Powerpoint Template

Accidents, Probable Causes and Recommendations 1 Accident Portage, Indiana Northern Indiana Commuter June 18, 1998 – 4:31 a.m. Grade Crossing – Commuter Struck a Steel Truck 3 Fatalities 5 Minor Injuries 2 3 4 Probable Cause …ineffective action by Federal, State, and private agencies to permanently resolve safety problems at the Midwest Steel grade crossing, which they knew to be a hazardous crossing. 5 Accident Butler, Indiana Norfolk Southern/Conrail March 25, 1998 – 4:48 a.m. Collision 1 Fatalities 2 Minor Injuries 6 7 8 Probable Cause • …was the failure of the [crew] to comply with operating rules • …the railroad’s failure to ensure employees’ compliance with operating rules. • …the railroad’s failure to ensure that its locomotive engineer training prepared students for operational situations • …the railroad’s signal maintenance program failure to respond to a reported signal deficiency 9 Accident Flora, Mississippi Canadian National/Amtrak April 6, 2005 – 6:33 p.m. Derailment 1 Fatality 10 11 12 Probable Cause …was the failure of the Canadian National Railway Company to properly maintain and inspect its track, resulting in a rail shift and the subsequent derailment of the train, and the Federal Railroad Administration's ineffective oversight to ensure the proper maintenance of the track by the railroad 13 Accident Dupont Circle, DC Washington Metropolitan Area Transit Authority May 14, 2006 – 10:16 a.m. Wayside Worker 1 Fatality . 14 15 Probable Cause • …was the failure of the automatic train control system (senior) mechanic to [be] aware of the presence of the train or …identify a safe area outside the train’s dynamic envelope. • …procedures did not provide adequate safeguards • …the lack of an aggressive program of rule compliance testing and enforcement 16 Accident Eisenhower Station, Alexandria, Virginia Washington Metropolitan Area Transit Authority November 30, 2006 – 9:30 a.m. Wayside Worker 2 Fatalities 17 18 Probable Cause • The failure to maintain an effective lookout for trains and the failure of the train operator to be certain that the workers ahead were aware of its approach and had moved to a safe area • Contributing was the lack of procedures to provide adequate safeguards to protect wayside personnel • Also contributing to the accident was the lack of an aggressive program of rule compliance testing and enforcement 19 Accident Woburn, Massachusetts Massachusetts Bay Commuter Authority January 9, 2007 – 1:38 p.m. Wayside Workers 2 Fatalities 2 Serious Injuries 20 21 Probable Cause • …was the failure of the train dispatcher to maintain blocking that provided signal protection and the failure of the work crew to apply a shunting device • Contributing was MBCR‘s failure to ensure that maintenance-of-way work crews applied shunting devices as required 22 Accident Shepherdsville, Kentucky CSX Transportation January 16, 2007 – 8:43 a.m. Derailment/HazMat Release 500 Evacuated 52 Minor Injuries from HazMat 23 24 25 Probable Cause • …was the failure of a car to properly negotiate a curve because of the inadequate side bearing clearance • Contributing was the undesirable contact of the truck bolster bowl rim with the car body center plate, and the hollow worn wheels on the car, which diminished the steering ability of the truck 26 Accident Providence, Rhode Island Amtrak March 13, 2008 – 1:11 p.m. Wayside Workers 1 Fatalities 1 Serious and 1 Minor Injury 27 Engineer’s view eastbound on track 2, approaching the Charles Street Bridge. Point of impact was located under the bridge. 28 Probable Cause • was the foreman’s failure to communicate critical changes made to on-track safety protection and to utilize all assigned trackmen as watchmen while working in a hot spot • Contributing to the accident was the watchman’s failure to recognize that he was poorly positioned to perform his duties 29 Accident Newton, Massachusetts Massachusetts Bay Transit Authority May 28, 2008 – 5:51 p.m. Rear-End Collision 1 Fatalities 1 Serious and 7 Minor Injuries 30 31 Probable Cause • …was the failure of the operator to comply with the controlling signal indication, likely as a result of an episode of micro-sleep • Contributing to the accident was the lack of a positive train control 32 Accident Chatsworth, California UPRR/Metrolink September 12, 2008 – 4:22 p.m. Collision 25 Fatalities 102 Injured Passengers Transported 33 34 Probable Cause • …was the failure of the Metrolink engineer to appropriately respond to the red signal at Control Point Topanga because he was engaged in prohibited use of a wireless device, specifically text messaging • Contributing to the accident was the lack of a positive train control system 35 Accident Miami, Florida Miami International Airport People Mover November 28, 2008 – 4:44 p.m. Collision End of Track 6 Injuries 36 37 38 39 40 41 Probable Cause …was the installation of a jumper wire that prevented the overspeed/overshoot system from activating to stop Contributing was: (1) the failure to provide the technicians with specific procedures regarding disabling of vital train control systems, (2) ineffective oversight by the Miami-Dade Aviation Department, (3) lack of adequate safety oversight by the state of Florida, and (4) lack of authority by the U.S. DOT to provide adequate safety oversight of such systems 42 Accident Cherry Valley, Illinois Canadian National June 19, 2009 – 8:36 p.m. Derailment/Haz-Mat Release 1 Fatality 2 Serious and 7 Minor Injuries 43 44 Probable Cause • …was the washout of the track structure and the failure to notify the train crew in time to stop the train because of the inadequacy of the emergency communication procedures • Contributing was the failure to develop a storm water management design to address the previous washouts • Contributing to the severity of the accident was the inadequate design of the DOT-111 tank cars 45 Accident Fort Totten, District of Columbia Washington Metropolitan Area Transit Authority June 22, 2009 – 4:58 p.m. Rear-End Collision 9 Fatalities 52 Injured 46 47 Probable Cause • a failure of the track circuit modules, …[that lost] detection of train 214 • WMATA’s failure to ensure that the enhanced track circuit verification test (developed following the 2005 NTSB Railroad Accident Report Rosslyn near-collisions) was institutionalized and used systemwide 48 Probable Cause • Contributing . WMATA’s lack of a safety culture, . WMATA’s failure to effectively maintain and monitor the performance of its automatic train control system, . GRS/Alstom Signaling Inc.’s failure to provide a maintenance plan to detect spurious signals that could cause its track circuit modules to malfunction, . ineffective safety oversight by the WMATA Board of Directors, 49 Probable Cause • Contributing Cont’d… . the Tri-State Oversight Committee’s ineffective oversight . the FTA’s lack of statutory authority to provide federal safety oversight. …to the severity of injuries and fatalities was WMATA’s failure to replace or retrofit the 1000-series railcars after these cars were shown in a previous accident to exhibit poor crashworthiness. 50 Accident Lake Buena Vista, Florida Disney World Monorail July 5, 2009 – 2:00 a.m. Collision 1 Fatality 51 52 Probable Cause • …was the shop panel operator’s failure to properly position switch-beam 9 and the failure of the monorail manager acting as the central coordinator to verify the position of switch-beam 9 before authorizing the reverse movement of the Pink monorail • Contributing was the lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system 53 Accident Falls Church, Virginia Washington Metropolitan Area Transit Authority November 29, 2009 – 4:28 a.m. Rear-End Collision 3 Minor Injuries 54 55 Probable Cause • …was the failure of the train operator to control the movement of his train as it approached the standing train, possibly due to his fatigue. 56 Accident Miami, Florida Miami-Dade Transit Metromover July 20, 2010 – 5:39 p.m. Collision 16 Minor Injuries 57 58 Accident Sequence 1. Metromover No. 35 - initially damaged the signal rail due to a guide wheel dropping from its spindle. 2. Metromover No. 32 - passed over the signal rail damaged by Metromover No. 35, incurring signal rail damage and loss of power. 3. Metromover No. 20 - moved from the maintenance facility to replace Metromover No. 35, triggering system alarms which alerted RTCs of abnormal activity on the signal rail. 4. The false occupancy alarm was reset (cleared) in the ATC system. 5. Metromover No. 38 - collided with the trailing end of Metromover No. 32. 59 Probable Cause • … the rail traffic controllers’ decision to restart automated train operations without accounting for the location of all Metromovers following a safety shutdown after the signal rail had been damaged by a defective Metromover guide wheel. • Contributing to the accident was inadequate oversight by Miami-Dade Transit. 60 Accident Two Harbors, Minnesota Canadian National September 30, 2010 – 4:05 p.m. Head-End Collision 5 Injuries 61 62 Probable Cause • …was the train crew departing the Highland siding before the northbound train had passed. • Contributing was the use of after-arrival track authorities in non-signaled territory, that is vulnerable to human error and lacks inherent safety redundancies • Contributing to the accident was crew fatigue and inadequate crew resource management 63 Accident Red Oak, Iowa Burlington Northern Santa Fe April 17, 2011 – 6:55 a.m. Rear-End Collision 2 Fatalities 64 65 Probable Cause • …the failure of the crew [to] stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions • …the absence of a positive train control system that identifies the rear of a train and stops a following train • … contributing to the severity was the absence of crashworthiness standards for modular locomotive crew cabs 66 Accident Mineral Springs, North Carolina CSX Transportation May 24, 2011 – 3:35 a.m.

Load more