NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


July 11, 1996

Washington, DC) -- The National Transportation Safety Board (NTSB) is urging federal railroad regulators and the rail industry to focus on an uncommon and little understood rail condition -- know as a "flattened rail head" -- because it poses a potential safety hazard.

A "flattened rail head" -- a yard-long depression in the top of a section of rail -- was the main ingredient in a 1994 Amtrak passenger train derailment near Batavia, NY.

Based on the investigation, the NTSB determined that the accident's probable cause was "the fact that federal and rail industry guidelines do not currently address flattened rail conditions due to an insufficient understanding of the risk that flattened rail poses to train operations."

At about 3:44 a.m. on Aug. 3, 1994, Amtrak Train 49, the "Lake Shore Limited," was traveling westbound at 79 miles an hour when it derailed on Conrail track near Batavia. No one was killed on the New York City to Chicago train, but 108 passengers and 10 crewmembers were injured. The train carried 320 passengers and 14 crew.

"Dynamic interaction" between a material handling car and the flattened rail head allowed the wheel to lose contact with the track beginning a sequence of events that led to the derailment, investigators determined.

The Batavia accident prompted the NTSB to issue several recommendations to the Federal Railroad Administration (FRA) urging it to alert rail inspectors to the problem and take corrective action. The Safety Board also wants the FRA to conduct research and develop a data base to assess the risk posed by flattened rail heads. Based on that research, the NTSB said, the FRA is strongly encouraged to issue guidelines to track inspectors and issue regulations requiring necessary corrections.

Currently, the FRA does not provide guidance on what size or type of flattened rail head is potentially hazardous to train operations. The flattened rail head at the initial point of the Batavia derailment, described by NTSB investigators as the "granddaddy of them all," was not considered a defect because it did not meet the FRA's existing definition, the Board said.

In its report, the NTSB said the performance of the train's crew, the signal system and weather were not factors in the accident. The Safety Board also said that local emergency response was prompt and effective.

The Safety Board's investigation also uncovered another safety hazard. Exposed metal seat back braces in a double deck "dome" passenger car -- one of 14 cars that derailed -- were a potential safety hazard when it overturned. Although Amtrak has taken dome cars out of service, the NTSB urged Amtrak to correct the problem by installing a positive seat locking system. In the future, these cars could be sold to other rail passenger carriers or put back into service by Amtrak.

The Board also issued recommendations to the Association of American Railroads and the American Short Line Railroad Association. The Board recommended that these groups inform their members about the Batavia accident and help the FRA build a flattened rail head data base.

The NTSB's complete report PB96-916302 may be purchased from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. The telephone number is (703) 487-4650.

Media contact: NTSB Office of Public Affairs

(202) 314-6100




The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.