Index:NTSB RAR-92 01.pdf

Title	Railroad Accident Report 92-01: Derailment and Collision of Amtrak Passenger Train 66 with MBTA Commuter Train 906 at Back Bay Station, Boston, Massachusetts, December 12, 1990
Author	National Transportation Safety Board
Year	1992
Publisher	U.S. Government Printing Office
Location	Washington, D. C.
Source	pdf
Progress	Proofread—All pages of the work proper are proofread, but not all are validated
Transclusion	Fully transcluded
OCLC	26178331

Pages (key to Page Status)

i ii iii iv v vi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

CONTENTS

EXECUTIVE SUMMARY	v
INVESTIGATION	1
The Accident	7
Injuries	7
Damages	8
Crew Information	8
⁠MBTA Train 906	8
⁠Amtrak Train 66	8
Train Information	9
⁠MBTA Train 906	9
⁠Amtrak Train 66	9
Tunnel. Signal, and Track Information	10
⁠Tunnel	10
⁠Signals	10
⁠Track	10
⁠Post Acident Track Examination	10
Operations information	11
⁠Operating Procedures	11
⁠Amtrak Train 66	11
⁠Management Oversight	12
Meteorological Information	12
Medical and Toxicological Information	12
Fire	13
Survival Aspects	13
⁠Emergency Response	13
⁠Passenger Evacuation	13
⁠META Train 906 Crew	14
⁠Amtrak Train 66 Crew	14
⁠MBTA Train 906 Exits	15
⁠Amtrak Train 66 Exits	15
⁠Emergency Preparedness	15
Tests and Research	19
⁠Speed Indicator Test	19
⁠Maintenance Records	19
⁠Locomotive Airbrake Valve Tests	19
⁠Event Recorder Information	19
⁠Event Recorder Tests	20
⁠Sto ping Distance Simulation Tests	22
⁠Braking Speed Simulation Tests	24
Amtrak's Postaccident Actions	24
Locomotive Engineer Training	25
⁠Sources of Information	25
⁠Program Organization	25
⁠Classroom Training Phase	25
⁠Physical Characteristics Familiarization	26
⁠Simulator Training Phase	27
⁠On-the—Job Training Phase	27
⁠Final Evaluation of Apprentices	28
⁠Program Administration	28
⁠Development and Evolution of the Program	29
Engineers'and Apprentice Engineers‘ Concerns:	29
⁠FRA Engineer Certification	29
⁠Event Recorder Regulations	30
ANALYSIS
General	30
The Accident	31
⁠Advance Warning Devices	32
⁠Brake Inspections and Test	33
Instructing Engrneer's and Apprentice's Performance Before Derailment	33
Locomotive Engineer Training and FRA Qualification	35
⁠Locomotive Engineer Training Program	35
⁠Amtrak Locomotive Engineer Training Deficiencies	35
⁠Training and Qualification on the IIT Simulator	37
⁠Training and Qualifications for instructing Engineers	38
⁠Sources of Engineer Training Program Deficiencies	38
⁠FRA Locomotive Engineer certification Requirements	39
Locomotive Event Recorders	39
Survival Aspects and Emergency Response	40
CONCLUSIONS
Findings	40
Probable Cause	41
RECOMMENDATIONS	41
APPENDIXES
⁠Appendix A—Investigation and Hearing/Deposition	43
⁠Appendix B—Personnel Information	45
⁠Appendix C—Outline of Locomotive Engineer Training Program	47
⁠Appendix D—Apprentice Performance valuation Farm to Be Completed by Instructing Engineers	55