National Transportation Safety Board
Office of Public Affairs
Washington, D.C. - The National Transportation Safety Board (NTSB) has proposed that voice recorders be installed in the cabs of all freight trains and long-distance passenger and commuter trains to improve safety and help investigators pinpoint the causes of accidents.
The recommendation, sent to the Federal Railroad Administration (FRA), is one of 36 issued by the Safety Board following its investigation into a fatal Maryland train accident that claimed 11 lives last year.
On February 16, 1996, a MARC commuter train collided with an Amtrak passenger train near Silver Spring, Maryland. All three crew members and eight of the 20 passengers on the MARC train were killed. Eleven passengers on the MARC train, which was traveling to Washington's Union Station, and 15 of the 182 crew members and passengers on Amtrak's 'Capitol Limited,' on a run from the nation's capital to Chicago, were injured. Estimated damages exceeded $7.5 million.
In its final accident report, the NTSB spelled out a series of causes and factors that led up to the fiery collision, and numerous safety shortcomings that contributed to the severity of the accident and loss of life.
The NTSB said the probable cause of the accident was the apparent failure of the MARC train engineer and the train crew, because of multiple distractions, to obey a signal that required the train to proceed at a slow speed after a station stop and be prepared to stop at the next signal. The engineer apparently forgot the restrictive signal, increased the train's speed, saw the stop signal and put the train into emergency braking too late to avoid colliding nearly head on with the Amtrak train.
Other accident causes, the Safety Board said, were failures by the FRA; Federal Transit Administration (FTA); Maryland Mass Transit Administration (MTA), which oversees MARC commuter trains; and the CSX Transportation Inc. to conduct a comprehensive human factors analysis of signal modifications. An analysis could have identified potential sources of human error after signals in the area were moved several years prior to the accident.
None of the federal and state agencies, nor CSX, which owns the tracks and signals and operates the trains with CSX crews under contract to Maryland, provided a redundant safety system that would have alerted the crew to their error or automatically stopped the train, the NTSB concluded.
Contributing to the accident was the lack of comprehensive safety oversight on the CSX-MARC system, the NTSB said. To correct safety oversight problems, the NTSB urged Maryland's governor and the state general assembly to instruct and empower a state agency to provide continuous, effective, and independent safety oversight of all aspects of MARC commuter rail operations.
Contributing to the severity of the accident and the loss of life was the lack of federal and state regulations and rail industry standards to ensure adequate emergency egress features on railroad passenger cars, the NTSB said.
Investigators concluded that at least eight of the 11 fatalities were caused by smoke inhalation and burns because passengers couldn't get out of the lead MARC car and emergency responders didn't know how to get in. The collision ruptured the nearly-full Amtrak fuel tank which sprayed fuel and flames into the MARC car.
In other conclusions, the NTSB said:
All crew members on both trains were in good health, had no evidence of fatigue, and were experienced in and qualified for their duties.
Weather conditions did not impair the ability of MARC train crew members to see signals and the signal system functioned as designed.
The MARC conductor and assistant conductor did not appear to have effectively monitored the engineer's operation of the MARC train.
The accident investigation prompted the NTSB to issue numerous recommendations. Many are similar to ones the Safety Board made more than 20 years ago and were not effectively acted upon by the FRA until after the Silver Spring accident.
The voice recorder recommendation is a first, however. It would require that trains be equipped with recorders similar to those in aircraft. Aircraft cockpit voice recorders have been used since the mid-1960s and have given accident investigators valuable information. In some cases, voice recordings have been the sole source of information for solving an accident.
The NTSB wants the FRA to require devices that would record crew members' voices while they are in the train cab. The recorded voices would be used in accident investigations and, similar to aircraft voice recorders, have appropriate limitations on their public release.
The NTSB also urged the FRA to move quickly on its long-delayed proposed rules to improve passenger rail car safety and to implement positive train separation - a system that would provide a safety net by automatically overriding engineers who make mistakes because they forgot signals, were fatigued, incapacitated or distracted.
Until positive train separation is implemented, the NTSB wants the FRA to require interim steps such as the installation of cab signals, automatic train stop, automatic train control and other redundant safety systems.
In other recommendations, the NTSB urged the FRA to:
Require comprehensive failure modes and effects analyses, including a human factors analysis, for all signal system modifications.
Develop and maintain separate identifiable data records for commuter and intercity rail passenger operations.
Require that a comprehensive inspection of all commuter passenger cars be performed to independently verify that interior materials in rail cars meet expected performance requirements for flammability and smoke emissions characteristics.
Require more information be included in electronic record keeping of train dispatchers' records of train movements.
While the FTA does not regulate trains, the NTSB was disturbed that the FTA distributes billions of dollars annually in federal grants without specifying safety requirements. The agency does require, however, a series of other grant requirements including handicapped accessibility and equal employment provisions.
When dispensing public money to local rail systems, the NTSB urged the FTA to:
Revise its grant application process to require comprehensive failure modes and effects analyses, including a human factors analysis, be provided for all federally funded transit projects that are directly related to the transport of passengers.
Cooperate with the FRA to require the installation of cab signals, automatic train stop, automatic train control, or other similar redundant systems for all trains where commuter and intercity passenger railroads operate.
Cooperate with the FRA to implement positive train separation control systems for all trains where commuter and intercity passenger railroads operate.
The Safety Board also urged CSX, MARC and Maryland to implement positive train separation systems on its lines and require formal emergency management and training plans for agencies that respond to train accidents in local communities.
Local governments and emergency response agencies should conduct periodic rail disaster drills to assess their emergency management plans, to reinforce and evaluate their emergency training, and to test their communication with the appropriate organizations, the Safety Board recommended.
Additionally, the NTSB said Maryland's MTA should work with CSX to develop and implement training for passenger train crews to give them experience in the correct use of emergency equipment, emergency communications procedures, and emergency passenger evacuation. This information should be contained in a widely-distributed and comprehensive employee guidance manual.
The NTSB's complete report, PB97-916302, may be purchased from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161, (703) 487-4650.
Media Contact: Pat Cariseo (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.