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.