RAILROAD/HIGHWAY ACCIDENT REPORT
Adopted: October 23, 1990
COLLISION OF AMTRAK PASSENGER TRAIN NO. 708
ON ATCHISON, TOPEKA AND SANTA FE RAILWAY
WITH TAB WAREHOUSE AND DISTRIBUTION CO.
TRACTOR-SEMITRAILER
STOCKTON, CALIFORNIA
DECEMBER 19, 1989

NTSB Number: RHR-90/01
NTIS Number: PB89-917007 

SYNOPSIS
About 9:38 a.m., Pacific standard time, on December 19, 1989, National Railroad Passenger Corporation (Amtrak) passenger train 708, consisting of one locomotive unit and five passenger cars, struck a TAB Warehouse & Distribution Company tractor semitrailer in a dense fog at a highway grade crossing near Stockton, California. The collision derailed the locomotive and all five passenger cars. A fire followed the train impact with the truck.

The grade crossing had flashing lights and gates that were functioning at the time of the accident. The engineer, fireman, and truckdriver were killed in the collision and fire. Three of the 7 train crewmembers and 49 of the 150 passengers were injured. The total estimated damage was $2,435,000.

The National Transportation Safety Board determines the probable cause of this accident was the failure of the truckdriver to operate his vehicle at a speed consistent with the dense fog and to stop at the lowered grade crossing gate.

The major safety issues in the accident include:

· Grade crossing warning devices where sight distances are frequently reduced by fog.
· Standards for lamp bulb voltages for grade crossing warning devices.
· Truckdriver awareness and training for operating in dense fog.
· Inability of on-board train personnel to communicate with dispatcher in emergencies.
· Survival factors in passenger cars concerning the adequacy of seatlocks, the securement of food service equipment, the performance of luggage restraints, and the passengers' inability to exit through the vestibule doors.

Recommendations concerning these issues were made to National Railroad Passenger Corporation, Atchison, Topeka and Santa Fe Railway Company, Federal Highway Administration, California Department of Transportation, California Public Utilities Commission, TAB Warehouse & Distribution Company, California Trucking Association, and Federal Railroad Administration.

the Amtrak decision to install vestibule door locking devices without clear instructions for opening the doors in an emergency and to nullify the access from the outside to the interior of the new Horizon cars.

When a car has derailed in an upright position, nothing should prevent passengers from opening the vestibule door, providing the door is not jammed or obstructed, once they have located the pawl latch. Furthermore, when a car is in the upright position passengers encounter less risk when they can exit the car directly to the ground through the vestibule door. The Safety Board believes that Amtrak needs to provide visible interior markings and operating instructions at vestibule doors of all passenger equipment that cannot be opened from the exterior of the car.

RECOMMENDATIONS

As a result of its investigation of this accident, the National Transportation Safety Board made the following recommendations:

to the National Railroad Passenger Corporation:

Develop and implement a means for the conductor to contact a dispatcher by radio, should the locomotive radio be unavailable. (Class II, Priority Action) (R-90-45)

Provide visible interior markings and operating instructions at vestibule doors of all passenger equipment that cannot be opened from the exterior of the car. (Class II, Priority Action) (R-90-46)

Modify the luggage storage areas at the ends of Horizon cars to retain luggage in a collision or derailment. (Class II, Priority Action) (R-90-47)

Establish system-wide rules to ensure that only properly secured appliances are used in revenue service and to establish procedures for enforcing those rules. (Class II, Priority Action) (R-90-48)

Establish system-wide procedures to ensure that all seatlocks are engaged in the locked position before offering the equipment for revenue service. (Class II, Priority Action) (R-90-49)

to the Atchison, Topeka and Santa Fe Railway Company:

Cooperate with the California Department of Transportation and the California Public Utilities Commission for the installation of active warning devices in advance of railroad/highway grade crossings actuated by the railroad crossing warning system where sight distances are frequently reduced by dense fog. (Class II, Priority Action) (R-90-50)

to the Federal Highway Administration:

Revise the Manual of Uniform Traffic Control Devices to require the use of active warning devices in advance of railroad/highway grade crossings actuated by the railroad crossing warning system where sight distances are frequently reduced by dense fog. (Class II, Priority Action) (H-90-92)

to the California Department of Transportation:

Require and install active warning devices in advance of all new and existing railroad/highway grade crossings actuated by the railroad crossing warning system where sight distances are frequently reduced by dense fog. (Class II, Priority Action) (H-90-93)

to the California Public Utilities Commission:

Require the use of active warning devices in advance of railroad/highway grade crossings actuated by the railroad crossing warning system where sight distances are frequently reduced by dense fog. (Class II, Priority Action) (R-90-52)

to the TAB Warehouse & Distribution Company:

Establish, and maintain with supervisory oversight, a structured recurrent training program designed to sustain the performance of its drivers at high standards; include in this program instructions on safe operation in adverse weather conditions, with emphasis on overdriving visual range when operating in dense fog. (Class II, Priority Action) (H-90-94)

Participate in Operation Lifesaver to develop and implement a grade crossing awareness training program to instruct its truckdrivers in the dangers at railroad/highway grade-crossings. (Class II, Priority Action) (H-90-95)

to the California Trucking Association:

Establish, and maintain with supervisory oversight, a structured recurrent training program designed to sustain the performance of truckdrivers at high standards; include in this program instructions on safe operation in adverse weather conditions, with emphasis on overdriving visual range when operating in dense fog. (Class II, Priority Action) (H-90-96)

Participate in Operation Lifesaver to develop and implement a grade crossing awareness training program to instruct truckdrivers in the dangers at railroad/highway grade crossings. (Class II, Priority Action) (H-90-97)

to the Federal Railroad Administration:

Promulgate regulations providing for minimum standards for applied lamp bulb voltages for railroad/highway grade crossing warning lights to ensure optimum rated output, proper color, brilliance, and sight distance. (Class II, Priority Action) (R-90-51)