NEW YORK STATE PUBLIC TRANSPORTATION SAFETY BOARD RAIL SAFETY SECTION CASE #7663

INVESTIGATION OF A COLLISION INVOLVING THE MTA - METRO NORTH RAILROAD AT NEW ROCHELLE, NEW YORK ON AUGUST 15, 2003

SYNOPSIS At approximately 3 :30 am on August 15, 2003, two equipment trains were involved in a rear end collision that caused one car to derail in the vicinity of New Rochelle, New York. At the time of the accident, there was an electrical blackout affecting the entire Metropolitan area and resulting in a loss of signals and traction power throughout the entire Metro North operating region. Twelve employees complained of minor injuries as a result of the collision. Damage to the two sets of equipment amounted to approximately $23,000 .00 . Track damage was estimated at approximately $5,600.00.

Based on the information received, PTSB staff finds that the probable cause of this accident was the improper operation of the rescue equipment by the afternoon (PM) Mott Haven (MO) switcher crew (PMMO). Contributing to the cause of this accident was the unsafe actions of the Operations Manager ordering the movement of train #1742 with the brakes cut out on all cars; as well as his disregard for the opinion of the Qualified Maintenance Person on board that the move was unsafe. Further contributing to the cause of this accident was the lack of accurate information communicated between the Rail Traffic Control Center and the crew of the rescue switcher.

INVESTIGATION Accident Description :

On Thursday August 14, 2003, at approximately 4 :10 p.m., Metro North Railroad was affected by an electrical blackout that blanketed the Metropolitan area. The blackout caused the loss of all signal and traction power on the Metro North operating system. The sudden and unexpected outage resulted in numerous trains being stranded. Throughout the system, Metro North took immediate action relative to the evacuation of passengers from the forty-one trains that were stranded as a result of the power outage. Rescue crews were dispatched on locomotives to assist in the evacuation process and once the passenger evacuations were completed, the locomotives were utilized to tow the equipment from the tracks, back to the storage yards.

One of the rescue crews, identified as the "PMMO switcher" was dispatched to remove disabled trains from main line tracks. The rescue crew consisted of an engineer, conductor, and brakeman who were accompanied on engine #103 by an operations manager, a car man, and an electrician. Train #1742, with six M-2 cars, was stranded on track #3 of the Harlem Line, at Botanical Gardens. The passengers had been previously discharged from the equipment. At approximately 1 :46 a.m., the rescue train arrived and coupled up to the south end of the stranded, six car train. While preparing to tow the stranded train, the crew reported that they were unable to get air through the train resulting in an inoperable braking system. A decision was made by the Operations Manager to disable both the service brake and the emergency brake capability on the train and he instructed the crew to operate the train at restricted speed, with the hand brakes manned, utilizing only the locomotive brakes on engine #103 . Although engine #103 was the sole source of power, the train line circuits were not operational; therefore, power was not distributed to the six coach cars.

Approximately 40 minutes after it arrived, the rescue engine began to shove the equipment of train #1742 east towards New Haven with the conductor on the head end utilizing a portable radio for communication with the engineer. Their assignment was to proceed north then east on the to rescue the crew and equipment of train #1342 which was stranded in the vicinity of Larchmont. Once they were coupled up to the equipment of train #1342, the planned move was for the crew of the PMMO to shove the equipment and crew members of both trains east to Stamford Yard. The Operations Manager was on the east end of the rescue train supervising the move towards Larchmont. The headlights on the east end of the train were out due to the crew being unable to establish an electrical train line . The conductor was utilizing a hand held flashlight for visibility.

The Accident:

While en-route to Larchmont, the crew of the rescue train made a station stop on track #4 at to discharge a passenger. The lone passenger was later identified as the wife of a Metro North engineer who had remained on stranded train # 1742 at Botanical Gardens . While attempting to make the station stop at Pelham, the crew noted that although the train was only traveling at 15 mph, it took approximately three extra car lengths to stop the train. This concern was expressed to the Operations Manager by the crew. Despite this apprehension and the expressed opinion ofthe car man on board that the movement of the train under these circumstances was unsafe without sufficient braking capability, the Operations Manager ordered the crew to proceed east to New Haven.

The crew continued and subsequently stopped at the dark home signal at CP 217 without incident. After receiving permission to proceed through the 4E signal, the move continued east at speeds of approximately 15 mph towards the equipment of train # 1342 which was reportedly stranded on track #4 in the vicinity of Larchmont. As a result of the magnitude of the blackout, Rail Traffic Control (RTC) had to estimate the location of the forty-one trains that had been stranded throughout the system. With regard to train #1342, the RTC estimated it to be stopped near Larchmont Station when, in fact, it was actually sitting approximately 7,260 west of Larchmont at centenary pole #86 in New Rochelle. This erroneous information was relayed to the crew of the rescue train by the RTC.

When the rescue train reached New Rochelle, it was proceeding east around a slight curvature on track #4 when the conductor suddenly observed the equipment of train #1342 stopped directly ahead with no marker lights displayed . He attempted to contact the engineer several times via his portable radio to stop the train. According to the download of engine #103's event recorder, the rescue train was traveling at approximately 15 miles per hour, ten seconds prior to the collision. Records further indicate that the engineer applied a full service brake application six seconds prior to impact and a second later placed the train's brakes into emergency braking mode . The emergency brake application had little to no effect on slowing the equipment. At approximately 3 :30 a.m., the equipment of train #1742 struck the rear of the standing seven cars of train #1342 . Upon impact with the rescue train, the equipment of train #1342 was shoved east approximately 90 feet. The collision injured twelve employees and derailed all wheels of car # 8724, which was the third east car of the equipment being pushed by the rescue engine.

Additional Information :

Radio, cell phone, and telephone communications were extremely limited and at times impossible. Battery life on portable radios and cell phones had diminished due to the length of the blackout. The AC power at railroad facilities including the Operations Center was sporadic, at best, and availability of alternate power source was dependent on the wattage supplemented by portable generators.

The Operations Manager reported for duty at 11 :00 a.m. on August 14th and was assigned as the Operations Manager for the and 125th Street Protect. He was employed with Metro North since 1992 . Prior to his involvement with train #1742 at Botanical Gardens, the Operations Manager had supervised several moves involving the rescue of train #1244 at 110 t'' Street and train #551 at 99th Street. Both trains were stranded with passengers and crew as a result of the blackout. The Operations Manager directed that the trucks be cut out on both sets of equipment after problems were encountered while attempting to charge the respective braking systems. Passengers from both trains were eventually transported to the 125th Street Station on the equipment of train #1244 that was shoved by engine #103 using locomotive braking only.

The Operations Manager in his post accident statement reported that he had departed the east end of the rescue train as it approached New Rochelle with the intention of talking to the engineer of the rescue train. It is not known why there was no attempt by the Operations Manager to communicate with the engineer directly via portable radio.

According to post accident statements, two crew members from train #1342 were on the ground flagging at the east end of the train expecting the rescue train to approach from the east. The eleven employees on board the two trains complained of minor injuries and received hospital treatment. One of the employees on the ground who was flagging complained of breathing difficulty, and also received hospital treatment. As a result of the collision and derailment, seventy three railroad ties were damaged on track #4 and the running rail was knocked out of alignment between catenaries 85 and 86. Weather conditions at the time of the accident were clear and dry with a temperature in the 70's. Visibility however, was poor due to the power outage and loss of ambient light.

Post accident interviews with the electrician and car man assigned to the rescue train alleged that the Operations Manager was rushing the move at Botanical Gardens, apparently not allowing a sufficient amount of time to troubleshoot the air problems and ordering that the brakes be cut out.

The conductor of the rescue train reported for duty at 6 :30 p .m. on August 14th and was assigned to Job #A-141, the PMMO Switcher crew responsible for the afternoon rush and various other switching duties. He has been employed with Metro North since 1993 . The locomotive engineer of the PMMO reported for duty at 3 :45 p .m. on August 14th and was assigned to the PMMO Switcher also. He has been employed with Metro North since 1987 . The brakeman of the PMMO reported for duty at 3 :45 p.m. on August 14th and was assigned to the PMMO Switcher. He has been employed by Metro North since 1984 . Toxicological testing was conducted on the engineer and conductor of the rescue engine along with the Operations Manager. Results of the tests were negative.

Discipline :

Metro North's investigation of the accident determined that the conductor and engineer on the PMMO failed to adhere to the restricted speed definition of Metro North's Rules of the Operating Department which states that while operating under restricted speed, you must be able "to stop within one-half the range of vision, short of train, obstruction, or switch improperly lined, looking out for broken rail or crossing protection out of order and not exceeding 15 miles per hour" .

The conductor was additionally charged with violating Operating Rules #26, #434, and #490 of Metro North's Rules of the Operating Department. Rule #26 states that "the conductor, engineer and pilot are equally responsible for the safety of the train or engine and the observance of the rules and special instructions, and under conditions not provided by the rules, or should there be any doubt as to the authority or safety of proceeding from any cause, must take every precaution for protection" .

Rule #434, paragraph 1 states that, "when radio communications is used in lieu of hand signals in connection with the switching, backing or pushing of a train, engine, or car, the employee directing the movement shall give complete instructions or keep continuous radio contact with the employees receiving the instructions. When means of communication is changed, no movement may be made until crew members have been notified". Investigation revealed that the conductor did not notify his crew members of the change in communication, when his hand radio was switched for an older model, yet he allowed the movement of the train to continue in violation of this rule . Rule #434, paragraph 2 states that, "when backing or pushing a train, engine, or cars, the distance of the movement must be specified, and the movement must stop in one-half the remaining distance unless additional instructions are received" .

Rule #490 states that, "conductors have charge of the train to which they are assigned, and all persons employed on board are subjected to their instructions . They are responsible for the prompt movement, safety and care of their trains, for the vigilance, conduct, and proper performance of duty of train employees, and for the observance and enforcement of all rules and instructions" . The conductor was dismissed in all capacities, but subsequently had his discipline reduced on appeal to a suspension of 60 days of which he served 45 days and had 15 days deferred.

The engineer was charged with violating rules #26 and #489 of the Operating Department. Rule #489 states that, "when the engine is moving, (the engineer) must be vigilant and use care to prevent avoidable injury to persons, collisions, derailments and, damage to lading or property. They must, if anything withdraws their attention from constant lookout ahead, or if weather or other conditions make observance of signals or warnings in any way doubtful, at once regulate the speed of their train so as to make progress entirely safe". The engineer was dismissed in all capacities, but subsequently had his discipline reduced on appeal to a 60 day suspension. (30 days actual suspension, 30 days deferred). The Operations Manager was dismissed in all capacities for failing to testify during the investigation process. It was noted that a significant amount of information regarding the negligent actions of the Operations Manager was provided by the other employees involved in the accident. The information was uncontested due to the Operations Manager not testifying during the investigative process.

Corrective Actions:

As a result of this accident, Metro North began providing additional training to their train crews and car men to ensure that they are familiar with the task of setting a train up for tow. The training is being incorporated into the rules class and will cover the duties and responsibilities involving equipment moves. In addition, after discussions with the FRA, Metro North agreed to initiate training for their Operations Managers in 2004 including a review of 49CFR238 that deals with Passenger Equipment Safety Standards with special emphasis on 49CFR238 .15 that refers to movement of passenger equipment with power brake defects. Training will also include additional time reviewing 49CFR239, a review of Emergency Evacuation Procedures and provide for the annual rules instruction for all supervisors.

CONCLUSION

PTSB staff finds that the probable cause of this accident was the improper operation of the rescue equipment by the PMMO switcher crew. Contributing to the cause of this accident was the unsafe actions of the Operations Manager ordering the movement of train # 1742 with the brakes cut out on all cars; as well as his disregard for the opinion of the Qualified Maintenance Person on board that the move was unsafe. Further contributing to the cause of this accident was the lack of accurate information communicated between the Rail Traffic Control Center and the crew of the rescue switcher.

Based on the information developed during this investigation and the corrective actions taken by Metro North Railroad including the assessed discipline, the PTSB staff concurs and makes no further recommendations.

NAME OF INVESTIGATOR: John L. Compitello DATE SUBMITTED : June 4, 2004

SIGNATURE :

Rail Safety Bureau