Good morning and welcome to the Boardroom of the National Transportation Safety Board. I am Christopher Hart, and it is my privilege to serve as Chairman of the NTSB. Joining the Board for the first time to consider an accident report is Vice Chairman Bella Dinh-Zarr. In addition, I am also joined by Member Robert Sumwalt and Member Earl Weener.
I would also like to recognize Chief Transit Operations Officer David Kowalski, Chief Engineer James Harper, and other leaders from the Chicago Transit Authority who have joined us this morning. Welcome.
We would also like to recognize our international visitors. Air Marshal Dick Garwood -- Director General of the UK Defense Safety Authority -- Colonel J.C.M. Orr; Captain Rob Woods; and Captain Jim Mansell. I would also like to recognize Hungarian Rail Investigator Janos Rozsa.
Thank you for your shared interest in making transportation safer around the world.
Today, we meet in open session, as required by the Government in the Sunshine Act, to consider the report on the March 24, 2014 accident in which a Chicago Transit Authority (CTA) train rode over a bumping post at the O’Hare Airport station, continued past the end of the track and struck an escalator that was located at the end of the track. The accident resulted in injuries to 33 passengers. On behalf of the NTSB, I would like to offer those passengers our sincere wishes for a full recovery.
Fortunately, nobody was on the escalator at the time of the accident, which occurred about 2:49 a.m. If this accident had occurred a few hours later, during rush hour, it could have had far more tragic results. Our investigation uncovered that the layers of protection that were designed to prevent such an accident failed.
First, the train’s operator was severely fatigued and had fallen asleep as the train entered the O’Hare station. As we will hear, the accident came during a known low in the body’s circadian rhythm. In today’s 24/7 culture, a work shift that crosses this circadian low is not atypical, even in safety-critical positions.
Consequently, it is vitally important that all transportation agencies incorporate fatigue science when scheduling their employees’ work shifts. This train operator was working her twelfth straight day on-duty. To its credit, CTA has revised its work/rest policy since the accident. But as we will hear, this begs the question of what is happening elsewhere in the country where operations are conducted during this circadian low.
Second, safety features at the O’Hare station that were designed to reduce the possibility of such an accident were ineffective. Two of these safety features were a track trip -- a device that is intended to automatically apply the brakes -- and an automatic command to the train to reduce its speed to zero when it approached a red signal.
However, a train’s brakes, unlike those of a car, take a few seconds to apply. Given the train’s speed and the available stopping distance, neither these safety features, as they were implemented, nor the operator, who was awakened by hitting the track trip, could apply the train’s brakes in time.
Finally, the bumping post that the train struck was designed to stop an eight-car train at speeds up to 15 miles per hour, if installed as intended. However, because of space restrictions, the bumping post’s energy friction shoes were not installed. Moreover, the bumping post was designed to stop a train up to 15 miles per hour, but the speed restriction on the track was 25 miles per hour.
The result: A bumping post that was designed to prevent a train traveling at up to 15 miles per hour from running off the end of the track was the final layer of protection against a train traveling at 23 miles per hour.
And this accident is about more than a train operator who fell asleep and the layers of safety protection that failed at O’Hare station. In addition, this accident led us to examine the safety oversight role of the Federal Transit Administration. It also prompts us to ask whether the accident would have occurred had Transmission Based Train Control been in effect -- a form of positive train control that can be used in transit systems.
The inadequate safety measures at the O’Hare Station existed long before March 24, 2014. It is fortunate that the accident train encountered an unoccupied escalator that day. In any similar future accident we might not be so lucky.
The report that we consider today helps point the way toward a future in which we rely on better technologies, policy, and oversight to fill these safety gaps -- rather than luck.
Now Acting Executive Director Tom Zoeller will introduce the staff.