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Safety Recommendation Details

Safety Recommendation R-80-051
Details
Synopsis: ON JULY 17, 1980, SOUTHEASTERN PENNSYLVANIA TRANSPORTATION AUTHORITY (SEPTA)-CONSOLIDATED RAIL CORPORATION (CONRAIL) COMMUTER TRAIN NO. 472 STRUCK THE REAR OF SEPTA-CONRAIL COMMUTER TRAIN NO. 406 WHILE IT WAS STANDING ON THE NO. 2 TRACK EAST OF THE STATION AT NORTH WALES, PENNSYLVANIA. THE REAR CAR OF TRAIN NO. 406 OVERRODE AND DESTROYED THE EMPTY LEAD CAR OF TRAIN NO. 472. OF THE ESTIMATED 321 PERSONS ON THE 2 TRAINS, 64 PASSENGERS AND 3 CREWMEMBERS RECEIVED INJURIES. DAMAGE TO THE EQUIPMENT WAS ESTIMATED AT $1,475,000.
Recommendation: THE NTSB RECOMMENDS THAT THE CONSOLIDATED RAIL CORPORATION: DEVELOP AND IMPLEMENT A PROGRAM FOR TRAINING AND PERIODICALLY REQUALIFYING OPERATING PERSONNEL AND TRAIN DISPATCHERS ON THE PHYSICAL CHARACTERISTICS OF THE SYSTEM OVER WHICH THEY OPERATE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: North Wales, PA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA80AR045
Accident Reports: Rear End Collision of Septa Conrail Trains Nos. 406 and 472 on Conrail Track
Report #: RAR-80-11
Accident Date: 7/17/1980
Issue Date: 1/5/1981
Date Closed: 9/7/1982
Addressee(s) and Addressee Status: Conrail (Consolidated Rail Corporation) (Closed - Acceptable Action)
Keyword(s): Dispatch, Training and Education

Safety Recommendation History
From: NTSB
To: Conrail (Consolidated Rail Corporation)
Date: 9/7/1982
Response: This is in reply to your letter of August 10, 1981, concerning Safety Recommendations R-80-51 through -53, which resulted from our investigation of the rear-end collision of Southeastern Pennsylvania Transportation Authority (SEPTA) -Consolidated Rail Corporation (Conrail) commuter trains on July 17, 1980, at North Wales, Pennsylvania. Recommendation R-80-51 asked Conrail to develop and implement a program for training and periodically requalifying operating personnel and train dispatchers on the physical characteristics of the system over which they operate. The Safety Board believes the intent of Rule 986 is adequate to cover the continued qualification of train and enginecrews on those lines over which they operate. The Board will accept Conrail’s interpretation of Rule 986. as meeting the requirements of Recommendation R-80-51 if the phrase Il. . .or a special trip in such a manner as to review the physical characteristics of any portion. . .‘I means that the employee will not be involved in duties that would preclude an opportunity to carefully observe and study roadway characteristics, and it is thus applied and enforced. The record indicates that Mr. Steward, train dispatcher, had not been making annual requalifying trips, but the Board will accept that the 1980 trip put him in compliance with Rule 904 at that time. The Board is of the opinion that the dispatchers’ supervisors should take the initiative in. this matter and annually schedule qualifying trips for the dispatchers. We note that Conrail has issued procedures to train dispatchers regarding operation of a train from other than its leading platform. The development and implementation of these procedures should reduce the potential for recurrence of an accident similar to North Wales and should establish a safer operation. The Board concurs with Conrail’s rationale and has classified Recommendation R-80-51 as Vlosed-Acceptable Action.” Recommendation R-80-52 asked Conrail to develop and implement a program for training and periodicall;y requalifying operating personnel on the mechanical and electrical characteristics of commuter cars to include some elementary troubleshooting and corrective measures. The Board recognizes that electrical troubleshooting procedures are included in various instruction classes and distributed to train service personnel. And we further recognize that special precautions must be taken when working to correct electrical failures, particularly on high voltage equipment. The intent of the recommendation, however, was for the crew to know what to look for in the way of operating breakers, switches, etc, in order to be better able to get a train going. Conrail’s stated position is clear, but does not completely satisfy the objective of R-80-52. Since no further action is proposed by Conrail, the Board has classified this recommendation as *‘Closed--Unacceptable Action.'

From: Conrail (Consolidated Rail Corporation)
To: NTSB
Date: 8/10/1981
Response: CONRAIL LTR: IT IS OUR OPINION THAT RULE 986 PROVIDES FOR OPERATIONAL SAFETY. IN SUPPORT OF THIS VIEW, THE FOLLOWING SHOULD BE CONSIDERED: (1) NO OTHER RAILROAD PUBLISHES A RULE WHICH PROVIDES FOR MORE STRINGENT QUALIFICATIONS. (2) THE FEDERAL AVIATION ADMINISTRATION ADVISES US THAT "FEDERAL AIR REGULATIONS" REQUIRE PILOTS OF REGULARLY SCHEDULED PASSENGER FLIGHTS TO MAKE ONE TRIP IN TWELVE MONTHS, IN ORDER TO MAINTAIN THEIR ROUTE QUALIFICATIONS. (3) IF CONRAIL EMPLOYEES ARE CALLED TO PERFORM SERVICE AS A CONDUCTOR OR ENGINEER OVER ANY PORTION OF THE RAILROAD FOR WHICH THEY ARE NOT QUALIFIED, RULE 986 REQUIRES THEM TO IMMEDIATELY INFORM THE TRAIN DISPATCHER. THIS INSURES THAT ACTION WILL BE TAKEN. CONRAIL HAS TAKEN ACTION TO REDUCE THE POSSIBILITY OF RECURRENCE OF SUCH SITUATIONS BY ESTABLISHING THE FOLLOWING PROCEDURES: (1) IN THE EVENT OF EMERGENCY, WHEN M.U. TRAINS MUST BE OPERATED FROM OTHER THAN THE LEADING PLATFORM, A QUALIFIED CONDUCTOR WILL TAKE POSITION ON LEADING PLATFORM. (2) IF CONDUCTOR CAN CONTROL EMERGENCY BRAKES, COMMUNICATING SIGNAL AND WHISTLE (HORN) AS CONFIRMED BY TEST PERFORMED BY MEMBERS OF CREW, TRAIN MAY PROCEED AT SPEED NOT TO EXCEED 30 MPH, ON SIGNAL INDICATION. (3) IF CONDUCTOR IS UNABLE TO CONTROL ALL OF THE FEATURES SPECIFIED IN PRECEDING PARAGRAPH, LEADING CAR(S) MUST BE CLEARED OF PASSENGERS AND TRAIN MAY PROCEED ON HAND SIGNALS NOT EXCEEDING RESTRICTED SPEED, TO FIRST POINT WHERE CAR(S) MAY BE SET OFF. CONRAIL'S RULE 904 REQUIRES TRAIN DISPATCHERS TO BE FAMILIAR WITH THE PHYSICAL CHARACTERISTICS OF THE TERRITORY IN THEIR CHARGE.

From: NTSB
To: Conrail (Consolidated Rail Corporation)
Date: 7/7/1981
Response: This is in reply ‘to your letter of March 18, 1981, responding to Safety Recommendations R-80-51 through -53, which resulted from the July 17, 1980, collision between two Southeastern Pennsylvania Transportation Authority (SEPTA) - Consolidated Rail Corporation (Conrail) commuter trains at North Wales, Pennsylvania. The Safety Board notes Conrail’s comments concerning the lack of qualifications of the brakeman on the physical characteristics of the roadway. These comments support conclusions drawn by the Board as well as the contributing cause of the accident. Recommendation R-80-51 concerns the need to develop and implement a program for training and periodic requalification of operating personnel and,train dispatchers on knowledge of the physical characteristics of the system over which they operate. The point of R-80-51 is that Conrail has a responsibility to insure that operating personnel and train dispatchers maintain a high level of knowledge of the territory over which they operate. As your practice stands now, the one year rule for engineers may not be sufficient. For example, an engineer could make one trip in 1977, one in 1978, one in 1979, and one in 11980, and remain qualified. We doubt that this is sufficient. The conductor is usually so involved with ticket collecting and reports that he normally has little time to observe the ro&d and remain fully knowledgeable about its characteristics. Trainmen should be qualified on the road for just such emergencies as the North Wales accident, as they too have little time to observe the road and its physical characteristics. Another concern of R-80-51 was that train dispatchers should cover the territory over which they direct train movements periodically to remain conversant with the physical characteristics. The Safety Board requests that Conrail reconsider its position concerning Recommendation R-80-51; it will be held in an “Open--Unacceptable Action” status pending Conrail’s further consideration. Recommendation R-80-52 Concerns the need to develop and implement a program for training and periodically requalifying operating personnel on the mechanical and , electrical characteiristics of commuter cars to include some elementary troubleshooting and corrective measures. We are pleased to learn that Conrail had conducted such programs in the past and intends to continue them. However, R-80-52 deals with what the Safety Board felt was an inadequate exposure to troubleshooting and recognizing” symptoms. We bellieve; the training sho+d be more intensive and broader so that the onboard operating. personnel ,can satisfactorily correct malfunctions of some of the onboard systems and appliances. Recommendation R.-80-51 The Safety Board requests that you reconsider , and pending receipt of your response, it will be held in an Open-Unacceptable Action” status. .

From: Conrail (Consolidated Rail Corporation)
To: NTSB
Date: 3/18/1981
Response: CONSOLIDATED RAIL CORPORATION LTR: CONRAIL'S PRESENT PRACTICE REQUIRES ALL ENGINEERS AND CONDUCTORS TO BE QUALIFIED ON THE PHYSICAL CHARACTERISTICS OF THE TERRITORY OVER WHICH THEY OPERATE, AND TO RE-QUALIFY ON ANY PORTION OVER WHICH THEY HAVE NOT OPERATED FOR ONE YEAR. WE BELIEVE THIS IS AN ADEQUATE PRECAUTION TO ENSURE OPERATIONAL SAFETY. THE CONDUCTOR OF TRAIN #472 WAS QUALIFIED ON THE CHARACTERISTICS OF THIS TERRITORY AND SHOULD HAVE, HIMSELF, CONTROLLED THE MOVEMENTS OF HIS TRAIN, RATHER THAN ASSIGNING AN UNQUALIFIED TRAINMAN FOR THIS PURPOSE.