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6. Because no supervisor had conducted a check of his job performance in the year and 22 days of his employment, the operator continued to use the improper practice of not applying the blocking device to the signal lever which he had learned due to improper instruction during his on-the-job training.
7. The Federal Railroad Administration Regulation 49 CFR 217.9 does not require Conrail or any other railroad to have a plan to regularly check specific employees, such as operators, in the proficiency of their job performance.
8. The operating cab of the power car of train No. 74 was destroyed in the low—speed collision because of the lack of adequate crashworthiness features.
Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the OW operator to apply a blocking device to the signal lever which permitted him to clear the signal and allowed train No. 74 to proceed on an occupied track, and Conrail's condoning the transmission of train orders without requiring the operator to display the train order signal. Contributing to the accident were the improper training and inadequate supervision of the tower operator, and the failure of Conrail to provide a reasonable means of displaying train order signals at OW. Contributing to the injuries were the design of the seats and lack of emergency evacuation instructions.
RECOMMENDATIONS
As a result of its investigation of this accident, the National Transportation Safety Board made the following recommendations:
——to the Federal Railroad Administration:
Conduct a safety review of the Metropolitan Region to determine why the actual operation of trains was not in compliance with Conrail rules, and provide the Safety Board a report of the findings. (Class II, Priority Action) (R-81-52)
Amend 49 CFR 217.9 to require sufficient monitoring to insure that each operating employee is evaluated for compliance with operating rules on a regular basis. (Class II, Priority Action) (R-81-53)
-—to the Consolidated Rail Corporation (Conrail):
Establish better precedures for the training and followup by supervisors of Operators and dispatchers to insure compliance with the rules. Provide formal training. (Class II, Priority Action) (R-81-54)
Require that all trains operating on the main line monitor the same channel as designated in the timetable. (Class II, Priority Action) (R—81-55)
Provide the operators on the Metropolitan Region with the ability to display a train order signal at train order stations as required by the Operating rules. (Class 11, Priority Action) (R-81-56)
