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Railroad Accident Brief [PDF version]

ATL 97 FR 003
JANUARY 30, 1997

Accident Description

On January 30, 1997, about 9:42 a.m., eastern standard time, a Massachusetts Bay Transportation Authority (MBTA) system track repairman was fatally injured when he was struck by northbound MBTA subway train No. 1285, north of the Ruggles Street Station.

The repairman was performing maintenance at the crossover switches north of the Ruggles Street Station. The motorman said he did not see the track repairman until the train was about 4 feet away. The motorman placed the train into emergency braking, but was unable to stop before striking the repairman. The repairman was fatally injured. No passengers or crewmembers were injured. No hazardous material releases occurred. At the time of the accident it was cloudy, with an ambient temperature reported at 13° F.

Postaccident investigation revealed that the MBTA uses monthly Safety Bulletins to convey operational and safety messages to its employees. The Safety Bulletins' purpose is to reinforce right-of-way safety practices to protect employees and others on MBTA right-of-way in order to prevent loss of life or injury to passengers or employees.

Safety Board investigators discovered that the MBTA does not have a track department Safety Rule Book and they do not conduct periodic safety rules training for the track department employees.

The MBTA had issued a monthly Safety Bulletin dated June 1, 1995. The bulletin requires that work crew, officials, and operating personnel obtain permission from the Operations Control Center (OCC) before entering the right-of-way area and notify the OCC when they leave the area. The bulletin also requires persons entering upon the right-of-way area to wear an approved high visibility safety vest or coat and be equipped with a flashlight in proper working order. The MBTA had no sign-up sheet indicating that the track repairman had received and understood the bulletin dated June 1, 1995.

Postaccident investigation revealed that the repairman was wearing a MBTA highly visible safety vest and a hood covering his head. The safety vest had only highly visible material on the front and back of the vest. However, this safety vest provided no safety visibility when the person wearing it is sideways to oncoming equipment. The MBTA has no rule prohibiting the wearing of hooded clothing. The hood may have limited both the hearing and peripheral vision of the workman.

The radio tapes between the trains and the OCC revealed that the track repairman did not arrange or request protection from OCC. Safety Board investigation also revealed that the track repairman was not issued a company radio. Radios were issued to supervisors and foremen.

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the inadequate oversight of track maintenance employees on the right-of-way by the Massachusetts Bay Transportation Authority. Contributing to the accident was the lack of a Safety Rule Book and periodic safety rules training for the track department employees by the Massachusetts Bay Transportation Authority. Additionally, the MBTA had no procedures that assured that all employees read and understand the Monthly Safety Bulletins.

Adopted: August 18, 1998

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