Page:NTSB RAR-81-4.pdf/24

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end of the unit rearward into the electrical locker. In addition to crushing the operating cab, train No. 74 was pushed rearward 112 feet. The engineer and fireman were injured when they jumped from the operating cab to the ground before the collision.

Many of the passengers, who had no warning before the collision and were not aware of the impending collision, were thrown forward into seatbacks at impact. Many seats rotated when struck from behind when passengers were thrown against them. The largest number of injuries to passengers were to the legs when they became caught under the seats ahead. The next largest number was facial lacerations, bruises, and teeth broken and knocked out. One female passenger was seriously injured and required emergency surgery.

When a fire started outside of the second car, the conductor and a trainman removed a fire extinguisher from the power car to extinguish the fire. There was some panic when word of the fire spread through the cars and passengers began to smell the smoke. However, this was of a short duration and when the passengers realized the fire was not spreading, they calmed down.

Passengers experienced extreme difficulty when they attempted to evacuate the cars. Many passengers tried to push the emergency windows outward; however, because the windows were designed to be taken out by pulling inward, they would not open. Other passengers could not determine how to open the trapdoor over the steps, so many passengers jumped from the car to the ground.

The Westchester County disaster plan resulted in speedy response by police, fire, and rescue personnel, and in the swift evacuation of the passengers. The Dobbs Ferry Police Department was notified of the accident at 4:13 p.m. They immediately dispatched personnel to the accident site, requested ambulances, and notified local hospitals. The Fire Department and the Dobbs Ferry ambulance arrived simultaneously within 12 minutes after being notified. The Dobbs Ferry Hospital had its disaster plan in effect within 5 minutes after notification. Previous drills conducted by the hospital and ambulance corps were of substantial benefit in the prehospital response. The hospital's disaster plan was so detailed that doctors and nurses knew which streets to take to avoid blocked traffic.

ANALYSIS

Protection For Trains

When the dispatcher decided to run train OPSE-7 against the current of traffic, the primary safeguardaplacing a blocking device on the signal lever and the primary redundant feature - displaying the train order signal- were ignored by the OW operator. Additionally, the dispatcher failed to comply with the instruction governing the "J" holding orders which required him to assure that the train order signal was displayed.

The action of the OW operator in displaying a clear signal for train No. 74 to proceed onto a segment of track in conflict with an opposing train which had been given absolute rights by a train order is a perfect example of why its necessary to block signal levers in such operations. Throughout the years, investigation of accidents and incidents have shown that human failure cannot be eliminated completely; therefore, the needed redundant requirement to display the train order signal which made the engineer of a restricted train also responsible for not passing the point where the train order was in effect was lacking. The dispatcher violated a Conrail rule by transmitting a holding order to the CW operator without requiring the Operator to state that "stop signal and train order signal displayed". A further safeguard would have been to address the order to the engineer of train No. 74; however, this is not required by Conrail operating rules.