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:
- Pipeline, and
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.
Jim Hall's Speeches