Page:NTSB RAR-77-10.pdf/24

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10. Roving supervisors cannot assess adequately a motorman's complete understanding of operating rules.

11. The display on the same indicator units of cab signal aspects that are similar but which require different responses can be confusing to an operator in an emergency situation.


Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the motorman to exercise due care in meeting his responsibilities and the unauthorized operation of the Lake-Dan Ryan train into a signal block occupied by the standing Ravenswood train, at a speed that was too fast to stop after the operator sighted the standing train.

RECOMMENDATIONS

As a result of its investigation of this accident, the National Transportation Safety Board made the following recommendations to the Chicago Transit Authority on June 29, 1977:

"Initiate a program which will:

1. Provide a systematic review of the operating rules so that all employees will have a clear understanding of such rules and of any changes.

2. Insure employee compliance with the rules. (Class II, Priority Followup) (R-77-14)

"Discontinue the automatic display and control function of the flashing red cab signal and its associated flashing yellow 15 mph on the speedometer. (Class II, Priority Followup) (R-77-15)

"Operate trains on an absolute block. If it becomes necessary to enter an occupied block in emergency, provide procedures that will insure safe operation. (Class II, Priority Followup) (R-77-16)

"Consider an operating employee's complete service record when judging the employee's Operating capabilities. (Class II, Priority Followup) (R-77-17)"