NTSB Press Release
National Transportation Safety Board
Office of Public Affairs
Railroad Special Investigation Report
Derailment of Amtrak Train No. 12 and Sideswipe of Amtrak Train No. 79
on Portal Bridge near
Secaucus, New Jersey
November 23, 1996
October 7, 1997
ACCIDENT SUMMARY
About 6:28 a.m. on Saturday, November 23, 1996, eastbound National Railroad Passenger Corporation (Amtrak) train No. 12 derailed while crossing Portal Bridge, a swing bridge spanning the Hackensack River in Secaucus, New Jersey. When the train derailed, it sideswiped Amtrak train No. 79, which was crossing the bridge in the opposite direction on an adjacent track. All 12 cars of train No. 12 derailed, with both locomotives, 1 material handling car, and the 3 head passenger coaches coming to rest at the bottom of an embankment at the east end of the bridge. Train No. 79 sustained damage but was able to stop with the entire train intact and on the rails some distance west of Portal Bridge. No fatalities resulted from the accident, but 42 passengers and crewmembers aboard train No. 12 were injured, as was 1 passenger aboard train No. 79. Estimated cost of the damaged train, track, and signal equipment and site cleanup exceeded $3.6 million.
The two primary safety issues discussed in this report are: (1) Amtrak management oversight of the inspection, maintenance, and repair of the miter rail assemblies on Portal Bridge; and (2) the effectiveness of Amtrak's emergency notification procedures. The Safety Board also examined the effectiveness of Amtrak locomotive event recorders in capturing critical operational data.
As a result of its investigation of this accident, the Safety Board makes safety recommendations to Amtrak, to the Federal Railroad Administration, to the Association of American Railroads, and to the American Short Line Railroad Association.
CONCLUSIONS
1. Fatigue, drugs, weather, and the signal system were not causal or contributory factors in this accident.
2. The design, the materials, and the operation of the miter rail system in place on Portal Bridge at the time of this accident made the side bars susceptible to fatigue cracking and led to the side bar failure that precipitated this accident.
3. The welding that was performed on the side bars was inadequate and inappropriate as a permanent repair and served to concentrate stress on the already fractured areas of the side bars.
4. The weld repairs could have been adequate as a temporary fix had a detailed and repetitive inspection program been established to ensure continued safe operation until permanent repairs or replacements could be made.
5. Amtrak management was aware of failures in miter rail side bars at least 10 months prior to the derailment, but because the company erroneously considered cracked or broken side bars to be a maintenance issue rather than a safety issue, it did not make replacements or permanent repairs that could have prevented this accident.
6. Amtrak management did not develop and implement miter rail inspection procedures that were adequate to identify defects in all components of the miter rail assemblies on Portal Bridge.
7. Had Amtrak, when it first learned about the cracked side bars on the miter rails, revised its miter rail inspection procedures to include raising the miter rails for inspection, the accident may have been prevented.
8. If Amtrak management had had in place on Portal Bridge a functioning rail position detection system or procedures that required visual confirmation of the proper positioning of all miter rails, this accident probably would not have occurred.
9. Had this accident resulted in more serious injuries, the confusing communication of the accident location by the Amtrak police dispatcher and the resulting delay in emergency response could have resulted in additional risks to train occupants.
10. Traction motor current data do not accurately indicate throttle position and, therefore, use of the data for this purpose by Amtrak does not meet Federal Railroad Administration requirements for monitoring and recording train throttle position.
11. Amtrak's use of a multiplexer to monitor and record both traction motor current and cab signal on a single channel of the event recorder is inappropriate and ineffective and, as a result, Safety Board investigators found it impossible to determine cab signal indications in this accident.
12. If the entire event recorder systems, including sensors, wiring, etc., in Amtrak locomotives 910, 901, and 930 had been thoroughly tested during their most recent 60-day inspections, the incorrect current module configuration would likely have been found and corrected, and the traction motor current data retrieved after this accident would have been useful in determining preaccident cab signals received by the traincrews.
13. If Amtrak had been required to meet Federal standards for inspection and maintenance of the special trackwork on Portal Bridge, the defects in the miter rail bars may have been detected and repaired before they could cause a derailment.
14. The results of the Federal Railroad Administration movable bridge survey would be beneficial to the railroad and rail rapid transit industry in preventing accidents similar to the derailment on Portal Bridge.
PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of the accident was the failure of Amtrak management to foster an environment that promoted an adequate inspection, maintenance, and repair of the miter rail assemblies on Portal Bridge and to permanently correct defects in the miter rail side bars that were discovered 10 months before the accident. Contributing to the accident were (1) the failure of the Federal Railroad Administration to develop track inspection standards for special track work and to periodically inspect such track as part of it's oversight responsibilities, (2) and Amtrak's removal of the miter rail position detection circuitry without installing replacement circuitry or implementing procedures to compensate for the loss of this safety critical system.
SAFETY RECOMMENDATIONS
As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:
-- to the National Railroad Passenger Corporation (Amtrak):
1. Perform a comprehensive stress analysis of the design of any miter rail assembly currently in use or intended for use on Portal Bridge to identify critical areas of high cyclic stress. Ensure that the miter rail design adequately accommodates these cyclic loads. (R-97-XX)
2. Continue to monitor the safety of special trackwork on your movable bridges and ensure that your special inspections are adequate and of sufficient frequency to detect failures or potential failures involving all components of all your special trackwork. Develop and put procedures in place to ensure that any failures or potential failures that are noted during these inspections are corrected before they develop into safety hazards. (R-97-XX)
3. Ensure that current or future miter rail installations on Portal Bridge are equipped with a miter rail position detection/indication system that provides the maximum protection possible and that is interlocked with other bridge systems to prevent the bridge from being opened or cleared for train traffic until the position of the miter rails can be confirmed to be safe. (R-97-XX)
4. Review the training of your police dispatchers and ensure that dispatchers are trained to correctly identify all Amtrak locations to emergency response agencies. (R-97-XX)
5. Perform a thorough test of the entire recording system on every locomotive equipped with an event recorder to ensure that cab signal data records can be easily and positively identified and evaluated. (R-97-XX)
6. Conduct a comprehensive internal management review of the circumstances of this accident to determine why several layers of Amtrak management failed to act in a timely fashion to correct a known hazardous condition on Portal Bridge. Make the management or procedural changes necessary to ensure that conditions affecting the safety of rail operations are given the highest priority. (R-97-XX)
-- to the Federal Railroad Administration:
7. Expand the scope of your track safety standards to include special trackwork such as movable miter rails and ensure that the condition and operation of special trackwork are included, when appropriate, in all Federal Railroad Administration track inspections. (R-97-XX)
8. Inform the railroad industry that traction motor current is not a valid indicator of throttle position, and the requirement to record throttle position contained in 49 Code of Federal Regulations 229.5(g) cannot be met by recording traction motor current. Ensure that all operators currently using traction motor current as a substitute for throttle position modify their event recording systems to monitor and record throttle position directly. (R-97-XX)
9. Pending the results of your Railroad Safety Advisory Committee Event Recorder Working Group and your implementation of suitable requirements concerning event recorder system maintenance, require that micro-processor-based event recorders equipped to perform self tests be subject to the testing and inspection procedures currently applicable to all other types of event recorders. (R-97-XX)
10. Provide, in full or summary form, the results of the Federal Railroad Administration movable bridges survey to all railroads and rail rapid transit agencies. (R-97-XX)
--to the Association of American Railroads:
11. Pending the results of the Federal Railroad Administration (FRA) Railroad Safety Advisory Committee Event Recorder Working Group and the FRA's implementation of suitable requirements concerning event recorder system maintenance, advise your member railroads of the need to test and inspect all micro-processor-based event recorders equipped to perform self tests in accordance with those procedures outlined in 49 Code of Federal Regulations 229.25(e)(2), which currently apply to all other types of recorders to confirm proper event recorder function. (R-97-XX)
--to the American Short Line Railroad Association:
12. Pending the results of the Federal Railroad Administration (FRA) Railroad Safety Advisory Committee Event Recorder Working Group and the FRA's implementation of suitable requirements concerning event recorder system maintenance, advise your member railroads of the need to test and inspect all micro-processor-based event recorders equipped to perform self tests in accordance with those procedures outlined in 49 Code of Federal Regulations 229.25(e)(2), which currently apply to all other types of recorders to confirm proper event recorder function. (R-97-XX)
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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.
