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Public Transportation Safety Board Rail Abbreviated Report Form

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Public Transportation Safety Board Rail Abbreviated Report Form PUBLIC TRANSPORTATION SAFETY BOARD RAIL ABBREVIATED REPORT FORM PTSB Case Property Name Accident Date 10042 NYCT –Staten Island Railway December 26, 2008 Injuries Fatalities Accident Type Accident Cause 0 0 Collision Operator Fatigue Location Borough, City, Village, Town Tottenville Station Staten Island On Friday, December 26, 2008, at approximately 6:27 a.m., eastbound NYCT Staten Island Railway (SIR) train #26 was driven past the line-ending stop signal and struck the bumper block at Tottenville Station. The train dislodged the bumper block, traveled off the end of the rails derailing onto the right-of-way. The train consisted of four, R-44 coach cars being operated by a crew consisting of an engineer and a conductor; neither employee claimed injury. Damage assessment to the track, the signal system and the car equipment was over $550,000. Non revenue train #26 departed St. George Terminal at 5:55 a.m. for Tottenville Station where it was to be positioned for westbound passenger service during the morning rush. The crew had been on duty for approximately four hours and fifteen minutes prior to the derailment. The event data recorder from the lead car (#420) indicated that the trip from St. George to Tottenville was as expected. The data further indicated that train #26 switched from automatic train control (ATC) to terminal mode as it entered the interlocking west of Tottenville Station at 6:24:09 a.m. At this point, train #26 was traveling about 10 MPH when the engineer placed the master controller into the braking range slowing the train further to 5 MPH. After slowing to 5 MPH, train #26 passed through a required Safety Stop, in violation of SIR Operating Rule 9.33 which states that “…all Tottenville trains must come to a complete stop at the stop marker, and then proceed no faster than 5 MPH into the station.” Subsequently at this point, the event recorder confirmed that the train’s controller was moved into a power setting and the train began to slowly accelerate. Approximately 38 seconds later, as the train reached a speed of 16 MPH and while the master controller was still in a power setting, the train’s brakes went into a penalty brake application when the train passed a station signal indicating stop (violation of SIR Operating Rule12.13). The collision speed of approximately 16 MPH was recorded as the brake pipe pressure rapidly dropped indicating an emergency brake application. Post accident investigation determined that the emergency brake application occurred when the automatic coupler sheared at impact with the bumper block, rupturing the brake pipe. 1 The bumper block’s anchor bolts were sheared off and the block components became wedged under the lead car which continued approximately 60 feet past the end of the running rails, down an incline, stopping at the shoreline of the Arthur Kill creek (see photo above). Car #402’sfront truck was resting upon a marine retaining wall and the car body was adjacent to the station’s handicapped access ramp. The rear end of car #402 remained on the station track #2; at about the position where the bumper block used to be. The engineer and conductor of train #26 were taken to the NYCT Medical Assessment Center for post incident drug and alcohol testing. Testing was administered within the required NYCT time limit of two hours and the results were negative. NYCT's Maintenance of Way Derailment Team and Department of Car Equipment Emergency Response team assisted SIR in the recovery operations at Tottenville. To re-rail car #402, the area beneath the car had to be built up, creating a ramp to pull the two lead cars up and back onto the tracks. The re-railing operation was reported complete and without incident at 6:04 p.m. Work Assignment The engineer and the conductor were crew members assigned to job “Relief 1”which is a weekly work assignment that covers the regular days off for SIR Run A, Run B, and partial Run F. Relief 1 has regular days off on Tuesday and Wednesday and the start times vary according to the Run. Since the day prior to the accident was a holiday, Relief 1’s scheduled was pushed forwardto 8:41 a.m., to 4:53 p.m. and then back to their normal report time of 1:41 a.m. on Friday morning. Staten Island Railway Operating rule 3.17, requires train operators to get at least 8 hours rest between assignments.The schedule alteration was permissible; providing 8 hours and 48 minutes of down time between runs. Post Accident Statements Both the engineer and the conductor made voluntary written statements regarding their involvement in this accident. The engineer admitted not getting enough rest in the eight plus hours between runs while off duty on the evening before the accident. The engineer admitted to being tired from the Holiday. She further stated that she used poor judgment and was unable to make the proper safety stop (prior to Tottenville Station). The conductor’s written statement said that she was riding in the back of the train and noticed they were traveling at a higher rate of speed then normal while approaching the Tottenville Station. The conductor further stated that she attempted to pull the emergency brake cord, but pulled the train’s horn handle by mistake. (Note: The emergency brake cord and the train’s horn cord look similar and reside in close proximity.) Damage The head car (#402) experienced significant damage to the #1 end bonnet and the automatic- coupler and electric portion which were sheared off the draft gear assembly. The #1 anti-climber was also damaged. There was significant damage to the undercar equipment on car #402 which included the #1 HVAC compressor/condenser units, the air brake compressor and the propulsion group box. The #1 truck frame sustained structural damage and was scrapped. The rear bulk head inside the operator’s cab behind the engineer buckled and a piece of the bumper block punctured the cab floor opening an approximate 1 foot wide gash under the engineer’s seat. The B-side frame (left) structure on car #402 was also significantly damaged by the impact with the station handicap ramp. The remaining three cars in the train had no reported damage. Staten Island Railway Operating Rules Violations Staten Island Railway Operating Rules state that eastbound trains that travel the length of the system without stopping are required to make a full safety stop (Rule 9.33) at a posted stop 2 marker just prior to entering the Tottenville Station, and then to proceed into the station at a speed no greater than 5 MPH. Based on analysis of the data obtained from the data logger, the engineer slowed the train down to 5 mph before taking power again and did not make the required safety stop, accelerating to a speed of 16 MPH; well above the 5 MPH limit imposed by Rule 9.33. Furthermore, the train passed a station signal indicating stop (violation of Operating Rule 12.13) just prior to striking the bumper block and derailing. This is the second major incident involving the engineer. In 2007, the engineer was involved in single car derailment while making a yard move at the Clifton Maintenance Shop, for which the engineer received a 4 day suspension. The conductor failed in her duties to take the necessary actions to stop the train when the conductor felt the engineer is operating in the train in an unsafe manner; violating SIR Operating Rules 9.18 and 9.19. For their actions on the morning of December 26, 2008, the engineer and the conductor were both taken out of service. The engineer was charged with several SIR Operating Rules violations and, pending any further postponements, a decision is due. The conductor was charged with a single Operating Rules violation and as the result of a hearing held in January 2009, the charges against the conductor were substantiated and, after considering the facts, the conductor was re- trained and re-instructed on the equipment’s nomenclature, function, and proper train handling procedures. Weather Weather conditions at the time of the accident were mostly cloudy with temperature of 28 degrees. The accident took place in the morning darkness prior to sunrise, which was at 7:15 a.m. PTSB does not believe weather to be a contributing cause to this accident. Corrective Actions In January of 2009, the Operations Department issued an Operational Modifications Memorandum to the Transportation and Mechanical Departments in response to issues brought to light in the Tottenville derailment. The corrective actions include measures to: Paint the horn handle in the R-44 operating cabs a contrasting color to distinguish it from the red emergency brake valve handle (see Photo #2); Establish an additional stop eastbound at the Atlantic Station and westbound at the east portal of the St. George tunnel, in order to give the crew more time in an emergency; and Revise its work schedule assignments for the relief crews covering the weekly assignments for the late night F-Run resulting in a minimum turn around time greater than 11 hours Photo #2 –New contrasting cord arrangement in R 44 cabs. CONCLUSION The Public Transportation Safety Board staff finds that the most probable cause of this collision was the failure of the train operator to comply with Staten Island Railway Operating Rules due to fatigue. The Public Transportation Safety Board staff has reviewed the corrective actions taken by the NYCT and Staten Island Railway Operations Department makes no further recommendations.
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