NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


UNDISCLOSED EYESIGHT PROBLEMS CITED IN FATAL TRAIN CRASH;
NTSB URGES TIGHTER MEDICAL RULES FOR LOCOMOTIVE ENGINEERS

March 25, 1997

Washington, D.C. - The failure of a New Jersey Transit commuter train engineer to disclose his deteriorating eyesight led to a fatal accident last year and has prompted the National Transportation Safety Board (NTSB) to urge tighter nationwide medical rules for locomotive engineers.

The accident occurred at 8:40 a.m. on February 9, 1996, when an eastbound New Jersey Transit (NJT) commuter train ran a red stop signal and collided nearly head-on with a westbound NJT commuter train near Secaucus, New Jersey. About 400 passengers were on the two trains. The engineers on both trains and one passenger were killed and 158 passengers were injured.

At a public meeting in Washington, D.C., the NTSB determined the accident's probable cause was the failure of eastbound train 1254's engineer to perceive correctly the red stop signal because of diabetic eye disease and color vision deficiency.

The NTSB also said the engineer, who was killed in the accident, failed to report these deficiencies to New Jersey Transit as required during annual medical examinations.

Contributing to the accident, the NTSB said, was the physician's use of an eye examination not intended to measure color discrimination. The physician was under contract to New Jersey Transit.

To prevent similar accidents in the future, the NTSB issued a series of safety recommendations. The Safety Board urged the Federal Railroad Administration (FRA) to revise its color vision testing requirements for locomotive engineers. Based on expert medical guidance, the FRA should specify the test to be used, testing procedures, scoring criteria, and qualification standards.

The Safety Board also wants the FRA to require as a condition of certification that no person may act as an engineer with a known medical deficiency, or increase of a known medical deficiency, that would make that person unable to meet medical certification requirements.

 

The NTSB recommends that New Jersey Transit inform its employees, especially those in safety-critical positions, of the facts and circumstances of this accident. NJT should stress that employees must accurately report their use of medications or any changes in their medical condition, the Board said.

In other conclusions, the NTSB also determined weather, train equipment, track, and signal systems did not cause or contribute to the collision. Toxicological tests for alcohol and drugs were negative. Train operators had the necessary training and experience to competently perform their duties and no evidence indicates that fatigue was a factor.

The NTSB said emergency response efforts by state and local authorities were timely and appropriate, but the actions of some NJT train crewmembers were not adequate. The lack of public announcements caused passengers to act independently, evacuate the train, and wander along the tracks, potentially contributing to the dangerous conditions at the collision site, investigators said.

To remedy the situation, the NTSB issued a recommendation to New Jersey Transit to revise its employee emergency response training courses. The revisions should include simulation drills and a refresher training program to reinforce employee skills in emergency procedures. In all emergency training, the NTSB urged New Jersey Transit to stress that employees use the public address system to communicate with passengers.

Recommendations were issued to the Association of American Railroads and the Brotherhood of Locomotive Engineers.

They urged the two organizations to provide their members with information about this accident, specifically explaining acquired vision deficiency and emphasizing the importance of ensuring the color vision requirement. They should also stress that railroad employees in safety sensitive positions, especially engineers, report their use of medications or any changes in their medical condition to their employer.

The NTSB's complete report, PB97-916301, may be purchased from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161, (703) 487-4650.

 

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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.