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. Rear-End Collision 2 Fatalities
67 68 69 Probable Cause
• was the failure of the striking train crew to comply with the speed restriction required when they encountered a dark signal
• Contributing to the accident was the lack of a positive train control system that could have prevented the accident
70 Accident
Tiskilwa, Illinois Iowa Interstate Railroad October 7, 2011 – 2:14 a.m. Derailment/Haz-Mat Release
71 72 Probable Cause
• …was a broken rail.
• Contributing was inadequate puncture resistance of the tank heads and shells of the DOT-111A- 100W1 general service tank cars and the failure of draft sill attachments.
73 Accident
Westville, IN CSX Transportation January 6, 2012 Rear-end Collision & Passing Train Collision 2 Injures
74 75 Probable Cause
• “…failure of the crew to maintain vigilant attention to wayside signals, communicate effectively, avoid distractions from prohibited text messaging, and comply with the speed restrictions required by the railroad signal system. • Contributing was the lack of a positive train control system…”
76 Accident
Madison, Illinois UPRR/Amtrak February 28, 2012 – 11:57 a.m. Highway Grade Crossing 1 Fatality
77 78 79 Probable Cause
• …was the failure of the signal inspector and signal technician to provide for the safety of train movements and highway users prior to disabling the highway-rail grade crossing warning system • Contributing to the accident was the failure of the railroad management to ensure proper procedures were followed during the software upgrades to provide for the safety of train movements and highway users
80 Accident
Goodwell, Oklahoma Union Pacific Railroad June 24, 2012 - 10:02 a.m. Head-On Collision 3 Fatalities
81 82 Probable Cause
• ...the engineer’s inability to see and correctly interpret the signals;
• …the conductor’s disengagement from his duties; and the lack of positive train control,
• …Contributing was a medical examination process that failed to decertify the engineer
83 Accident
Columbus, OH NS Railway Derailment/Haz-Mat Release July 11, 2012 1 Injury
84 85 Probable Cause
“…was a broken rail that exhibited evidence of rolling contact fatigue.”
86 Accident
Barton County, MO July 21, 2012 KCS Railway/BNSF Railway Side Collision 2 Injuries
87 88 Probable Cause
“…was the failure of the KCS train crew to comply with trackside signal indications. Contributing was the lack of a positive train control system…”
89 Accident
Ellicott City, MD CSX Transportation August 20, 2012 Derailment 2 Fatalities
90 91 92 Probable Cause
“…was a broken rail with evidence of rolling contact fatigue.”
93 Accident
Niles, Michigan Amtrak October 21, 2012 - 10:10 a.m. Derailment 13 Injuries 8 Transported
94 95 Probable Cause • …was the unauthorized use of a jumper wire that provided a false proceed signal with a mainline switch lined to Niles Yard. • The use of the jumper wire was inconsistent with Amtrak procedures… • Contributing to the accident was the inadequate oversight by Amtrak management to ensure proper jumper wire safeguards were employed.
96 Accident
Paulsboro, NJ Consolidated Rail Corporation November 30, 2012 Derailment/Haz-Mat Release
97 98 99 Probable Cause
“…allowing the train to proceed past the red signal aspect with the rail slide locks not fully engaged…” “…relying on a training and qualification program that did not prepare the train crew to examine the bridge lock system.”
100 Probable Cause
Con’t. “Contributing to the accident was the lack of a comprehensive safety management program…" “Contributing to the consequences was the failure of the incident commander to implement established hazardous materials response protocols…”
101 Accident
Keithvile, LA BNSF Railway/UPRR December 30, 2013 Head-on Collision 4 Injuries
102 103 Probable Cause
“…was the BNSF train conductor’s improper positioning of a switch for movement into the siding occupied by the BNSF train.”
104 Accident
Bridgeport, CT May 17, 2013 Metro-North Commuter Railroad Collision 65 Injuries
105 106 107 Probable Cause
“…was an undetected broken pair of compromise joint bars, resulting from • lack of comprehensive track maintenance program • regulatory exemption for high-density commuter railroads • decision to defer scheduled track maintenance.”
108 Accident
Chaffee, MO UPRR/BNSF May 25, 2013 Collision 2 Injuries
109 110 111 112 Probable Cause
“…was the failure of the UPRR train crewmembers to comply with wayside signals leading into the interlocking as a result of their disengagement from their task likely because of fatigue- induced performance degradation.
113 Probable Cause Con’t. Contributing was the lack of: • Positive train control system • Medical screening requirements • Action by FRA to fully implement the fatigue management components required by the RSIA of 2008
114 Probable Cause
• Con’t. • Contributing to the engineer’s fatigue was undiagnosed obstructive sleep apena. • Contributing to the accident was inadequate crew resource management.
115 Accident
Hays, Kansas July 16, 2013 UPRR Collision 3 Injuries
116 117 Probable Cause
“…was the failure of the brakeman to return a main track switch to the normal position after the crew had secured the train on a siding track. Contributing was the inability of the other train crew to determine the position of the main track switch in nonsignaled territory.”
118 Accident
Los Angeles, California September 5, 2013 Angels Flight Railway Foundation Derailment
119 120 Probable Cause
“…was the intentional bypass of the funicular safety system with Angels Flight management knowledge; and Angels Flight management continuation of revenue operations despite prolonged, and repeated, unidentified system safety shutdowns.”
121 Accident
Forest Park, Illinois September 30, 2013 Chicago Transit Authority Collision 34 Injuries
122 123 124 Probable Cause
“…was water in the control cables of two cars, which caused errant control signals to be sent to the cars’ power system. Contributing was the CTA’s practice of not securing unattended equipment.”
125 Accident
Bronx, New York December 1, 2013 Metro-North Commuter Railroad Derailment 4 Fatalities 61 Injuries
126 127 Probable Cause
“…was the engineer’s noncompliance with the 30-mph speed restriction because he had fallen asleep due to undiagnosed severe obstructive sleep apnea exacerbated by a recent circadian rhythm shift required by his work schedule.”
128 • Con’t. • Contributing was the acsence of a policy or regulation requiring medical screening for sleep disorders. • Also contributing was the absence of a positive train control system. • Contributing to the severity was the loss of window glazing.”
129 Accident
Jessup, Georgia February 20, 2014 CSX Transportation Trespassing 1 Fatality 6 Injuries
130 131 Probable Cause
“…was the film crew’s unauthorized entry onto the CSX right-of-way with personnel and equipment, despite CSX repeated denial of permission to access railroad property. Contributing was the adjacent property owner’s actions to facilitate access…”
132 Accident
Manhattan, New York March 10, 2014 Metro-North Commuter Railroad 1 Fatality
133 134 Probable Cause
“…was the miscommunication of the limits of on-track protection resulting from incomplete and inaccurate worker job briefings. Contributing was use of a reference point for on-track protection (AB split) that was poorly understood by some of the workers…”
135