Page:NTSB RAR-73-5.pdf/37

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5. The engineer of train 416 did not require that flagging be provided and thus did not fulfill the responsibilities assigned to him by Rules 106 and 1022.

6. The collector of train 416 was available to perform flagging duties, but did not do so nor was he so instructed by the conductor or engineer.

7. The conductor of train 416 located himself in the center vestibule of the rear car to direct the backup movement, a position necessary for communication with the engineer. From this position, he was unable to see train 720 until too late because of the curve of the track.

8. Signal 3-3.60 displayed a yellow aspect as train 720 approached it. The yellow aspect required that 720 reduce speed to 30 m.p.h. after passing the signal and approach Signal 3-3.10 prepared to stop.

9. The rear of train 416 was camouflaged from the view of the engineer of train 720. The back end of the Highliner blended with the background, and the marker lights were not distinctive enough to be discerned by the engineer of 720.

10. The speed of train 720 as it approached 27th Street exceeded the required 30 m.p.h. by at least 20 m.p.h., a speed difference large enough to be detected as in excess of 30 m.p.h. without a speedometer.

11. If train 720 had been traveling at 30 m.p.h., it could have stopped short of impact if emergency braking had been initiated when the engineer first sighted train 416.

12. If the engineer of train 720 had made an emergency brake application when train 416 first was clearly visible, the train could have stopped short of the impact point.

13. The crewmembers' interpretations of the various signal aspects were not consistent with the interpretations of ICG representatives.

14. Based upon the actions and knowledge displayed by the crewmembers of trains 416 and 720, the rule training, examination, and enforcement activities of the ICG were inadequate to insure rule compliance.

15. A rule that imparts dual responsibilities to an employee invites partial employee understanding. The crewmembers of trains 416 and 720 understood the need for medium speed under authority of an approach signal, but did not realize that the train must be prepared to stop at the next signal.