FOR IMMEDIATE RELEASE: June 17, 1997 SB 97-15
NTSB URGES VOICE RECORDERS FOR TRAINS, QUICK ACTION ON RAIL CAR SAFETY UPGRADES AS A RESULT OF FATAL MARYLAND COMMUTER ACCIDENT
Washington, D.C. - The National Transportation Safety Board (NTSB) has
proposed that voice recorders be installed in the cabs of all freight trains
and long-distance passenger and commuter trains to improve safety and help
investigators pinpoint the causes of accidents.
The recommendation, sent to the Federal Railroad Administration (FRA),
is one of 36 issued by the Safety Board following its investigation into
a fatal Maryland train accident that claimed 11 lives last year.
On February 16, 1996, a MARC commuter train collided with an Amtrak
passenger train near Silver Spring, Maryland. All three crew members and
eight of the 20 passengers on the MARC train were killed. Eleven passengers
on the MARC train, which was traveling to Washington's Union Station, and
15 of the 182 crew members and passengers on Amtrak's 'Capitol Limited,'
on a run from the nation's capital to Chicago, were injured. Estimated
damages exceeded $7.5 million.
In its final accident report, the NTSB spelled out a series of causes
and factors that led up to the fiery collision, and numerous safety shortcomings
that contributed to the severity of the accident and loss of life.
The NTSB said the probable cause of the accident was the apparent failure
of the MARC train engineer and the train crew, because of multiple distractions,
to obey a signal that required the train to proceed at a slow speed after
a station stop and be prepared to stop at the next signal. The engineer
apparently forgot the restrictive signal, increased the train's speed,
saw the stop signal and put the train into emergency braking too late to
avoid colliding nearly head on with the Amtrak train.
Other accident causes, the Safety Board said, were failures by the FRA;
Federal Transit Administration (FTA); Maryland Mass Transit Administration
(MTA), which oversees MARC commuter trains; and the CSX Transportation
Inc. to conduct a comprehensive human factors analysis of signal modifications.
An analysis could have identified potential sources of human error after
signals in the area were moved several years prior to the accident.
None of the federal and state agencies, nor CSX, which owns the tracks
and signals and operates the trains with CSX crews under contract to Maryland,
provided a redundant safety system that would have alerted the crew to
their error or automatically stopped the train, the NTSB concluded.
Contributing to the accident was the lack of comprehensive safety oversight
on the CSX-MARC system, the NTSB said. To correct safety oversight problems,
the NTSB urged Maryland's governor and the state general assembly to instruct
and empower a state agency to provide continuous, effective, and independent
safety oversight of all aspects of MARC commuter rail operations.
Contributing to the severity of the accident and the loss of life was
the lack of federal and state regulations and rail industry standards to
ensure adequate emergency egress features on railroad passenger cars, the
NTSB said.
Investigators concluded that at least eight of the 11 fatalities were
caused by smoke inhalation and burns because passengers couldn't get out
of the lead MARC car and emergency responders didn't know how to get in.
The collision ruptured the nearly-full Amtrak fuel tank which sprayed fuel
and flames into the MARC car.
In other conclusions, the NTSB said:
The accident investigation prompted the NTSB to issue numerous recommendations.
Many are similar to ones the Safety Board made more than 20 years ago and
were not effectively acted upon by the FRA until after the Silver Spring
accident.
The voice recorder recommendation is a first, however. It would require
that trains be equipped with recorders similar to those in aircraft. Aircraft
cockpit voice recorders have been used since the mid-1960s and have given
accident investigators valuable information. In some cases, voice recordings
have been the sole source of information for solving an accident.
The NTSB wants the FRA to require devices that would record crew members'
voices while they are in the train cab. The recorded voices would be used
in accident investigations and, similar to aircraft voice recorders, have
appropriate limitations on their public release.
The NTSB also urged the FRA to move quickly on its long-delayed proposed
rules to improve passenger rail car safety and to implement positive train
separation - a system that would provide a safety net by automatically
overriding engineers who make mistakes because they forgot signals, were
fatigued, incapacitated or distracted.
Until positive train separation is implemented, the NTSB wants the FRA
to require interim steps such as the installation of cab signals, automatic
train stop, automatic train control and other redundant safety systems.
In other recommendations, the NTSB urged the FRA to:
While the FTA does not regulate trains, the NTSB was disturbed that
the FTA distributes billions of dollars annually in federal grants without
specifying safety requirements. The agency does require, however, a series
of other grant requirements including handicapped accessibility and equal
employment provisions.
When dispensing public money to local rail systems, the NTSB urged the
FTA to:
The Safety Board also urged CSX, MARC and Maryland to implement positive
train separation systems on its lines and require formal emergency management
and training plans for agencies that respond to train accidents in local
communities.
Local governments and emergency response agencies should conduct periodic
rail disaster drills to assess their emergency management plans, to reinforce
and evaluate their emergency training, and to test their communication
with the appropriate organizations, the Safety Board recommended.
Additionally, the NTSB said Maryland's MTA should work with CSX to develop
and implement training for passenger train crews to give them experience
in the correct use of emergency equipment, emergency communications procedures,
and emergency passenger evacuation. This information should be contained
in a widely-distributed and comprehensive employee guidance manual.
The NTSB's complete report, PB97-916302, may be purchased from the National
Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161,
(703) 487-4650.
Media Contact: Pat Cariseo (202) 314-6100
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