What Happened
What Happened
On November 29, 2023, about 12:13 a.m., northbound New York City Transit (NYCT) passenger train 2317-D struck and killed an NYCT employee working as a flagger on a work crew on track B2 of the D line near the 34th Street-Herald Square Station in Manhattan, New York.1 (See figure.) As the train entered the work crew’s work zone, it experienced an equipment-induced brakes-in-emergency application.2 When the train operator exited the train to see what caused the brake application, she saw that the flagger was under the fifth car of the train and was unresponsive. The flagger was transported to a nearby hospital and was pronounced dead. There were no other injuries. The accident took place in an underground tunnel and the weather was not a factor. Train 2317-D did not have an event recorder, nor did it have inward- and outward-facing audio and image recorders.
What We Found
What We Found
We determined that the probable cause of the employee fatality that occurred in Manhattan, New York, was the flagger being in the foul of the track for unknown reasons as the New York City Transit passenger train entered a work area. Contributing to the likelihood of the accident was New York City Transit’s ineffective oversight and insufficient enforcement of rules and procedures.
What We Recommended
Roadway Worker Protection. This accident serves as a reminder about the necessity of vigilance in regard to roadway worker safety. The flagger was supposed to keep the red light on until all members of the work crew, including himself, were in a place of safety. However, that did not occur. The red light was found extinguished on the bench wall and the flagger was not standing in the clear at the time of the accident.
Event and Video Recorders on Trains. This accident investigation demonstrates the importance of having functional event and video recorders on trains. Had NYCT passenger train 2317-D been equipped with operational event and video recorders, the NTSB would have been able to ascertain what caused this accident on November 29, 2023. In addition, NYCT would be able to revise its regulations and procedures to prevent similar events from occurring in the future.
Improved Oversight. The NTSB investigation found several examples of rules violations, whether by commission or omission, that contributed to the accident. Had there been more vigilant enforcement of the rules, perhaps this accident could have been prevented.
