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Safety Recommendation Details

Safety Recommendation R-84-019
Details
Synopsis: ON MARCH 17, 1984, THE NATIONAL TRANSPORTATION SAFETY BOARD INVESTIGATED AN ACCIDENT THAT OCCURRED IN THE NEW YORK CITY TRANSIT AUTHORITY (NYCTA) SUBWAY SYSTEM. DURING THE INVESTIGATION, THE SAFETY BOARD IDENTIFIED PROBLEMS IN THE SUPERVISION OF CONSTRUCTION AND MAINTENANCE PRACTICES; THE EMERGENCY RESCUE PROCEDURES; AND THE LACK OF OVERSIGHT BY FUNDING SOURCES. THE MOST IMMEDIATE CONCERN, HOWEVER, WAS THE VERY POOR METHOD THAT HAD BEEN USED BY THE CONTRACTOR FOR SUPPORTING THE SKELETONIZED TRACK. THEREFORE, THIS RECOMMENDATION IS ADDRESSING THAT ISSUE.
Recommendation: THE NTSB RECOMMENDS THAT THE NEW YORK CITY TRANSIT AUTHORITY: REQUIRE THAT INSPECTORS RESPONSIBLE FOR INSURING SAFE CONDITIONS OF TRACK KNOW THE NECESSARY STANDARDS FOR MAINTAINING THOSE CONDITIONS. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: New York City, NY, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA84RM007
Accident Reports: Derailment of New York City Transit Authority Subway Train in the Joralemon Street Tunnel
Report #: RAR-85-07
Accident Date: 3/17/1984
Issue Date: 4/9/1984
Date Closed: 4/12/1990
Addressee(s) and Addressee Status: Metropolitan Transportation Authority New York City Transit (Closed - Acceptable Action)
Keyword(s): Oversight,Transit

Safety Recommendation History
From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 4/12/1990
Response:

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 10/3/1988
Response: THE TRACK INSPECTORS TRAINING COURSE WAS INSTITUTED IN 1986 87. IT CONSISTS OF 80 HOURS OF CLASSROOM TRAINING AND 80 HOURS OF FIELD TRAINING. AS OF MAY 1988, 70 PARTICIPANTS HAVE COMPLETED THIS COURSE. A REFRESHER COURSE IS GIVEN EACH YEAR. THE PURPOSE OF THE COURSE IS TO PROVIDE PROSPEC TIVE TRACK INSPECTORS WITH A THOROUGH WORKING KNOWLEDGE OF: 1. SAFETY PROCEDURES 2. TRACK STANDARDS 3. TRACK CONSTRUCTION 4. TRACK MAINTENANCE PROCEDURES 5. SWITCH INSPECTION 6. TRACK DEFECTS 7. INSPECTION AND REPORTING PROCEDURES AT THE CONCLUSION OF THIS PROGRAM, THE PARTICIPANT WILL BE ABLE TO: 1. APPLY SAFETY PROCEDURES TO EVERY JOB-RELATED ACTIVITY. 2. INSPECT AND EVALUATE TRACK DEFECTS AND MAKE NECESSARY REPAIRS. 3. DESCRIBE ALL TYPES OF TRACK MAINTENANCE TOOLS AND THEIR USES. 4. IDENTIFY: A. RAIL WEAR TOLERANCES AND DEFECTS B. ALL TYPES OF TRACK DESIGN C. ALL TYPES OF FASTENINGS AND THEIR PURPOSES D. ALL TYPES OF INSULATED RAIL JOINTS E. ALL SPECIAL WORK COMPONENTS 5. PROPERLY INSTALL ALL TYPES OF EMERGENCY BARS 6. CHANGE FAILING INSULATED JOINTS 7. PROPERLY INSPECT TRACKS AND FILL OUT T.D.I.S FORMS AND COMPLAINT FORMS FOR COMPUTERIZED RECORDS 8. REFER CONDITIONS OTHER THAN TRACK CONDITIONS TO THE RESPONSIBLE DEPARTMENT.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 7/25/1988
Response: In a letter dated December 18, 1986, a copy of which is enclosed for your reference, the Board placed Safety Recommendation R-84-19 in an "Open-Acceptable Action" status pending a further progress report on the ongoing training and qualification programs and a clarification as to whom the training would apply. Again, in view of the time that has elapsed since our previous letter, the Board is requesting an update on NYCTA's efforts in this area.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 12/18/1986
Response: The Safety Board is pleased to note that in addition to the ongoing training programs for Engineering and Construction, and Track Structures Department personnel, NYCTA is now developing a schedule to requalify all track inspectors who completed an initial phase of training and have been working in the field over 2 years. While it would appear that this schedule to requalify track inspectors would include the personnel positions involved in the DeKalb Avenue accident, the Board would appreciate specifically being so informed. The Board notes also that the Track and Structures Department has issued the Track Standards and Reference Manual, which addresses the issues involved in the DeKalb Avenue derailment and will be used for all work and training programs that involve track. Further, all Track and Structures Department managers, supervisors, engineers, and track inspectors will be required to participate in a 1-day review and qualification for this manual. In view of NYCTA's recent efforts to improve the expertise of all track inspectors, Safety Recommendation R-84-19 has now been placed in an "Open-Acceptable Action" status, pending a further progress report on these ongoing training and qualification programs and a clarification as to whom the training will apply.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 10/24/1986
Response: THE TRAINING COURSES FOR ENGINEERING AND CONSTRUCTION, AND TRACK AND STRUCTURES DEPARTMENT (TSD) PERSONNEL WHICH WERE DEVELOPED FOLLOWING THE JORALEMON STREET TUBE DERAILMENT ARE STILL BEING TAUGHT AT THE RAPID TRANSIT TRAINING CENTER. THE INITIAL PHASE OF TRAINING FOR THE TRACK INSPECTOR TRAIN ING CURSE FOR ALL TRACK INSPECTORS AND SUBSTITUTE INSPECTORS HAS BEEN COMPLETED. A SCHEDULE IS NOW BEING DEVELOPED TO REQUALIFY ALL TRACK INSPECTORS WHO COMPLETED THE INITIAL PHASE OF TRAINING AND HAVE BEEN WORKING IN THE FIELD OVER 2 YEARS. IN ADDITION TO THE TRACK INSPECTORS TRAINING COURSE, TSD HAS ISSUED THE MW-1, TRACK STANDARDS AND REFERENCE MANUAL. THIS MANUAL SPECIFICALLY ADDRESSES THE ISSUES INVOLVED IN THE DEKALB AVENUE DERAILMENT AND WILL BE USED FOR ALL WORK AND TRAINING PROGRAMS THAT INVOLVE TRACK. ALL TSD MANAGERS, SUPERVISORS, ENGINEERS AND TRACK INSPECTORS WILL BE REQUIRED TO PARTICIPATE IN A 1-DAY REVIEW AND QUALI FICATION OF THIS MANUAL. THIS QUALIFICATION PROGRAM IS EXPECTED TO BEGIN IN NOVEMBER 1986 AND BE COMPLETED BY JUNE 1987. WITH RESPECT TO ENGINEERING AND CONSTRUCTION PERSON NEL, 212 ENGINEERS OUT OF AN ESTIMATED 300 HAVE ATTENDED THE TWO WEEK TRACK INSPECTION COURSE FOR ENGINEERING AND CON STRUCTION DEPARTMENT PERSONNEL. FOR THOSE THAT HAVE NOT ATTENDED, A SCHEDULE IS BEING DEVELOPED AT THIS TIME THAT WILL PROVIDE THE REQUIRED TRAINING AS SOON AS POSSIBLE.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 7/30/1986
Response: The Safety Board notes the New York City Transit Authority's (NYCTA) comments concerning the different circumstances surrounding the derailment that occurred at DeKalb Avenue on May 15, 1985, and the training programs that were developed as a result of the Joralemon Street Tube derailment. The Board is aware that the subject training programs were designed to upgrade the level of expertise of track construction engineers and contract inspectors in the Engineering and Construction Department and track inspectors in the Track and Structures Department. While encouraged by this action, the Board believes that the recommendation should not be interpreted as being limited only to a certain category of employees; the recommendation is applicable to all employees who are qualified and required to make inspections of track regardless of whether the inspections are performed following contract work, ongoing surveillance, or maintenance work. In the DeKalb Avenue accident, both the capital improvement division line supervisor and the deputy superintendent were qualified and required to make track inspections and both stated following the accident that they each had inspected the finished work and took no exception. The Board believes that competent inspections were not performed in this instance for if they had been, the inadequately performed track work would have been discovered. The Safety Board encourages the NYCTA to continue its training courses for contract inspectors and track inspectors in the Track and Structures Department, but at the same time urges the NYCTA to assure that all employees who are required to make track inspections and who are responsible for insuring safe conditions of track know the standards for maintaining those conditions. Pending a further response to the Board's concerns, Safety Recommendation R-84-19 will remain in an "Open-Unacceptable Action" status. For your information, we have enclosed a copy of the Board's report of the DeKalb Avenue accident investigation.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 5/6/1986
Response: NYCTA LTR: AFTER REVIEWING THE COMMENTS MADE IN YOUR FEB. 27TH LETTER, IT APPEARS AS IF THERE MAY BE SOME MISUNDER STANDING CONCERNING THE CAUSE OF THE DERAILMENT THAT OCCURRED AT DEKALB AVENUE ON MAY 15, 1985, AND THE TRAIN ING PROGRAMS THAT WERE DEVELOPED AS A RESULT OF THE JORALEMON STREET TUBE DERAILMENT. THE TRACK TRAINING COURSES THAT WERE DEVELOPED BY THE RAPID TRANSIT TRAINING DIVISION, FOLLOWING THE JORALEMON STREET TUBE DERAILMENT, WERE DESIGNED TO UPGRADE THE LEVEL OF EXPERTISE OF TRACK CONSTRUCTION ENGINEERS AND CONTRACT INSPECTORS IN THE ENGINEERING AND CONSTRUCTION DEPARTMENT, AND TRACK INSPEC TORS IN THE TRACK AND STRUCTURES DEPARTMENT. THIS ACTION WAS TAKEN BECAUSE OUR INVESTIGATION OF THE INCIDENT REVEALED THAT THERE WERE SERIOUS DEFICIENCIES WITH RESPECT TO CON TRACT AND ON-GOING MAINTENANCE INSPECTIONS OF TRACK THAT WAS BEING SKELETONIZED. THE CONTRACT INSPECTORS WERE NOT QUALI FIED TO INSPECT TRACK WORK THAT WAS BEING PERFORMED BY AN OUTSIDE CONTRACTOR. IN PARTICULAR, THEY FAILED TO APPLY THE PROPER STANDARDS FOR SKELETONIZED TRACK WHILE MONITORING THE CONTRACTOR'S WORK. IN ADDITION, THE TRACK INSPECTORS WHO CHECKED THE CONDITION OF THE SKELETONIZED TRACK AS PART OF THEIR NORMAL TRACK INSPECTION FAILED TO DETECT AND TAKE APPROPRIATE ACTION TO DEAL WITH THE DEFICIENCIES THAT EXISTED. ALL OF THESE FUNCTIONS WERE RELATED TO "TRACK INSPECTION," EITHER AS PART OF CONTRACT WORK OR ON-GOING SURVEILLANCE. THE DERAILMENT THAT OCCURRED AT DEKALB AVE. WAS THE DIRECT RESULT OF IMPROPERLY APPLIED "MAINTENANCE PROCEDURES" ON THE PART OF THE TRACK AND STRUCTURES LINE SUPERVISOR (L/S) AND THE SIGNAL MAINTAINER (S/M) ASSIGNED TO THE RAIL REPLACEMENT PROJECT FOR THE SWITCH INVOLVED IN THE INCIDENT. THE L/S WAS DETERMINED TO BE RESPONSIBLE BECAUSE HE DIRECTLY SUPERVISED THE IMPROPER INSTALLATION OF THE WEST STOCK RAIL. THE S/M WAS FOUND RESPONSIBLE BECAUSE HE FAILED TO PROPERLY ADJUST THE SWITCH AFTER THE STOCK RAIL WAS IN STALLED. BOTH OF THESE PROCEDURES ARE MAINTENANCE FUNCTIONS THAT ARE PERFORMED SOLELY BY TRANSIT AUTHORITY PERSONNEL AND DO NOT INVOLVE CONTRACTORS. IT SHOULD ALSO BE NOTED THAT THE DERAILMENT OCCURRED WITHIN HOURS OF WHEN THE MAINTENANCE WORK HAD BEEN COMPLETED, AND PRIOR TO ANY TRACK INSPECTOR EXAMINING THE TRACK. AS SUCH, THE PROCEDURES INVOLVED ARE TOTALLY UNRELATED TO THE TRACK INSPECTION DISCUSSED EARLIER, OR THE TRAINING COURSES WHICH WERE DEVELOPED AFTER THE JORALEMON STREET TUBE DERAILMENT. FOR THAT REASON, WE BELIEVE THAT THERE IS LITTLE, IF ANY, RELATION BETWEEN THE TRACK INSPECTION TRAINING COURSES AND THE CAUSE OF THE DERAILMENT AT DEKALB AVENUE ON MAY 15, 1985. THEREFORE, WE REQUEST THE SAFETY BOARD TO RECONSIDER ITS LATEST ACTION IN CHANGING THE STATUS OF R-84-19 TO "OPEN--UNACCEPTABLE ACTION."

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 3/27/1986
Response: From the accident report of the New York City Transit Authority Subway train Dekalb Avenue Station in Brooklyn, New York on May 15, 1985. The Board adopted this report on 3/27/1986. In addition, the National Transportation Safety Board reiterated Safety Recommendation R-84-19 issued on April 9, 1984, and Safety Recommendation R-85-30 issued on March 29, 1985, to the New York City Transit Authority.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 2/27/1986
Response: The Safety Board notes the progress reports on the training programs for track construction engineers and track inspectors. However, the Board's investigation of the May 15, 1985, DeKalb Avenue accident revealed that there remain shortcomings in the manner in which track inspections are being conducted by those responsible for insuring the safe conditions of track. As a result of the Board's discussion of the DeKalb Avenue accident report at the Board's meeting of February 4, 1986, Safety Recommendation R-84-19 is being reiterated to the New York City Transit Authority (NYCTA). Since there is still a problem with the adequacy of track inspections, the status of Safety Recommendation R-84-19 has been changed to "Open-Unacceptable Action." The Board looks forward to the NYCTA's further response to this recommendation following receipt of the DeKalb Avenue accident report.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 11/19/1985
Response: WE REPORTED IN OUR LETTER OF JUNE 10, 1985, THAT A TOTAL OF 139 ENGINEERS HAVE ATTENDED THE 2 WEEK TRACK INSPECTION COURSE FOR ENGINEERING AND CONSTRUCTION DEPARTMENT PERSONNEL AND 123 TRACK INSPECTORS HAVE ATTENDED THE TRACK INSPECTOR TRAINING COURSE. TO DATE, 145 ENGINEERS HAVE COMPLETED TRAINING AND 8 MORE ARE SCHEDULED TO COMPLETE TRAINING ON NOVEMBER 15, 1985. ONE ADDITIONAL CLASS WITH 12 ENGINEERS IS SCHEDULED FOR 1985. FOR THE BEGINNING OF 1986 WE HAVE SCHEDULED FIVE CLASSES WITH 12 STUDENTS EXPECTED TO ATTEND EACH CLASS. WITH RESPECT TO THE TRACK INSPECTOR TRAINING COURSE, 140 INSPECTORS HAVE BEEN TRAINED AS OF OCTOBER 25, 1985. TWO ADDITIONAL CLASSES WITH 12 STUDENTS IN EACH CLASS ARE SCHEDULED TO BE COMPLETED BY THE END OF DECEMBER 1985.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 8/19/1985
Response: The Safety Board notes that the projected completion date for training track construction engineers is December 1986 and for training all track inspectors is December 1985. The Safety Board would appreciate being updated periodically on the progress of these training programs and, at the same time, encourages the NYCTA to expedite the training of these personnel. Pending review of progress reports on these training programs, Safety Recommendation R-84-19 will remain in its current status of "Open-Acceptable Action."

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 6/10/1985
Response: NEW YORK CITY TRANSIT AUTHORITY LETTER: WE REPORTED IN OUR LETTER OF DECEMBER 4, 1984 THAT THE RAPID TRANSIT TRAINING DIVISION HAS DEVELOPED NEW TRAINING COURSES FOR THE PURPOSE OF UPGRADING THE LEVEL OF EXPERTISE OF TRACK INSPECTORS AND TRACK CONSTRUCTION ENGINEERS. AS OF MAY 31, 1985 A TOTAL OF 139 ENGINEERS HAVE ATTENDED THE TWO WEEK TRACK INSPECTION COURSE FOR ENGINEERING AND CONSTRUCTION DEPARTMENT PERSONNEL. THIS FIGURE CONSTITUTES APPROXIMATELY ONE THIRD OF THE ENGINEERS THAT REQUIRE TRAINING. THE PROJECTED COMPLETION DATE FOR THIS TRAINING PROGRAM IS DECEMBER 1986. WITH RESPECT TO THE TRACK INSPECTOR TRAINING COURSE, 123 MEN HAVE BEEN TRAINED AS OF MAY 31, 1985. THERE ARE A TOTAL OF 183 TRACK INSPECTOR POSITIONS, OF WHICH 35 ARE PRESENTLY VACANT. WE ANTICIPATE THAT ALL TRACK INSPECTOR TRAINING WILL BE COMPLETED BY DECEMBER 1985.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 4/23/1985
Response: The Board commends the NYCTA for its efforts in developing training courses and programs for the purpose of upgrading the level of expertise of track inspectors and track construction engineers. The Board is pleased that the training programs developed include "hands-on" experience as well as classroom instruction. The Board notes that as of November 27, 1984, a number of track construction engineers, new track inspectors, and existing track inspectors is scheduled to complete training by the end of 1985. The Safety Board would appreciate being informed of the total number of employees who are to receive the training and the projected completion date for training the track construction engineers and the new track inspectors. Pending further response, Safety Recommendation R-84-19 will be held in an "Open-Acceptable Action" status.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 12/4/1984
Response: NYCTA LTR: THE RAPID TRANSIT TRAINING DIVISION HAS DEVELOPED A NUMBER OF TRAINING COURSES FOR THE PURPOSE OF UPGRADING THE LEVEL OF EXPERTISE OF TRACK INSPECTORS AND TRACK CONSTRUCTION ENGINEERS, AND TO PROVIDE AN INTENSIVE TRAINING PROGRAM FOR "NEW" TRACK INSPECTORS. THESE TRAINING COURSES INCLUDE THE FOLLOWING. IN JUNE 1984, A 2 WEEK TRACK INSPECTION COURSE FOR ENGINEERING AND CONSTRUCTION DEPARTMENT PERSONNEL WAS INSTITUTED. THE FIRST WEEK OF THIS COURSE INVOLVES CLASSROOM TRAINING WITH EMPHASIS ON TRACK STANDARDS, DESIGN AND GEOMETRY. THE SECOND WEEK IS SPENT IN THE FIELD, APPLYING THE THEORETICAL KNOWLEDGE THAT HAS BEEN PROVIDED. AS OF NOVEMBER 27TH, A TOTAL OF 89 TRACK CONSTRUCTION ENGINEERS HAVE BEEN TRAINED. IN JULY 1984, A 6 WEEK TRACK INSPECTORS PROGRAM FOR TRACK AND STRUCTURES DEPARTMENT PERSONNEL WAS IMPLEMENTED. THIS COURSE EMPHASIZES TRACK DESIGN, GEOMETRY, AND FASTENINGS INSPECTION PROCEDURES AND STANDARDS. IT IS THE RESULT OF THE JOINT EFFORTS OF THE NYCTA COURSE DEVELOPMENT SECTION AND CONTROL DATA CORPORATION. THE COURSE CONSISTS OF THREE PHASES, AS FOLLOWS: O TWO WEEKS CLASSROOM TRAINING O TWO WEEKS IN THE FIELD FOR "HANDS-ON" EXPERIENCE O TWO WEEKS OF FOLLOWUP EVALUATION THAT IS PERFORMED 6 MONTHS AFTER THE CONCLUSION OF CLASSROOM AND FIELD TRAINING. ONE OF THESE WEEKS CONSISTS OF COMPUTER ASSISTED EVALUATION AND REFRESHER TRAINING, AND THE SECOND WEEK CONSISTS OF AN EVALUATION IN THE FIELD AND A FINAL WRITTEN TEST. AS OF NOVEMBER 27TH, A TOTAL OF 66 NEW TRACK INSPECTORS HAVE BEEN TRAINED. IN OCTOBER 1984, A REFRESHER TRAINING PROGRAM FOR EXISTING TRACK INSPECTORS WAS DEVELOPED AND IMPLEMENTED. THIS IS A 1 WEEK PROGRAM THAT UTILIZES A PERSONAL COMPUTER TO EVALUATE, INSTRUCT, AND PRESCRIBE ADDITIONAL TRAINING, AS REQUIRED. IN ADDITION, A PRACTICAL EXAM IS ADMINISTERED WHERE INSPECTORS ARE REQUIRED TO EXAMINE A SECTION OF TRACK AND IDENTIFY TRACK DEFECTS THAT HAVE BEEN DELIBERATELY INCORPORATED INTO THE TRACK. THREE INSPECTORS PER WEEK ARE SCHEDULED FOR THIS PROGRAM AND THE ENTIRE TRACK INSPECTION WORKFORCE SHOULD BE REEVALUATED BY THE END OF 1985. AS OF NOVEMBER 27TH, A TOTAL OF 11 TRACK INSPECTORS HAVE COMPLETED THIS TRAINING. IN ADDITION TO THE AFOREMENTIONED TRAINING PROGRAMS, THE RAPID TRANSIT TRAINING DIVISION AND TRACK AND STRUCTURES DEPARTMENT HAVE JOINTLY DEVELOPED SEVERAL AIDS TO ASSIST TRACK INSPECTORS IN THE PERFORMANCE OF THEIR JOB. THESE INCLUDE A MODIFIED TRACK TRAINING MANUAL AND A POCKET-SIZE INSPECTOR GAUGE.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 11/6/1984
Response: On April 9, 1984, the National Transportation Safety Board issued Safety Recommendations R-84-17 through -19 to the New York City Transit Authority (NYCTA). These recommendations were issued as a result of the Board's investigation of an accident that occurred on the NYCTA subway system on March 17, 1984. The National Transportation Safety Board is an independent Federal agency with the statutory responsibility "…to promote transportation safety by conducting independent accident investigations and by formulating safety improvement recommendations" (Public Law 93-633). The Safety Board is vitally interested in any actions taken as a result of its Safety Recommendations. Our records show that we have not received any indication of action taken by the NYCTA regarding the recommended actions. We would appreciate being informed as to what efforts are being made to implement these recommendations. The Safety Board's letter including these recommendations is enclosed for your information.