Railroad Accident Report 92-01

by National Transportation Safety Board

PB92-916301
NTSB/RAR-92/01

NATIONAL
TRANSPORTATION
SAFETY
BOARD

WASHINGTON, D.C. 20594

 

RAILROAD ACCIDENT REPORT

 

DERAILMENT AND COLLISION OF
AMTRAK PASSENGER TRAIN 66 WITH
MBTA COMMUTER TRAIN 906
AT BACK BAY STATION
BOSTON, MASSACHUSETTS
DECEMBER 12, 1990

US GOVERNMENT PRINTING OFFICE 1990 0-942 855

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous material ssafety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports. safety studies, special investigation reports, safety recommendations, and statistical reviews.

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NATIONAL
TRANSPORTATION
SAFETY BOARD

WASHINGTON. D.C. 20594

RAILROAD ACCIDENT REPORT

ADOPTED:FEBRUARY 25, 1992

NOTATION 5434A

Abstract: At 8 23 a m on December 12, 1990, National Railroad Passenger Corporation (Amtrak) passenger train 66, consisting of a two-unit locomotive, two material handling cars, five passenger cars, one dining car, and two baggage cars, derailed and struck Massachusetts Bay Transit Authority (MBTA) commuter train 906, consisting of one locomotive, six passenger cars, and one control car, as both trains entered Back Bay station in Boston. Massachusetts

In this report the following safety issues are discussed: tram operations and speed limits, locomotive engineer training and Federal Railroad Administration certification, and locomotive event recorder data

As a result of its investigation, the Safety Board made recommendations addressing these issues to the National Railroad Passenger Corporation, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, and the United Transportation Union

CONTENTS

EXECUTIVE SUMMARY	v
INVESTIGATION	1
The Accident	7
Injuries	7
Damages	8
Crew Information	8
⁠MBTA Train 906	8
⁠Amtrak Train 66	8
Train Information	9
⁠MBTA Train 906	9
⁠Amtrak Train 66	9
Tunnel. Signal, and Track Information	10
⁠Tunnel	10
⁠Signals	10
⁠Track	10
⁠Post Acident Track Examination	10
Operations information	11
⁠Operating Procedures	11
⁠Amtrak Train 66	11
⁠Management Oversight	12
Meteorological Information	12
Medical and Toxicological Information	12
Fire	13
Survival Aspects	13
⁠Emergency Response	13
⁠Passenger Evacuation	13
⁠META Train 906 Crew	14
⁠Amtrak Train 66 Crew	14
⁠MBTA Train 906 Exits	15
⁠Amtrak Train 66 Exits	15
⁠Emergency Preparedness	15
Tests and Research	19
⁠Speed Indicator Test	19
⁠Maintenance Records	19
⁠Locomotive Airbrake Valve Tests	19
⁠Event Recorder Information	19
⁠Event Recorder Tests	20
⁠Sto ping Distance Simulation Tests	22
⁠Braking Speed Simulation Tests	24
Amtrak's Postaccident Actions	24
Locomotive Engineer Training	25
⁠Sources of Information	25
⁠Program Organization	25
⁠Classroom Training Phase	25
⁠Physical Characteristics Familiarization	26
⁠Simulator Training Phase	27
⁠On-the—Job Training Phase	27
⁠Final Evaluation of Apprentices	28
⁠Program Administration	28
⁠Development and Evolution of the Program	29
Engineers'and Apprentice Engineers‘ Concerns:	29
⁠FRA Engineer Certification	29
⁠Event Recorder Regulations	30
ANALYSIS
General	30
The Accident	31
⁠Advance Warning Devices	32
⁠Brake Inspections and Test	33
Instructing Engrneer's and Apprentice's Performance Before Derailment	33
Locomotive Engineer Training and FRA Qualification	35
⁠Locomotive Engineer Training Program	35
⁠Amtrak Locomotive Engineer Training Deficiencies	35
⁠Training and Qualification on the IIT Simulator	37
⁠Training and Qualifications for instructing Engineers	38
⁠Sources of Engineer Training Program Deficiencies	38
⁠FRA Locomotive Engineer certification Requirements	39
Locomotive Event Recorders	39
Survival Aspects and Emergency Response	40
CONCLUSIONS
Findings	40
Probable Cause	41
RECOMMENDATIONS	41
APPENDIXES
⁠Appendix A—Investigation and Hearing/Deposition	43
⁠Appendix B—Personnel Information	45
⁠Appendix C—Outline of Locomotive Engineer Training Program	47
⁠Appendix D—Apprentice Performance valuation Farm to Be Completed by Instructing Engineers	55

EXECUTIVE SUMMARY

At 8:23 am. on December 12, 1990, National Railroad Passenger Corporation (Amtrak) passenger train 66, consisting of a two-unit locomotive. two material handling cars, five passenger cars, one dining car. and two baggage cars, derailed and struck Massachusetts Bay Transit Authority (MBTA) commuter train 906, consisting of one locomotive, six passenger cars, and one control car, as both trains entered Back Bay station in Boston, Massachusetts

Operated by an apprentice engineer, Amtrak train 66 was traveling 76 mph, within a 30-mph speed restriction, on a 9" 30' curve when it derailed and struck META train 906 on the adjacent track. A fire ignited after the collision. On Amtrak train 66, 7 crewmembers and 43 passengers sustained injuries, on MBTA train 906, Screwmembers and 391 passengers were injured, and 7 firefighters sustained injuries Estimated damage exceeded $12.5 million

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the apprentice locomotive engineer to reduce speed in sufficient time to negotiate the curve into Back Bay station as a result of inadequate supervision provided by the locomotive engineer. Contributing to the accident was Amtrak‘s failure to provide adequate quality control oversight for its locomotive engineer training program, including the adequacy of selection and training for apprentices an selection and training of engineers who serve as supervisors to apprentices during on—the-job training Also contributing to the accident was Amtrak's failure to have advance warning devices for a speed reduction for the curve entering Back Bay station

The safety issues discussed in this report are:

• train operations and speed limits,and
• locomotive engineer training and Federal Railroad Administration certification, and
• locomotive event recorder data

As a result of its investigation, the Safety Board made recommendations addressing these issues to the National Railroad Passenger Corporation, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, and the United Transportation Union.