PB88-916301 NATIONAL TRANSPORT SAFETY BOARD WASHINGTON, D.C. 20594 RAILROAD ACCIDENT REPORT REAR-END COLLISION OF AMTRAK PASSENGER TRAIN 94, THE COLONIAL AND CONSOLIDATED RAIL CORPORATION FREIGHT TRAIN ENS-121, ON THE NORTHEAST CORRIDOR CHASE, MARYLAND JANUARY 4, 1987 NTSB/RAR-88/01 UNITED STATES GOVERNMENT TECHNICAL REPORT DOCUMENTATION PAGE 1. Report No. 2.Government Accession No. 3.Recipient's Catalog No. NTSB/RAR-88/01 . PB88-916301 Title and Subtitle Railroad Accident Report^ 5-Report Date Rear-end Collision of'*Amtrak Passenger Train 949 the January 25, 1988 Colonial and Consolidated Rail Corporation Freight -Performing Organization Train ENS-121, on the Northeast Corridor, Code Chase, Maryland, January 4, 1987 -Performing Organization 7. "Author(s) ~~ Report No. Performing Organization Name and Address 10.Work Unit No. National Transportation Safety Board Bureau of Accident Investigation .Contract or Grant No. Washington, D.C. 20594 k3-Type of Report and Period Covered 12.Sponsoring Agency Name and Address Iroad Accident Report lanuary 4, 1987 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 1*+.Sponsoring Agency Code 15-Supplementary Notes 16 Abstract About 1:16 p.m., eastern standard time, on January 4, 1987, northbound Conrail train ENS -121 departed Bay View yard at Baltimore, Mary1 and, on track 1. The train consisted of three diesel-electric freight locomotive units, all under power and manned by an engineer and a brakeman. Almost simultaneously, northbound Amtrak train 94 departed Pennsylvania Station in Baltimore. Train 94 consisted of two electric locomotive units, nine coaches, and three food service cars. In addition to an engineer, conductor, and three assistant conductors, there were seven Amtrak service employees and about 660 passengers on the train. At this time, the Edgewood block station operator requested that switch 12 at Gunpow, a remote-controlled interlocking, be lined for straight through movement for train traffic on track 2, on which Amtrak train 94 was operating. The wayside signal aspects displayed for train 94 approaching Gunpow on track 2 were 17 Key Words Wayside signal; automatic control 18.Distribution Statement systems; ACS; ATC; ATS; predeparture tests; drugs; This document is available safety backup systems; high-speed trains; Northeast to the public through the Corridor; supervisory oversight; crashworthiness; National Technical interior design Information Service, Springfield, Virginia 22161 19.Security Classification Security Classification 21 No. of Pages 22. Price (of this report) (of this page) 208 UNCLASSIFIED UNCLASSIFIED NT SB Form 1765.2 (Rev. 9/74) "clear" at both the distant (81-2) and home (2N) signal locations, and the wayside signal aspects displayed for train ENS-121 on track 1 was "approach" at distant signal 816-1 and "stop" at the home signal IN. Automatic control systems in both trains should have displayed aspects corresponding to those of the wayside signals, except that the cab signals of train ENS- 121 should have displayed a "restricting" aspect beginning 4,450 feet south of signal IN. About 1:30 p.m., Conrail train ENS-121 entered switch 12 onto track 2 causing the switch to realign for movement from track 1 to track 2. When train ENS -121 entered switch 12, the aspect of signal Z:U for track 2 changed from "clear" to "stop." The engineer of tr^in 94 "apparently recognized that the aspect of signal 2N was "stop" and ''put hi/s train into emergency braking. However, the tra/in was travel i.fig between 120 and 125 mph and could not be stopped before colliding with train ENS -121. The engineer and 15/passengers aboard train 94 were fatally injured; 174 other perspn aboard the .trains received minor to serious injuries. The *u,rear Conrai 1/ 1 ocomotive unit, both Amtrak locomotive units, and the /head three passenger cars were destroyed. The middle Conriail locomotive unit was heavily damaged, and the rear nine cars of the passenger train sustained varying degrees of damage. The National Transportation Safety Board determines that the probable cause of this accident was the failure, as a result of impairment from marijuana, of the engineer of Conrail train ENS -121 to stop his train in compliance with home signal IN before it fouled track 2 at Gunpow, and the failure of the Federal Railroad Administration (FRA) and Amtrak to require and Conrail to use automatic safety backup devices On all trains on the Northeast Corridor. Contributing to the accident were: 1) the failure of the brakeman of ENS-121 to observe signal aspects and to alert the engineer when they became restrictive; 2) the failure of the crewmembers of train ENS -121 to make the required automatic cab signals (ACS) test; 3) the muting of the ACS alerter whistle on the lead unit of train ENS-121; and 4) the inadequacies of the FRA oversight of Amtrak's and Conrail's supervision of corridor trai ns. Operation of Amtrak train 94 at 125 mph, rather than its restricted speed of 105 mph, contributed to the severity of the accident. ii CONTENTS EXECUTIVE SUMMARY v INVESTIGATION 1 The Accident 1 Injuries 5 Damage 6 Method of Operation 12 Speed Restrictions 12 Operational Strategy 15 Northeast Corridor Users 16 The Corridor "Window" 17 Train Mix and Density 18 Dispatchers and Block Station Operators 21 Track Information 23 Signal Information 23 Wayside Signal System 23 Automatic Cab Signal System 32 Train Information 35 Amtrak Train 94 35 Conrail Train ENS -121 41 Meteorological Information 49 Personnel Information 49 Crewmembers of Amtrak Train 94 50 Amtrak Supervision 51 Crewmembers of Conrail Train ENS-121 53 Conrail Supervi s i on 57 Supervisory Efficiency Checks 59 Medical and Pathological Information 62 Toxicological Testing 63 Survival Aspects 68 Amtrak Train 94 68 Conrail Train ENS-121 73 Emergency Response 73 Tests and Research 78 On-Site Inspections and Tests 78 Sight and Stopping Distance Tests 78 Signal Tests 79 Gunpow Signal Event Recorder 80 Locomotive Speed Indicators and Recorders 81 Computer Simulations 85 Radio Tests 85 Other Tests and Research 86 Other Information 86 iii ANALYSIS 90 Summary of the Accident 90 Predeparture Testing 94 Operation of Train ENS-121 96 Human Performance 98 Toxicology 100 Adequacy of the Signal and Safety Backup Systems 104 Dispatching Procedures 109 Speed Restrictions Ill Mixing Freight and Passenger Trains on the Corridor.... 113 Supervision and Management 114 Conrail's Supervisory Management 114 Conrail's Oversight of the Traincrew 115 Conrail's Equipment Inspection 117 Amtrak's Supervisory Management 118 Amtrak's Oversight of the Traincrews 120 Supervision of Toxicological Testing 123 FRA Oversight of the Northeast Corridor 125 Response to the Emergency 127 Survival Aspects 127 CONCLUSIONS 137 Findings 137 Probable Cause 144 RECOMMENDATIONS 144 APPENDICES 149 Appendix A - Investigation and Hearing..... 149 Appendix B - Personnel Information 151 Appendix C - Excerpts from Amtrak and Conrail Operating Rules 155 Appendix D - Excerpts from Amtrak Northeast Corridor Timetabl e 1 165 Appendix E - Amtrak Northeast Corridor Bulletin Orders 173 Appendix F - Amtrak Equipment Condition Report 175 Appendix G - Conrail EL 106-A and MP-94 Inspection Reports 177 Appendix H - Brotherhood of Locomotive Engineers' Letter to Amtrak 185 Appendix I - Amtrak Response to Brotherhood of Locomotive Engineers' Letter 187 Appendix J - Statements of Amtrak Assistant Vice President of Transportation and FRA Associate Administrator for Safety to Safety Board Member Joseph Nail \. 1 191 Appendix K - Toxicological Analysis Reports from the Center for Human Toxicology 193 Appendix L - History of Safety Backup Devices on the Northeast Corridor 203 Appendix M - Safety Board Safety Recommendations for Automatic Train Control Installation on the Northeast Corridor 207 i v EXECUTIVE SUMMARY About 1:16 p.m., eastern standard time, on January 4, 1987, northbound Conrail train ENS -121 departed Bay View yard at Baltimore, Maryland, on track 1. The train consisted of three diesel-electric freight locomotive units, all under power and manned by an engineer and a brakeman. Almost simultaneously, northbound Amtrak train 94 departed Pennsylvania Station in Baltimore. Train 94 consisted of two electric locomotive units, nine coaches, and three food service cars. In addition to an engineer, conductor, and three assistant conductors, there were seven Amtrak service employees and about 660 passengers on the trai n. At this time, the Edgewood block station operator requested that switch 12 at Gunpow, a remote-controlled interlocking, be lined for straight through movement for train traffic on track 2, on which Amtrak train 94 was operating. The wayside signal aspects displayed for train 94 approaching Gunpow on track 2 were "clear" at both the distant (81-2) and home (2N) signal locations, and the wayside signal aspects displayed for train ENS-121 on track 1 was "approach" at distant signal 816-1 and "stop" at the home signal IN. Automatic control systems in both trains should have displayed aspects corresponding to those of the wayside signals, except that the cab signals of train ENS -121 should have displayed a "restricting" aspect beginning 4,450 feet south of signal IN. About 1:30 p.m., Conrail train ENS-121 entered switch 12 onto track 2 causing the switch to realign for movement from track 1 to track 2. When train ENS-121 entered switch 12, the aspect of signal 2N for track 2 changed from "clear" to "stop." The engineer of train 94 apparently recognized that the aspect of signal 2N was "stop" and put his train into emergency braking. However, the train was traveling between 120 and 125 mph and could not be stopped before colliding with train ENS-121. The engineer and 15 passengers aboard train 94 were fatally injured; 174 other person aboard the trains received minor to serious injuries. The rear Conrail locomotive unit, both Amtrak locomotive units, and the head three passenger cars were destroyed.