PB97-916301

NTSB/RAR-97/01

NATIONAL

TRANSPORTATION

SAFETY

BOARD

Washington, D.C. 20594

RAILROAD ACCIDENT REPORT

NEAR HEAD-ON COLLISION AND DERAILMENT OF

TWO NEW JERSEY TRANSIT COMMUTER TRAINS

NEAR SECAUCUS, NEW JERSEY

FEBRUARY 9, 1996

6674A
Abstract: This report explains the collision of two New Jersey Transit trains near Secaucus, New Jersey,

on February 9, 1996. Three people were killed and 69 people were treated at area hospitals for minor to

serious injuries sustained in this accident. The total estimated damage exceeded $3.3 million.

From its investigation of this accident, the Safety Board identified the following safety issues: the

medical condition of the engineer of train 1254, the adequacy of medical standards for locomotive

engineers, and the adequacy of the response to the accident by New Jersey Transit train crewmembers.

Based on its findings, the Safety Board made recommendations to the Federal Railroad Administration,

the New Jersey Transit, the Association of American Railroads, the American Public Transit Association,

the Brotherhood of Locomotive Engineers, and the United Transportation Union.

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 cause of 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 East, 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
NTSB/RAR-97/01 PB97-916301

NATIONAL TRANSPORTATION

SAFETY BOARD

Washington, D.C. 20594

RAILROAD ACCIDENT REPORT

Near Head-On Collision and Derailment of

Two New Jersey Transit Commuter Trains

Near Secaucus, New Jersey

February 9, 1996

Adopted: March 25, 1997

Notation 6674A
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iii

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

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

Accident Synopsis ........................................................................................................................................1

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

Injuries ......................................................................................................................................................... 3

Damages....................................................................................................................................................... 4

Personnel Information ................................................................................................................................. 4

General ........................................................................................................................................... 4

Duty/Rest Schedule ........................................................................................................................ 5

Other Activities .............................................................................................................................. 5

General Health ............................................................................................................................... 5

Medical History .............................................................................................................................. 6

Visual Acuity ................................................................................................................................. 6

Color Vision ................................................................................................................................... 7

Driver History ................................................................................................................................ 8

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

Train 1254 ...................................................................................................................................... 8

Train 1107 ...................................................................................................................................... 8

Track ........................................................................................................................................................... 9

Signal ........................................................................................................................................................... 9

Operations Information ............................................................................................................................. 12

General ......................................................................................................................................... 12

Employee Oversight ..................................................................................................................... 12

Meteorological Information ...................................................................................................................... 12

Medical and Pathological Information ...................................................................................................... 12

Fatalities ....................................................................................................................................... 12

Injury Sources .............................................................................................................................. 13

Toxicological Testing .................................................................................................................. 13

Survival Factors ........................................................................................................................................ 13

NJT Safety Awareness Program ......................................................................................................... 13

Actions by NJT Crews ........................................................................................................................ 14

Emergency Response .......................................................................................................................... 15

Wreckage ............................................................................................................................................ 16

Tests and Research .................................................................................................................................... 18

Visibility Tests..................................................................................................................................... 18

Sight Distance Tests ........................................................................................................................... 18

Speed and Stopping Tests ................................................................................................................... 19

Event Recorders................................................................................................................................... 19

Other Information ...................................................................................................................................... 19

NJT Postaccident Actions ............................................................................................................ 19

FRA Emergency Order ................................................................................................................. 19

Medical Standards ........................................................................................................................ 20

The Railroad Safety Advisory Committee ................................................................................... 21

CONTENTS
iv

ANALYSIS ................................................................................................................................................22

General ...................................................................................................................................................... 22

Exclusions ................................................................................................................................................. 22

Analysis of the Accident ............................................................................................................................ 22

Medical Condition of the Train 1254 Engineer ........................................................................................ 23

Adequacy of Medical Standards for Locomotive Engineers .................................................................... 25

Adequacy of the Train Crews’ Response .................................................................................................. 26

Postaccident Actions .................................................................................................................... 26

Employee Training ....................................................................................................................... 27

Survival Factors ........................................................................................................................................ 28

Crashworthiness ........................................................................................................................... 28

Emergency Response ................................................................................................................... 29

NJT’s Postaccident Efforts ....................................................................................................................... 29

CONCLUSIONS ...................................................................................................................................... 30

Findings ..................................................................................................................................................... 30

Probable Cause........................................................................................................................................... 30

RECOMMENDATIONS ........................................................................................................................ 31

APPENDIXES

Appendix A — Investigation ..................................................................................................................... 33

Appendix B — Train 1107 Engineer Personnel Information ................................................................... 35

Appendix C — The Dvorine PIP Testing Protocol Instructions................................................................ 37

Appendix D — Excerpts from New Jersey Transit Rail Operations

Timetable No. 9 Special Instructions .............................................................................. 39
v

On February 9, 1996, about 8:40 a.m., eastbound New Jersey Transit (NJT) commuter train

1254 collided nearly head-on with westbound

NJT commuter train 1107 near Secaucus, New

Jersey. About 400 passengers were on the two

trains. The engineers on both trains and one

passenger riding on train 1254 were killed in the

collision.

The National Transportation Safety Board

determines that the probable cause of New Jersey Transit (NJT) train 1254 proceeding through

a stop indication and striking another NJT

commuter train was the failure of the train 1254

engineer to perceive correctly a red signal aspect

because of his diabetic eye disease and resulting

color vision deficiency, which he failed to report

to New Jersey Transit during annual medical

examinations. Contributing to the accident was

the contract physician’s use of an eye

examination not intended to measure color

discrimination.

The major safety issues discussed in this

report are the medical condition of the engineer

of train 1254, the adequacy of medical standards

for locomotive engineers, and the adequacy of

the NJT train crewmembers' response to the

accident. In addition, the Safety Board examines

crashworthiness of the trains and the response

effort of emergency personnel.

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

to the Federal Railroad Administration, the New

Jersey Transit, the Association of American

Railroads, the American Public Transit Association, the Brotherhood of Locomotive Engineers, and the United Transportation Union.

EXECUTIVE SUMMARY
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Accident Synopsis

On February 9, 1996, about 8:40 a.m., eastbound New Jersey Transit (NJT) commuter train

1254 ran a stop signal at an interlocking1

near

Secaucus, New Jersey (figure 1), and collided

nearly head-on with westbound NJT commuter

train 1107. About 400 passengers were on the

two trains. The engineers on both trains and one

passenger riding on train 1254 were killed in the

collision.

Accident Narrative

According to New Jersey Transit (NJT)

officials, signal problems north of Suffern, New

York, on the evening of February 8, 1996,

resulted in a disruption of rail operations the following morning.2

 To accommodate a backlog of

passengers on the more heavily traveled portions

of the line from Suffern, New York, to

Hoboken, New Jersey, the NJT’s Hoboken control center provided additional service. To staff

one of the extra trains, the chief road foreman

asked a train crew who had just completed their

regular shift at 7:28 a.m. if they would be interested in operating a train from Waldwick to

Hoboken. The crew accepted the assignment.

The road foreman later said that none of the

crewmembers acted or appeared tired when he

offered them the extra run.

This added service, NJT commuter train

1254, consisting of a diesel locomotive unit and

five passenger cars, departed Waldwick station

at 8:03 a.m. Its three-man crew comprised an

engineer, a conductor, and an assistant conduc-

 

1 An interlocking is an arrangement of signals and signal

appliances interconnected such that operation and/or movement of the components must succeed each other in proper

sequence.

2 The events in this narrative are reconstructed using

recorder data and testimony from NJT personnel and train

passengers. All times are eastern standard time.

tor. Shortly after Waldwick, train 1254 was

lined to Bergen County line track No. 2. The

conductor for train 1254 later stated that he took

no exception to the engineer’s train handling,

including his braking, his responses to communication signals, and his positioning of the

train at stations. Event recorder data indicate

that the engineer was operating the train in

compliance with applicable speed restrictions

during the trip.

Meanwhile, NJT commuter train 1107, consisting of a diesel locomotive unit and six passenger cars, left Hoboken at 8:31 a.m. en route

to Suffern. The train had a crew of three, including an engineer, a conductor, and an assistant

conductor, and was carrying about 125 passengers. Two NJT engineers who were deadheading

to other assignments were on board train 1107.

Neither the off-duty NJT engineers nor the conductor and assistant conductor took exception to

the engineer’s train handling.

INVESTIGATION

Figure 1—NJT train 1254 originated at Waldwick

and was en route to Hoboken via the Bergen Line.
2

Hoboken tower personnel who were controlling area signal operations the morning of

February 9 said that train 1254 had not “hit the

bell”3

 at the approach signal to the West End

interlocking when train 1107 departed Hoboken.

The tower therefore “held” signal 28E-1; that is,

it maintained a stop indication at the signal, in

case train 1254 approached the interlocking

before train 1107 cleared it.

When train 1254 left Harmon Cove station

about 8:33 a.m., it was carrying about 275 passengers. The engineer accelerated to 53 mph.

According to tower personnel, as train 1254

neared the West End interlocking, the approach

signal (R-6) would have been displaying a

Medium Approach signal and the signal at the

interlocking (28E-1) would have been displaying a stop indication. Event recorder data indicate that when train 1254 passed the approach

signal, it was traveling about 34 mph and its

throttle was in idle, meaning it was coasting.

The train continued slowing until about 71 feet

before 28E-1, at which point the engineer applied the throttle and train 1254 accelerated past

the Stop signal traveling about 20 mph. Shortly

thereafter, train 1254 went into emergency braking. It continued onto the Main line track No. 1.

At the same time, westbound train 1107, operating on a clear signal on Main line track No. 1,

entered the interlocking traveling 53 mph. Train

1254 was moving about 18 mph when the

collision occurred about 165 feet past signal

28E-1 (figure 2).

Train 1254 had been operating in the push

configuration with the locomotive in the rear

and the engineer controlling the train from a cab

car in the lead. Train 1107 had been operating in

the pull mode with the engineer controlling the

train from the locomotive in the lead. The right

corner of train 1254’s cab car struck the right

corner of train 1107’s locomotive and was

sheared off. The conductor of train 1254 later

stated that he had been collecting tickets and

walking in the direction of the engineer’s compartment when the train began “ripping apart.”

 

3 As trains pass given signals in the system, a bell rings to

alert tower personnel controlling the switches and signals.

The cab car derailed and came to rest at a 45-

degree tilt to the track. The locomotive and the

first five trailing cars of train 1107 derailed

(figure 3).

Error! No topic specified.

Figure 2—Accident layout. Train 1254 was in the

push configuration with the locomotive in the rear

and the engineer controlling the train from the

cab car in the front. Train 1107 was in the pull

configuration with the engineer operating the

train from the locomotive in the front.

4

Damages

The NJT provided the damage estimates

shown in table 2. A detailed description of damages appears in the Wreckage section of this

report.

Table 2 — Damage Estimates

Equipment - Cars $1,128,624

Equipment - Locomotives 2,200,000

Track Repair 50,000

Wreckage Removal 50,000

TOTAL $3,328,624

Personnel Information

Safety Board staff reviewed the personnel

files and work records of all crewmembers involved in the accident. The job history and medical information for the train 1254 engineer

follows. Information about the engineer of train

1107 appears in appendix B.

General—The 59-year-old engineer of

train 1254 had been employed by NJT and its

predecessors for 40 years. He was promoted to a

locomotive engineer on January 4, 1961. He had

passed his last rules examination on February

21, 1995. He was recertified for his position as a

locomotive engineer on March 24, 1994, receiving an operating evaluation rating of 3.34, or

“Standard” on a scale of 5, and an efficiency test

rating of 91.5 percent. During the 3 years before

the accident, company officials had made 242

announced and unannounced observations of

him for rules compliance as part of the NJT’s

normal operating procedures. (See Operations

section in this report.) Of the 242 compliance

checks, 56 involved adhering to signal indications. His compliance rate overall was 97.52

percent. Of the six infractions noted, five were

minor offenses resulting in verbal reprimands;

none of the six infractions involved failure to

comply with signal indications. Table 3 shows

all disciplinary actions listed in the engineer’s

personnel records for the period between 1983

and 1993.

Based on his seniority, the engineer had

been able to select the duty assignment of his

choice. Since 1992, he had elected to work an

overnight split shift as allowed by the Hours of

Service Act, as revised (49 CFR 228). Monday

through Friday, he reported for duty at 6:11 p.m.

at Hoboken terminal, completed five train

movements, and then marked off duty at 12:58

a.m. at Suffern for a rest period of 4 hours and

47 minutes. He then went back on duty at Suffern at 5:44 a.m. and operated a train back to

Hoboken terminal, where he went off duty at

7:28 a.m. According to other crewmembers who

worked this assignment, the engineer normally

would rest in the coaches at Suffern for about

41⁄2 hours before reporting back on duty.

Table 3—Disciplinary Actions Against the Engineer of Train 1254

Date Action Infraction

1-26-83 30 Day Suspension Derailed engine in yard

9-26-85 Reprimand Reported late for duty

6-2-86 45 Day Suspension Passed stop signal

7-10-87 10 Day Suspension Passed passenger stop

7-20-89 Reprimand Reported late for duty

12-28-89 30 Day Suspension Passed stop signal
5

Duty/Rest Schedule—The Safety Board

reconstructed the engineer’s activities during the

3 days before the accident using NJT records

and statements from his co-workers and his

spouse (table 4). The conductor of train 1254

had worked the split shift with the engineer off

and on for almost 2 years. He testified that although he and the engineer never really talked

about their daytime routines, he thought that the

engineer normally slept in the afternoon. He

said that the engineer never appeared to have

any problems getting to sleep and staying asleep

during the break in their shift. Further, the conductor said that during the years that they had

worked together, the engineer had never complained of being tired and had never appeared

tired, including the night before and the morning

of the accident.

The engineer’s wife was employed outside

the home and usually left for her job about 6:30

a.m., before he returned from work. On weekdays, they typically saw each other only during

the late afternoon. She said that to her knowledge, he spent his off-duty hours around the

house watching television, sleeping, or at a

nearby marina working on his boat.

Other Activities—In her statement to the

Safety Board, the engineer's spouse said that he

did not work a second job or have a business.

Investigators determined that the engineer reportedly had owned a Staten Island, New York,

company, JDC Enterprise, during the 10 years

before the accident. The business, which he

operated with one of his sons, was engaged in

rebuilding automotive and marine starters and

alternators. During his time off duty from NJT,

he was involved in all aspects of the business,

including taking orders and making deliveries to

customers. Owners and managers of area auto

parts stores and marinas characterized him as an

honest and reliable businessman.

General Health—The engineer's spouse

reported that he was “never sick,” that he had

not suffered from any illnesses or unusual life

events in recent months, and that he was

physically and mentally in good health at the

time of the accident. He had not suffered any

financial or personal problems and had indicated

to her that he planned to work until age 65 or

older and then retire to Florida. According to his

spouse, he did not drink alcoholic beverages or

smoke tobacco products, and did not use illicit

drugs. She said that he took a pill twice daily for

diabetes, but otherwise kept his medical

condition to himself. She said that he had worn

bifocal glasses for about 2 years and that she

had not noticed a significant change in his

hearing or vision. She did not know if he had

any color perception problems. She said that he

was due for a medical examination at the time of

the accident.

Medical History—NJT medical examination records indicate that the engineer was

Table 4—72-Hour Work/Rest History

of the Train 1254 Engineer

Date Activity

Feb 6

Daytime activity unknown. After wife

returned home with carryout, he ate

dinner about 5 p.m. and left for work at

5:20 p.m. according to his routine.

Feb 7

Daytime activity unknown. Wife found

him sleeping on couch when she

returned home. He ate dinner and left

for work at 5:20 p.m.

Feb 8

Daytime activity unknown. Wife found

him asleep when she returned home at

3:15 p.m. She woke him at 4:50 p.m.,

whereupon he ate dinner and left for

work at 5:20 p.m. Crewmembers stated

that the engineer reported on schedule

at 6:11 p.m.

Feb 9

Marked off duty on schedule at 12:58

a.m. at Suffern yard. Slept about 4.5

hours in a passenger coach of his train.

At 5:30 a.m., another crewmember

woke him and he reported for duty on

time at 5:44 a.m. He operated his train

to Hoboken, arriving at 7:13 a.m., and

went off duty. He accepted an overtime

assignment and dead-headed to Waldwick, arriving at 7:57 a.m. He departed

Waldwick operating train 1254 at 8:03

a.m. When the accident occurred at

8:40 a.m., he had been in an overtime

status 1 hour and 12 minutes.
6

medically disqualified from his duties for 2

weeks in 1987 after sugar was detected in his

urine during an annual physical examination.

After visiting his personal physician, receiving

prescribed medication, modifying his diet, and

lowering his blood sugar, he returned to the NJT

physician, who determined that he was medically qualified for duty.

NJT records show that the engineer received

his last company physical on February 6, 1995,

and was found to be medically qualified for

duty. His next NJT physical was due during

February, 1996. NJT records indicate that he received a random drug/alcohol test, which checks

only for the presence of illicit or disqualifying

drugs, on January 24, 1996, 3 weeks before the

accident. The test was negative.

The engineer’s NJT medical file contains no

record indicating that he had diabetes. As part of

the NJT annual examination, employees are required to fill out a medical history form that has

40 “yes” or “no” questions about present and

past medical conditions. Since 1985, the engineer had answered “no” to the following

questions on every NJT medical examination,

including his most recent physical in 1995.

Since your last examination in the

Medical Department:

• Have you been examined or treated

by any physician or other practitioner?

• Are you taking any medicine?

• Have you had diabetes?

• Have you taken any medication in

the past 60 days? If so, what and

why?

The Safety Board subpoenaed and reviewed

the engineer’s personal medical records and

interviewed his personal physician. The doctor

stated that the engineer had been a non-insulindependent (type II) diabetic for 19 years and, as

a result, suffered from peripheral vascular

disease, which affects blood vessels, especially

in the extremities. She said that she had counseled him about his condition and treated him

with various oral medications to reduce high

blood sugar since 1982, and he had been essentially asymptomatic until 1987. In 1987 and

1988, she had prescribed Diabinese for elevated

blood sugar.

During the 6-year period between 1988 and

1994, the engineer did not visit any physician. In

1994, he saw his personal doctor with complaints of weakness, numbness in his toes, a foot

lesion that would not heal, and a persistent cold,

which he attributed to working two jobs. Laboratory tests indicated elevated blood sugar levels,

and the doctor prescribed Glynase to control his

blood sugar and other medications. At that time,

she referred him to an ophthalmologist for an

eye examination.

During a 1995 examination conducted by

his personal physician, the engineer had a very

high blood sugar level for which the doctor

prescribed Glucotrol. She learned that he had

been seeing an eye surgeon and had undergone

laser surgery treatments in both eyes for diabetic

retinopathy, an eye disease that damages the

blood vessels of the retina, frequently causing

severe and permanent vision loss.

Visual Acuity—Records of the eye examination given during the engineer’s latest

company physical in February 1995 indicate that

his visual acuity was 20/40, corrected to 20/20,

and that corrective lenses were required for

reading and distant vision.

The Safety Board obtained copies of the eye

surgeon's medical records. An April 1995

(Snellen4

) examination indicates that the engineer had 20/40 vision with correction in his

right eye and no central vision in his left eye.5

Documents show that since April 1995, the eye

 

4 Hermann Snellen (1834-1908), a Dutch ophthalmologist,

developed the type of charts with lines of progressively

smaller letters that are now universally used as a simple test

of visual acuity.

5 As opposed to peripheral vision, central vision is that

portion of the visual field closest to the center (visual axis),

where the density of (primarily color) vision receptors is
7

surgeon had treated the engineer for diabetic

retinopathy using a combination of focal, grid,

and panretinal photocoagulation6

 laser eye surgeries as the engineer’s vision deteriorated. By

December 1995, he had 20/400 vision with

correction in the left eye, and 20/70 with correction in the right eye.7

 On January 19, 1996, he

had visited the eye doctor to report that he had

experienced “smoke” in his right eye for 2 days.

On January 26, 1996, 2 weeks before the

accident, his visual acuity remained unchanged,

and he underwent additional panretinal photocoagulation laser surgery to his right eye. He

had not had a follow-up examination with his

personal physician before the accident occurred.

Color Vision—The only records containing information about the engineer’s color

vision were the NJT annual medical examination files. According to the engineer’s certifying

 

highest in the retina, and where form and color vision are

most acute. Generally refers to at least the central 5 degrees

of the visual field.

6 A treatment making hundreds of small laser burns away

from the center of the retina, shrinking abnormal blood

vessels. Loss of peripheral vision results, and loss of color

and night vision is not uncommon.

7 That is to say, while wearing prescription lenses, the train

1254 engineer had to be within 20 feet of a reference point

to identify what a person with normal (20/20) vision could

discern from 400 feet or 70 feet (the engineer’s left eye and

right eye, respectively).

NJT physician, trained personnel administer the

Dvorine Pseudo-Isochromatic Plates (PIP) test

in an examination room lighted with overhead

fluorescent (cool white) lamps. Investigators

examined the Dvorine PIP test book used to test

the engineer's color vision and found the book to

be in good condition.

In the Dvorine PIP test that was administered to the engineer, the patient is shown a

demonstration plate having a red number on a

blue background and asked to identify it from a

distance of 30 inches. The person is then asked

to call out numbers on 14 other plates having

different color combinations. The testing

instructions contain the chart shown in table 5

for estimating the degree of color vision defect.

(Appendix C contains a copy of the complete

testing protocol.)

The engineer had been tested in this manner

annually by the same NJT contract physician

since at least 1985. Between 1985 and 1993, he

missed none of the Dvorine plates. In 1994, he

missed 2 of 15 plates. During his February 1995

test, he missed 6 of the 15 plates and was classified as having a moderate color vision handicap.

The physician said that because of the number

of plates that the engineer missed, he then gave

him the Dvorine Nomenclature Test to further

evaluate his color vision. The nomenclature test

involves having the patient identify colors as the

Table 5— Dvorine PIP Test Classifications

Number of

Plates Missed

Degree of

Color-Blindness

Expected

Percentages

Degree of

Handicap

0 to 2 Normal 89.5 No handicap, Acceptable

3 to 4 Borderline 3.0 Mild handicap. May improve score on

retest. Acceptable

5 to 11 Moderate 2.0 Moderate handicap. May be employed in

occupations where critical color judgment is

not essential. Not acceptable for civil

aviation.

12 to 14 Severe 5.5 A definite handicap and hazard to industrial

and military occupations. Not acceptable for

civil aviation.
8

tester rotates an eight-color disk. The testing

protocol states that the nomenclature test is not

a test of color discrimination ability, stating

“...many color blind individuals learn to name

the colors correctly by their brightness instead

of their hue....”

According to the physician, when the

engineer successfully identified the colors presented in the Dvorine nomenclature test, he

medically certified him for duty.

The Safety Board consulted a color vision

expert from the Federal Aviation Administration's Civil Aeromedical Institute. His report

states that the Dvorine PIP Test is a highly valid

and reliable test for differentiating normal color

vision from any color vision deficiency, including the type that can occur due to advanced

diabetic retinopathy and other causes.

Driver History—Safety Board investigators examined New York and New Jersey

driver and accident records to determine if the

engineer had any traffic violations or had been

involved in any motor vehicle accidents where

he lived or worked. His New York driving

record contained no record of traffic violations.

Jersey City (New Jersey) Police Department

records indicate that on December 9, 1995, the

engineer had been involved in a collision in

which the engineer failed to negotiate a righthand curve in the road, skidded, and struck a

vehicle traveling in the opposite direction in the

curve. The police investigators did not charge

the engineer with a violation.

Train Information

Both trains were configured for push/pull

service, which allows trains to make round trips

without repositioning the locomotive unit. A

locomotive is at one end and a control (cab) car

is at the other end of the consist. The locomotive

provides the power, which the engineer controls

either directly from the locomotive or remotely

from the cab car. When the engineer operates

from the locomotive, the train is in the pull

mode; when he operates from the cab car, the

train is in the push mode.

Train 1254—Eastbound train 1254 had

been operating in the push configuration with

the locomotive unit in the rear and the operator

controlling the train from a cab car in the lead.

Front to back, the 6-unit consist included cab car

5146, coach cars 1760, 1603, 1738, and 1728,

and locomotive unit NJT 4110 (a GPH40

model). During the on-site postaccident examination, Safety Board investigators found that

the controller mechanism had been ripped out

and was on the ground under derailed equipment. Investigators noted that the automatic

brake handle was in the emergency position, the

pilot valve was cut in, and the lock mechanism

was intact, although its key was missing. The

alerter mechanism had been ripped out and was

among debris inside the front of the cab car.

Train 1107—Westbound train 1107 was in

the “pull” configuration with the operator

running the train from a locomotive in the lead.

Front to back, the 7-unit consist included

locomotive unit NJT 4148, coach cars 5712,

5739, 5708, 5735, and 5815, and cab car 5120.

During the on-scene postaccident inspection,

investigators noted that the throttle was in the

number 8 position, the automatic brake valve

was in the release position, the reverser was in

the forward position, the independent brake

valve handle was on the floor, and the engine

run switch was in the run position.

Safety Board investigators examined the

mechanical records, which indicate that all

FRA-required inspections and tests had been

conducted on the accident equipment. Maintenance records disclose only routine maintenance

patterns and no recurring problems or trends.

Track

The accident occurred on the NJT railroad

at milepost (MP) 2.8 within the limits of the

West End interlocking. The Bergen County line

connects to the West End interlocking via

Bergen Junction interlocking (MP 3.3).
9

At the accident site, the Main line track

grade has a 0.52 percent descent from east to

west. The maximum allowable speed on the

Main line is 60 mph. The Bergen County line

track grade has a 0.72 percent ascent from west

to east. The maximum allowable speed of this

section of the Bergen County line is 60 mph;

however, the proximity of signals limit the

operating speed to medium, or 30 mph. The two

Main line tracks merge at a right-hand switch.

Inspection of the switch disclosed no defects.

Investigators observed sand on the rail from the

locomotive’s lead axle to a point 47 feet 3

inches behind train 1254, a distance of 108

feet.8

According to NJT officials, the tracks in the

collision area receive a walking inspection twice

a week. Track inspection records for the 3

months before the accident, including the last

inspection on February 5, 1996, indicate that no

anomalies had been detected in the derailment

area. Geometry car inspections of the Main line

track No. 1 and the Bergen County line track

No. 2 in the derailment area on October 2, 1995,

indicate no exceptions were taken. The most

recent detector car examination on December

12, 1995, indicates no defects were found.

Signal

The Main line has an automatic block signal

(ABS) system, meaning train movement is

controlled by the circuitry in the rail and that

each of the two Main line tracks is signaled in

one direction with signals that automatically

indicate track conditions ahead. The Bergen

County line has a traffic control signal system,

meaning train movement is controlled by the

tower personnel (at Hoboken) and the two tracks

are signaled for movement in either direction.

The Bergen Junction interlocking has search

light-type signals that govern movements in both

directions through the interlocking.

 

8

 The emergency braking system includes a box of sand,

which is forced through a hose over the wheels and onto

the rail whenever the train is placed in emergency braking.

The dumped sand allows for increased traction and therefore better stopping distances.

The three main tracks comprising the West

End interlocking have Transcontrol color light

signals (figures 4 and 5), General Railway Signal (GRS) Company model 5G electric switch

machines, and 100 Hz phase selective track

circuits.

The initial postaccident investigation disclosed that all signal housings had been properly

locked, sealed, and protected against tampering

until the Safety Board could examine the signals

in the accident area. Investigators documented

the position of the vital relays, including the

date they were last tested. They took ground

readings at all locations to determine whether a

Signal 28E-1 is a

pole-mounted, longrange color-light-type

device having three

heads arrayed vertically. The top head

has one lens, which

is always illuminated

red, and the two

lower heads have

two “active” lenses,

yellow and red,

which are illuminated

depending on the

signal indication. An

enlargement of the

lower head is below.

As manufactured, this model of signal head

has three lenses: green at upper right, yellow

at upper left, and red at lower middle.

However, a carrier using two-aspect combinations in its signal system, such as NJT,

can order the signal head with a blank lens.

Figure 4—Type of light unit at Signal 28E-1.
10

ground could have caused the false energizing

of a signal circuit. The position of certain relays

and illumination of certain lights on the local

control panel (LCP)9

 at the central instrument

location (CIL) at the West End interlock

 

9 The 28 east stick relay (28ESR) was energized and the 28

west stick relay (28WSR) was de-energized. According to

West End Signal plans, this indicates that the route had

been established for westbound movement.

ing indicated that switches Nos. 37, 39, and 49

had been lined and locked in position and that

signal 24W had been displaying an indication

for a westbound train to proceed on track No. 1

(figure 6).

Safety Board investigators had all lamps

illuminated at signals R6, 28E-1, and 24W, and

recorded their voltages. No signal lamps were

burned-out. After inspecting the lamps on scene,

investigators had them removed and sent to the

Safety Board’s Washington, D.C., laboratory for

further analysis and testing. Safety Board metallurgists inspected a total of 14 signal lamps and

found that the filaments in all bulbs were intact,

appeared to be in working order, and showed no

evidence of damage, deformation, or separation.

Medium Approach indicates “Proceed prepared to stop at next signal. Trains exceeding Medium Speed must

begin reduction to Medium Speed as soon as the Medium Approach signal is clearly visible.”

Restricting indicates “Proceed at Restricted Speed until the train has passed a more favorable signal.”

Figure 5—Alignment of aspects for indications displayed by signal 28E-1. According to industry

experts, the alignment of lenses on this type of signal cannot be determined from a distance. Engineers

rely on the colors of the aspects.
11
12

On February 11, 1996, investigators conducted

“locking” tests of the electrical circuits to ensure

that the signals and signal appliances, such as

switches, operated properly, that is, did not

change within the prescribed relay time interval.

Investigators tested the relays, meggered all

cables, and verified all track circuits in the

routes. All tests revealed that the signal system

functioned as designed, in accordance with FRA

requirements.

The NJT Trouble Desk Logbook indicates

that the number of failures at the West End

interlocking and the Bergen Junction interlocking had been 92 and 47, respectively, during the

2-year period before the accident. The failures

included such routine signal system problems as

burned out bulbs, broken rails, blown fuses, and

defective relays, and no defects that could have

resulted in a train receiving “a more favorable

signal aspect than intended,” meaning any signal

indication other than a Stop indication.

Operations Information

General—Train movement over this

territory is governed by the Northeast Operating

Rules Advisory Committee (NORAC) Operating

Rules, fifth edition, effective January 1, 1995.

At the time of the accident, train and engine service employees were also governed by New

Jersey Transit Rail Operations Timetable No. 9

and Special Instructions in General Order (GO)

902, effective 12:01 a.m., January 1, 1996 (NJT

Timetable No. 9); Hoboken Division Bulletin

Order 9-H-S203, effective 12:01 a.m. February

3, 1996; Air Brake and Train Handling Rules

and Instructions, effective June 1, 1991; and

Hoboken Division Employee Train Schedules,

effective 2:01 a.m. on November 12, 1995.

The Main line train dispatcher at the Hoboken terminal is responsible for all train movements between the Bergen Junction interlocking

and Port Jervis, New York, which includes the

Main line, the Bergen County line, the Pascack

Valley line, and the Southern Tier line. The

Main line dispatcher also controls the interlockings on the Bergen County line and the

Main line.

Employee Oversight—Title 49 CFR Part

240 prescribes Federal safety requirements for

the eligibility, training, testing, certification, and

monitoring of all locomotive engineers. At a

minimum, railroad companies are required to

give locomotive engineers at least one unannounced operations test each calendar year.

Before this accident, the NJT policy was to have

supervisors or other testing personnel go to

outlying areas, such as Suffern, at least three

times a week to observe crews for rules

compliance. Records show that since January

16, 1996, the NJT made six unannounced observations of the train 1254 engineer’s operating

procedures, including four unannounced speed

compliance tests. The NJT made the most recent

speed compliance checks of the train 1254

engineer on January 25, 1996, 15 days before

the accident. The first test, a Limited Clear, was

at 6:33 a.m.; the second test, a Slow Approach,

was at 7:10 a.m. The engineer had been in compliance with all rules on which he was observed

and tested. Since this accident, the NJT has

increased the number of visits by testing personnel to Suffern to five a week.

Meteorological Information

Witnesses stated that the weather was clear

and sunny. A February 9, 1996, report from the

Newark, New Jersey, weather radar station

indicates at 8:50 a.m. the temperature was 42

degrees Fahrenheit with ceiling of 4,100 feet

and broken cloud cover. Visibility was 15 miles.

Medical and Pathological

Information

Fatalities—Citing religious reasons,10 the

family of the fatally injured passenger asked that

an autopsy not be performed on him, therefore

the type and scope of his internal injuries are

unknown. The examiner’s report shows that he

sustained a 1-inch laceration on his scalp, an

 

10 49 USC (United States Code) 1134 (f)(1) states, in part,

“...local law protecting religious beliefs related to autopsies shall be observed to the extent consistent with the

needs of the accident investigation.”
13

abrasion on his forehead, a contusion on his

right knee, and an abrasion on his left leg.

The engineer of train 1107 was killed at

impact. He sustained massive cranio-facial, cervical and thoracic injuries with traumatic amputation of the right arm.

The train 1254 engineer suffered multiple

blunt force injuries of the head and face with

multiple skull fractures; blunt force trauma of

the anterior neck with a fracture of the thyroid

cartilage; fracture and dislocation of the right

sternoclavicular joint; blunt force injury of the

abdomen with a laceration of the abdominal aorta, spleen, and associated hemoperitoneum;

fracture of the right femur and right patella; and,

multiple superficial abrasions, lacerations, and

contusions.

Injury Sources—Pathology photographs

taken during the engineer’s autopsy show a

scalp laceration with a circular serrated pattern.

Safety Board investigators and personnel from

the Armed Force Institute of Pathology (AFIP)

examined debris in the interior of cab car 5146

and an exemplar cab car in an attempt to determine possible sources of injury. Two possible

sources of injury were identified during these

examinations: the windshield control knob and

the brake handle.

Emergency medical personnel triaged about

400 passengers and treated 160 of them on

scene. Sixty-nine passengers and crewmembers

were transported to local hospitals for treatment

of minor to serious injuries, including contusions, strains, abrasions, lacerations, and fractures. Passengers surveyed stated that they had

been injured by striking interior surfaces, being

thrown into seatbacks and the aisles, striking

other passengers, or being struck by debris.

Toxicological Testing—In accordance

with FRA requirements at 49 CFR Part 219,

NJT administered toxicological tests to nine

employees on February 9, 1996, within 7 hours

of the accident. Six employees, including three

surviving crewmembers of trains 1254 and 1107

and the director, assistant director, and a

leverman at the Hoboken terminal tower, submitted blood and urine samples at St. Mary’s

Hospital in Hoboken. Medical personnel obtained samples from the injured conductor of

train 1254, who had been transported for treatment to the Meadowlands Medical Center in

Secaucus. Urine specimens from these employees were sent to Northwest Toxicology, Inc.,

Salt Lake City, Utah, for examination. All tests

were negative for drugs, including alcohol.

The New Jersey State Medical Examiner

collected blood and tissue specimens from both

fatally injured engineers for toxicological tests.

He reported that no drugs, alcohol, or other

compounds were detected in the blood of either

engineer. The engineer of train 1107 tested

positive for Salicylate (Aspirin) screen.

The Safety Board obtained toxicological

specimens from both engineers, which it forwarded for examination to the Center For

Human Toxicology in Salt Lake City, Utah. The

laboratory reported that caffeine was detected in

the blood specimens of both engineers. No other

drugs, including alcohol, were detected.

Survival Factors

This section is divided into four main sections: the NJT safety awareness program, postcollision actions by NJT crews, postcollision

actions by emergency responders, and the crashworthiness of the trains.

NJT Safety Awareness Program

Employee training—The NJT employee

training program has two types of courses: jobspecific, such as the “Assistant Conductor”

program, and skills enhancement, such as the

“Tunnel Evacuation” course and the “Passenger

Assistance/Sensitivity” course. All new operating employees, including engineers, conductors, assistant conductors, and dispatchers, are

required to take the program of classes specific

to their position before beginning work in that

type of job. Certain skills enhancement courses

are also required for employees in particular

jobs. All employees may request to take any of
14

the skills enhancement courses, but those whose

positions require the training have priority.

All of the job-specific courses include instruction on emergency procedures, including

types of emergencies, types of evacuations,

responsibilities of crewmembers, crowd control

techniques, and proper communications. Many

of the skills enhancement courses contain

applicable emergency procedures. Most of the

instruction is classroom lecture. Further, most of

the courses use written tests to evaluate what an

employee has learned. Courses such as the passenger assistance class and the customer sensitivity class do not administer written tests. Students are required to use the techniques taught

in role-playing scenarios, which the instructor

then critiques. None of the regular courses

includes site simulations, or drills, in emergency

procedures. Employees receive hands-on

training simulating an actual emergency on a

train only if they participate in joint disaster

drills with emergency response personnel.

The NJT training program requires all operating employees, including engineers, conductors, assistant conductors, and train dispatchers,

to attend an annual operating rules instruction

class and successfully pass a written test on the

subject matter presented. The railroad has no

time requirement for employees to attend

periodic refresher courses on emergency

evacuation procedures. Personnel records

indicate that the last time the conductors and

assistant conductors on trains 1107 and 1254

had received any emergency training ranged

from 1 to 9 years before the accident. When

interviewed after the accident, the assistant

conductor of train 1254 recalled that he once

had attended a training session on evacuating

from a tunnel. The train 1107 conductor recalled

having had emergency evacuation training. The

assistant conductor of train 1107 did not recall

having received emergency evacuation training.

Operating manuals—Each employee receives a copy of NJT’s Timetable No. 9 that

contains emergency evacuation procedures.

Further, the rail operations center in Hoboken

maintains for employee reference the NJT’s

Standard Operating Procedures Manual that

contains procedures for handling rail emergency

evacuations, smoke and fire in tunnels, and

bomb threats.

Public safety awareness—The NJT provides a brochure, Emergency Response Guidelines, to police, fire, and EMS personnel when

they attend the New Jersey Rail Operations

Emergency Responder Training Program. The

transit company also posts safety awareness

posters and places general and seasonal customer safety bulletins in the trains and stations. One

customer brochure includes procedures that

passengers should follow in the event of an

emergency on a New Jersey Transit train or bus.

Actions by NJT Crews—In addition to

interviewing the crews, the Safety Board sent

questionnaires to a sampling of the 400 passengers who had been on board the accident trains

to obtain their recollections of the events

following the collision. Of the 253 people surveyed, 71 responded to the questionnaire.

Crew recollections—The assistant conductor of train 1107 said that he and the conductor

were collecting tickets and talking to passengers

when he felt a jolt and the train came to a stop.

“I ran out, saw the cab car (of train 1254), and

went blank. I said to one of the deadheading

employees, ‘What do I say?’ He said (to call)

emergency.” The train 1107 assistant conductor

said that he started to make the call when he

heard someone else on the radio reporting the

emergency. He added, “The only thing I was

concerned about was the engineer (of 1254).”

He said that he screamed to another employee

that they had to help the engineer. He said that

as he ran into the train 1254 cab car, passengers

were scrambling out. He said when he saw the

bleeding conductor of train 1254, “I asked him

about the engineer and he asked me to help him

get the passengers out....”

The conductor of train 1107 testified that

she heard a bang, and the train started to lean to

the right. She said:
15

...my biggest fear was (if) everybody

stood up...that would tip us over the

rest of the way....I yelled for everybody

to stay calm....When I looked out, I saw

the cab car (of train 1254)....I ran back

to the radio (in the hind car), but there

was a lot of activity on the radio

already....By then passengers were

everywhere. They were on the

tracks....I don’t know what happened to

my rear brakeman (the assistant conductor)...he wasn’t on the train. As I

was walking forward I was thinking that

my engineer should be back here now,

and then I started to run. I started asking

the passengers, did anybody see the

engineer running back this way. And no

one said anything. Everybody was like

stunned or something.

The engineer who stopped his commuter

train to render assistance said that after radioing

Hoboken, he pulled his train to within one car

length of the accident trains and got out to check

on the engineer in 1107. When he saw the fuel

tank was leaking, he climbed aboard and “hit the

emergency fuel shutdowns.” When he got down

off the locomotive, he encountered the train

1107 conductor whom he described as

“hysterical.” He said that he told her to get herself together....(and) to “get those people back

on the train. We have fuel leaking. Don’t let

them light any cigarettes.”

One of the deadheading employees stated

that his first thought was that the accident trains

were blocking just enough track to cause

“another sideswipe” by a train traveling on the

adjacent track and that someone needed to flag

down any on-coming trains. He said that the

train 1107 conductor “...just wasn’t in the frame

of mind to think about that....We tried to calm

her down. She was screaming somebody was

dead up front.” He said that after checking out

the engineer in train 1254, he went around the

back end of 1107 where “...passengers were

milling all about.”

During postaccident interviews, the conductor of train 1254 stated that he did not know

whether the public address system had been

functional because he had not tried to use it. The

conductor of 1107 did not recall if the public

address system on her train was working.

Examination of the equipment after the accident

showed that the public address systems on both

trains were operating as designed.

Passenger observations—Several surveys stated that the crews did not provide any

instructions about exiting the train after the

collision. One passenger recalled that the crew

was “basically calm, instructing passengers on

where to go and how to proceed.” Another

passenger said that the conductor of train 1107

was crying when she told riders that a collision

had occurred and two people aboard the eastbound train had been killed. Several passengers

stated that they felt the crew was helpful in

instructing them to remain on board the train;

others said they felt uncomfortable remaining

onboard in case of a fire or being hit by an

oncoming train, so they decided to detrain.

Other surveys variously described the crew as

“crying and upset after the accident,” “fairly

upset and seemed rather nonfunctional due to

their emotional state,” or “dazed and stunned

like everyone else.” One responder stated that

the crews “...definitely did not take charge.”

Emergency Response—The accident

occurred in a remote area between Secaucus and

Jersey City, New Jersey, accessible only by a

single narrow, muddy dirt road. Upon being

notified of the accident at 8:40 a.m., Hoboken

dispatch center personnel first notified the NJT

central communication center, which in turn

dispatched three NJT police units to the scene

and notified emergency medical services (EMS)

personnel, police, and area fire departments.

According to incident command reports, 24

agencies responded to the accident. The Jersey

City Fire Department dispatched eight engine

companies, three truck companies, a special

squad, a rescue unit, and a hazardous materials

unit, totaling about 75 personnel. The Jersey

City EMS dispatched more than 90 units,

including 70 basic life support units, 8 advanced

life support units, 2 mass casualty response

units, 1 EMS rescue unit, 2 medical evacuation
16

helicopters, 8 supervisor units, 2 basic life

support non-transport units, and 1 field communications unit. Police reports indicate that 40

officers assisted with traffic and crowd control,

searched the trains, provided first aid, and

helped evacuate passengers.

The first NJT police officer arrived at the

scene at 8:53 a.m. Buses were sent to the scene

to transport passengers. Emergency personnel

said that the number and size of vehicles responding to the scene caused congestion and

made it difficult for them to maneuver emergency vehicles close to the collision site. The

incident commander subsequently established a

staging area for vehicles about 1/2 mile away

from the site to facilitate the movement of

ambulances. The NJT’s mobile command center

arrived at the scene about 10:30 a.m. to

coordinate the activities of responding agencies.

The fire chief stated that he had a problem

communicating with the different agencies at

the accident scene because various departments

were using radios tuned to different frequencies.

The fire chief said that because of the lack of a

common frequency, he continually had to move

from train car to train car and from train to train

to verbally coordinate activities with response

agency personnel.

According to the Hudson County deputy

emergency management coordinator, the county

had purchased a radio network system, which is

located at the Hudson County Police Department, about 15 years before this accident. The

system has one base station for each of the

twelve municipalities and one mobile unit for

each of three county areas, thereby affording all

response agencies the capability to communicate

on a common frequency. However, at the time

of this accident, only the Jersey City Fire

Department had purchased radios that were

compatible with the network system, therefore it

could not be used.

Following this accident, officials of the

responding agencies convened to critique the

emergency effort. As a result of the meeting, all

emergency response agencies agreed to purchase radios having the capability to carry the

county radio network frequency.

Wreckage—The lead truck of train 1254’s

cab car, unit 5146, had derailed about 4 to 5 feet

off of the rail. The roof of the car was sheared

off on the right side near the front end. Train

1107’s locomotive unit, NJT 4148, sustained

major intrusion and crush damage to the engineer’s side of the locomotive.

Train 1254—All five cars sustained damages; the locomotive unit had no reported damages. The lead unit, cab car 5146, which was a

Comet II type car (figure 7) with a body constructed primarily of aluminum extrusions and

aluminum sheet metal, suffered major damage.

The right11 buffer wing, which is attached to the

corner post stub, had separated from the car.

The end sheet had separated from the car. The

floor in the engineer’s compartment had been

sheared off. The trap door and stairwell were

missing. The right side of the compartment roof,

outboard of the collision post, had been sheared

off. A 10-foot section of roof rail had broken off

and lodged in the locomotive cab of train 1107.

The interior bulkhead directly behind the

engineer had been pushed rearward at the

bottom and pulled down at the top. The

engineer’s seat had folded back into the bulkhead. The first two seats aft of the bulkhead,

where the deceased passenger had been sitting,

had been pushed rearward into the seats behind

them. The space normally occupied by these

seats was filled with debris.

 

11 Right refers to the engineer’s side.


19

readily could see the approach signal (R6) from

the signal that preceded it (signal 422), a

distance of 5,000 feet. Investigators readily

could see signal 28-E1 from the approach signal

(R6), a distance of 1,230 feet. Neither weather

nor site conditions resulted in sight restrictions

from signal to signal.

Speed and Stopping Tests—The Safety

Board performed six tests, four of which were at

20 mph, the speed at which train 1254 was

traveling shortly after it passed signal R6. In two

20-mph-tests in which a full service brake was

applied, the respective stopping distances were

165 feet 10 inches and 166 feet. In the two 20-

mph-tests in which emergency braking was

applied, the respective stopping distances were

210 feet 1 inch and 246 feet 8 inches.

Event Recorders—The locomotive unit

and the cab car of both trains were equipped

with event recording machines. Safety Board

investigators removed the recorders shortly after

arriving on scene, and together with FRA, and

NJT investigators, downloaded the data from

each machine for tests and simulations. The

recorders were then delivered to the Safety

Board’s laboratory in Washington, D.C. for further analysis. The event recorder on the train

1254 locomotive taped data related to the train’s

movement, such as time, speed, throttle, and

reverser position. The Safety Board found that

the tape for the cab car recorder, which registers

brake applications, had not been fully inserted;

therefore, analysts could not verify when the engineer had applied the brakes..12 The laboratory

report on the tape readout indicates that after

train 1254 departed Harmon Cove station eastbound on the Bergen County line, its speed

increased to 53 mph, then gradually reduced to

34 mph at the R6 signal, and then to 23 mph

when it was 71 feet from the stop signal at 28E1. At this point, the throttle was applied and the

train accelerated. Train 1254 continued past the

 

12 The FRA granted the NJT a temporary waiver of compliance from certain provisions of Title 49 CFR Part

229.135 requiring that all trains operating over 30 mph be

equipped with event recorders by May 1995. The NJT has

an extension until May 1997.

stop signal and was traveling about 18 mph

when it struck train 1107.

Other Information

NJT Postaccident Actions—In addition

to having its staff conduct an investigation of

the Secaucus accident, the NJT convened a

committee to assess potential risk factors to

safety within its operations. In a letter to the

Safety Board, the executive director of the NJT

listed the staff recommendations endorsed by

the NJT Board of Directors, including the elimination of the transit company’s two overnight

split shift assignments by September 1996 and

installation of signal system enhancements by

2001. The NJT official stated that the industry’s

decreasing use of such overnight split shifts and

recent studies had prompted the company’s decision to eliminate overnight split shift assignments. The official indicated that the NJT had a

capital improvement program that originally had

called for cab signals and positive train separation (PTS) systems to be installed in all trains

by 2006. The letter states, “By December 31,

1997, all NJ Transit rail lines will be equipped

for either cab signals or positive train stop, and

by December 31, 2001, all NJT lines will be

equipped with both technologies.”

Further, NJT officials advised the Safety

Board that they have enacted more stringent

disciplinary measures for locomotive engineers.

Before this accident, the NJT had suspended

engineers who passed stop signals for a

minimum of 30 days in accordance with FRA

regulations. The NJT now requires the engineer

to attend a special recertification training class

before returning to work. Additionally, rather

than impose a suspension of at least 1 year as

required by FRA regulations, the company

policy now requires that an engineer be dismissed for a second stop signal violation.

FRA Emergency Order—As a result of

this accident and a February 16, 1996, nearhead-on collision between a commuter train and

a National Railroad Passenger Corporation

(Amtrak) train near Silver Spring, Maryland, in
20

which 11 people died, the FRA issued Emergency Order No. 20 (the Order) on February 21,

1996, which contains immediate and proposed

rules changes for commuter and intercity passenger railroads. The Order requires such railroads to prepare and file with the FRA an

interim safety plan that addresses, among other

issues, management of operating crews. The

Order notes the NJT’s decision to eliminate

night split shifts following the Secaucus accident and requires that passenger railroads to

review their operations “to determine if opportunities exist for risk reduction similar to the

action taken by New Jersey Transit.”

Medical Standards

Federal standards—The fitness requirement for certification of locomotive engineers

contained in CFR Part 240.121 (c ) states,

“Except as provided in paragraph [240.121]

(e),” a person must meet or exceed the following

visual acuity thresholds:

(1) For distant viewing either

(i) Distant visual acuity of at least

20/40 (Snellen) in each eye

without corrective lenses or

(ii) Distant visual acuity separately

corrected to at least 20/40

(Snellen) with corrective lenses

and distant binocular acuity of

at least 20/40 (Snellen) in both

eyes with or without corrective

lenses;

(2) A field of vision of at least 70

degrees in the horizontal meridian

of each eye; and

(3) The ability to recognize between the

colors of signals.

Paragraph (e) states:

A person not meeting the thresholds...of this section may be subject to

further medical evaluation by a railroad’s medical examiner to determine

that person’s ability to safely operate a

locomotive. If the medical examiner

concludes that, despite not meeting the

threshold(s), the person has the ability

to safely operate a locomotive, the

person may be certified as a locomotive

engineer and such certification conditioned on any special restrictions the

medical examiner determines in writing

to be necessary.

NJT protocol—According to company officials, NJT has had a standard practice addressing physical requirements for personnel before it

took over the commuter rail system from Conrail in 1983. The NJT contracts with area practitioners to perform employee physicals. In

1990, the company appointed a full-time

medical services chief who established a protocol of visiting the fee-for-service physicians to

determine if their offices complied with NJT’s

basic standards. Before this accident, the NJT

medical services staff last had made an oversight visit to the company’s contract physicians

in 1993, at which time several offices were

dropped from contract for failing to maintain

NJT’s basic medical standards.

After this accident, the NJT Medical Office

established specific fitness for duty standards,

including vision testing requirements, for rail

operations employees. The NJT has given each

of its contract doctors a handout listing the tests

to be conducted for each class of employee and

what measures to take if any abnormalities are

detected. The testing protocol states, “Employees are not to be returned to work unless the

medical issues are resolved in full.”

The NJT vision screening now requires the

physician to conduct ten tests, including the

Dvorine PIP test or a comparable color-screening examination, the Ishihara PIP test. Further,

the NJT testing protocol now requires a physician to refer an employee for additional testing

if the employee cannot identify any one of the

15 Dvorine plates.

The medical services director also conducted a program of review related to employee

physicals to ensure the compliance of its fee-for-
21

service practitioners with Federal Regulations

and NJT Corporate procedures. Medical services staff visited each of the contract

physicians to review their operations and to

determine if they had any questions about or

problems with NJT protocol. The medical services director stated in a February 1997 letter to

senior company officials that as a result of the

1996 oversight visits by medical staff, she had

dismissed some of the NJT contract physicians

and hired others who have facilities that will

enable them to “consistently comply with our

standards.”

Railroad Safety Advisory Committee

Background—The Railroad Safety Advisory Committee (RSAC), a group of carrier,

union, and government representatives, was

established to provide advice and recommendations to the FRA regarding the development

of the railroad safety regulatory program,

including the review and revision of existing

regulations. The RSAC structure has three

levels: (1) the RSAC committee itself; (2) working groups responsible for developing recommendations on one or more tasks assigned to the

RSAC by the FRA; and (3) task forces that

accumulate data and recommend actions for the

working groups.

Pending issues—On October 12, 1995, the

FRA presented an issues paper to RSAC asking

the committee to determine by July 1997 the

adequacy of the current engineer qualifications

standards. The FRA asks RSAC to review,

among other safety considerations, the hearing

and vision acuity standards in 49 CFR 240. The

issues paper states:

FRA believes that the current hearing

and vision acuity standards comply with

the Americans With Disabilities Act and

that they adequately assure that locomotive engineers possess the requisite

physical abilities to do their jobs.

Meanwhile, FRA is aware of at least

two or three persons who were

dissatisfied with the way in which the

rule was enforced to their detriment. In

addition, FRA is aware of at least one

instance in which an engineer was

denied certification by one railroad due

to the inability to recognize and

distinguish between the colors of signals

and yet was certified by another railroad....FRA recommends that RSAC

refer this issue for review by a working

group if RSAC can develop any

reason(s) why the current rule may need

amending.
General

This analysis is divided into three main

sections. In the first part, the Safety Board

identifies factors that can be readily eliminated

as causal or contributory to the accident as a

result of its investigation. The second section

focuses on the accident sequence, discussing

actions and events resulting in problem conditions. In the final section, the Board discusses

the findings that support each safety issue

identified in this investigation.

Exclusions

The weather and visibility were not factors

in this collision. Witnesses stated that it was

clear and sunny. During visibility tests conducted at the same time of day and in similar

weather conditions, Safety Board investigators

determined that no shadows, reflections, or glare

from the sun would have limited the visibility of

the signals. Nothing in the predeparture tests,

the postaccident equipment inspection, or the

event recorder data indicated any equipment

failure. Also, the train crew reported no

mechanical problems while the train was

enroute. Pre-and postaccident track and switch

inspections showed no anomalies. Pre- and

postaccident inspection of the signal system

indicated that the signal system functioned as

designed, in accordance with FRA requirements.

Signal inspection reports and block operators'

statements indicated no deficiencies that would

prevent proper operation of the signal system.

Therefore, the Safety Board concludes that the

weather, the train equipment, the track, and the

signal system did not cause or contribute to the

collision.

All crewmembers had the necessary initial

training to competently perform their operational duties. The toxicological tests for alcohol and

drugs were negative for all those tested. No

evidence indicated that fatigue may have

affected the crewmembers’ performance. The

Safety Board particularly scrutinized the work

habits and rest cycle of the engineer of train

1254. Although a complete account of his

daytime activities could not be reconstructed,

observations by his co-workers and his spouse

indicate that he did not vary from his regular

routine and that he probably received his usual

rest. He may or may not have worked at his parttime business after getting off work Thursday

morning; he slept Thursday afternoon before

reporting for work; and he slept about 4.5 hours

during his split shift break. At the time of the

accident, the 1 hour and 12 minutes that he had

been in an overtime status for the railroad

probably coincided with the time that he usually

was preparing to begin work at his business. The

Safety Board therefore concludes that fatigue,

operational training, and alcohol or drug use

were not factors in the collision.

Analysis of the Accident

Eastbound train 1254 departed Harmon

Cove station en route to Hoboken about 8:33

a.m. Event recorder data show that the engineer

was actively controlling his train from the time

he left the station until the collision. According

to block operators controlling the signals, as

train 1254 neared the West End interlocking, the

approach signal was displaying a red/yellow/

red aspect, indicating proceed prepared to stop

at next signal (in this case signal 28E-1). Event

recorder data show that when train 1254 passed

the approach signal, it was coasting, which

would be a common maneuver by an experienced operator who was allowing rolling

resistance to slow the train in preparation to

respond to the next signal. However, when train

ANALYSIS
23

1254 was less than 100 feet from signal 28E-1,

which was displaying a red/red/red, or Stop, indication, the engineer applied the throttle,

accelerating the train past signal 28E-1 at 20

mph. Sand on the tracks indicates that the train

went into emergency braking shortly thereafter,

probably the result of the engineer applying the

brakes when he saw that the interlocking track

was not lined for him or that train 1107 was in

his path. Despite the emergency brake application, train 1254 was traveling 18 mph when it

struck westbound train 1107, which was

traveling 53 mph on a clear signal on main line

track No. 1. The right front corner of train

1254’s cab car struck the right front corner of

train 1107’s locomotive, instantly killing the

engineer of train 1107. The engineer and a passenger in the cab car of train 1254 also died as a

result of injuries sustained in the collision.

The Safety Board identified three primary

safety issues in this accident: the medical condition of the train 1254 engineer, the adequacy

of medical standards for locomotive engineers,

and the adequacy of the train crews’ response to

the accident. The Safety Board also examined

crashworthiness of the trains and the response

effort by emergency personnel.

Medical Condition of the Train

1254 Engineer

The Safety Board attempted to determine

why the train 1254 engineer, a highly experienced railroad employee with 40 years overall

railroad service and 34 years service as a locomotive engineer, proceeded past the stop indication at signal 28E-1. His operating errors

since 1989 had been minor infractions, typically

resulting in verbal warnings. He had been

recertified less than 2 years before the accident.

Postaccident tests determined that all signals in

the vicinity of the interlocking were functioning

properly.

In his approach to signal 28E-1, the engineer

did not merely fail to stop; he actually

accelerated as if he had received a more favorable signal indication. Signal 28E-1 is a polemounted, long-range color-light-type device

with three heads in a vertical array. During postaccident sight distance tests, when Safety Board

investigators were measuring the sight distance

to the approach signal (R-6), they readily could

see the colors of the illuminated lenses on two

heads of signal 28E-1. Had signal 28E-1 not

been partially obscured by brush next to a curve

in the track, testers would have been able to

state that the sight distance to signal 28E-1 was

more than a mile. The investigation disclosed

that the medical condition of the engineer,

specifically his diabetic retinopathy and resulting color vision deficiency, probably affected

the manner in which he operated his train on the

day of the accident.

During its review of NJT medical records,

the Safety Board noted that the train 1254

engineer had been medically disqualified from

duty in 1987 when a urine sample taken during

his company physical showed the presence of

sugar. The medical files of his personal physician revealed that at the time of the accident, the

engineer had been a non-insulin-dependent (type

II) diabetic for 19 years. As part of its physical

examination protocol, the NJT requires its

employees to report certain medical conditions,

including diabetes, and the use of all prescription medications on a medical history form.

However, when the engineer was disqualified

from duty, he sought treatment from his personal physician to obtain medicine to control his

diabetic condition. After taking the medicine for

2 weeks, the engineer provided the NJT physician with a urine sample that did not show the

presence of sugar, whereupon he was reinstated.

He did not report his diabetes or the medication

he was taking to the NJT at that time or on the

history forms for any subsequent NJT physicals.

Thus, by not reporting his diabetic condition and

his medication, he was able to avoid any adverse

effect it might have on his assignment and

employment. The Safety Board concludes that

the engineer of train 1254 consistently failed to

report his medical condition to NJT contrary to

the railroad company’s medical testing requirements.
24

The engineer's personal medical records

indicate that his vision deteriorated dramatically

during the year before the accident. He underwent several laser surgeries in both eyes to

correct for the effects of diabetic retinopathy;

however, the disease continued to develop.

Records of his last eye tests indicate that he had

little vision in his left eye (20/400 acuity with

correction), and the vision in his right eye varied

from 20/30 to 20/70 (with correction). Significant complications occurred in the engineer's

“good” right eye, resulting in proliferative

retinopathy. Panretinal photocoagulation surgery was performed to treat proliferative

retinopathy in the engineer's right eye as late as

January 1996, 2 weeks before the accident.

Research has shown that in addition to a

loss of visual acuity, many patients with severe

retinopathy fail color discrimination tests. As

part of his company physical, the engineer had

been given the Dvorine PIP test, a reliable measure of color discrimination, annually since

1985. Between 1985 and 1993, he missed none

of the Dvorine plates. In 1994, he missed 2 of 15

plates. During his February 1995 test, he missed

6 of the 15 plates and was classified as having a

moderate color vision handicap. The sudden

decrease in color discrimination ability in the

1995 examination was accompanied by a small

decrease in visual acuity in his left eye. These

vision changes suggest that the engineer’s

advanced diabetic retinopathy resulted in a

deterioration of visual acuity and an acquired

color vision deficiency.

Signal 28E-1 at the interlocking is a colorcoded signal that contains three aspects in a

vertical array, with a light always illuminated in

each aspect. The color of each aspect and the

order of colors from top to bottom determine the

signal indication. The signal has no non-color

cue that provides comparable information at all

viewing distances and in all conditions. The

colors red and yellow are used in three combinations. The top aspect always displays a red

light, and the middle and bottom aspects can

display either a red or yellow light. The signal

indications (from top aspect to bottom aspect)

are Stop (red, red, red); Restricting (red, red,

yellow), meaning proceed at restricted speed

until the entire train has passed a more favorable

signal; and Medium Approach (red, yellow, red),

meaning proceed prepared to stop at the next

signal.

Individuals with color vision deficiency are

known to identify colors in some situations by

their relative brightness rather than their hue. If

an individual with color vision deficiency cannot discern the actual colors of red or yellow

signal lights that are adjacent to each other, he

probably would identify the brighter light as

yellow and the dimmer light as red, regardless

of which is actually yellow or red. In the case of

the train 1254 engineer, he had been recertified

for duty, albeit erroneously, when he was able to

name the respective colors on the Dvorine

nomenclature test, probably by virtue of their

relative brightness rather than their hue.

Given his color vision deficiency, the engineer could have erred when interpreting the

illuminated lenses at signal 28E-1. He might

have perceived that either the middle or bottom

aspect was brighter than the top aspect. Believing the brighter aspect to be yellow, he might

have interpreted the signal to be a Medium Approach or Restricting indication rather than a

red Stop indication. His train handling supports

this finding. At the approach signal, he correctly

slowed his train as an engineer typically would

do when encountering a Medium Approach indication. He continued to slow as he neared signal

28E-1, which can clearly be seen by a person

with normal vision from at least 1,230 feet.13

However, about 71 feet before signal 28E-1,

which was displaying three red aspects, he

began to accelerate. The Safety Board concludes

that the engineer's acquired color vision deficiency caused him to interpret the color-coded

Stop indication at signal 28E-1 to be either a

Restricting indication or a Medium Approach

indication, either of which would have allowed

him to proceed past the signal.

 

13 Based on postaccident sight distance tests conducted by

the Safety Board.
25

Adequacy of Medical Standards

for Locomotive Engineers

During his 1995 NJT physical conducted by

a fee-for-service practitioner, the engineer who

caused the accident had not been able to identify

numbers on several color-coded plates of the

Dvorine PIP examination, which vision specialists recognize as being a reliable test for

identifying color vision deficiencies. The physician then administered the Dvorine nomenclature test, which is used to determine if a

patient knows the correct names of colors. After

the engineer correctly named the colors on the

color wheel, the physician certified him for

duty. The nomenclature test instructions specifically state that the test is not to be used to

determine an individual’s color discrimination

ability. The doctor later stated that he believed

that the nomenclature test was a supplemental

examination to the PIP test. The Safety Board

concludes that the fee-for-service physician’s

failure to comply with the Dvorine nomenclature testing protocol resulted in the erroneous

certification of the train 1254 engineer for duty.

Despite the doctor’s error, the argument can

be made that the testing and certification of this

engineer was in compliance with Federal certification standards, which only require that an

individual have “The ability to recognize and

distinguish between the colors of signals.” Further, the CFR allows a medical examiner to

certify an engineer with restrictions if the doctor

concludes that despite the individual not meeting the color vision threshold(s), he or she has

the ability to safely operate a locomotive.

The Safety Board believes that the color

vision requirement for railroad engineers is

extremely important because color is the primary information cue in safety-critical visual

signals. Moreover, the colors used in signal

aspects are very likely to be confused by individuals with color vision deficiency. Current

Federal regulations do not specify how to test

for the ability to discriminate colors, rather, they

permit a railroad to select the test or method it

will use to determine if its engineers comply

with the regulation. As a result, tests may differ

from railroad to railroad, or even from one

medical examination to another. While railroad

physicians may be aware of the color vision

requirement for locomotive engineers, they may

not recognize which color vision test is a valid

measurement tool.

Many available tests are undesirable; other

tests can be inconclusive by themselves. The

Secaucus accident and other cases demonstrate

that perhaps an alternative evaluation method,

such as a color vision test that accurately simulates color-coded railroad signals, should be developed as an additional screening for railroad

employees in safety-sensitive positions. Such a

test would have the advantage of having high

validity to applicants being tested, to those

administering the tests, and to judges who may

decide arbitration.

In an issues paper presented to RSAC

regarding engineer certification standards, the

FRA has stated that it believes that the current

hearing and vision acuity standards comply with

the Americans With Disabilities Act and that

they adequately ensure that locomotive engineers possess the requisite physical abilities to

do their jobs. However, the FRA recognizes that

the testing and the interpretation of test findings

is not uniform and therefore has asked the

RSAC to address the issue. The FRA cites as an

example a case in which an engineer who upon

failing a vision examination given by one railroad physician applied to work at another railroad whose physician certified him. The Safety

Board concludes that Federal standards lack

testing criteria to ensure that vision tests will be

administered uniformly or effectively. The

Safety Board believes that the current standards

should be revised to specify the tests, testing

procedures, and scoring criteria that railroad

physicians should use in administering color

vision tests.

This accident highlights another problem

that a physician has in determining the fitness

for duty of railroad engineers. In this case, the
26

engineer of train 1254 did not advise the fee-forservice doctor about his diabetes, his vision

problems, or his prescription medications. Because the engineer died, the Safety Board cannot

determine whether he failed to recognize or

refused to admit to the potential risk in which he

was placing himself and his passengers when he

operated a train. The reasons for people not admitting to medical problems are as diverse as the

individuals themselves. The Federal Aviation

Administration (FAA), recognizing this, has

enacted the following standard as a requirement

for the medical certification of pilots:

No person may act as pilot in command

... while he has a known medical

deficiency, or increase of a known

medical deficiency, that would make

him unable to meet the requirements of

his current medical certificate.14

The Safety Board believes that for the safety

of the traveling public, it is just as necessary to

compel railroad employees in safety sensitive

positions, especially engineers, to disclose any

change in their physical status that might affect

how they perform their job. As an interim measure, industry associations, such as the American Public Transit Association, the Association

of American Railroads, the Brotherhood of

Locomotive Engineers, and the United Transportation Union, can also assist in improving

railroad safety by providing their members with

information about this accident, specifically

explaining acquired vision deficiency and emphasizing the importance of ensuring the color

vision requirement. Further, associations should

stress that railroad employees in safety-sensitive

positions, especially engineers, report their use

of medications or any changes in their medical

condition to their employer.

After this accident, the NJT medical services office initiated a number of measures to

ensure compliance with Federal regulations and

NJT procedures. The NJT changed its color

vision testing protocol to require that a physician refer an employee for additional testing if

 

14 14 CFR 61.53

the employee cannot identify any one of the 15

Dvorine plates. Further, medical services office

staff visited each of the carrier’s medical practitioners to review their operations. The Safety

Board finds that the NJT medical review is an

effective risk management measure that NJT

should formalize as part of its on-going management oversight program. The Safety Board

does believe that as an additional measure, the

NJT should inform its employees, especially

those in safety-critical positions, of the facts and

circumstances of this accident stressing that they

must accurately report their use of medications

or any changes in their medical condition.

Adequacy of the Train Crews’

Response

Postaccident Actions—Although the

conductor on train 1254 was injured during the

impact, he was able to evacuate passengers

before he was transported to the hospital. The

assistant conductor on train 1254 asked passengers if they needed assistance and used his

cellular phone to call NJT officials for help. The

conductor on train 1107 was visibly upset and

crying, which caused concern among the passengers. However, when NJT employees who were

deadheading on the train realized that the train

1107 conductor was in no condition to assess

the situation and to make necessary decisions,

they took control of the situation. To prevent

another accident, they prepared to flag down an

oncoming train; they tended to and helped

evacuate the passengers. When the emergency

responders arrived on scene, passengers were

safely moved to another NJT train, triaged, and

transported to local hospitals. The Safety Board

concludes that the evacuation of passengers

from the accident site was not hampered even

though the actions of some train crewmembers

were less than adequate.

The scenario after the Secaucus accident is

typical of the conditions and problems following

a major train collision, which require the skills

of trained personnel who can maintain
27

their composure, make decisions, and control

and inform passengers to prevent further injuries

and panic. Because injuries were involved, this

accident met NJT's criteria for a “Critical Emergency,” which require that the conductor and

other train employees manage the emergency to

make sure that trains are stopped and appropriate instructions are given to passengers to

avoid panic. The assistant conductor on train

1107 said that he went "blank" after the collision and had to ask a deadheading employee

what he should say on the radio. He said that

upon seeing the damage to the train 1254 cab he

ran out of the door screaming for the engineer.

The uncertainty of the situation also caused the

train 1107 conductor to panic. She said that she

instructed the passengers in two cars to remain

seated; however, her demeanor and lack of

direction compromised her effectiveness.

According to passengers, the crewmembers

on trains 1254 and 1107 provided few instructions. Only one survey respondent stated that he

heard an announcement over the public address

system, but he did not know if it had been a

crewmember or an emergency responder who

made the announcement. Other passengers said

that they heard no announcements. Although the

train crews said that they went from car to car

instructing passengers to remain seated, passengers said that they were not told about the

severity of the situation and were concerned

about a possible fire or being struck by an oncoming train. They therefore left the train and

wandered around the tracks waiting for guidance, potentially posing a greater hazard because of the leaking fuel from train 1107.

No crewmember used the public address

system to communicate with passengers. By

using the public address system, all passengers

would have received the same message in less

time than it would have taken the NJT employees to walk from car to car. The assistant

conductor on train 1254 stated that he did not

know if the public address system worked because he did not try to use it. The conductor on

train 1107 stated that she did not recall if the

public address system worked. Postaccident

tests revealed that the public address systems on

both trains were operable after the collision.

Information about the possibility of a fire or a

collision with an oncoming train could have

been provided to passengers over the public address system to address their concerns and prevent them from leaving the train. The Safety

Board concludes that the lack of public announcements addressing the passengers' concerns caused them to act independently, evacuate the train, and wander along the tracks, thus

potentially contributing to the dangerous conditions at the collision site.

Employee Training—The NJT provides

its train crews with emergency procedures training; however, it does not have a refresher training program that establishes a time frame within

which employees must attend a refresher course

in emergency response actions. The last emergency training that the surviving crewmembers

on the accident trains had taken ranged from 1

year to 9 years before the accident.

The assistant conductor on train 1107 stated

that he did not recall receiving emergency evacuation training. Records show that it had been 9

years since he had attended a transportation

training program and 4 years since he had received customer sensitivity training that focused

on emergency evacuation procedures. Perhaps

he could not recall receiving the evacuation

training because of the 4-year time span since

his last course. It is reasonable to believe that if

he could not recall attending the course, he

probably could not recall the subjects covered.

Such a time gap between training does not provide the necessary frequency to reinforce special

skills. By periodically attending a refresher

course, employees can become more effective in

managing an emergency situation.

Drills are not included in NJT's training program even though most classes provide some

instruction about emergency procedures. Employees participate in drills only if they are

selected to participate in training for emergency

responders. The Safety Board believes that drills

should be incorporated into the training program
28

to help employees learn to properly assess an

emergency situation, to manage passengers, effective panic control techniques, and effective

communication skills. Passengers depend on

train employees for leadership and guidance in

an emergency. NJT employees should be prepared and confident that they can provide appropriate emergency services should the need arise.

The Safety Board concludes that the performance of train crewmembers during emergencies could be improved if the NJT included

drills and refresher training in its training program. The Safety Board believes that the New

Jersey Transit should conduct drills as part of its

training program and develop a refresher training program so that all employees with responsibilities during emergencies receive periodic

refresher training to reinforce their skills.

Survival Factors

Crashworthiness—The train 1107 locomotive and the train 1254 cab car collided at an

oblique angle, approximately engineer’s side

collision post to engineer’s side corner post. In

the initial moments of the collision, the cab

car’s right side buffer wing was torn from the

draft sill outer webbing, significantly reducing

the car’s ability to resist intrusion into the engineer’s compartment in the cab car. As the

collision progressed, the right front of the locomotive passed through the engineer’s compartment. Except for the anti-telescoping plate and

components below the underframe, all other

structural and non-structural components of the

compartment were torn loose, forced aft, or

pushed into the car interior. As the locomotive

moved forward during the collision, a section of

the cab car’s roof rail passed over the short hood

of the locomotive and entered the cab, striking

the train 1107 engineer in the head and neck

area and fatally injuring him.

The fatally injured passenger in the cab car

of 1254 was exposed to severe forces, demonstrated by the fact that he was thrown across the

car with enough momentum to cause injury to a

fellow passenger and damage to a seat. The train

1254 engineer, who was exposed to similar

forces, was in a compartment containing knobs,

handles, and switches, several of which could

become potential sources of blunt force trauma

in a collision. The Armed Forces Institute of Pathology (AFIP) report states that the cab car

driver received multiple blunt force injuries,

including fatal injuries to his head and lacerations of his abdominal aorta and spleen during

the collision. It concluded that “patterned injuries to the head were associated with multiple

skull fractures and extensive damage to the

underlying brain tissue.” Autopsy reports indicate the engineer sustained a scalp laceration

having a circular serrated pattern. Similar patterns were found on a control panel knob above

the engineer's windshield. Because no other surfaces having this pattern were found in the

operators compartment, it is reasonable to conclude that the engineer’s head made contact with

this knob. The Safety Board also believes that

the engineer’s abdominal injuries could have

been caused by the brake handle, which was

driven rearward by the collision.

Based on the AFIP report findings and the

cab car damage, the Safety Board concludes that

the fatal injuries of the engineer of train 1254

were consistent with the degree of destruction of

occupiable space in the cab car. In 1995, in

response to Safety Board recommendation R-93-

24, which asked that the FRA conduct a

feasibility study of using corner posts to afford

occupant protection during collisions, the FRA

formed a working group to examine the safety

issue of rail car passenger equipment design,

including structure. As part of its review, the

working group is considering several structural

designs and design changes that could mitigate

or prevent passenger car intrusion in future

corner-to-corner collisions. When this review is

finished, the FRA intends to publish a Notice of

Proposed Rule Making (NPRM) outlining the

design changes it believes are necessary to enhance passenger and cab car safety.

Emergency Response—The NJT police

were notified about 8:40 a.m., and arrived on

scene 13 minutes later. The accident occurred in
29

a remote area accessible only by a muddy and

narrow dirt road, which made it difficult for

emergency responders to maneuver vehicles and

caused congestion among arriving vehicles.

Following a delay while responders identified

the location and jurisdiction of the accident, the

emergency response activities proceeded in a

timely manner. Although communication was a

problem on scene, emergency responders were

able to obtain telephones, cellular phones and

radios to help coordinate activities. The Jersey

City Fire department’s hazardous materials unit

was able to contain about 50 gallons of diesel

fuel and battery acid that spilled into an embankment after the collision, avoiding a possible

fire. NJT provided a train and buses to be used

to triage and transport passengers. The Safety

Board concludes that, overall, the emergency

response efforts were timely and appropriate.

Further, the Safety Board is encouraged by the

emergency agencies’ efforts to improve their

response capability by purchasing radios that are

compatible with the county radio network

frequency.

NJT’s Postaccident Efforts

In addition to the changes made by its medical services office, the NJT has initiated other

measures to improve safety within its railroad

system, including the elimination of all night

split shifts and the number of compliance checks

of crews in outlying areas. It has enacted more

stringent disciplinary measures for employees

failing to comply with operating rules. Before

this accident, the NJT had suspended engineers

who passed stop signals for a minimum of 30

days in accordance with FRA regulations. The

NJT now requires the engineer to attend a

special recertification training class before

returning to work. Moreover, it now dismisses

any engineer cited for more than one stop signal

violation within a 36-month period. The NJT

has indicated that it is attempting to expedite a

capital program in which all of its rail lines will

be equipped for either cab signals or positive

train stop by December 31, 1997, and all NJT

lines will be equipped with both technologies by

December 31, 2001. The Safety Board

recognizes and commends the efforts of the NJT

to improve its system safety.

The Safety Board has long been an advocate

of train control systems and has included positive train separation (PTS) on its list of “Most

Wanted Transportation Safety Improvements.”

A PTS system provides an automatic means of

backing up the engineer’s actions by monitoring

the performance of the engineer and the train

when approaching signal or speed restriction

limits. Should the engineer or the train fail to

apply the proper brake action, the PTS system

will assume control, automatically apply the

brakes, and stop the train. Had a PTS system

been in place on this railroad line, this collision

would not have occurred. The lack of PTS is

also a major issue in a collision and derailment

of a Maryland Rail Commuter train with National Railroad Passenger Corporation (Amtrak)

train 29, The Capitol Limited, near Silver

Spring, Maryland, on February 16, 1996. In its

report of that accident investigation, the Safety

Board will discuss this issue in greater detail.
Findings

1. Factors related to the weather, the train

equipment, the track, and the signal system

did not cause or contribute to the collision.

Toxicological tests for alcohol and drugs

were negative. Train operators had the

necessary training and experience to competently perform their duties. No evidence

indicates that fatigue was a factor.

2. The engineer of train 1254 consistently

failed to report his medical condition to

New Jersey Transit contrary to the railroad

company’s medical testing requirements.

3. The engineer's acquired color vision

deficiency caused him to interpret the colorcoded Stop indication at signal 28E-1 to be

either a Restricting indication or a Medium

Approach indication, either of which would

have allowed him to proceed past the signal.

4. The fee-for-service physician’s failure to

comply with the Dvorine nomenclature

testing protocol resulted in the erroneous

certification of the train 1254 engineer for

duty.

5. Federal standards lack testing criteria to

ensure that vision tests will be administered

uniformly or effectively.

6. The evacuation of passengers from the

accident site was not hampered even though

the actions of some train crewmembers were

less than adequate.

7. The lack of public announcements

addressing the passengers' concerns caused

them to act independently, evacuate the

train, and wander along the tracks, thus

potentially contributing to the dangerous

conditions at the collision site.

8. The performance of train crewmembers

during emergencies could be improved if the

NJT included drills and refresher training in

its training program.

9. The fatal injuries of the engineer of train

1254 were consistent with the degree of

destruction of occupiable space in the cab

car.

10. The emergency response efforts were timely

and appropriate.

Probable Cause

The National Transportation Safety Board

determines that the probable cause of New

Jersey Transit (NJT) train 1254 proceeding

through a stop indication and striking another

NJT commuter train was the failure of the train

1254 engineer to perceive correctly a red signal

aspect because of his diabetic eye disease and

resulting color vision deficiency, which he

failed to report to New Jersey Transit during

annual medical examinations. Contributing to

the accident was the contract physician’s use of

an eye examination not intended to measure

color discrimination.

CONCLUSIONS
As a result of its investigation, the National

Transportation Safety Board makes the following recommendations:

--To the Federal Railroad Administration:

Revise the current color vision testing

requirements for locomotive engineers

to specify, based on expert guidance, the

test to be used, testing procedures,

scoring criteria, and qualification

standards. (R-97-1)

Require as a condition of certification

that no person may act as an engineer

with a known medical deficiency, or

increase of a known medical deficiency,

that would make that person unable to

meet medical certification requirements.

(R-97-2)

--To New Jersey Transit:

Revise your employee emergency response training courses to include simulation drills and develop a refresher

training program to reinforce employee

skills in emergency procedures. In all

emergency training, stress that employees use the public address system as a

means to communicate with passengers.

(R-97-3)

Inform your employees, especially those

in safety-critical positions, of the facts

and circumstances of this accident

stressing that they must accurately

report their use of medications or any

changes in their medical condition.

(R-97-4)

--To the Association of American

Railroads:

Provide your members with information

about this accident, specifically

explaining acquired vision deficiency

and emphasizing the importance of

ensuring the color vision requirement.

Stress that railroad employees in safety

sensitive positions, especially engineers,

report their use of medications or any

changes in their medical condition to

their employer. (R-97-5)

--To the Brotherhood of Locomotive

Engineers:

Provide your members with information

about this accident, specifically explaining acquired vision deficiency and

emphasizing the importance of ensuring

the color vision requirement. Stress that

railroad employees in safety sensitive

positions, especially engineers, report

their use of medications or any changes

in their medical condition to their

employer. (R-97-6)

--To the United Transportation Union:

Provide your members with information

about this accident, specifically explaining acquired vision deficiency and

emphasizing the importance of ensuring

the color vision requirement. Stress that

railroad employees in safety sensitive

positions, especially engineers, report

their use of medications or any changes

in their medical condition to their

employer. (R-97-7)

RECOMMENDATIONS
32

--To the American Public Transit

Association:

Provide your members with information

about this accident, specifically explaining acquired vision deficiency and

emphasizing the importance of ensuring

the color vision requirement. Stress that

railroad employees in safety sensitive

positions, especially engineers, report

their use of medications or any changes

in their medical condition to their

employer. (R-97-8)

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

Member

March 25, 1997
APPENDIX A

Investigation

The National Transportation Safety Board

was notified at 10:28 a.m., eastern standard

time, on February 9, 1996, of a collision and

derailment involving two New Jersey Transit

commuter trains near Secaucus, New Jersey.

The investigator-in-charge and other members

of the Safety Board investigative team were

dispatched from the Washington, D.C. office,

and from the Atlanta, Georgia, and Los Angeles,

California, field offices. Investigative groups

were established to study operations, track,

signals, mechanical, survival factors, and human

performance.

The Safety Board was assisted in the investigation by the Federal Railroad Administration,

New Jersey Transit Railroad, Brotherhood of

Locomotive Engineers, United Transportation

Union, New Jersey Transit Police, Jersey City

Emergency Medical Services, Jersey City Fire

Department, and the Hudson County Emergency

Management.

APPENDIXES
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35

APPENDIX B

Train 1107 Engineer

Personnel Information

General—At the time of the accident, the

47-year-old engineer of train 1107 had been employed by NJT for 7 years. He had been promoted to locomotive engineer on December 24,

1990, and had been recertified on December 20,

1995, receiving an operating evaluation rating of

3, or “Standard,” on a scale of 5, and an efficiency test rating of 97.6 percent. He had passed

his last rules examination, which had been

administered on November 7, 1995. He had no

disciplinary record and had been designated as

an instructor engineer. He had worked the same

shift, Monday through Friday from 5:50 a.m. to

1:20 p.m. since January 10, 1996. His

assignment required him to report to Hoboken

Terminal, complete four train movements, and

mark off duty at Hoboken Terminal.

Duty/rest Schedule—The engineer’s

spouse provided the following history of her

husband’s activities (table 6) for the 3 days

before the accident. She said that it was his

habit to go to bed about 9 p.m. and to arise for

work between 4:30 and 4:45 a.m.

Medical History—The engineer’s last

NJT medical examination was on December 8,

1995, 2 months before the accident; he was

found medically qualified, without restriction,

for duty. Records of the eye examination indicate that his visual acuity was 20/40, corrected

to 20/20, with normal color vision.

On his medical history form, he reported

that he had used Proventil for bronchial asthma

during the previous 60 days, and that he suffered

no other chronic or acute illnesses since his

previous examination on December 8, 1994.

NJT records indicate that on November 16,

1995, he had received a random drug/alcohol

test, which was negative.

According to his spouse, he was an active

person and was in excellent health, although he

had experienced asthma since childhood. She

said that he occasionally used an inhaler, which

he carried with him. Investigators found an oral

inhaler containing 200-17g metered aerosol

inhalations of Schering Proventil (Albuterol) in

his briefcase aboard train 1107. She also stated

that he did not use tobacco products, occasionally drank beer, ate a normal diet, and did

not use other prescription medications or illicit

drugs. She said that her husband had normal

hearing, and had been prescribed glasses for

driving about 2 months before the accident.

Table 6—72-Hour Work/Rest History for the Train 1107 Engineer

Date Activity

February 6 At home between 2 p.m. and 7 p.m., at which time his wife went out and left him at

home. Was asleep when she returned between 10 and 10:30 p.m.

February 7 Departed for work before wife awoke at 6:45 a.m. Returned home from work at 6 p.m.

Ate dinner between 6:45 and 7 p.m., at which time wife went out shopping. Was

asleep when wife returned home at 8:30 p.m.

February 8 At home from 3 to 7 p.m., ate dinner, and went to bed between 8 and 9 p.m.

February 9 Departed for work before wife awoke at 9 a.m.
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37

APPENDIX C

The Dvorine PIP Testing Protocol Instructions

The Dvorine Pseudo-Isochromatic Plates

consist of two sections. Section one contains

one demonstration plate (number 48 in red on a

blue background) and 14 plates made up of eight

different color combinations arranged in pairs of

identical colors.

Section two contains one demonstration

plate (a blue trail on a red background) and 7

plates featuring trails instead of digits; each of

these plates consists of different color combinations, but similar to the color combinations

of the first section. The second section may be

used to test pre-school-age children and illiterates, or as a corroborative test when an

individual fails to identify the plates of the first

section.

Best results are obtained when the illumination of the plates approximates that of daylight. A Macbeth Easel Lamp or a Daylight

Fluorescent Tube will give satisfactory results.

When these are not available, a 100-watt bluedaylight bulb should be used.

The plates are to be held about 30 inches in

front of the patient. After being shown the red

number 48 of the demonstration plate, the

patient is instructed to call off the numbers of

the 14 plates that follow. No more than 5

seconds are allowed for the identification of

each plate; and hesitant, studied responses, or

tilting and turning of the head should be noted

and recorded. Behavior of this nature is

generally associated with defective color vision.

A similar procedure is to be followed when

the second section is used, with one exception.

The patient should be furnished with a thin

brush or other non-scratching pointer and

directed to outline or trace the trail on the

demonstration plate and seven trails that follow

it.

Nomenclature Test

Test the individual for his knowledge of

names of colors by rotating the disk to expose

each of the eight circles of color. The responses,

both to saturated and unsaturated colors, should

be recorded.

If an individual names the colors on the disk

correctly but fails the general color test, he still

is to be classified as color blind; for many color

blind individuals learn to name the colors

correctly by their brightness instead of their hue.

Occasionally, an individual may pass the

color discrimination test but fails to name

correctly the colors of the circles on the rotating

disk. This indicates that he is not color blind but

that his knowledge of color names is faulty.

Estimating The Degree of Color Vision

Defect

The quantitative classification table is based

on a statistical analysis of 800 highly motivated

individuals examined with the DVORINE

PSEUDO-ISOCHROMATIC PLATES. This

method of estimating the degree of colorblindness rests on the assumption that the more

errors an individual makes on this test the more

serious is his defect. This assumption is

particularly applicable to the DVORINE

PLATES because the test samples a wide range

of confusion colors and has available published

research data.
38

QUANTITATIVE CLASSIFICATION TABLE

Number of

Plates Missed

Degree of

Color-Blindness

Expected

Percentages

Degree of

Handicap

0 to 2 Normal 89.5 No handicap, Acceptable

3 to 4 Borderline 3.0 Mild handicap. May improve

score on retest. Acceptable

5 to 11 Moderate 2.0 Moderate handicap. May be employed in occupations where

critical color judgment is not

essential. Not acceptable for

civil aviation.

12 to 14 Severe 5.5 A definite handicap and hazard

to industrial and military occupations. Not acceptable of civil

aviation.
39

APPENDIX D

Excerpts from New Jersey Transit Rail Operations

Timetable No. 9 Special Instructions

The NJT “Emergency Evacuation Procedures” under the subsection entitled “General

Information” defines CRITICAL EMERGENCY as:

Imminent danger to life including fire,

fumes, smoke, bomb threats, or injuries.

Critical emergency evacuation

authority: In the event of a CRITICAL

EMERGENCY, the chain of responsibility for making the decision to evacuate passengers from a train will be

made by the employee in charge as

indicated below:

a. Conductor

b. Engineer

c. Crew member

d. Transportation Department Supervisor

e. NJ Transit Police Officer

f. Other railroad management personnel

g. Other railroad employee

The employee taking charge during

an emergency will remain in charge

until relieved by a company official

designated by the Director of System

Operations or his representative.

The subsection entitled “Responsibilities”

describes the actions that personnel should take

during an evacuation. Part B, Crew Members Or

Other Employees, states, in part:

1. The safety of passengers must be

the primary concern. Passengers must

not be evacuated from a train without

authority of the Director of System

Operations or his representative, except

in a CRITICAL EMERGENCY. When

handicapped, elderly or other passengers who are unsure of their footing are

among those to be evacuated from a

rain, crew members must give them

special assistance.

2. During an EMERGENCY or

CRITICAL EMERGENCY, train and

engine crew members must immediately

provide the required flag protection.

3. Trains on adjacent tracks must be

stopped before evacuating passengers

across such track.

4. Crew members must immediately

take charge of the situation, making

announcements to passengers and

giving them appropriate instruction in

order to avoid panic.