catenary.

Train No. 12 -- Train No. 12 consisted of

two locomotives numbered 910 and 901; five

material handling cars numbered 1565, 1506,

1404, 1510, and 1415; six Amfleet I coaches

numbered 21647, 21637, 21095, 21195, 21648,

and 21125; and one Amfleet I café car numbered

43043. Amtrak records show that a mechanical

test was performed on the two locomotives at

2:00 p.m. on November 22, 1996, and that no

defects were found. An air brake test was

performed at 2:26 a.m. on November 23, 1996,

with no exceptions noted.

Train No. 79 -- Train No. 79 consisted of

one locomotive, No. 930; Amfleet coaches

numbered 44969, 21989, 21285, 21007, 21652,

21137, 21651, and 25026; and Amfleet dinette

number 202381. At Pennsylvania Station in New

York City, one baggage mail car, No. 1244, was

added to the rear of the train. Amtrak records

show that a mechanical test was performed on

locomotive No. 930 at 3:00 p.m. on November

22, 1996, and that no defects were found. On

November 23, 1996, at 5:15 a.m., train No. 79

received an initial terminal air brake test. No

exceptions were noted.

Signal Information

Portal Interlocking is a remotely controlled

interlocking on two main tracks. Union Switch &
9

Signal color position light8 signals are

supplemented with an automatic train control

system under the authority of the Amtrak Section

“A” train dispatcher in New York City. Portal

Bridge is within the limits of Portal Interlocking.

Traffic east and west of Portal Interlocking is

signaled for movements in both directions. The

method of operation is by timetable, by form D,

by special instructions, and by signal indications.

Site Description

The derailment occurred at milepost (MP)

6.1 within the Portal Interlocking on Amtrak

Northeast Corridor trackage. Amtrak designates

the track through the derailment area as Federal

Railroad Administration (FRA) Class 4 track,

and the track leading up to the bridge met FRA

Class 4 track safety standards. Although the

FRA maximum allowable speed for passenger

trains on Class 4 track is 80 mph, Amtrak’s

maximum authorized speed over the Portal

Bridge was 70 mph, established by the Amtrak

chief engineer in late 1992.

Portal Bridge -- Portal Bridge is a 960-footlong steel structure with masonry abutments. The

bridge consists of a 300-foot-long through-truss

swing span and six (three on each side of the

center span) 110-foot-long open-deck girder

approach spans. Construction of the bridge was

begun in August 1905, and the bridge was placed

in service on November 27, 1910. Overhead

catenary to supply power to electric locomotives

was installed in the 1930s.

Track and Special Trackwork -- In the area

of the derailment, Amtrak’s Northeast Corridor

consists of two main tracks. The south track is

designated track 1; the north track is track 2. On

the western approach to the bridge, the tracks are

located in a wetland area and are constructed on

an earth and rock fill, elevated about 30 feet

above the Hackensack River.

Approaching the accident site from the west,

track 1 is tangent (straight) from about 4,650 feet

from MP W 7.0 to the point of derailment near

MP 6.1 on the west end of Portal Bridge. The

track continues tangent over the bridge to MP W

6.0 and for some distance beyond. At the point of

 

8

A fixed signal in which the indications are given by

the color and position of two or more lights.

derailment, it is descending with a 0.05 percent

grade. The main tracks on Portal Bridge and on

the bridge approach are constructed of 140-

pound continuously welded rail. Guard rails are

installed between the rails on both tracks for the

entire length of the bridge. The purpose of the

guard rails is to deflect derailed wheels away

from adjacent bridge trusses.

A number of nonstandard track structures,

referred to collectively as “special trackwork,”

are installed on Portal Bridge. Special trackwork

is defined by the American Railway Engineering

Association as rails, track structures, and

fittings, other than plain unguarded track, that is

neither curved nor fabricated before laying. The

special trackwork on Portal Bridge forms the

junction between the fixed rails on the bridge

approach and the movable rails on the rotating

center span. The special trackwork makes it

possible for the rails to “disconnect” before the

bridge center span is swung open and to

“reconnect” after the bridge is closed.

A major component of the special trackwork

is the movable miter rail assembly that actually

makes and breaks the rail connections at the edge

of the rotating bridge span. At the time of the

accident, a single miter rail assembly9

 on the

Portal Bridge movable span consisted of one 10

1/2-foot miter rail with a 31-inch tapered, or

mitered, point known as the “toe”; one 11 1/2-

foot side bar; one 8-foot 11-inch side bar; a

section of running rail to which the miter rail was

joined with the two side bars; and a base (bed)

plate resting on an attaching base referred to as a

“shoe.” (See figure 4 – next page.) The miter rail

was made of manganese steel, a much stronger

steel than that used for the running rails.

 

9

There were eight miter rail assemblies (one for each

end of each rail of the two tracks) on the bridge.
10

The toe (tapered end) of the movable miter

rail mated with a section of fixed miter rail on

the stationary spans of the bridge.10 The other

end (the square end, or “heel”) of the miter rail

butted against a 39-foot section of running rail.

The rail sections were tied together by two side

bars fastened (with 12 bolts, each 1 inch in

diameter) on either side of the two rail sections

across the joint. (See figure 5 – below.)

The miter rail was a 3-inch-wide solid

rectangular beam. In contrast, the running rail

had the standard “I-beam” (or “T”) shape. To

 

10Although both the fixed and movable sections of the

mating rails were mitered, unless otherwise noted,

subsequent references in this report to miter rails refer to

the movable rail sections only.

accommodate this change in cross section where

the two rails joined, standard “D” bars (lengths

of steel formed with one flat side and one

curved side to create a D-shaped cross section)

were welded to the inside of each side bar on the

running rail side of the joint. The bottom edge

of that portion of the side bar that was attached

to the running rail was “notched,” and the

bottom edge of the notch was beveled to provide

clearance for the base flange of the running rail.

(See figure 6 – opposite.)

Figure 4 — Components of the miter rail assembly in place on Portal Bridge at the time of the accident

Figure 5 — Looking west along track 1 with miter rails in the lifted position
11

Figure 6 — Formation of the miter rail
12

The longer of each pair of side bars was

attached to the inside, or “gauge” side of the

track and extended from about 18 inches past the

joint on the running rail side to the tip of the

miter rail. The shorter side bar was fastened to

the outside, or “field” side of the rail and

extended from 18 inches past the joint on the

running rail side to the beginning of the mitered

portion of the miter rail. The tapered portion of

the miter rail was 31 inches long, which accounts

for the 31-inch difference in length between the

inside and outside side bars.

The side bars had a lifting lug about 25 1/4

inches from the heel of the miter rail on the miter

rail side of the rail joint. The lifting lug was

connected to a vertical spring rod lift assembly

underneath the bridge. Under normal

circumstances, a command to open the bridge

activated electric motors that drove the spring

rods under all eight miter rail assemblies upward,

raising the miter rails about 14 inches at the rail

ends.11 Raising the miter rails disconnected the

stationary and movable rail sections and freed the

center bridge span to swing open. When the

bridge was closed, the spring rods were retracted,

allowing the rail sections to lower. As the

lowered rail sections approached the horizontal,

the spring rods pulled down on the lifting lugs

with a force of 2,500 pounds to fully seat the

rails in the pocket of the bed plate.

Postaccident Inspection

When the locomotives and all the cars of

Amtrak train No. 12 derailed, they fouled

(partially blocked) track 2. Both locomotives,

three passenger cars, and a baggage car came to

rest on the south side of track 1 and down an

embankment east of the bridge. The second,

unoccupied, locomotive was positioned on its

side. The three passenger coaches came to rest at

various angles down the embankment.

Train No. 79 sustained minor sideswipe

damage from equipment on train No. 12 fouling

track 2. In addition, overhead catenary wires on

both tracks were knocked down, disrupting

electric propulsion. The derailment caused the

 

11From 14 inches at the rail end, the elevation of the

rail section gradually decreased until it ran out about 24

feet back from the joint between the miter and running

rails (a little more than 34 feet from the rail end).

closure of the Northeast Corridor at Portal

Bridge and halted all Amtrak and New Jersey

Transit rail operations between Newark, New

Jersey, and New York City.

Wheel markings from train No. 12 were

found on the field side of the south rail and the

gauge side of the north rail on track 1. The

markings began 31 1/4 inches east of the point of

derailment. Flange marks indicated where the

wheels of the derailed equipment had climbed the

south rail. Wheel markings also indicated that the

train wheels had struck and followed the

protective guard rail installed between the rails.

The track structure east of the point of derailment

had been displaced by the derailed equipment,

and the bridge walkway grating south of track 1

was damaged.

Examination of the bridge following the

accident focused on the north rail of track 1,

specifically, the joint between the miter rail and

the running rail. The west-facing point of the

miter rail was displaced approximately 2 1/2

inches east, but it remained seated in the bed

plate on the approach span of the bridge. The

side bars on either side of the miter rail joint had

completely cracked through about 18 inches east

of the lifting lugs, and the heel of the miter rail

was resting on the broken side bars of the

running rail. The resulting difference in elevation

between the miter and running rails created a 5-

inch ramp when viewed from the direction of

travel of train No. 12 (west to east). Although

misaligned, the miter rail made contact with both

the stationary approach rail and the running rail

on the movable span. This contact provided

electrical continuity that allowed the signals

governing train movements over the bridge to

display a clear aspect.

Close examination of the broken side bars on

the misaligned rail disclosed that about 80

percent of the break appeared to have developed

sometime prior to the accident. Preliminary

investigation of the other side bars on the bridge

revealed that both side bars on the west end of

the south rail of track 2 were cracked, as were

both side bars on the east end of the south rail of

track 1. After the preliminary track inspection,

the misaligned miter rail was returned to its

normal (seated) position to allow for the rerailing

of derailed equipment.
13

On November 24, 1996, the day after the

accident, Safety Board investigators on the

bridge requested that the miter rails be raised to

permit close inspection of all the side bars. The

following conditions were noted:

Track 1: The side bar on the field side of the

east end of the south rail was cracked from the

top edge into the third bolt hole along the miter

rail. The crack extended for about 60 percent of

the width of the side bar.

Track 2: The center of the side bar on the

gauge side of the west end of the south rail was

completely fractured. The side bar on the field

side of the west end of the south rail was cracked

from the top edge into the third bolt hole. The

crack extended for about 60 percent of the width

of the side bar.

Preaccident Bridge Inspections

Safety Board investigators reviewed reports

of regularly scheduled track and bridge

inspections that were conducted during the days

and weeks preceding the accident. (For a

discussion of preexisting conditions in the miter

rail assemblies, see “Previous Defects In and

Problems With the Miter Rail System” in the

“Other Information” section of this report.)

Track inspection records for the track

between MP W 3.0 and MP JC 8.0 for the period

of September 2, 1996, to November 21, 1996,

revealed no violations of FRA track safety

standards. The records did note that the miter

rails on tracks 1 and 2 on the east end of Portal

Bridge were battered and needed welding and

grinding.

About 10 days before the accident, track in

the accident area was checked by an Amtrak

track geometry test car. The track geometry

exception report and script chart from that test,

dated November 12, 1996, showed no exceptions

taken in the vicinity of Portal Bridge.

According to the report of the annual

inspection of miter and expansion joints that was

conducted on June 13, 1996, the rails on Portal

Bridge were ultrasonically tested for internal

defects, and no defects were noted. The report did

note that the rail ends on the east end of the north

rail of track 1 were damaged and in need of

repair.

According to Amtrak, and in accordance

with 49 CFR Part 213.233, Portal Bridge

trackwork receives a walking inspection at least

twice weekly, with an interval of at least 1

calendar day between inspections. Because of

heavy train traffic over the bridge, these

inspections had been made with the miter rails in

the seated, or normal, position, resting in the rail

bed plates. In this position, only the head of the

rail and the upper portions of the side bars were

visible. A number of the bolts and nuts that

secured the side bars to the joining rails were also

hidden from view when the miter rails were

down.

On November 22, 1996, the day before the

accident, an Amtrak track inspector qualified on

Amtrak’s MW 1000 made a walking inspection

of the tracks on the bridge. He reported no

defects and noted no exceptions regarding the

miter rails or their components. Track

measurements taken after the accident on the

gauge and cross level on the undisturbed section

of the track structure at or near the point of

derailment did not disclose any irregularities.

A review of Amtrak’s “Monthly-Quarterly

Inspection Record of Moveable Bridges” for the

3 months prior to the accident revealed that only

the structural, mechanical, and electrical sections

of the bridge inspection form for Portal Bridge

showed completed inspections; no test bridge

openings were recorded. The records indicated

that the bridge ties were rated 4 (“poor, barely

functioning, and needing repair”). The FRA track

inspector did not take exception to the bridge tie

condition during a track inspection on September

9, 1996, nor were exceptions to tie condition

taken during Amtrak’s twice-weekly walking

inspections.

Operations Information

Both Amtrak and New Jersey Transit trains

operate over this section of the Northeast

Corridor, and all train traffic is governed by

Northeast Operating Rules Advisory Committee

(NORAC) Operating Rules, Fifth Edition,

effective January 1, 1995. Operating Rule 261,

Interlocking Rules 600 through 616, and Cab

Signal System (CSS) Rules 550 through 561
14

were in effect at the time of the derailment.

About 300 Amtrak and New Jersey Transit trains

cross Portal Bridge each day.

Regulations regarding drawbridge operations

are contained in 33 CFR Part 117, with Part

117.723 making specific reference to Portal

Bridge. The regulation states that the bridge does

not have to be opened Monday through Friday,

except Federal holidays, from 7:20 a.m. to 9:20

a.m. and from 4:30 p.m. to 6:50 p.m. (morning

and evening rush hours). At all other times, a

requested opening may not be delayed by more

than 10 minutes unless the bridge operator and

the vessel operator, communicating by

radiotelephone, agree to a longer delay.

Portal Bridge has no regularly scheduled

openings. Requests for a bridge opening are

conveyed by radiotelephone from a vessel on the

river to the bridge operator. The bridge operator

occupies the bridge control house, which is

located at the center of the movable span about

22 feet above the tracks. The Portal Bridge

operating log indicated that, between November

1995 and November 1996, the bridge was opened

for river traffic or testing 303 times, with 31

operating failures reported.

In 1987, new trackwork and new electrical

controls and power devices were installed on the

bridge, a revised signal system was installed, and

new operating rules were implemented regarding

bridge operation. Since 1987, it has been

necessary for the bridge operator to obtain

permission from the Amtrak section “A” train

dispatcher before opening or closing the bridge.

Only the dispatcher, located in New York City,

can unlock the bridge and make available the

electric power needed to disconnect the bridge’s

electrical and structural elements and rotate the

movable span.

Before the bridge can be opened, all signals

governing train movement over the bridge must

be at stop, and the track circuits within the limits

of the interlocking must be unoccupied. If a

signal other than stop is displayed over the bridge

prior to opening, the dispatcher must request a

stop signal and then wait a predetermined time

before allowing the bridge to be opened.

The operation of Portal Bridge is described

in the three-volume manual, Portal Bridge

Maintenance and Operation, published in 1982

by Link Control, Inc., the manufacturer of the

bridge electrical controls. Volume II, Section No.

3, of the manual, titled “Electrical Control and

Operating Motor System,” outlines the step-bystep procedure to be used when operating the

bridge. According to the supervisor, prior to the

accident, new bridge operators were given onthe-job training and were considered qualified if

they could demonstrate successful operation of

the bridge. They were not trained on the

operating manual, nor were they required to be so

trained.

Portal Bridge was designed to be operated in

any of six operating modes: automatic opening,

automatic closing, manual opening, manual

closing, emergency opening, and emergency

closing. Both automatic and manual operation

are accomplished using controls at the bridge

operator’s control desk. Manual operation refers

to using pushbuttons to individually control each

component of the operating machinery.

Emergency operation is accomplished through

the use of hand cranks and should be employed,

according to the operating manual, only in the

event of component or system failure. Amtrak

told the Safety Board that the automatic mode of

operation was disabled after the miter rail

detection/indication limit switches were removed

in 1987.12

Portal Bridge operating devices, including

the catenary skids, center and end wedges, miter

rails, and centering devices are interconnected

such that the actions necessary to either open or

close the bridge must be taken in a predetermined

sequence. The bridge operating manual states

that “strict adherence to the operating sequence

should be maintained, in order to insure

successful operation.” The “operating sequence”

consists of a series of steps that must be taken to

either open or close the bridge. In either

automatic or manual mode, each of these steps

must be successfully completed before the

operation can progress to the next step. Indicator

lights on the bridge operator’s control desk show

 

12For more information on the removal of the rail

position indication circuitry, see “Portal Bridge Miter Rail

Configuration History” elsewhere in this report.
15

green or amber after each step to indicate

whether or not that action was successful. If a

light should indicate a failed operation, the bridge

operator can use a bypass switch on the control

desk to instruct the system to ignore the failure

indication and continue with the next step in the

operating sequence.

On February 11, 1987, Amtrak issued

instructions to Portal Bridge operators and

electricians that they were to physically inspect

bridge components after a failure indication and

before using a bypass switch. Amtrak officials

told the Safety Board that, because of the

removal later that year of the miter rail limit

switches and thus the electrical circuit that was

designed to detect the position of the miter rail,

the control system displayed a failure indication

after the miter rails were raised or lowered during

any opening or closing operation. In order to

carry out the operating sequence, bridge

operators had to use the miter rail bypass switch.

In 1987, use of the bypass switch became the

standard operating practice. Operators were not

required to physically inspect and confirm the

position of the miter rails before using the bypass

switch.

Meteorological Information

At 6:28 a.m., the approximate time of the

derailment, the weather was clear, with an

ambient temperature of 35°F.

Toxicological Information

In accordance with FRA requirements at 49

CFR Part 219, postaccident toxicological testing

was conducted on the crew of train No. 12

(engineer, conductor, and assistant conductor),

the train dispatcher, the Portal Bridge operator,

the B&B electrician, and the C&S maintainer

within about 9 hours of the accident. All results

were negative for drugs and alcohol.

Tests and Research

Bridge Tests -- On November 24, 1996,

Safety Board investigators observed a test bridge

opening to determine how the miter rails would

operate with broken side bars. The operator

began the sequence to open the bridge in the

manual mode. First, the catenary skids were

lifted, then the center wedges were pulled. The

next step was to pull the end wedges and raise the

miter rails. As the miter rail and its attached

running rail on the west end of the north rail of

track 1 (the accident location) were being raised,

the broken side bars allowed the miter rail to

separate from the running rail at the rail joint.

The running rail (with partial side bars still

attached) then dropped back into the bed plates

while the heel of the miter rail (also with partial

side bars attached) continued to be raised to its

fully elevated position. Meanwhile, the tapered

end (toe) of the miter rail remained in the bed

plate on the approach span, in contact with the

tapered end of the stationary rail on the bridge

approach. With the miter rail in this position, the

center span of the bridge could not be rotated

without damaging the tracks or other bridge

components.

When the bridge operator lowered the miter

rails, the broken side bars on the heel of the track

1 north rail miter bar came to rest on top of the

broken side bars of the running rail, leaving the

miter rail surface about 5 inches higher than the

running rail. This position corresponded to the

position in which the miter rail was found after

the derailment.

Another test was conducted to determine if

any other mechanical or electrical problems could

be identified that would have kept the bridge

from opening on the day of the accident.

Investigators determined that, with the catenary

skids raised, the center wedges pulled, the end

wedges pulled, and (all) the miter rails raised, the

bridge could be rotated counterclockwise without

difficulty.

Signal Tests -- Safety Board investigators

tested the signal circuits for the miter rails on

track 1 on the west end of the bridge to determine

if they complied with the requirements of 49 CFR

Part 236.312. The regulations require that before

a signal governing movement over a bridge can

display an aspect to proceed, the rails on the

movable span must be within 3/8 inch of the

correct mating surface and in alignment with the

rail seating device on the bridge abutment or

fixed span. To carry out the test, investigators

placed a 1/2-inch-thick obstruction on each rail

seat and tested whether the normal indication

circuit controller contacts remained opened. The

tests revealed that a signal to proceed across the
16

bridge could not be displayed with the track rail

on the movable span more than 3/8 inch from the

mating surface on the rail of the fixed span.

Bridge Event Recorder Information -- The

Portal Bridge event recorder, located at MP 6.1,

records the positions of relays that monitor the

positions of various bridge operating devices.

The event record for the period between 2:03

a.m. November 22, 1996, and 6:28 a.m.

November 23, 1996, showed that the last

successful bridge opening prior to the accident

was at 2:03 a.m. on November 22, the day before

the accident. The bridge was fully open from

2:07 a.m. until it began to close at 2:11 a.m. At

2:16 a.m., the bridge was fully closed, and the

electrical power necessary to operate the bridge

was removed by the Amtrak train dispatcher.

The next bridge opening attempt took place

about 26 hours later, on November 23, 1996, at

4:03 a.m. The event recorder indicated that 310

trains had moved over the bridge since its last

opening. According to the event recorder data,

the bridge operating devices sequenced properly

for an opening, but when the operator attempted

to rotate the swing span, the bridge brakes cycled

between release and apply modes, but the bridge

span did not move. The bridge was electrically

locked at 4:17 a.m. At 5:41 a.m., the event

recorder indicated the manipulation of the brakes

by the B&B electrician. At 5:50:32 a.m., the

bridge was unlocked by the train dispatcher at the

bridge operator’s request. It was locked at

5:50:51 a.m. by the train dispatcher at the B&B

electrician’s request.

The recorder data indicated that the B&B

electrician continued to test the brakes from 6:00

a.m. to 6:25 a.m. At 6:27:42 a.m., the track

circuit on track 2 became deenergized (occupied

by train No. 79), and at 6:27:47, the track circuit

on track 1 became deenergized (occupied by train

No. 12). At 6:27:56 a.m., the normal miter rail

repeater relay for track 1 east deenergized.

Signal System Event Recorder

Information -- The Portal Interlocking signal

system event recorder records the position of

relays monitoring signals, track, and various

bridge operating devices. According to event

recorder data, westbound train No. 79 entered the

east limits of Portal Interlocking on track 2 at

6:27:28 a.m., operating under a clear signal.

Eastbound train No. 12 entered the west limits of

Portal Interlocking on track 1 at 6:27:32 a.m.,

operating under a clear signal.

Locomotive Event Recorder Information

-- The three locomotives involved in the accident

were all equipped with Bach-Simpson TMACS

100 event recorders. The recorders were designed

to monitor and collect data on a number of

locomotive operating parameters, including date,

time, speed, distance, brake pipe pressure,

traction motor current, direction of travel,

dynamic and independent brake application,

brake stand position, cab signal acknowledgment

and alerter reset, and horn/strobe/bell usage.

Event recorders from the three locomotives were

removed under Safety Board supervision and

delivered to Safety Board laboratories in

Washington, D.C., where the data were

downloaded and analyzed by Safety Board staff.

The TMACS 100 event recorder creates two

data files: an event file and a crash file. The event

file holds data reflecting any monitored activity

that has taken place during the 2 days13 preceding

the time the recorder data are downloaded or the

recorder is removed. The event file creates a

record only when events occur; that is, when

parameter values change. The crash file, on the

other hand, comprises a second-by-second

account of all monitored locomotive activity that

has taken place in the 45 minutes prior to

downloading the data or removing the event

recorder. Safety Board staff used the crash file to

interpret the event recorder data and provide a

summary of each train’s operations immediately

prior to the accident.

Event recorder data from locomotive 910

(the lead locomotive of train No. 12) indicated

that at recorder time 06:28:43 a.m.,14 while train

No. 12 was traveling at about 68 mph, the horn15

 

13The time periods covered by both the event recorder

(2 days) and crash recorder (45 minutes) are approximate.

Actual data periods will vary.

14Recorder times are not synchronized from unit to

unit, and they may not reflect exact actual time.

15The recorder’s horn input monitors both horn and

bell activity and does not distinguish between them. The

“on” reading may indicate that the operator activated the

bell, which causes the strobe light on the top of the

locomotive to turn on as well, or that the operator sounded
17

sounded, and remained on for about 36 seconds.

Approximately 32 seconds after the horn activity

began, the brake pipe pressure decreased from

107 to 42 psi within a 1-second period.16 During

the following 1-second period, the brake pipe

pressure dropped to 0 psi. About 3 seconds later,

dynamic braking17 was initiated. The independent

brake18 remained off throughout the length of the

recording.

Data from locomotive 910 showed that, at

recorder time 06:29:16 a.m., the train’s speed—

calculated from the number of wheel rotations—

dropped from 56 to 45 mph within approximately

1 second. Based on Safety Board experience,

such a deceleration rate would not be expected

except in extreme circumstances, such as a headon collision. Because the derailment of the train

would have affected the ability of the event

recorder to obtain an accurate count of wheel

rotations, Safety Board laboratory analysts

interpreted as invalid any speed recording

between 06:29:16 a.m. and the time the recorded

speed dropped to 0 mph at 06:29:22 a.m.

Recorded data from locomotive 901 (the second

unit on train No. 12) were consistent with data

from locomotive 910.19

 

the horn, which activates the bell and the strobe. In this

report, therefore, any mention of horn activity refers to the

horn and/or the bell and strobe light.

16Train air brakes are applied in response to

reductions in brake pipe pressure. In normal operations,

the locomotive operator initiates the brake pipe pressure

reduction, but a broken or disconnected train line will

result in an automatic brake application.

17Dynamic braking is a method of train braking in

which the locomotive’s traction motors are converted to

electric generators driven by kinetic energy from the

moving train. The generated electricity flows into a

resistor grid on the locomotive and is dissipated as heat.

This electrical “load” on the traction motor/generator acts

to slow the motor shaft rotation, resulting in a braking

action being applied to the train wheels.

18Independent brakes affect the locomotive consist

only and can be applied or released independently from

the train brakes.

19After the accident, the event recorder from

locomotive 901 remained submerged in salt water for

about 48 hours. During the first attempt to retrieve the

data, power could not be delivered to the recorder. The

memory module was then removed and successfully

downloaded using the recorder from locomotive 930.

Event recorder data from locomotive 930

(the only locomotive on train No. 79) showed

that while train No. 79 was traveling at a speed

of about 68 mph, the horn was activated and

remained on until the end of the recorded data.

About 20 to 22 seconds after horn activity began,

the brake pipe pressure decreased from 108 to 81

psi, dropping to 0 psi in the following 2 seconds.

The train came to rest at recorder time 06:26:42

a.m., about 48 seconds after the horn was

activated.

Analysts found anomalies in the automatic

brake stand settings20 recorded for the lead

locomotives of both trains. Crash data from

locomotive 910 showed that the automatic brake

stand setting changed from in to out for periods

of 1 to 7 seconds throughout the data. Crash data

from locomotive 930 showed that the setting

changed from in to out intermittently about 12 to

14 seconds after the horn was turned on, and

continued doing so until the end of the data. The

event files, which record any changes in a

monitored parameter, showed no changes to

brake stand settings during the accident trip for

either locomotive. Safety Board analysts

consulted with Amtrak event recorder specialists

and representatives of the manufacturer but were

unable to resolve the discrepancy between the

two data files.21

In accordance with the design of TMACS

100 event recorders, Safety Board laboratory

analysts attempted to use traction motor current

(TMC) readings to determine the activation,

 

20The automatic brake stand is the control station for

the train air brake system. The brake stand control handle

has three positions: in is the normal setting when the train

is in operation and the train brakes are being controlled

from that station; out is the normal setting at a

nonoperating station, such as that in a trailing locomotive;

test is the normal position when the train brake system is

being tested for leaks, which usually occurs before a train

leaves the yard. The automatic brake stand setting is

usually placed in the in or out position before the train

leaves the terminal and is not changed for the duration of

the trip.

21Amtrak told the Safety Board that, at the time of the

accident, it was in the process of upgrading its event

recorders. Part of the upgrade was to eliminate the crash

data record and change the event recorder update

frequency to once per second. This upgrade was reported

to have been completed for all AEM-7 Bach-Simpson

event recorders in May 1997.
18

duration, and aspect (display) of any cab

signals22 during the accident sequence. These

efforts were unsuccessful. (See “Other

Information” section of this report for more

detailed information.)

Metallurgical Information -- Six cracked or

broken side bars were removed from Portal

Bridge and examined in the Safety Board

Materials Laboratory. For reference, the side

bars were labeled “A” through “F.” (As indicated

on figure 7 – opposite.) Side bars A, B, C, and D

were broken into two pieces. Bars A and B had

been broken through at the time of the

postaccident inspection; bars C and D were

cracked when inspected after the derailment and

broke as they were being removed from the

assembly. Bars E and F were cracked but not

broken through.

All the fractures and cracks were located

near the beginning point of the notch where the

width of the side bar changed from the full width

along the miter rail to the reduced width (to

accommodate the base flange) along the running

rail. This was also the area where the bottom

edge of the side bar transitioned from straight

(along the miter rail) to beveled (along the

running rail, to clear the base flange). The

engineering drawings for the side bars showed

the beginning of the notch as a straight cut

resulting in a 90° transition. Side bars E and F

displayed such a straight, right-angle cut, but the

beginning point of the notches on bars A, B, C,

and D had the appearance of a curved chamfer.

Because of cracking and fracturing, investigators

could not obtain an exact measurement of the

radii of any of the notch transitions.

The drawings also indicated that the beveled

notch should terminate 18 inches from the end of

the bar. This location corresponds to the joint

between the miter and running rails (and the end

 

22The three locomotives involved in this accident

were equipped with cab signals. Cab signals, located in

the locomotive operating compartment, are a supplement

to the standard trackside signaling system and display the

signal—clear, approach medium, approach, and restricting

(or stop)—in effect for the block in which the locomotive

is operating. If a locomotive operator fails to acknowledge

(by activating a switch) receipt of a cab signal that is more

restrictive than the one under which the train has been

operating, the train will automatically come to a stop.

of the D bar) and is equidistant from the two

nearest bolt holes. The notches of bars A, B, and

C were 20 inches from the end of the bar, or

about 2 inches past the rail joint. The notch of

bar D was about 19 inches from the end, or

about 1 inch past the rail joint. Measurements on

bars E and F established that the notch ended at

the specified 18 inches from the bar end.

The fractured areas of side bars A and B

(taken from the location of the misaligned miter

rail) were cut from the side bars and are shown in

figure 8 (opposite). Amtrak told the Safety Board

that cracks in both these side bars had been

welded during trackwork performed during April

and August 1996. Remnants of the repair welds

were visible on the lower bar surfaces and in the

countersunk portion of the bolt holes. Weld beads

on the exposed faces of both bars appeared to

have been smoothed with a grinder, slightly

reducing the thickness of bar A at the fracture

location.

Examination of the cross section of the

fracture area revealed that the weld repair beads

had fractured generally in the same plane as the

previously existing cracks. The welds only

penetrated 1/4 to 1/2 of the thickness of the bars

and did not completely consume the existing

cracks in the lower fracture segments. The

fractured welds and surrounding surfaces

displayed areas of porosity, slag inclusions, and

lack of fusion in the weld fusion zone. In some

areas on both bars, molten weld metal and slag

had flowed onto the crack surfaces and solidified

without fusing to the crack surfaces.

Dark discoloration at the weld fracture areas

and in the remaining areas of the original fracture

surfaces obscured the fine fracture features on

the remaining areas of the original fracture

surfaces. The visible, larger-scale features,

including arrest lines, on both the upper and

lower segments of both fractures were typical of

fatigue crack progression. Ratchet marks at the

lower edge of the fractures indicated that lower

fracture segments of both the A and B bars

initiated at multiple fatigue origins along the

radius of the transition point for the notch.
19

Figure 7 — Location and identification of the six side bars removed from Portal Bridge

and examined in Safety Board laboratories

Figure 8 — Inner surfaces (with D bars attached) of the broken side bars removed

 from the accident location
20

On both bars, the fatigue propagated upward

completely across the lower fracture segments,

intersecting with the bolt holes. Fatigue zones

were also apparent on the upper fracture

segments of both bars. The upper segments of

both bars showed evidence of weld repairs that

partially consumed the preexisting fatigue zones.

Engineering drawings for the side bars called

for the use of ASTM A36 steel.23 In Safety

Board tests, the side bar steel displayed a typical

perlite ferrite microstructure consistent with the

specified low-carbon structural steel.

Other Information

Portal Bridge Miter Rail Configuration

History -- According to documentation provided

by Amtrak, prior to 1985, the miter rails on

Portal Bridge consisted of sections of regular

running rail mitered at one end. The mitered ends

of the mating rails were gapped to allow for

expansion, but the gap resulted in battered rail

ends. To correct this problem, Amtrak contracted

with the Conley Frog/Switch & Forge Company

to install Conley Expansion Rails, which were

designed to provide a transition between the fixed

and movable spans of a variety of drawbridge

types. According to Conley literature, a device

near the joint pulled down on the heel of the miter

rails, which raised the opposite (tapered) ends to

allow clearance for the bridge sections to move

apart. A limit switch under the miter rail was

part of rail position detection circuitry that

provided electrical confirmation that the rail was

down. Installation of the Conley rails on steel ties

was completed in 1985.

Amtrak found that, because the toe ends of

the Conley miter rails were not secured to the rail

bed, the rail ends “bounced” when subjected to

train traffic. The bouncing movement not only

created vibrations in the bridge structure, it also

forced the heels of the miter rails downward,

which damaged the limit switches that detected

rail position. Finding it uneconomical to maintain

the repeatedly malfunctioning limit switches,

Amtrak removed all the miter rail limit switches,

and thus the rail position detection circuitry, in

1987, with the intent of replacing them with more

 

23American Society for Testing and Materials, A36,

“Standard Specification for Structural Steel.”

durable components. Amtrak officials told the

Safety Board that when the new limit switches

arrived in 1988, the miter rail system was being

redesigned, and the more durable limit switches

were never installed.

In 1991, Amtrak began installing the highspeed miter rail system that was in place at the

time of this accident. Installation of the new

system, designed and built by Promex Company,

Inc., was completed in 1992 and allowed train

speeds across the bridge to be increased from 60

to 70 mph. According to an Amtrak official, the

redesigned miter rail configuration required that

the miter rail be joined with running rail using

side bars because the steel used for the miter rail

(at that time, SAE 4340) was not available in a

billet longer than about 10 1/2 feet. Although the

design of the system provided for the connection

of circuitry to detect the position of the miter rail,

the position detection circuitry was never

installed. The absence of this circuitry required

bridge operators to use bypass switches during

any opening or closing of the bridge.

In 1993, the approach (stationary) miter rail

on the west end of the north rail of track 2

cracked. Amtrak inspected the rail but could not

determine the cause of the fracture. In 1994, the

approach miter rail on the west end of the south

rail of track 2 cracked completely through.

Amtrak determined that a Promex employee or

contractor had applied an oxyacetylene cutting

torch to several bolt holes in the rail, weakening

the rail in the hole area.

Two other swing bridges currently use the

same Promex miter rail configuration as Portal

Bridge: Spuyten Duyvil Bridge, located on

Amtrak’s Empire Connection and spanning the

Harlem River in New York City; and Beach

Bridge, located on New Jersey Transit’s Atlantic

City Line in Atlantic City, New Jersey. Both

these bridges have miter rail position detection

circuitry installed. An average of 18 trains

traverse Spuyten Duyvil Bridge each weekday

with a 30-mph speed limit for freight trains and a

45-mph limit for passenger trains. An average of

34 trains use Beach Bridge each weekday. A

New Jersey Transit official told the Safety Board

that the timetable speed for trains using Beach

Bridge is 30 mph for passenger trains and 10

mph for freight, but that after the derailment at
21

Portal Bridge, a general order was issued

implementing a restricted speed across the

bridge.24 Both Spuyten Duyvil and Beach bridges

are low bridges that must open frequently to

permit the passage of pleasure boats. Spuyten

Duyvil Bridge is opened an average of 2,248

times per year; Beach Bridge is opened an

average of 4,800 times per year.

New Jersey Transit officials told the Safety

Board that, because of the cost of maintaining the

Promex system, the agency is planning to replace

the Promex miter rails with a miter rail system of

Conrail design.

Previous Defects In and Problems With

the Portal Bridge Miter Rail System -- In

November 1995, Amtrak imposed a speed

restriction on Portal Bridge track 2 after the side

bars on the approach (fixed) miter rails were

found to be cracked on the east end of the north

rail. In December 1995, the approach span side

bars were replaced with redesigned side bars.

The daily log of the Amtrak foreman of

movable bridges indicated that on January 11,

1996, he went to Portal Bridge to replace a nut

that a work crew on the bridge had discovered on

the west end of the north rail of track 1. The log

indicated that the loose bolt had backed out of its

bolt hole and into a recessed bolt hole on the

approach miter rail. When an attempt was made

to lift the miter rail, the loose bolt prevented the

rail from rising. With the tip of the rail jammed,

the lift rod bent the rear part of the miter rail

upward, elevating it slightly above the running

rail. A passing train forced the rail back into

position.

The movable bridges foreman’s log indicated

that, on January 22, 1996, he discovered that a

nut was missing from a bolt on the spring lift rod

assembly on the west end of track 1. The end of

the bolt was mushroomed, so the foreman cut 1/4

inch off the bolt and replaced the nut. The next

day, when the foreman returned to the bridge to

put a lock nut on the spring rod assembly, he

found bolts missing from the side bars on the

 

24Restricted speed under NORAC operating rules is

15 mph (or the timetable speed if that speed is lower).

Train crews are required to be on the lookout for broken

rails or other unsafe conditions and to be prepared to stop.

west end of the north rail of track 1. After having

the rails raised, he found that the remaining side

bar bolts were loose. As he tightened the bolts, he

noticed that the side bars were cracked. He stated

that he immediately reported the conditions to the

supervisor of structures, and that, the following

day, January 24, 1996, he and the supervisor of

structures returned to Portal Bridge where they

inspected the other side bars for cracks. They

reported finding cracks in the side bars on the

west end of the south rail of track 2 and on the

east end of the south rail of track 1.

On February 15, 1996, the Amtrak

supervisor of structures sent a memorandum

regarding the cracked side bars to the director of

structures maintenance and the assistant division

engineer for structures. The memorandum

advised that three of the eight miter rail side bars

on the west end of Portal Bridge were cracked at

the bolt holes near the joint with the running rail.

Photographs were enclosed with the

memorandum. (See figure 9 – next page.)

On February 20, 1996, the director for

engineering tests and standards received a copy

of the February 15 memorandum. According to

Amtrak, because the side bars, when fully seated,

were cradled by the sides of the bed plate and

therefore could not move, the cracked bars were

considered a maintenance, rather than a safety,

issue. The director for engineering tests and

standards initiated plans to replace the side bars

with bars made of a higher-strength steel. On

February 27, 1996, an Amtrak employee from

the Philadelphia office traveled to Portal Bridge

to inspect the cracks on the side bars.

On March 5, 1996, the foreman of movable

bridges escorted a representative of RN Utilities

Sales, Inc., to Hunter Yard in Newark, New

Jersey, where five spare manganese miter rails

and three sets of A36 steel side bars were stored.

RN Utilities Sales estimated that the side bars

constructed of 4142 steel could be produced for

$7,135 per set with a 3-week delivery time.
22

On April 1, 1996, the movable bridges

foreman went to Portal Bridge to replace five

expansion rail bolts. While changing out the

bolts and inspecting the bridge, he discovered

that the side bars on the movable side of the

bridge on the west end of the north rail of track

1 were cracked “all the way.” On April 3, 1996,

the director of engineering tests and standards

sent a memorandum to the supervisor of

structures with instructions to order 16 pairs of

high-strength side bars.

On April 4, 1996, the director of structures

maintenance, the director of engineering tests

and standards, and the division engineer (who

was also acting assistant chief engineer of the

New York zone) met in Philadelphia with the

assistant chief engineer for track to discuss the

cracked miter rail side bars and a proposed plan

for correcting the problem. This was the first

time the division engineer was made aware of

the cracked side bars on Portal Bridge.

The division engineer instructed the

assistant division engineer for track to prepare

to replace, that night, the entire miter rail

assembly with a spare (preassembled) one from

Hunter Yard. The supervisor of structures and

the assistant division engineer for track were on

site the night of April 4, 1996, when a track

crew attempted to replace the miter rail

assembly. According to Amtrak officials, the

spare assembly could not be made to fit and was

thought to be defective. Officials on the scene

decided to reinstall the original miter rail

assembly with its broken side bars. The

supervisor of structures suggested that the

broken side bars be welded, and the division

engineer, the deputy division engineer (acting

division engineer), the assistant division

engineer for structures, and the assistant

division engineer for track agreed to have the

cracks welded as a temporary repair.

One week later, on April 13, 1996, an

Amtrak welder was sent to weld the cracks in

the side bars. The welder stated that he told his

supervisor that a proper weld of the side bars

would require removing them from the miter rail

assembly so that the cracks could be welded

Figure 9 — One of the photographs of cracked Portal Bridge side bars sent in February 1996 by the

Amtrak supervisor of structures to the director of structures maintenance and the assistant

division engineer for structures. Note that the notch along the bottom edge of the side bar (a)

extends beyond the end of the running flange (b), placing the transition to the notch (c) in

proximity to a bolt hole.
23

Amtrak’s assistant chief engineer for track later

told the Safety Board that welding was not an

approved Amtrak repair method for these

components.

In May 1996, the supervisor of structures

ordered two sets of high-strength side bars from

RN Utility Sales. On July 9, 1996, the first pair

of high-strength side bars arrived at Hunter Yard;

the second pair arrived on July 20. At the time of

the accident on November 23, 1996, none of the

replacement side bars had been installed.25

The electrical foreman’s daily log indicated

that, on August 29, 1996, one of the side bars on

a rail on the west end of track 1 was “broke thru

on one side,” and the other side bar on that rail

was cracked across 3/4 of its width. The log

indicated that welding was to begin that night

(August 29) at 10:00 p.m. The welder stated that,

on August 29, 1996, he welded the side bars on

the west end of track 1, using the same procedure

he had used previously.

When Amtrak’s assistant chief engineer for

track was asked if a speed restriction had ever

been put in place on Portal Bridge because of

cracked or broken side bars, he said

My personal judgment at that time was

that a speed restriction was not required,

but that the bars should be changed

quickly, and that was the direction I gave

to the division engineer at that time.

Amtrak Postaccident Actions --

Immediately after the accident, Amtrak issued a

45-mph speed restriction for Portal Bridge and

placed a 24-hour watch on the bridge until all

assistant chief engineers had inspected and

approved it for train operations. The day after the

accident, Amtrak crews began replacing the miter

rail assemblies using material stored in Hunter

Yard. The broken side bars were replaced (with

the side bars that could not be made to fit on

April 4). The work was completed on November

25, 1996.

 

25Amtrak officials said they had planned to wait to

make the side bar replacements until the following spring

when the bridge was scheduled to undergo extensive work.

On November 26, 1996, Amtrak issued a

memorandum with the subject: “Movable

Bridges.” The memorandum read

Until further notice, after any movable

BRIDGE has been opened, and then

closed, trains are not permitted to

operate over the bridge until a visual

inspection is performed by a qualified

employee. These INSTRUCTIONS

MUST BE FOLLOWED regardless of

the status of the bridge lock indication

received (i.e. miter rails seated, bridge

lock indication received, etc.). [Emphasis

in the original.]

The memorandum also specified which class

of employees, B&B or C&S, was qualified to

inspect and authorize train movements over each

bridge.

On December 4, 1996, Amtrak issued a

memorandum to Portal Bridge operators, subject:

“Portal Bridge Inspection - Miter Rails.” The

memorandum read

In the middle of each tour of duty, and at

the change of your shifts on Portal

Bridge, you are hereby instructed to

inspect all four corners of the bridge for

changes or deviations of any kind. If

discrepancies are found they are to be

reported immediately to the Trouble

Desk in New York, and Section A. In

addition, if there is an opening for marine

traffic you are to physically inspect all

eight rails to ensure they are properly

seated, and in the proper position for

railroad traffic. All inspections will be

logged into the Movable Bridge Log

Book, it is imperative we keep accurate

records of these inspections.

On January 13, 1997, an Amtrak

memorandum was distributed that read, in part,

“Miter rail responsibility will be, as it should

always have been, the responsibility of the Track

Department.”
24

On January 27, 1997, Amtrak experienced

another incident on the west end of the north rail

of track 1, similar to the incident 1 year before

(referenced earlier in this report) at the same

location. The nut and washer had fallen off the

second bolt from the toe of the movable miter

rail. When that rail was down and mated to the

toe of the stationary miter rail, the countersunk

bolt holes on the tapered side of the movable

miter rails were flush against the countersunk

bolt holes on the tapered side of the stationary

miter rail. The missing nut on the second bolt in

the movable miter rail allowed that bolt to work

out of the bolt hole far enough to penetrate the

countersunk area in the adjacent miter rail,

preventing the movable miter rail from being

raised. When the bridge operator attempted to

raise the obstructed miter rail, the force of the

lifting rod on the heel of the rail caused the heel

portion of the rail to bend upward.

According to radio transcripts, the C&S

maintainer working out of the nearby work trailer

saw the heel of the miter rail bend and notified

the bridge operator, instructing him to lock the

bridge and advising him that track 1 was “out of

service.” The bridge operator requested that the

train dispatcher lock the bridge, but he did not

tell the dispatcher that track 1 was out of service.

With the bridge locked, the signal governing train

movement over track 1 was set at clear to

proceed.

A short time later, New Jersey Transit train

No. 3820 approached the bridge, operating under

the clear signal. The train’s engineer applied the

brakes to bring the train speed below the 45 mph

temporary speed restriction across Portal Bridge.

About this time, the train dispatcher, overhearing

the C&S maintainer communicating with the

bridge operator about the condition of the miter

rail on track 1, changed the signal governing

Portal Bridge to stop. The engineer stopped his

train approximately 200 feet west of the Portal

Interlocking signal.

As a result of this incident, on January 27,

1997, the Amtrak memorandum dated November

26, 1996, was amended to read that MW

personnel were the only employees qualified to

perform inspections and authorize train

movements over Portal Bridge. Additionally, a

24-hour watch was instituted on the bridge to

check the miter rails after every bridge opening to

ensure that they were in place. Before this

incident, Portal Bridge had last been jointly

inspected by the C&S, B&B, and track

departments on January 21, 1997.

On January 28, 1997, Amtrak issued a

memorandum that read

Effective Immediately!: We will have

stationed at Portal Bridge, one (1) MW

Foreman, whose responsibility will be as

follows:

1. When any attempt is made by the

Bridge Operator to activate the Bridge,

whether or not the Bridge is open, each

miter rail must be inspected Prior to any

train movement to verify that it is safe

for train movement and to verify that all

miter rails have been seated properly.

2. While miter rails are in the up

position, the foreman must check for

loose bolts and take the appropriate

action if required to ensure the safe

passage of trains.

On January 30, 1997, Amtrak issued a

memorandum to Portal Bridge operators and

Spuyten Duyvil signal maintainers on the subject:

“Movable Bridge Observation Procedures.” The

memorandum read

Effective immediately, and without

compromise to any former instruction(s),

you will comply with the following for

bridge operation:

(1) Upon receiving a request for a bridge

opening, you will visually observe all

miter rails for... possible obstruction(s)

to normal operation. This observation

will be conducted at the track level.

(2) With no exception taken with this

observation, the bridge may be operated

in accordance with standard operating

procedures.

The following corrective action will be

immediately taken if any unusual vibration, unusual or loud noise, resistance to

swing or any other refusal to properly

operate occur: Place hold on track(s)

immediately with respective dispatcher.
25

Supply appropriate information for

taking this action. Make appropriate request(s) for assistance. Hold all trains

clear of bridge until inspected (repaired)

by qualified personnel. This procedure

must be followed even when possible to

display a signal over the bridge.

(3) Prior to returning the bridge and

track(s) for train traffic, You will visually observe, for compliance, the following: (a) At track level, all miter rails

for proper seating and alignment; (b)

Proper control panel indication for rail

seating, wedges fully driven and span

locks in position.

(4) Document any exception taken, with

regard to specific areas of concern, in the

“comments” section of your respective

operators log book.

During January and February 1997, the

Amtrak signal department installed and activated

proximity switches near the heel of the miter rails

on all Amtrak swing bridges. The devices were

wired in series with the circuit controllers

(required by the FRA and already in place on the

bridges) that monitored the position of the toe of

the miter rail. With the additional components

installed, a signal to proceed could not be

displayed if either the toe or heel of a miter rail

was positioned 3/8 inch or more from its mating

surface.

On February 27, 1997, Amtrak issued a draft

memorandum with instructions for the inspection

and protection of miter rail assemblies. The new

procedures, which were an addition to Amtrak’s

MW 1000 specifications for inspection and

maintenance of track, were put in effect

immediately. The final instructions were issued

on March 6, 1997, and all employees assigned

the duties of inspecting miter rail assemblies were

trained in the new procedures. The bridge

inspection training course consisted of 7 days of

field and classroom training through the

University of Wisconsin. In addition, a 1-week

track inspection training course emphasizing “fix

it,” “slow order it,” or “take it out of service” has

been implemented.

In 1994, Amtrak began restructuring its

engineering department and metropolitan division

organizational structure. Amtrak officials stated

that a major component of this reorganization

was an effort to identify all areas within Amtrak

engineering where additional standard plans,

construction and maintenance procedures, and

protection or protection design applications and

policies were needed. Where these elements were

lacking, they were to be developed, and

employees were to be trained in their application.

Investigators learned that at the time of this

accident a data base was being developed to

automate the inspection tracking system. After

the derailment, the process was “fast tracked”

and in September 1997, field testing of the data

base was underway. Additionally, an Amtrak

audit team was reestablished in January 1997.

In February 1997, Amtrak, in consultation

with experts on vibration and bridge design,

undertook to redesign the miter rail system in use

on Portal Bridge. The new design is being tested

at Lehigh University prior to installation. The

redesign will incorporate flash-butt welding of

the miter rail in addition to the use of side bars.

Amtrak Locomotive Event Recorders --

Railroad locomotive safety standards26 require

that, as a minimum, locomotive event recorders

be able to monitor and record the following

parameters: train speed, direction of motion,27

time, distance, throttle position, brake

applications and operations (including train brake

and dynamic brake applications and operations)

and, where the locomotive is so equipped, cab

signal aspect.

Throttle Position Recording -- Diesel-electric

locomotives typically have a throttle control that

is “notched” at several predefined throttle

positions: dynamic braking, idle, and positions 1

through 8, all of which are monitored by the

recording system. The electric locomotives

involved in this accident were equipped with

throttles that do not have predefined settings but

 

26Contained in 49 CFR 229.5(g).

27Amtrak provided the Safety Board with copies of an

FRA document permanently waiving the requirement for

Amtrak to monitor and record direction of motion in its

trains. The TMACS 100 did, however, monitor this

parameter.
26

instead can be positioned in varying increments

anywhere within their operating ranges.

Amtrak provided the Safety Board with a

March 31, 1994, letter from the FRA

administrator to Amtrak’s executive vice

president providing guidance and instruction on

issues related to event recorder regulation. The

letter stated

FRA’s intention, expressed at 59 FR

36611, is that the recorder ‘see’ what the

engineer sees (including cab signals) and

record what the engineer does.

The letter further stated that

FRA recognizes that in certain instances

the intent of the rule may be satisfied

either by recording events directly or by

using a pre-determined and verifiable

method to calculate or derive the

required data from other data recorded

directly. Where [ ] the latter approach is

taken, the calculated or derived data

should offer the same accuracy,

reliability and precision as data recorded

directly.

In particular, the letter addressed the issue of

recording throttle position and/or TMC as

follows:

Traction motor current, dynamic braking

current: The rule does not require the

recording of traction motor current in

either the power or the dynamic brake

phase, although it is one way to provide

the required recording of data on brake

operations and equivalent throttle

position or motoring mode.

Based on this guidance, Amtrak currently

uses the recording of TMC in lieu of throttle

position on all AEM-7 locomotives. According to

Bach-Simpson, the manufacturer of the TMACS

100 event recorder, a high TMC value

“generally” corresponds to a high throttle

position, but the TMC and throttle inputs do not

record identical information. While TMC

typically ranges from 0 to 1,800 amperes (amps),

a particular amperage does not necessarily

correspond to a specific throttle position because

grade and other track conditions can cause TMC

to vary without a change in throttle setting.

Cab Signal Aspect Recording -- TMC is

measured in amps. The TMC channel is

multiplexed with cab signal aspect, meaning that

the TMC input monitors both parameters. When

the cab signal aspect changes, the recording of

TMC is interrupted, and a record of the cab

signal aspect and duration is made. According to

the event recorder manufacturer, specific

amperage values correspond to cab signal

aspects, as follows:

Clear: 1,500 amps

Approach medium: 1,600 amps

Approach: 1,700 amps

Restricting: 1,800 amps

According to the manufacturer, these values

are not precise, and the actual current may vary

by about ± 20 amps. The length of the record for

cab signal aspect is approximately 10 seconds.

On June 19, 1997, Amtrak’s event recorder

specialist notified Safety Board staff that in

Amtrak’s fleet of AEM-7 locomotives, including

the three accident locomotives, the electric

current module, a device that sends TMC data to

the recording system, had been improperly

configured at the time of the accident. The wrong

TMC shunt had been used, with the result that

the TMC value delivered by the current module

to the event recorder was double the actual value.

Because the event recorder does not record TMC

values greater than 2,000 amps, any value of

TMC that exceeded 1,000 amps (which was then

doubled to 2,000 amps), was not recognized and

stored properly by the event recorder. Thus,

according to Amtrak, TMC data obtained from

the three locomotives involved in this accident

were invalid. According to Amtrak’s event

recorder specialist, Amtrak discovered the

problem with the current module on December

16, 1996, and immediately began correcting the

settings of the current module for all its AEM-7

locomotives. The specialist stated that the

modules are currently configured properly for the

full fleet.
27

Amtrak’s event recorder specialist initially

informed the Safety Board that cab signal aspect

was recorded properly and was contained within

the TMC data. When Safety Board analysts were

unable to identify the cab signal aspect records

throughout the event recorder data, they

requested assistance from Amtrak. Amtrak then

told the Safety Board that the problem with the

current module settings that caused the TMC

data to be anomalous also affected the cab signal

data. According to Amtrak, cab signals had not

been recorded, and it was therefore not possible

to determine from event recorder data the cab

signal that each train was operating under at the

time of the accident.

A representative of an event recorder

manufacturer told the Safety Board that the

current module is not linked to cab signal aspect,

and a problem with the current module should

not cause the cab signal data to be erroneous.

Although Amtrak has stated that the problem

with the current module was corrected, an

Amtrak representative said that the matter

requires further investigation, because it is not

clear whether cab signal data were recorded

properly at the time of the accident.

According to Amtrak’s event recorder

specialist, TMC can reach values as high as

1,800 to 2,000 amps, which overlap the values

assigned to specific cab signal aspects (1,500,

1,600, 1,700, and 1,800 amps). Safety Board

analysts could not determine whether the value

captured by the TMC input reflected the current

drawn by the traction motor or the cab signal

aspect. Nor could analysts determine with

certainty the times at which the TMC signal may

have been interrupted to create a record of a cab

signal.

According to an event recorder

manufacturer, an effective cab signal multiplexer

design depends on the fact that locomotives do

not normally operate at high traction motor

currents, making the high values associated with

cab signal aspect easy to distinguish from the rest

of the data. The AEM-7 locomotives operated by

Amtrak have high TMC values during normal

operation, and analysts could identify no

distinctive characteristic that could be used to

mark the record of cab signal aspect. An Amtrak

representative stated that the distinguishing

feature of a cab signal record is its duration of 10

seconds, because under normal operation, TMC

measurements are not constant for such a long

period. The TMC data for locomotives 910, 901,

and 930 showed several instances where the

value was constant for longer than 10 seconds.

None of the records in the TMC data were

consistent with the values of cab signal aspects.28

Event Recorder Tests and Inspections -- Federal

regulations require that locomotive event

recorders be inspected every 92 days. Title 49

CFR 229.25(e) describes the tests to be

performed during an inspection. The regulations

require that,

At a minimum, the event recorder test

shall include cycling all required

recording parameters and determining

the full range of each parameter by

reading out recorded data. A

microprocessor-based event recorder

equipped to perform self-tests has passed

the pre-maintenance inspection

requirement if it has not indicated a

failure.

The event recorders installed on Amtrak

locomotives 910, 901, and 930 were

microprocessor-based, and were equipped to

conduct self-tests. According to Bach-Simpson,

the event recorder’s self-test feature would not

have detected the configuration problem that

caused input current to be doubled as long as the

TMC channel was not saturated.29 The system

cannot determine if the inputs are correct so long

as they stay within the normal operating range.

Amtrak inspects each locomotive, including

the event recorder, every 60 days. Locomotive

910 was inspected 17 days prior to the accident;

locomotive 901 was inspected 46 days prior to

the accident; and locomotive 930 was inspected

16 days prior to the accident. The 60-day

inspections of all three locomotives did not

identify any faults with the event recorder

systems.

 

28Amtrak has said that, with the completion of its

upgrade of Bach-Simpson event recorders, cab signal

aspect and TMC are now recorded on separate channels.

29The TMC channel is considered to be “saturated” if

the input exceeds the predetermined maximum value of

2,040 amps.
28

Safety Board laboratory staff observed a 60-

day test being performed at an Amtrak

maintenance facility in April 1997. When

inspecting the event recorder, Amtrak personnel

first check the self-test feature and complete a

checklist. They then attach a laptop computer to

the event recorder and observe all parameters in

real time. As operating conditions are simulated,

each parameter is cycled through all possible

positions while the data transmitted to the

recorder are displayed on the computer screen.

One page of the tabular event recorder data is

included in the inspection records.

The examination that led to the discovery of

the TMC configuration problem was not part of

a periodic inspection but was an independent test

of the TMC channel. The invalid TMC data were

not noticed during periodic inspections. An

Amtrak representative told the Safety Board that

the problem was not detected earlier because

TMC was not considered a significant parameter.

A representative of Bach-Simpson informed

the Safety Board that testing of the system at the

factory prior to delivery and procedural testing

during installation should have ensured correct

operation. He could not explain why the error

went undetected. He said that installation

drawings, instructions, manuals, and software are

included with any new installation, and that when

Amtrak installs and configures the recording

devices and related equipment, Bach-Simpson

representatives may be present.

Federal Oversight of Special Trackwork -

- Special trackwork such as that found on Portal

Bridge, as part of the “standard gage track in the

general railroad system of transportation,” is

subject to the FRA inspection standards

contained in 49 CFR Part 213, “Track Safety

Standards,” but such track is not normally

included in FRA track inspections. FRA officials

have told the Safety Board that track inspection

standards have not been developed for special

trackwork such as miter rail assemblies because

these assemblies vary widely in their design and

operation.

After this accident, the FRA initiated a

program to inspect all movable bridges in the

United States. According to FRA officials, 321

bridges were inspected as part of the program,

which was completed December 31, 1996. The

results of the survey were never distributed.

Safety Board staffers requested a summary of the

results and were told that a summary would not

be produced. After several attempts, the Safety

Board obtained from the FRA a copy of the

completed survey.

FRA inspectors conducting the survey used a

form to document, among other items, the proper

seating and locking of bridge movable spans, and

surface and alignment of movable and fixed rail

sections. The inspectors also looked for cracks or

breaks in the bars at the heels of miter rails and

for mismatches of rail ends.

The survey contains about 600 pages of

inspection reports and survey forms,

supplemented by limited narrative information.

Some defective conditions were noted, including

cracks on miter rail castings, and FRA signal

inspectors noted several bridges that did not

comply with the requirements of 49 CFR Part

236.
29

ANALYSIS

General

The investigation determined that the

crewmembers of trains No. 12 and No. 79 were

qualified for their duties and that neither fatigue

nor alcohol or other drug use was a factor in their

performance during this accident. The weather

was clear. Inspection and testing of the signal

system indicated that the signal system

functioned as designed, in accordance with FRA

requirements, prior to the derailment. The Safety

Board concludes that fatigue, drugs, weather, and

the signal system were not causal or contributory

factors in this accident.

The Accident

At 4:00 a.m. on November 23, 1996, the

bridge operator on duty at Portal Bridge received

a call from a marine vessel requesting that the

bridge center be swung open to allow the vessel

to proceed north up the Hackensack River. The

bridge operator notified the Amtrak train

dispatcher, who unlocked the bridge at 4:03 a.m.

in preparation for the opening. The bridge

operator testified that the first steps in the bridge

opening sequence were completed normally.

After he activated the switch to lift the miter

rails, the operator did not receive a control panel

indication that it was safe to proceed, because

Amtrak had removed the rail position indication

circuitry for the miter rails. In accordance with

standard operating practice, the operator used a

bypass switch to continue the bridge opening

sequence. When he attempted to swing the bridge

open, the swing span would not rotate. Feeling

the bridge shake and vibrate, the operator aborted

the opening.

The accident investigation determined that

either prior to or during the attempt to lift the

miter rail for the north rail on the west end of

track 1, both side bars joining the miter rail to a

longer running rail broke. As the lift rod pushed

up on the miter rail, the miter rail and the running

rail separated at the joint. The lift rod continued

to lift the heel of the miter rail, but the toe of the

rail remained seated in the bed plate for the

stationary rail on the bridge approach span.

When the bridge operator attempted to swing the

movable span, the miter rail hung in the bed plate

on the stationary span, preventing the bridge

from opening.

When the bridge operator aborted the bridge

opening, the lift rods lowered the miter rails, but

the heel of the hung miter rail did not seat

properly. Instead of falling back into the bed

plate, it came to rest on top of the broken side bar

sections attached to the running rail. The 5-inch

difference in elevation between the two tracks

created a ramp that would derail the next train to

cross the bridge on track 1. The rail position

detection circuitry that would have indicated on

the bridge operator’s control panel that the rail

was not seated properly had been removed in

1987. Because electrical continuity was

maintained across the rails despite the

misalignment, the signals governing the Portal

Interlocking displayed a clear indication. Amtrak

procedures in effect at the time did not require

that the bridge be physically inspected after a

failed opening and before clearing the bridge for

train traffic.

About 5:40 a.m., an Amtrak electrician

arrived to troubleshoot the bridge and determine

why it had failed to open. Although he walked

onto the bridge from the well-lighted west end, he

did not notice the misaligned rail. The electrician

was still attempting to determine why the bridge

had not opened properly when train No. 12

derailed on the bridge and sideswiped passing

train No. 79.

In its investigation of this accident, the

Safety Board identified two primary safety

issues: Amtrak oversight of the inspection,

maintenance, and repair of the miter rail

assemblies on Portal Bridge; and the

effectiveness of Amtrak’s emergency notification

procedures. The Safety Board also examined the

effectiveness of Amtrak locomotive event

recorders in capturing critical operational data.
30

Design of Portal Bridge Miter Rail

System

The miter rail assemblies in place on Portal

Bridge at the time of this accident had been

installed in 1992. A salient feature of the design

was the joint between the miter rail and a section

of running rail necessitated by the brittleness of

the metal used for the miter rail. This joint was

held together by side bars bolted onto each side

of the two rails across the joint.

As lifting force was applied to the miter rails

at a point about 25 1/4 inches from the joint, the

rail’s dead weight exerted tensile stresses along

the bottom surface of the side bars and

compression stresses along the top surface.

Repeated lifting and lowering of the miter rails

subjected the side bars to fatigue stress cycles.

Fatigue stresses were increased by the presence

of the beveled notch along the bottom edge of the

side bars, which represented a major, stressconcentrating change in section on the tension

side of the bars. In the area immediately on either

side of the rail joint gap, all of the assembly’s

bending tension loads were carried by the side

bars; none of this load was borne by either the

miter or running rails.

These stress cycles resulted in 6 of 16 side

bars on Portal Bridge sustaining fatigue cracks.

All of the cracks originated at the transition point

to the beveled notch where the design of the miter

rail assembly tended to concentrate the forces

(loads) when the rails were raised. Moreover, all

the cracked and broken side bars taken from the

west end of the bridge were improperly

machined. The beveled notch on these side bars

extended from 1 to 2 inches farther than

necessary, which exaggerated the stress

concentration by putting the change in side bar

width closer to adjacent bolt holes. The bolt holes

themselves were stress concentrators, and the

material that was removed to create them further

reduced the load-bearing cross section at that

location. The change in side bar width and its

proximity to the bolt holes on the improperly

machined side bars may account for the earlier

fracture of these side bars when compared to the

correctly machined ones on the east end of the

bridge. However, even the properly machined

side bars showed evidence of fatigue cracks.

The fatigue cycles to which the side bars

were subjected when they were lifted represented

only a portion of the stresses the side bars were

required to withstand. Added to this was the

stress applied by the passage across the bridge of

about 300 trains each day at an authorized speed

of 70 mph. The extent and speed of the train

traffic on Portal Bridge is in sharp contrast to the

slower and much less frequent traffic across the

other two bridges that use the Promex miter rail

system. This difference in speed and number of

trains each day likely accounts for any

differences in reported side bar failures among

the three bridges. The Safety Board concludes

that the design, the materials, and the operation

of the miter rail system in place on Portal Bridge

at the time of this accident made the side bars

susceptible to fatigue cracking and led to the side

bar failure that precipitated this accident. The

Safety Board believes that Amtrak should

perform a comprehensive stress analysis of the

design of any miter rail assembly currently in use

or intended for use on Portal Bridge to identify

critical areas of high cyclic stress. Amtrak should

ensure that the miter rail design adequately

accommodates these cyclic loads.

Maintenance of the Miter Rail System

Cracked side bars on the movable span of

Portal Bridge were first documented in January

1996 when the foreman of movable bridges

noticed cracks in the bars as he was replacing

missing bolts at the west end of the north rail of

track 1. He notified his supervisors, who

arranged an inspection and took photographs of

the cracked side bars. Amtrak’s solution was to

replace the bars with side bars constructed of

higher-strength steel.

Eventually, new side bars of stronger

material were ordered; in the meantime, however,

Amtrak took no steps to repair the cracks, to

slow trains crossing the bridge, to step up

inspections of the miter rail assemblies, or to

modify bridge operating procedures. Despite the

critical function of the side bars, Amtrak officials

did not consider the cracked side bars a safety

issue since the rails and side bars were secured

by the bed plate when in the seated position.

They apparently did not consider that

approximately once per day, the miter rails were

raised to allow the bridge to open. Lifting the

rails not only removed them from the security of
31

the bed plate, it also subjected the side bars to the

same stresses that had likely caused them to

crack initially.

Only in April 1996, when the cracked side

bars on the west end of the north rail of track 1

had broken completely through, did Amtrak

undertake to replace the entire miter rail

assembly. Unable to effect the replacement

because the spare miter rail assembly could not

be made to fit, Amtrak officials decided to weld

the side bar cracks. Even then, however, the

broken side bars were allowed to remain in place

for a full week before a weld repair was

attempted.

According to the Amtrak welder, he told his

supervisor that the side bars could not be

properly welded while they remained attached to

the miter rail assembly, but he was told to weld

them in place. Safety Board laboratory

examination bore out the welder’s concerns,

revealing that the weld repairs were poorly

carried out and should, at best, have only been

considered a temporary fix.

The weld repairs were most likely made by

shielded metal arc welding and, while this is an

acceptable process for this material, the fact that

the side bars were not removed for welding meant

that the welds were partial joint penetration

groove welds that extended only part of the way

through the thickness of the bars and left residual

fatigue cracks. According to the American

Welding Society (AWS) code D1.1, section 2.5,

Partial Joint Penetration Groove Weld,30 “Partial

joint penetration groove welds subject to tension

normal to their longitudinal axis shall not be used

where design criteria indicate cyclic loading

could produce fatigue failure.”

The 1995 Manual for Railway Engineering

goes further and expressly prohibits the use of

partial joint penetration groove welds in steel

bridge structures.31 Evidence from one Amtrak

official indicated that even Amtrak did not

consider welding to be an approved repair

 

30AWS Structural Welding Code-Steel, American

National Standards Institute/AWS D1.1-86.

31Chapter 15, section 1.10.2 (e), reapproved with

revisions in 1995.

method for the side bars, although several

officials concurred in its use.

The weld repairs left the bars with

significantly reduced cross-sectional areas, along

with the remains of the cracks and the original

notch ends, which acted as stress concentrators.

The commentary on the Structural Welding

Code-Steel32 states, in part,

A partial penetration groove weld has an

unwelded portion at the root of the

weld.... These unwelded portions

constitute a stress raiser having

significance when fatigue loads are

applied transversely to the joint.

The side bars had obvious fatigue loads

applied when opening and closing. The Safety

Board therefore concludes that the welding that

was performed on the side bars was inadequate

and inappropriate as a permanent repair and

served to concentrate stress on the already

fractured areas of the side bars. The Safety

Board further concludes that the weld repairs

could have been adequate as a temporary fix had

a detailed and repetitive inspection program been

established to ensure continued safe operation

until permanent repairs or replacements could be

made.

In July 1996, the first set of new, higherstrength steel side bars was delivered, but

Amtrak made no effort to replace any of the

existing side bars, even those that had already

broken through and had been welded. The Safety

Board concludes that Amtrak management was

aware of failures in miter rail side bars at least

10 months prior to the derailment, but because

the company erroneously considered cracked or

broken side bars to be a maintenance issue rather

than a safety issue, it did not make replacements

or permanent repairs that could have prevented

this accident.

Inspection of the Miter Rail System

A review of periodic track inspection reports

from September 2, 1996, through November 21,

 

32American National Standards Institute/AWS D1.1-

86.
32

1996; monthly bridge inspections from January

19, 1993, through October 2, 1996; a Sperry

Rail Track Geometry Report dated May 13,

1996; and the annual miter rail and expansion

joint inspection on June 13, 1996, disclosed no

defects in any of the side bars on any of the miter

rails on Portal Bridge. On November 22, 1996,

the day before the accident, an Amtrak track

inspector made a walking inspection of the tracks

on the bridge and reported finding no defects

regarding the miter rails or their components.

The day after the accident, Safety Board

investigators found that both side bars on three

miter rail assemblies (six side bars total) were

cracked. The Safety Board considers it unlikely

that these cracks developed within a single day of

the accident. More likely, the cracks had

originated weeks or months before the accident

and progressed slightly with each stress cycle.

The Safety Board is concerned that repeated

Amtrak inspections failed to reveal the presence

of the cracks.

In the view of the Safety Board, Amtrak

inspection procedures on Portal Bridge did not

adequately address the special circumstances

created by the Promex miter rail assemblies. The

inspection procedures did not require that the

miter rails be lifted to be inspected, even though

the most critical components of the assembly

were almost completely hidden when the rails

were seated. At least as early as January 11,

1996, Amtrak became aware that a nut had fallen

off a bolt in the toe of a miter rail, allowing the

bolt to work out of its bolt hole and hang in the

adjacent stationary miter rail. A short time later,

on January 22, 1996, the movable bridges

foreman found bolts missing from the side bars

on the west end of the north rail of track 1. When

he had the miter rails raised, he found that the

remaining bolts were loose (it was also at this

time that he noticed the cracked side bars). These

nuts and bolts had obviously loosened gradually

over time, but no inspection procedure had

detected the problem before a potentially

hazardous situation developed.

The loose or missing bolts and nuts in the

miter rail assemblies should have prompted

Amtrak management to amend its inspection

procedures to include raising the miter rails for

inspection to detect cracked or broken side bars,

loose or missing track bolts, displaced track bolt

heads, lifting arm mechanism cotter pins, etc.

Experience with the amended procedures would

have allowed Amtrak to determine an optimum

inspection schedule that would have ensured

miter rail integrity with the least adverse effect on

train schedules. Instead, Amtrak management

continued the inspection procedures that had

proven to be completely ineffective in detecting

problems with the miter rail assemblies. The

Safety Board concludes that Amtrak management

did not develop and implement miter rail inspection

procedures that were adequate to identify defects

in all components of the miter rail assemblies on

Portal Bridge. The Safety Board further concludes

that, had Amtrak, when it first learned about the

cracked side bars on the miter rails, revised its

miter rail inspection procedures to include raising

the miter rails for inspection, the accident may

have been prevented.

Only in January 1997, after the second

incident in which a loose bolt jammed a miter rail

and created a potentially hazardous situation, did

Amtrak establish short-term procedures to ensure

a thorough inspection of the miter rail assemblies

while in the raised position. In March 1997, more

than 1 year after problems with the miter rails

had initially been detected, Amtrak issued new

instructions for the inspection and protection of

miter rail assemblies and established new training

standards for inspectors. The Safety Board

believes that Amtrak should continue to monitor the

safety of special trackwork on its movable bridges

and ensure that its special inspections are adequate

and of sufficient frequency to detect failures or

potential failures involving all components of all its

special trackwork. The Safety Board further

believes that Amtrak should develop and put

procedures in place to ensure that any failures or

potential failures that are noted during these

inspections are corrected before they develop into

safety hazards.

Removal of the Miter Rail Position

Detection Circuits

Problems with excessive vibration on Portal

Bridge began almost immediately after the

installation of Conley miter rails on Portal Bridge

in 1985. One result of the vibration was that the

limit switches that had been installed to detect the

position of the miter rails and to relay this
33

information to the bridge operator’s control panel

failed repeatedly and could not be economically

maintained. To correct this problem, Amtrak

removed the limit switches and associated miter

rail indication circuitry in 1987. Even though

Amtrak purchased a new type of heavy duty

circuit controller to replace the limit switches, the

new devices were never installed on the Conley

miter rails. When the Conley rails were replaced

by miter rails of Promex design in 1992, no

detection circuitry was installed, even though the

mechanism had provisions for such devices.

The rail position detection circuitry served

the important safety function of reporting to the

bridge operator that the rails were properly lifted

before an attempt was made to open the bridge

and firmly seated again after the bridge was

closed. In fact, the bridge interlocking

mechanisms would not allow a bridge opening or

closing operation to proceed unless (1) the

system received a safe indication from the

detection circuitry, or (2) the bridge operator

used a bypass switch to allow the operation to

continue without a safe indication. With no

detection circuitry in place, bridge operators

always used the bypass switch, even though,

absent a visual inspection of the rails before and

after each opening (which Amtrak did not

require), the bridge operator had no way of

knowing whether the attempt to raise or lower the

miter rails had been successful. This explains

why, on the morning of the accident, the bridge

operator attempted to swing the bridge center

span even while the toe of the miter rail on the

west end of the north rail of track 1 was still

seated in the bed plate on the approach span. The

torque applied to the miter rail as the bridge span

attempted to rotate may, in fact, have bent the

rail slightly and contributed to the failure of the

heel of the rail to align properly when the lift rods

were retracted.

After he aborted the bridge opening, the

bridge operator assumed that the rails were safe

for train traffic because the signal system showed

a clear indication. But the signal system indicated

only that the rails made a complete electrical

circuit and that the toe of the miter rail was

positioned properly; the system could not and did

not indicate that the heel of the miter rail was

properly aligned.

If Amtrak management understood the

important safety function served by the rail

position detection circuitry, it did nothing to

compensate for the removal of the system. An

appropriate course may have been to require a

visual inspection of the miter rails to confirm that

they were completely lifted before opening and

completely seated afterward. This practice could

have been continued until the detection circuitry

could be replaced. In a January 30, 1997,

memorandum to Portal Bridge operators and

Spuyten Duyvil Bridge signal maintainers,

Amtrak instituted such visual inspections. The

Safety Board is concerned, however, that for

almost 10 years, Portal Bridge operators were

allowed to assume that a critical procedure in the

opening or closing of the bridge would always be

successful and that no confirmation, electronic or

visual, was required before using a bypass

switch. The Safety Board concludes that if

Amtrak management had had in place on Portal

Bridge a functioning rail position detection

system or procedures that required visual

confirmation of the proper positioning of all

miter rails, this accident probably would not have

occurred. The Safety Board believes that Amtrak

should ensure that current or future miter rail

installations on Portal Bridge are equipped with a

miter rail position detection/indication system that

provides the maximum protection possible and that

is interlocked with other bridge systems to prevent

the bridge from being opened or cleared for train

traffic until the position of the miter rails can be

confirmed to be safe.

Emergency Response

Emergency response to the accident was

delayed because of confusion about the accident

location. The problem can be traced to the

Amtrak police dispatcher who called the

appropriate agency, the Secaucus Police

Department, but relayed the accident location as

“Portal Tunnel” instead of “Portal Bridge.” The

dispatcher further confused the issue when he

called the North Bergen Police Department and

reported the accident location as “Portal Tunnel

Bridge.”
34

Amtrak’s computerized geographical data

base indicated that the derailment fell within the

Secaucus police area. The data base also

provided the closest access roads. Even with the

confusion about the specific accident site, the

location of the two nearby roads should have

provided enough information to allow either the

Secaucus police or the North Bergen police to

determine the most likely accident location. This

did not occur, however. One reason may have

been that the Secaucus police were apparently

unaware that a Portal Bridge was located within

their jurisdiction. It was only when a construction

worker flagged down a Secaucus police cruiser

that had been sent out to investigate and check

known bridges in the area that the actual accident

location became known.

As a result of this confusion about the

accident location, the first ambulance did not

arrive at the accident scene until 47 minutes after

the initial notification. The Safety Board

concludes that, had this accident resulted in more

serious injuries, the confusing communication of

the accident location by the Amtrak police

dispatcher and the resulting delay in emergency

response could have resulted in additional risks to

train occupants. The Safety Board believes that

Amtrak should review the training of its police

dispatchers and ensure that dispatchers are

trained to correctly identify all Amtrak locations

to emergency response agencies.

Locomotive Event Recorders

Using Traction Motor Current to Indicate

Throttle Position -- As shown by a 1994 letter

from the FRA to Amtrak, the FRA considers the

recording of TMC to be an acceptable method of

monitoring throttle position on those locomotives,

such as the AEM-7 locomotives involved in this

accident, whose throttle controls do not have a

finite number of predefined throttle positions.

The Safety Board is concerned, however, that

TMC data do not reflect the operator’s actions,

but only the response of the locomotive’s traction

motor to those actions. Depending on the

circumstances, the traction motor will not always

react the same way to a given throttle setting.

While a high TMC value “generally”

corresponds to a high throttle position and a low

TMC value “generally” denotes a low throttle

setting, the throttle position cannot be derived

from TMC with reasonable accuracy, reliability,

and precision because the response of the system

depends on grade and other track conditions that

vary continuously while the train is in operation.

Additionally, for the locomotives involved in

this accident, the TMC data were invalid because

of an improperly configured electric current

module (a condition that was later found to be a

fleet-wide problem with Amtrak’s AEM-7

locomotives). However, even if the recording

system had recorded TMC properly, the data

would not have provided any information

indicating the exact throttle settings used by the

operator.

While TMC alone is a valuable operating

parameter, knowledge of throttle position can be

critical in the analysis of train handling. The

Safety Board concludes that TMC data do not

accurately indicate throttle position and,

therefore, use of the data for this purpose by

Amtrak does not meet FRA requirements for

monitoring and recording train throttle position.

The Safety Board believes that the FRA should

inform the railroad industry that TMC is not a

valid indicator of throttle position, and the

requirement to record throttle position contained

in 49 CFR 229.5(g) cannot be met by recording

TMC. Additionally, the FRA should ensure that

all operators currently using TMC as a substitute

for throttle position modify their event recording

systems to monitor and record throttle position

directly.

Cab Signal Multiplexer and Current

Module -- According to information provided by

Bach-Simpson, the manufacturer of the event

recorders installed on the accident locomotives,

when a cab signal aspect changes, the TMC

signal is interrupted, and a record of the cab

signal is inserted in the data record. The signal

activation and aspect are distinguishable within

the recorded data by their high relative current

levels. However, according to Amtrak, TMC

values as high as 1,800 to 2,000 amps can be

reached during normal operation of an AEM-7

locomotive. Thus, the range of TMC values

overlaps the range of values assigned to specific

cab signals, making it difficult, if not impossible,

to determine whether the value depicted for the

TMC channel reflects the current draw of the

traction motor alone or the additional current
35

draw that results from activation of a cab signal.

For example, if the traction motor is operating at

about 1,700 amps when the locomotive receives

an approach cab signal (also 1,700 amps), the

event recorder data provide no means of

identifying the source of the current draw.

Moreover, an approach signal will not always be

recorded at 1,700 amps; the readings could be

1,684, 1,712, 1,690, or another value, making it

even more difficult to identify cab signal data.

Amtrak initially informed the Safety Board

that cab signal aspect was recorded properly for

the accident locomotives, and that cab signal

records were contained within the TMC data.

After consultation with Safety Board staff,

however, Amtrak agreed that cab signal

indications were not recorded in a way that made

it possible to determine the cab signal that each

train was operating under at the time of the

accident. As of August 1997, Amtrak was still

not certain whether cab signal indications, a

parameter the FRA requires to be monitored and

recorded, is recorded properly on its locomotives.

The Safety Board concludes that Amtrak’s use of

a multiplexer to monitor and record both TMC

and cab signal on a single channel of the event

recorder is inappropriate and ineffective and, as a

result, Safety Board investigators found it

impossible to determine cab signal indications in

this accident. The Safety Board believes that

Amtrak should perform a thorough test of the

entire recording system on every locomotive

equipped with an event recorder to ensure that

cab signal data records can be easily and

positively identified and evaluated.

Event Recorder Inspections -- Amtrak

inspects each locomotive, including the event

recorder, every 60 days, and each of the accident

locomotives had been inspected and approved

within 6 weeks of the accident. These inspections

did not, however, identify the incorrect current

module configuration that rendered invalid all

recorded TMC information. Amtrak’s event

recorder specialist told the Safety Board that the

problem was not detected earlier because TMC

was not considered a significant parameter. In the

view of the Safety Board, TMC is an important

parameter, particularly since potentially critical

cab signal data are recorded on the same channel.

The Safety Board concludes that if the entire

event recorder systems, including sensors, wiring,

etc., in Amtrak locomotives 910, 901, and 930

had been thoroughly tested during their most

recent 60-day inspections, the incorrect current

module configuration would likely have been

found and corrected, and the TMC data retrieved

after this accident would have been useful in

determining preaccident cab signals received by

the traincrews.

It is important to note that the invalid data

found during this investigation resulted from

failed or inappropriately configured “sensors”

and not from the actual event recorder units

themselves. Most solid-state recorders have a

self-test feature that can diagnose problems with

the event recorder, but this feature does not test

the validity of the data being provided to the unit.

For example, a broken speed sensor might send

the event recorder a speed of 0 mph. The recorder

cannot detect whether the sensor is broken or the

train simply is not moving, and the self-test does

not extend to sensors or sending units. Currently,

no testing or inspection is required for

microprocessor-based self-testing recorders so

long as the recorder indicates no faults during

self-tests. Even for recorders that have no selftest feature, regulations do not require that the

entire system be inspected, only the recording

unit itself.

The issue of inadequate event recorder

testing and inspection is not new to the Safety

Board. As a result of its investigation of an

accident involving the derailment of a freight

train near Cajon Junction, California, in

February 1996,33 the Safety Board made four

safety recommendations to the FRA regarding

event recorders. One of those recommendations

specifically addressed event recorder

maintenance and inspection procedures:

R-96-70

Revise 49 Code of Federal Regulations

229.25(e)(2) to require that event

recorders, including microprocessorbased event recorders that are equipped

with a self-test function, be tested during

the quarterly inspections of the 

33Railroad Accident Report — Derailment of Freight

Train H-BALTI-31 Atchison, Topeka, and Santa Fe

Railway Company near Cajon Junction, California,

February 1, 1996 (NTSB/RAR-96/05).
36

locomotive in such a manner that the

entire event recording system, including

sensors, transducers, and wiring, is

evaluated. Such testing should include, at

a minimum, a review of the data

recorded during actual operation of the

locomotive to verify parameter

functionality as well as cycling all

required recording parameters and

determining the full range of each

parameter by reading out recorded data.

In an August 15, 1997, letter to the Safety

Board, the FRA stated that it had referred this

recommendation to its Rail Safety Advisory

Committee (RSAC). The letter stated that “the

RSAC process will lead to expedited action” on

the recommendation. The Safety Board will

follow the progress on this recommendation

closely. Based on the FRA letter, the Safety

Board has classified Safety Recommendation R96-70 “Open—Acceptable Response.” At the

same time, however, the Safety Board believes

that additional FRA action is needed

immediately. All three recorders involved in the

Portal Bridge accident, as well as the one

recorder involved in the Cajon Junction accident,

were tested and found to be fully functional after

the accident. The problems discovered with all

four recorders were not related to the recording

units themselves, but to the vital system

components that send signals to the recording

device. The self-test functions do not, nor are

they intended to, detect failures in these

components. The Safety Board therefore believes

that, pending the results of the RSAC Event

Recorder Working Group and the FRA’s

implementation of suitable requirements

concerning event recorder system maintenance,

the FRA should require that microprocessorbased event recorders equipped to perform selftests be subject to the testing and inspection

procedures currently applicable to all other types

of event recorders. The Safety Board does not

believe that the FRA should any longer consider

a recorder to have passed the premaintenance

inspection requirement based solely on the results

of the self-test feature of a recorder.

Also pending the results of the RSAC event

recorder working group and the FRA’s

implementation of suitable requirements

concerning event recorder system maintenance,

the Safety Board believes that the Association of

American Railroads and the American Short Line

Railroad Association should advise their member

railroads of the need to test and inspect all

microprocessor-based event recorders equipped

to perform self-tests in accordance with those

procedures outlined in 49 CFR 229.25(e)(2),

which currently apply to all other types of

recorders, to confirm proper event recorder

function.

Amtrak Management Oversight of Safety

Issues

The circumstances of this accident indicate

that Amtrak’s oversight policies may be lacking.

Amtrak management did not take sufficient

action to address the ineffectual inspection

practices, delays in installing safety-critical miter

rail assembly components, and unsuccessful

repair procedures that preceded the Portal Bridge

derailment.

Regarding inspection, Amtrak management

did not adapt the inspection procedures on Portal

Bridge to the special circumstances created by

the Promex miter rail assemblies. The inspection

procedures did not require that the miter rails be

lifted to be inspected, even though the most

critical components of the assembly were almost

completely hidden when the rails were seated.

Repeated incidents of personnel reporting loose

or missing nuts and bolts in the assemblies did

not prompt Amtrak management to make its

normal inspection procedures more rigorous by

requiring that the miter rails be raised during

inspections. Not until March 1997, more than 1

year after problems with the miter rail side bars

had first been detected, did Amtrak issue new

instructions for the inspection of miter rail

assemblies.

Amtrak management also did not effectively

encourage prompt action in carrying out safetycritical maintenance. The cracked or broken side

bars on Portal Bridge were discovered and

reported to higher levels of Amtrak management

at least 10 months before this accident, but

satisfactory corrective action was not taken until

after the derailment occurred. Also, although

Amtrak management recognized the necessity of

replacing the side bars, it did not direct personnel

to make the replacements immediately. Even after
37

replacement side bars were on hand, Amtrak

management planned to delay installing the

replacements until spring 1997, when other work

was scheduled to be done on the bridge.

Finally, Amtrak management allowed the use

of inadequate repair methods on the Portal

Bridge miter rail assemblies. Amtrak

management permitted temporary weld repairs

that were contrary to Amtrak’s own maintenance

and repair guidelines to be used. In fact, the

welder stated that even when he advised his

supervisor that a proper weld of the side bars

would require removing them from the miter rail,

he was ordered to weld them in place.

These examples indicate that Amtrak

management may not have emphasized safety as

strongly as possible, at least with regard to the

inspection, maintenance, and repair of the Portal

Bridge miter rail assemblies. Therefore, the

Safety Board concludes that Amtrak management

failed to foster an environment that promoted

adequate inspection, maintenance, and repair of

the miter rail assemblies on Portal Bridge and to

permanently correct defects in the miter rail side

bars that were discovered 10 months before the

accident.

While this investigation found that those

employees who carried out inspections and

maintenance on the bridge followed Amtrak

guidance, it also indicated that the guidance was

not always appropriate and forceful. The

circumstances of this accident, which could have

had far greater consequences in terms of injury

and loss of life, point out significant deficiencies

in the Amtrak response to safety issues. The

Safety Board therefore believes that Amtrak

should conduct a comprehensive internal

management review of the circumstances of this

accident to determine why several layers of

Amtrak management failed to act in a timely

fashion to correct a known hazardous condition

on Portal Bridge. The Safety Board further

believes that Amtrak should make the

management or procedural changes necessary to

ensure that conditions affecting the safety of rail

operations are given the highest priority.

Federal Oversight of Special Trackwork

Special trackwork such as that found on

Portal Bridge, unlike virtually all other segments

of track, is not routinely included in FRA track

inspections and is therefore not subjected to the

same FRA standards of maintenance and

inspection as other track on the general railroad

system. In the view of the Safety Board, such

exception to the standards is not provided for in

the FRA regulations promulgated in 49 CFR Part

213. Furthermore, this exception is totally

inappropriate in that inadequately inspected and

maintained special trackwork can have serious

safety implications, as it did in this accident. The

tracks leading up to Portal Bridge were held to

FRA standards, and, while these Class 4 tracks

accommodated about 300 trains per day

operating at speeds approaching 70 mph, the

special trackwork on the bridge was subjected to

the same traffic. Yet, the condition and operation

of this complex configuration of movable and

stationary rails were virtually ignored by the

FRA during its normal track inspections. The

Safety Board concludes that if Amtrak had been

required to meet Federal standards for inspection

and maintenance of the special trackwork on

Portal Bridge, the defects in the miter rail side

bars may have been detected and repaired before

they could cause a derailment. The Safety Board

believes that the FRA should expand the scope of

its track safety standards to include special

trackwork such as movable miter rails and ensure

that the condition and operation of special

trackwork are included, when appropriate, in all

FRA track inspections.

FRA Bridge Survey

Although the FRA inspected 321 movable

bridges throughout the United States following

the Portal Bridge accident, the agency did not

distribute the survey results in complete or

summary form. Based on its review of the

survey, the Safety Board concludes that the

results of the FRA movable bridge survey would

be beneficial to the railroad and rail rapid transit

industry in preventing accidents similar to the

derailment on Portal Bridge. The Safety Board

believes that the FRA should provide, in full or

summary form, the results of its movable bridges

survey to all railroads and rail rapid transit

agencies.
38

Conclusions

1. Fatigue, drugs, weather, and the signal

system were not causal or contributory

factors in this accident.

2. The design, the materials, and the operation

of the miter rail system in place on Portal

Bridge at the time of this accident made the

side bars susceptible to fatigue cracking and

led to the side bar failure that precipitated

this accident.

3. The welding that was performed on the side

bars was inadequate and inappropriate as a

permanent repair and served to concentrate

stress on the already fractured areas of the

side bars.

4. The weld repairs could have been adequate

as a temporary fix had a detailed and

repetitive inspection program been

established to ensure continued safe

operation until permanent repairs or

replacements could be made.

5. Amtrak management was aware of failures in

miter rail side bars at least 10 months prior

to the derailment, but because the company

erroneously considered cracked or broken

side bars to be a maintenance issue rather

than a safety issue, it did not make

replacements or permanent repairs that could

have prevented this accident.

6. Amtrak management did not develop and

implement miter rail inspection procedures

that were adequate to identify defects in all

components of the miter rail assemblies on

Portal Bridge.

7. Had Amtrak, when it first learned about the

cracked side bars on the miter rails, revised

its miter rail inspection procedures to include

raising the miter rails for inspection, the

accident may have been prevented.

8. If Amtrak management had had in place on

Portal Bridge a functioning rail position

detection system or procedures that required

visual confirmation of the proper positioning

of all miter rails, this accident probably

would not have occurred.

9. Had this accident resulted in more serious

injuries, the confusing communication of the

accident location by the Amtrak police

dispatcher and the resulting delay in

emergency response could have resulted in

additional risks to train occupants.

10. Traction motor current data do not

accurately indicate throttle position and,

therefore, use of the data for this purpose by

Amtrak does not meet Federal Railroad

Administration requirements for monitoring

and recording train throttle position.

11. Amtrak’s use of a multiplexer to monitor and

record both traction motor current and cab

signal on a single channel of the event

recorder is inappropriate and ineffective and,

as a result, Safety Board investigators found

it impossible to determine cab signal

indications in this accident.

12. If the entire event recorder systems, including

sensors, wiring, etc., in Amtrak locomotives

910, 901, and 930 had been thoroughly

tested during their most recent 60-day

inspections, the incorrect current module

configuration would likely have been found

and corrected, and the traction motor current

data retrieved after this accident would have

been useful in determining preaccident cab

signals received by the traincrews.

13. Amtrak management failed to foster an

environment that promoted adequate

inspection, maintenance, and repair of the

miter rail assemblies on Portal Bridge and to

permanently correct defects in the miter rail

FINDINGS
39

side bars that were discovered 10 months

before the accident.

14. If Amtrak had been required to meet Federal

standards for inspection and maintenance of

the special trackwork on Portal Bridge, the

defects in the miter rail side bars may have

been detected and repaired before they could

cause a derailment.

15. The results of the Federal Railroad

Administration movable bridge survey would

be beneficial to the railroad and rail rapid

transit industry in preventing accidents

similar to the derailment on Portal Bridge.

Probable Cause

The National Transportation Safety Board

determines that the probable cause of the

accident was the failure of Amtrak management

to foster an environment that promoted adequate

inspection, maintenance, and repair of the miter

rail assemblies on Portal Bridge and to

permanently correct defects in the miter rail side

bars that were discovered 10 months before the

accident. Contributing to the accident were (1)

the failure of the Federal Railroad Administration

to develop track inspection standards for special

trackwork and to periodically inspect such track

as part of its oversight responsibilities and (2)

Amtrak’s removal of the miter rail position

detection circuitry without installing replacement

circuitry or implementing procedures to

compensate for the loss of this safety-critical

system.
40

As a result of its investigation of this

accident, the National Transportation Safety

Board makes the following safety

recommendations:

— to the National Railroad Passenger

Corporation (Amtrak):

Perform a comprehensive stress analysis

of the design of any miter rail assembly

currently in use or intended for use on

Portal Bridge to identify critical areas of

high cyclic stress. Ensure that the miter

rail design adequately accommodates

these cyclic loads. (R-97-49)

Continue to monitor the safety of special

trackwork on your movable bridges and

ensure that your special inspections are

adequate and of sufficient frequency to

detect failures or potential failures

involving all components of all your special

trackwork. Develop and put procedures in

place to ensure that any failures or potential

failures that are noted during these

inspections are corrected before they

develop into safety hazards. (R-97-50)

Ensure that current or future miter rail

installations on Portal Bridge are equipped

with a miter rail position

detection/indication system that provides

the maximum protection possible and that

is interlocked with other bridge systems to

prevent the bridge from being opened or

cleared for train traffic until the position

of the miter rails can be confirmed to be

safe. (R-97-51)

Review the training of your police

dispatchers and ensure that dispatchers

are trained to correctly identify all

Amtrak locations to emergency response

agencies. (R-97-52)

Perform a thorough test of the entire

recording system on every locomotive

equipped with an event recorder to

ensure that cab signal data records can

be easily and positively identified and

evaluated. (R-97-53)

Conduct a comprehensive internal

management review of the circumstances

of this accident to determine why several

layers of Amtrak management failed to

act in a timely fashion to correct a

known hazardous condition on Portal

Bridge. Make the management or

procedural changes necessary to ensure

that conditions affecting the safety of rail

operations are given the highest priority.

(R-97-54)

— to the Federal Railroad Administration:

Inform the railroad industry that traction

motor current is not a valid indicator of

throttle position, and the requirement to

record throttle position contained in 49

Code of Federal Regulations 229.5(g)

cannot be met by recording traction

motor current. Ensure that all operators

currently using traction motor current as

a substitute for throttle position modify

their event recording systems to monitor

and record throttle position directly. (R97-55)

Pending the results of your Railroad

Safety Advisory Committee Event

Recorder Working Group and your

implementation of suitable requirements

concerning event recorder system

maintenance, require that microprocessor-based event recorders equipped to

perform self-tests be subject to the

testing and inspection procedures

currently applicable to all other types of

event recorders. (R-97-56)

Expand the scope of your track safety

standards to include special trackwork

such as movable miter rails and ensure

that the condition and operation of

special trackwork are included, when

appropriate, in all Federal Railroad

RECOMMENDATIONS
41

Administration track inspections. (R-97-

57)

Provide, in full or summary form, the

results of the Federal Railroad

Administration movable bridges survey

to all railroads and rail rapid transit

agencies. (R-97-58)

— to the Association of American Railroads:

Pending the results of the Federal

Railroad Administration (FRA) Railroad

Safety Advisory Committee Event

Recorder Working Group and the FRA’s

implementation of suitable requirements

concerning event recorder system

maintenance, advise your member

railroads of the need to test and inspect

all microprocessor-based event recorders

equipped to perform self-tests in

accordance with those procedures

outlined in 49 Code of Federal

Regulations 229.25(e)(2), which

currently apply to all other types of

recorders, to confirm proper event

recorder function. (R-97-59)

— to the American Short Line Railroad

Association:

Pending the results of the Federal

Railroad Administration (FRA) Railroad

Safety Advisory Committee Event

Recorder Working Group and the FRA’s

implementation of suitable requirements

concerning event recorder system

maintenance, advise your member

railroads of the need to test and inspect

all microprocessor-based event recorders

equipped to perform self-tests in

accordance with those procedures

outlined in 49 Code of Federal

Regulations 229.25(e)(2), which

currently apply to all other types of

recorders, to confirm proper event

recorder function. (R-97-60)

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

December 18, 1997

43

The National Transportation Safety Board

was notified at 8:30 a.m., eastern daylight time,

on November 23, 1996, that National Railroad

Passenger Corporation (Amtrak) passenger train

No. 12 had derailed and sideswiped Amtrak

passenger train No. 79 while traversing Portal

Bridge in Secaucus, New Jersey. The

investigator-in-charge and other members of the

Safety Board investigative team were dispatched

from the Washington, D.C., headquarters and the

Atlanta, Georgia, regional offices. The

investigative groups studied track and structures,

signals and bridge operations, rail operations,

mechanical factors, emergency response,

locomotive event recorders, and metallurgy.

The Federal Railroad Administration,

Amtrak, the Brotherhood of Locomotive

Engineers, the United Transportation Union, the

Brotherhood of Maintenance of Way Engineers,

and Jersey City Emergency Medical Services

assisted in the Safety Board investigation.

The Safety Board did not conduct a public

hearing during this investigation.

APPENDIX — Investigation