Remarks of Jim Hall
Chairman, National Transportation Safety
Board
before the 1997 American Public Transit
Association
Rail Rapid Transit Conference
Washington, D.C., June 11, 1997
Good afternoon ladies and gentlemen, and thank
you for your most gracious welcome.
Some of you have worked side by side with National
Transportation Safety Board staff in investigating recent rail
transit accidents. Many others have been fortunate enough to have
had very little contact with the NTSB. For the benefit of those
of you who are not familiar with the Safety Board, I would like
to provide you with a short introduction. First, I will describe
the Safety Board's responsibilities for transportation safety
in all modes of transportation. Then, I will discuss several of
the tragic railroad accidents that occurred last year. Finally,
I want to talk about the role the Safety Board can play in the
future of transit. I also hope that the forum will include a discussion
on how the Safety Board can work closer with the transit industry
on safety issues.
The National Transportation Safety Board has
been in existence since 1967 when it was established within the
United States Department of Transportation. The mission of the
agency was and still is:
To determine the probable cause or causes of
selected transportation accidents and to promote transportation
safety by conducting independent accident investigations and by
formulating safety improvement recommendations.
The Independent Safety Board Act of 1974 removed
the Safety Board from the Department of Transportation and established
the Board as a truly independent agency. The NTSB is now totally
independent of all other government agencies and operates solely
under the authority of the President and the Congress.
The Safety Board is composed of five Members
who are nominated by the President and confirmed by the Senate
for a five-year term. The Board does not make or enforce regulations,
nor do we have the authority to force other agencies to establish
or enforce regulations. Simply put, we investigate accidents,
conduct safety studies and make safety recommendations.
The Safety Board's accident investigation responsibilities cover five transportation modes:
Recommendations are made to the appropriate
parties involved in an accident, be they government or private
industry. Although these recipients have no obligation to comply
with the recommendations, historically, over 82 percent of our
recommendations have been accepted and adopted by the recipients.
The NTSB is the eyes and ears of the American
people at accident sites. Because of our high profile, most people
are shocked to learn that we have only 360 employees and conduct
our work at an annual cost of about 15 cents a citizen.
So … What do you - as a taxpayer - get
for your 15 cents per year? Well … you get a variety of safety
features and safety systems designed to mitigate or prevent accidents.
I am sure that most of you who traveled here
from out of town probably traveled by air. The traveling public
is fairly familiar with the NTSB's role in aviation accident investigations
- but how familiar are you with the results of these investigations?
NTSB recommendations led to smoke detectors in airplane lavatories,
floor level lighting strips to lead passengers to emergency exits,
and fire blocking materials used in seats and interior panels.
Other NTSB recommendations have addressed de-icing procedures,
wind shear warning systems, and collision avoidance systems. These
are just some of the most visible results of our aviation recommendations
- but they have made flying significantly safer and will help
ensure that all of you visiting Washington for this conference
will have a safe flight home.
The NTSB also has had a major impact in highway,
marine and pipeline safety. It was a Safety Board study released
last fall that began the recent national debate on the safety
of air bags for children and small adults. It was the NTSB that
spurred improvements in school bus construction standards. We
have improved the safety of commercial fishing vessels and recreational
boating. And we have led a nationwide campaign to prevent excavation
damage to pipelines.
The Safety Board is equally proud of our part
in bringing about significant safety improvements to the railroad
and rail transit industry. Over the last thirty years, our investigations
have resulted in over 1,700 railroad safety recommendations. We
have played a prominent role in a variety of passenger car safety
features, including luggage and equipment restraints, emergency
exit signage, and portable emergency lighting. We were also instrumental
in establishing requirements for mandatory drug and alcohol testing,
and two-way end of train devices. Other safety improvements include
updated track safety standards and revised power brake standards.
Now, I would like to move on and talk about
some of the more recent rail transit accidents that the NTSB has
investigated over the past year. Our panel members represent some
of the transit properties that were involved in these and other
major accidents and should be able to offer some personal insights.
I want to make it clear that there is certainly no intent to embarrass
any of these individuals or the transit properties or, for that
matter, the transit industry, by discussing these accidents. I
only mention them because it is important that we all learn the
important lessons they provide. These are lessons that can be
applied to any transit authority because they are accidents that
could have occurred anywhere. The Safety Board is pleased with
the way the transit authorities have reacted to these accidents.
They have come a long way towards ensuring that these accidents
will not be repeated on their properties.
We are all familiar with the Fox River Grove,
Illinois, tragedy, where on October 25, 1995, an eastbound METRA
commuter train struck a Crystal Lake School District bus at the
Algonquin Road grade crossing. According to the onboard event
recorder, the train was traveling at about 59 miles per hour when
it struck the left rear of the school bus.
Of the 35 student passengers on board the school
bus, 7 were fatally injured, and 24 others received injuries varying
from minor to critical.
The bus driver told investigators that she
stopped on the south side of the railroad tracks. The traffic
signal at Algonquin Road and U.S. Route 14 was red. The bus driver
proceeded across the tracks and stopped at a point where the rear
of the bus extended about 30 inches into the space required for
passage of an eastbound commuter train. The bus driver stated
that she was not aware that the rear of the school bus was extending
into the train's space.
The bus driver involved in the accident was
in charge of training for the Crystal Lake School District. Although
she had responsibility for training other drivers, the day of
the accident she was a substitute and was unfamiliar with this
particular run. The regular bus driver knew that there was inadequate
room at the far side of the crossing for her bus and, therefore,
never moved her bus across the grade crossing unless the light
was green. The bus driver involved in the accident thought that
she had to cross the tracks and trip a sensor before the signal
would turn green and allow her to turn west onto Route 14.
Post-accident testing revealed that a northbound
vehicle could, under certain circumstances, have only two seconds
of green light before a train physically occupied the crossing.
Consequently, the Safety Board asked appropriate state and federal
agencies to identify and monitor similar highway rail grade crossings
and highway intersections to determine if a sequencing problem
exists.
The Safety Board found many human factors issues
related to communication break downs in this accident:
The regular bus driver was required to brief
the substitute bus driver with any special information that she
needed to complete the run. The briefing was to include safety
information. The briefing never took place.
The Chicago Northwestern and the Illinois Department
of Transportation were to coordinate the preemption of the signal
at Algonquin Road whenever a train tripped the crossing gates.
Neither organization understood how the other organization was
providing or using the preemption signals.
The local police department had received several
complaints about the operation of the Algonquin Road crossing.
The police chief was at the intersection at the time of the accident
troubleshooting yet another complaint. In response to those complaints,
signal maintenance personnel from both the railroad and the highway
had been dispatched to monitor their respective signal's operation.
The results of these site inspections had generally been that
the signal system was working as designed.
The Safety Board concluded that the probable
cause of the collision was that the bus driver had positioned
the school bus so that it encroached upon the railroad tracks
because of the failure of the Illinois Department of Transportation
to recognize the short queuing area on northbound Algonquin Road
and to take corrective action; and to recognize the insufficient
time the signal system gave to vehicle traffic before a train
arrived at the crossing; and the failure of the local school district
to identify route hazards and to provide its drivers with alternative
instructions for such situations.
Contributing to the accident was the failure
of the Illinois Department of Transportation and its contractors,
the Illinois Commerce Commission, and the railroads to have a
communication system that ensures understanding of the integration
and working relationship of the railroad and highway signal systems.
Twenty eight separate safety recommendations
were issued as a result of the Fox River Grove investigation.
Another rail transit accident occurred right
here in the Washington Metropolitan Area. During a snowstorm on
the night of Saturday, January 6, 1996, a four-car Washington
Metropolitan Transit Authority train, Train No. 111, was operating
above ground on the Red line, from Rockville to Shady Grove, Maryland.
The train collided head-on with a six car "Gap" train
which was standing beyond the end of the Shady Grove Station platform.
The operator of train 111 was killed in the collision.
Train 111 was being operated in Automatic Mode
(also known as Mode 1) and train movements were totally controlled
by the computer.
According to transcripts of the communications
tapes, the operator of Train 111 reported by radio to the Operations
Control Center that he had overrun the Twin Brook station platform
by four car lengths and the Rockville Station platform by one
car length.
When the operator overran the Rockville Station,
Train 111 lost the Automatic Train Supervision (ATS) information
that was stored in its computer. The ATS system was set to limit
the train's speed to 59 mph, which is the normal maximum speed
for the run between Rockville and Shady Grove. Instead, the system
defaulted to a higher speed of 75 mph.
A few minutes later the operator of Train 111
reported to OCC that he had an actual speed of 75 mph. The Controller
told him to continue in Mode 1. Moments later, the train overran
the Shady Grove Station by over 470 feet and collided with the
standing "Gap" train.
The Washington Metro system has had a policy
of operating in Manual Mode during inclement weather for the previous
20 years. The policy was rescinded in the months preceding the
accident. The new policy required that train operations remain
in Automatic Mode (Mode 1) during inclement weather. The purpose
of this policy change was to extend wheel life and eliminate flat
spots that were thought to be associated with manual operation.
Among the issues addressed by the Safety Board
in the investigation was the rail equipment. Investigators tried
to determine why the train did not - or could not - stop at the
station platform. Our investigation revealed that there were incompatibilities
between the spin/slide system and the automatic train control
system.
We also looked at the Automatic Train Supervision
system and specifically, why the system defaulted to a higher
speed when a signal was lost. Washington METRO explained that
the system was not fail-safe because the ATS system was designed
to help adjust train schedules. This is the same system that was
being used to slow trains during inclement weather to prevent
them from sliding through stations. Washington METRO management
also told us that they did not consider station overruns to be
a safety issue. They considered it only to be a passenger inconvenience.
Finally, the Safety Board attempted to find
out why the operator, the OCC Controllers, or their supervisors
did not stop the train when they knew that it was going too fast,
especially when they knew that it had overrun the two previous
stations and that there was a gap train parked beyond the Shady
Grove station.
The bottom line was that these individuals
probably feared for their jobs. Employees were required to follow
WMATA policies to the letter or risk dismissal. They were not
empowered to take responsible for safety. Thus, they took no action
to prevent the accident from happening.
The National Transportation Safety Board determined
that the probable cause of this accident was the failure of Washington
Metropolitan Area Transit Authority management and board of directors
to fully understand and address design features of the automatic
train control system, to allow controllers to use their experience
and judgment to make safety decisions, and to make sure standing
trains were not allowed to sit on the same track as incoming trains.
The Safety Board issued 23 recommendations
as a result of its investigation of the Shady Grove, Maryland
accident.
About a month later, the Safety Board was called
to investigate another tragic rail transit accident - this time
near Secaucus, New Jersey. About 8:40 a.m. on February 9, 1996,
a New Jersey Transit commuter train, operating eastbound from
Waldwick to Hoboken, New Jersey, collided head-on with the lead
locomotive of a westbound commuter train.
The westbound train was operating on a clear
signal and traveling at about 53 miles per hour in an area authorized
for 60 miles per hour. The eastbound train left Harmon Cove station,
accelerated to 53 miles per hour, reduced speed to 30 miles per
hour, then to 19 miles per hour, and impacted the westbound train
at about seven miles per hour. The eastbound train had passed
a stop signal and fouled the mainline when the collision took
place.
There were over 400 passengers on the two trains. Three fatalities, the engineers on both trains and a passenger, and 162 injuries resulted from the collision.
The investigation revealed that the engineer
of the eastbound train had a color vision deficiency that was
due to long term diabetes. The engineer had successfully covered
up his condition for a number of years. As his eyesight grew worse,
he contacted his personal doctor and had laser surgery up to two
weeks before the accident. The investigators determined that the
engineer was unable to determine the color of the signal and proceeded
to accelerate his train past a signal and into the path of the
oncoming train.
The Safety Board determined that the probable
cause of the accident was the failure of the engineer of the eastbound
train to perceive correctly a red signal aspect because of his
diabetic eye disease and resulting color vision deficiency, which
he failed to report to New Jersey Transit during annual medical
examinations. Contributing to the accident was the contract physician's
use of an eye examination not intended to measure color discrimination.
As a result of the Safety Board's investigation
of this accident, the FRA's Railroad Safety Advisory Committee,
the Locomotive Engineer Certification Working Group, has agreed
to address the current color vision testing requirements for locomotive
engineers as an issue in their agenda.
What do these three accidents have in common?
They all involve revenue passenger trains - they all involve rail
transit operations - and they were all preventable. When serious
accidents occur, they reflect on the entire transit industry.
And they do seem to continue to occur.
Currently, the Safety Board is investigating
a track worker fatality at the Ruggles passenger station on the
MBTA in Boston, a passenger fatality at Trevos Station on the
SEPTA Trenton line near Philadelphia, a track worker fatality
at the SEPTA 52nd Street subway station, and a derailment
on the San Francisco MUNI. Just last week, the Safety Board launched
an investigator to a grade crossing collision that occurred on
one of transit's newest operations - Dallas Area Rapid Transit
light rail system. Fifteen passengers were reported injured in
this collision.
Despite this litany of accidents, let's not
lose sight of the role transit plays in our society. Each year
the rail transit industry provides 2.6 billion safe passenger
trips. Transit has a good safety record and a great future. To
ensure that the full potential of that future is realized, we
must do all that we can to eliminate preventable accidents.
The transportation community has come to recognize
that everyone has a responsibility for creating and fostering
a climate that will ensure safe operations. The rail transit industry
must do all it can to ensure safe operation. The practice of safely
moving passengers is not just good business, it is a moral responsibility
that everyone in this room has to the rail transit industry, their
customers, and the American public -- a responsibility to provide
safe and efficient rail transportation.
The NTSB is here to help. We are a public agency
funded by your tax dollars . Transit agencies should consider
us as a resource to help address and control the safety issues
that face us each day. I look forward to the discussion that this
forum will generate so that I can learn exactly how we can best
assist the transit industry in our common mission - a mission
to make 1997 the safest year for railroad transportation ever.
Thank you.
