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The brake equipment tests and event recorder analyses showed that no initial brake application was made, that the full-service, 32-psi application was made with the locomotive brake off nearer to MP 227 than to the Ruggles Street station at MP 226.2, and that the throttle remained in the run 8 position until after the full-service brake application was made. Since sand was discovered at a location consistent with an emergency application 480 feet, or about 4 seconds, before the POD, the train was probably placed in emergency as stated by the crew but not at the location identified by them. As is reasonably clear from the testimony, which the event recorder corroborates, the apprentice followed the braking instructions given to him by the engineer, and nothing indicates that they did not continue in that mode of instruction on the approach to Back Bay station. The engineer was not chemically impaired and was familiar with the route.
The Safety Board believes that if the engineer had provided the customary instructions for braking to reduce the train's speed for the curve at MP 227.4, he would have told the apprentice at about MP 225.7 to reduce the throttle from the run 8 position to the run 4 position and to follow with an initial brake application of 10 to 12 psi with no locomotive brakes. Then, as Amtrak train 66 began to slow, the engineer would have instructed the apprentice to reduce the throttle to the run 1 position and make a full-service brake application. Under these conditions, Amtrak train 66 train should have slowed in sufficient time to negotiate the curve Amtrak engineers and officials identified the Pickle Factory (about MP 225.7) as the point where they begin their braking of mixed consists in anticipation of the speed restriction at MP 227.
Speed/distance calculations show that about 40 seconds elapsed as Amtrak train 66 traveled from the usual braking location to the point at which the event recorder indicates the full-service application was made. Why the engineer did not take action to slow the train during this time is not certain. Forty seconds is more than the time needed to instruct the apprentice to make a brake application and to cross the cab from the fireman's seat to the engineer's position, if necessary, to accomplish any brake application instructions that were not promptly executed. Therefore, the Safety Board postulates that the engineer did not give the directive to begin braking at the usual location and that something other than the location of the train must have been occupying his attention.
One possibility is that the engineer was preoccupied with instruction tasks. Another apprentice who had ridden with him on several OJT trips described his supervision as: "constantly asking questions about where I was "and" a pretty steady flow of questions about the [physical] characteristics from the time we left.. until we arrived." He also said the engineer sometimes observed him from the fireman's seat, the usual position from which The Safety Board postulates that when the engineer recognized that they had gone beyond the usual braking point for the initial application, he responded with some urgency, directing the apprentice to make a brake application, probably full service. Whatever that directive was, the apprentice's execution was not consistent with acceptable braking technique. Since the engineer himself did not quickly place the train in emergency, he must have initially believed that the apprentice had made the full-service application properly and that enough time remained to slow the train sufficiently to negotiate the curve. The statements of both the engineer and apprentice agree that when the engineer did place the train in emergency, he reached past the apprentice for the brake valve handle; his action
