Silver Spring, Maryland
February 16, 1996
NTSB Number: RAR-97-02
NTIS Number: PB97-916302
Adopted July 3, 1997
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About 5:39 p.m. on February 16, 1996, Maryland Rail Commuter (MARC) train 286 collided with National Railroad Passenger Corporation (Amtrak) passenger train 29 near Silver Spring, Maryland. En route from Brunswick, Maryland, to Union Station in Washington, DC, MARC train 286 was traveling under CSX Transportation Inc. (CSXT) operation and control on CSXT tracks. MARC train 286 passed an APPROACH signal before making a station stop at Kensington, Maryland; proceeded as if the signal had been CLEAR; and, then, could not stop for the STOP signal at Georgetown Junction, where it collided with Amtrak train 29. All 3 CSXT operating crewmembers and 8 of the 20 passengers on MARC train 286 were killed in the derailment and subsequent fire. Eleven passengers on MARC train 286 and 15 of the 182 crewmembers and passengers on Amtrak train 29 were injured. Estimated damages exceeded $7.5 million.
The National Transportation Safety Board determines that the probable cause of this accident was the apparent failure of the engineer and the traincrew because of multiple distractions to operate MARC train 286 according to signal indications and the failure of the Federal Railroad Administration (FRA), the Federal Transit Administration (FTA), the Maryland Mass Transit Administration (MTA), and the CSXT to ensure that a comprehensive human factors analysis for the Brunswick Line signal modifications was conducted to identify potential sources of human error and to provide a redundant safety system that could compensate for human error.
Contributing to the accident was the lack of comprehensive safety oversight on the CSXT/MARC system to ensure the safety of the commuting public. Contributing to the severity of the accident and the loss of life was the lack of appropriate regulations to ensure adequate emergency egress features on the railroad passenger cars.
The major safety issues discussed in this report are the performance and responsibility of the MARC train 286 crewmembers, the oversight of CSXT signal system modifications, the Federal oversight of commuter rail operations, the lack of positive train separation control systems, and the adequacy of passenger car safety standards and emergency preparedness. In addition, the Safety Board examined the use of the reverser during an emergency brake application, the effectiveness of the computer-aided train dispatching recordkeeping, the crashworthiness of locomotive fuel tanks, and the contents of the CSXT and MARC operating agreement.
On March 12 Emergency Management Agency, the Metropolitan Washington Council of Governments, the Jefferson County Commissioners, the Berkeley County Commissioners, the American Short Line Railroad Association, the Brotherhood of Locomotive Engineers, the United Transportation Union, the International Brotherhood of Teamsters, and the American Public Transit Association. In addition, the Safety Board reiterates safety recommendations to the FRA, the General Electric Company, and the Electro-Motive Division of General Motors.
As a result of its investigation, the National Transportation Safety Board makes the following recommendations:
To the Federal Railroad Administration: Amend 49 Code of Federal Regulations Part 229 to require the recording of train crewmembers' voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings. (R-97-9)
Require comprehensive failure modes and effects analyses, including a human factors analysis, for all signal system modifications. (R-97-10)
Develop and maintain separate identifiable data records for commuter and intercity rail passenger operations. (R-97-11)
Require, in the interim of a positive train separation control system being available, the installation of cab signals, automatic train stop, automatic train control, or other similar redundant systems for all trains where commuter and intercity passenger railroads operate. (R-97-12)
Require the implementation of positive train separation control systems for all trains where commuter and intercity passenger railroads operate. (R-97-13)
Require all passenger cars to have easily accessible interior emergency quickrelease mechanisms adjacent to exterior passageway doors and take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (R-97-14)
Require all passenger cars to have either removable windows, kick panels, or other suitable means for emergency exiting through the interior and exterior passageway doors where the door could impede passengers exiting in an emergency and take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (R-97-15)
Issue interim standards for the use of luminescent or retroreflective material or both to mark all interior and exterior emergency exits in all passenger cars as soon as possible and incorporate the interim standards into minimum passenger car safety standards. (R-97-16)
Require all passenger cars to contain reliable emergency lighting fixtures that are each fitted with a self-contained independent power source and incorporate the requirements into minimum passenger car safety standards. (R-97-17)
Provide promptly a prescribed inspection and maintenance test cycle to ensure the proper operation of all emergency exit windows as well as provide that the 180-day inspection and maintenance test cycle is prescribed in the final rule. (R-97-18)
Require that all exterior emergency door release mechanisms on passenger cars be functional before a passenger car is placed in revenue service, that the emergency door release mechanism be placed in a readily accessible position and marked for easy identification in emergencies and derailments, and that these requirements be incorporated into minimum passenger car safety standards. (R-97-19)
Require that a comprehensive inspection of all commuter passenger cars be performed to independently verify that the interior materials in these cars meet the expected performance requirements for flammability and smoke emissions characteristics. (R-97-20)
Update 49 Code of Federal Regulations Part 228.17, Train Dispatcher's Record of Train Movements, to include the same parameters for electronic recordkeeping of the dispatcher's record of train movements. (R-97-21)
To the Federal Transit Administration:
Revise the grant application process to require a comprehensive failure modes and effects analyses, including a human factors analysis, be provided for all federally funded transit projects that are directly related to the transport of passengers. (R-97-22)
Cooperate with the Federal Railroad Administration for requiring, in the interim of a positive train separation control system being available, the installation of cab signals, automatic train stop, automatic train control, or other similar redundant systems for all trains where commuter and intercity passenger railroads operate. (R-97-23)
Cooperate with the Federal Railroad Administration for requiring the implementation of positive train separation control systems for all trains where commuter and intercity passenger railroads operate. (R-97-24)
Cooperate with CSX Transportation Inc. in the development and installation of a positive train separation control system where Maryland Rail Commuter equipment operates on CSX Transportation Inc. tracks. (R-97-25)
To the CSX Transportation Inc.:
Develop and install a positive train separation control system on track segments that have commuter and intercity passenger trains. (R-97-26)
Develop and implement a formal emergency management plan that contains procedures specific to employee responsibilities and interaction with emergency response agencies and other transportation entities. (R-97-27)
Develop and implement, in cooperation with Maryland Mass Transit Administration/Maryland Rail Commuter, a complete training agenda for all CSX Transportation Inc. passenger traincrews that provides experience in the correct use of emergency equipment, in emergency communications procedures, and in passenger evacuation and assistance in an emergency and also includes the distribution of a comprehensive employee guidance manual. (R-97-28)
Conduct, in cooperation with Maryland Mass Transit Administration/Maryland Rail Commuter, the Baltimore County Emergency Management Agency, the City of Baltimore Emergency Management Agency, the Metropolitan Washington Council of Governments, the Jefferson County Commissioners, and the Berkeley County Commissioners, periodic disaster drills to assess their emergency management plans, to reinforce and evaluate their emergency training, and to test the communication with the organizations. (R-97-29)
Inform all operating train crewmembers of the circumstances of this accident and emphasize the crew responsibility while in the operating compartment for the safe operation of the train. (R-97-30)
Inform your engineers of the circumstances of this accident and caution them not to use the reverser during emergency brake applications for those trains on which the use of the reverser will eliminate the dynamic braking, thus increasing stopping distance. (R-97-31)
To the Maryland Mass Transit Administration:
Cooperate with CSX Transportation Inc. in the development and installation of a positive train separation control system where Maryland Rail Commuter equipment operates on CSX Transportation Inc. tracks. (R-97-32)
Develop an emergency plan that will provide a detailed description of emergency response procedures as well as a protocol to coordinate activities with the emergency response organizations and other transportation entities when an accident occurs. (R-97-33)
Develop and implement, in cooperation with CSX Transportation Inc., a complete training agenda for all CSX Transportation Inc. passenger traincrews that provides experience in the correct use of emergency equipment, in emergency communications procedures, and in passenger evacuation and assistance in an emergency and also includes the distribution of a comprehensive employee guidance manual. (R-97-34)
Conduct, in cooperation with the CSX Transportation Inc., the Baltimore County Emergency Management Agency, the City of Baltimore Emergency Management Agency, the Metropolitan Washington Council of Governments, the Jefferson County Commissioners, and the Berkeley County Commissioners, periodic disaster drills to assess their emergency management plans, to reinforce and evaluate their emergency training, and to test the communication with the organizations. (R-97-35)
To the U.S. Department of Transportation:
Review the testing protocols within the various modal administrations regarding the flammability and the smoke emissions characteristics of interior materials and coordinate the development and implementation of standards for material performance and testing with the Federal Railroad Administration and the Federal Transit Administration. (R-97-36)
To the Federal Emergency Management Agency:
Include in your training at the U.S. Fire Administration National Fire Academy a curriculum that addresses the needs of State and local emergency management agencies to respond to a major railroad accident and that familiarizes emergency response organizations with railroad equipment and appropriate rescue methods for railroad accidents. (R-97-37)
To the Governor and the General Assembly of the State of Maryland:
Instruct and empower an appropriate State agency to provide continual, effective, and independent safety oversight of all aspects of the Maryland Rail Commuter operations. (R-97-38)
To the Association of American Railroads:
Assist the railroad industry with the development of positive train separation control systems through a continuing review of nonrailroad technology and assess its adaptability to railroad communication-based control systems. (R-97-39)
Assist the railroad industry with the development of positive train separation control systems by acting as a clearinghouse for information on the status and results of pilot projects and by disseminating that information to the railroad industry and the Federal and participating State transportation organizations. (R-97-40)
Assist the railroad industry with the installation and operation of positive train separation control systems by maintaining industry standards to ensure open architecture and an interoperability of equipment for train control systems. (R-97-41)
Inform your membership of the circumstances of this accident and caution them not to use the reverser during emergency brake applications for those trains on which the use of the reverser will eliminate the dynamic braking, thus increasing stopping distance. (R-97-42)
To the Montgomery County Emergency Management Agency:
Develop comprehensive procedures for responding to railroad passenger train accidents and include these procedures in your disaster plan. (R-97-43)
To the Baltimore County Emergency Management Agency, the Baltimore City Emergency Management Agency, the Metropolitan Washington Council of Governments, the Jefferson County Commissioners, and the Berkeley County Commissioners:
Conduct, in cooperation with the CSX Transportation Inc. and the Maryland Mass Transit Administration/Maryland Rail Commuter, periodic disaster drills to assess their emergency management plans, to reinforce and evaluate their emergency training, and to test the communication with the organizations. (R-97-44)
To the American Short Line Railroad Association, the Brotherhood of Locomotive Engineers, the United Transportation Union, the International Brotherhood of Teamsters, and the American Public Transit Association:
Inform your membership of the circumstances of this accident and caution them not to use the reverser during emergency brake applications for those trains on which the use of the reverser will eliminate the dynamic braking, thus increasing stopping distance. (R-97-45)
To the Federal Railroad Administration:
Promulgate Federal standards to require the installation and operation of a train control system on main line tracks that will provide for positive separation of all trains. (R-87-16)
Conduct, in conjunction with the Association of American Railroads, the General Electric Company, and the Electro-Motive Division of General Motors, research to determine if the locomotive fuel tank can be improved to withstand forces encountered in the more severe locomotive derailment accidents or if fuel containment can be improved to reduce the rate of fuel leakage and fuel ignition. Consideration should be given to crash or simulated testing and evaluation of recent and proposed design modifications to the locomotive fuel tank, including increasing the structural strength of end and side wall plates, raising the tank higher above the rail, and using internal tank bladders and foam inserts. (R-92-10)
In conjunction with the Association of American Railroads and the Railway Progress Institute, establish a firm timetable that includes at a minimum, dates for final development of required advanced train control system hardware, dates for an implementation of a fully developed advanced train control system, and a commitment to a date for having the advanced train control system ready for installation on the general railroad system. (R-93-12)
To the General Electric Company:
Conduct, in conjunction with the Federal Railroad Administration, the Association of American Railroads, and the Electro-Motive Division of General Motors, research to determine if the locomotive fuel tank can be improved to withstand forces encountered in the more severe locomotive derailment accidents or if fuel containment can be improved to reduce the rate of fuel leakage and fuel ignition. Consideration should be given to crash or simulated testing and evaluation of recent and proposed design modifications to the locomotive fuel tank, including increasing the structural strength of end and side wall plates, raising the tank higher above the rail, and using internal tank bladders and foam inserts. (R-92-16)
To the Electro-Motive Division of General Motors:
Conduct, in conjunction with the Federal Railroad Administration, the Association of American Railroads, and the General Electric Company, the research to determine if the locomotive fuel tank can be improved to withstand forces encountered in the more severe locomotive derailment accidents or if fuel containment can be improved to reduce the rate of fuel leakage and fuel ignition. Consideration should be given to crash or simulated testing and evaluation of recent and proposed design modifications to the locomotive fuel tank, including increasing the structural strength of end and side wall plates, raising the tank higher above the rail, and using internal tank bladders and foam inserts. (R-92-17)
