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Safety Recommendation Details

Safety Recommendation R-85-057
Details
Synopsis: ABOUT 5:27 P.M. ON MARCH 17, 1984, A 10-CAR SUBWAY TRAIN OPERATED BY THE NEW YORK CITY TRANSIT AUTHORITY (NYCTA) DERAILED IN THE JORALEMON STREET TUNNEL UNDER THE EAST RIVER ABOUT 1,900 FEET SOUTH OF THE BOWLING GREEN STATION IN NEW YORK, NEW YORK. THE TRAIN, WHICH WAS LOADED TO VIRTUAL CAPACITY WITH ABOUT 1,500 PASSENGERS, WAS EXCEEDING THE 10-MPH SPEED RESTRICTION ESTABLISHED BECAUSE THE TRACK SECTION WAS UNDER REPAIR. THE DERAILMENT DID NOT RESULT IN SERIOUS INJURIES TO THE PASSENGERS OR SIGNIFICANT DAMAGE TO THE EQUIPMENT. AFTER EXTENSIVE DELAY, THE PASSENGERS DETRAINED AND WALKED ABOUT 700 FEET TO AN EMERGENCY EXIT, WHERE THEY CLIMBED A STAIRCASE FROM THE TUNNEL TO THE STREET. A SECOND TRAIN STALLED IN THE TUNNEL JUST SOUTH OF THE BOWLING GREEN STATION WHEN THE DERAILMENT INTERRUPTED TRACTION POWER TO THE TRAIN. PASSENGERS FROM THIS TRAIN WERE EVACUATED ONTO THE STATION PLATFORM THROUGH ANOTHER TRAIN WHICH WAS POSITIONED FOR THIS PURPOSE.
Recommendation: THE NTSB RECOMMENDS THAT THE NEW YORK CITY TRANSIT AUTHORITY: DEVELOP AND ENFORCE PROCEDURES TO ENSURE APPROPRIATE SIGNS AND SIGNALS ARE DISPLAYED TO INDICATE SPEEDS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: New York City, NY, United States
Is Reiterated: No
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: 5/20/1985
Date Closed: 12/18/1990
Addressee(s) and Addressee Status: Metropolitan Transportation Authority New York City Transit (Closed - Acceptable Action)
Keyword(s): Transit, Signals

Safety Recommendation History
From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 12/18/1990
Response: Safety Recommendation R-85-57 urged the NYCTA to develop and enforce procedures to ensure that appropriate signs and signals are displayed to indicate restricted speeds. We have reviewed your response and determined that the changes made regarding the display of restricted speed signs meet the intent of this recommendation. Accordingly, Safety Recommendation R-85-57 has been classified as "Closed-Acceptable Action."

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 9/12/1990
Response: TRACK AND STRUCTURES DEPARTMENT INITIATES AND COORDINATES REQUESTS FROM THE ENGINEERING AND CONSTRUCTION DIVISION FOR THE PLACEMENT OF "SLOW SPEEDS". THE ELECTRICAL DEPARTMENT SIGNAL DIVISION THEN PLACES "SLOW SPEED ORDERS" FOR TEMPORARY SHORED TRACKWAY. AT ATTACHMENT 2, 3, AND 4 ARE COPIES OF THE ELECTRICAL DEPARTMENT PROCEDURES FOR SLOW SPEED PLACEMENT AND MAINTENANCE. ATTACHMENT 5 IS THE SLOW SPEED REQUEST FORM FROM THE TRACK AND STRUCTURES DEPARTMENT. ATTACHMENT 6 IS THE SLOW SPEED SIGNAL DIAGRAM FOR INSTALLA TION AND MAINTENANCE BY ELECTRICAL PERSONNEL. ATTACHMENT 7 IS THE ELECTRICAL DEPARTMENT LISTING OF CURRENT SLOW SPEED AREAS.

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: CURRENT INSTRUCTIONS IN THE FORM OF GENERAL ORDERS, SIGNAL BULLETINS AND FLAGGING INSTRUCTIONS ARE IN PLACE AND DOCUMENTED. EFFORTS ARE BEING TAKEN TO ENSURE THAT EXISTING PROCEDURES ARE ENFORCED.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 7/25/1988
Response: In its letter of November 19, 1985, a copy of which is enclosed, the Board noted that the NYCTA was reviewing its current procedure regarding the requirements for restricted speed signs and signals and, based on this review, would be issuing a revised procedure which outlines clearly the requirements for restricted speed signs and signals and the responsibilities of the appropriate departments for ensuring that these requirements are met. We noted further NYCTA's indication that it would provide additional education and training as required when it completed its review and issued a revised procedure. On January 28, 1986, the NYCTA informed the Safety Board that it expected to have the new procedure completed by March 1986 and that the Board would be provided a copy at that time. Our records indicate, however, that no further correspondence has been received, and the Board is, therefore, requesting an update on this issue.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 1/28/1986
Response: We expect to have the new procedure completed by March 1986, and we will provide you with a copy of it at that time. In the interim, procedures have been established whereby the Electrical Department is responsible for posting the required slow speed lights and signs and the Track and Structures Department monitors the locations where such restrictions exist. While we recognize this to be a temporary solution, it does provide for an acceptable level of safety until a formal procedure is established.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 11/19/1985
Response: The Safety Board notes that the NYCTA is reviewing its current procedure regarding the requirements for restricted speed signs and signals and, based on this review, will be issuing a revised procedure which outlines clearly the requirements for restricted speed signs and signals and the responsibilities of the appropriate departments for ensuring that these requirements are met. The Board notes further that in addition to the instruction that is currently being given in response to Safety Recommendation R-84-19, NYCTA will provide additional education and training as required when it has completed its review and issued a revised procedure for slow speed restrictions. The Board considers the NYCTA's efforts positive steps toward fulfilling the intent of Safety Recommendations R-85-57 and -58 which have been placed in an "Open-Acceptable Action" status. The Board urges the NYCTA to expedite its efforts in this area and would appreciate receiving a copy of the revised procedure when it is issued and an update on the training to be given in connection with the revised procedure.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 9/6/1985
Response: RULE 63(K) OF THE NYCTA RULES AND REGULATIONS PROVIDES SPECIFIC REQUIREMENTS FOR DISPLAYING SLOW AND/OR RESTRICTED SPEED LIGHTS AND SIGNALS FOR TRACKS THAT ARE TEMPORARILY SHORED UP DUE TO REHABILITATION WORK (SEE ENCLOSURE #1). IT ALSO STATES THAT THE MAINTENANCE OF WAY DEPARTMENT IS RESPONSIBLE FOR DISPLAYING AND MAINTAINING THE LIGHTS OR FLAGS REQUIRED BY RULE 63(K). IN 1984, THE NYCTA RAPID TRANSIT DIVISION UNDERWENT A MAJOR REORGANIZATION WHICH RESULTED IN A SIGNIFICANT RESTRUCTURING OF FUNCTIONAL RESPONSIBILITIES IN THE MAINTENANCE OF WAY AREA. IN SUMMARY, THE MAINTENANCE OF WAY DEPARTMENT WAS DIVIDED INTO TWO SEPARATE DEPARTMENTS, TRACK AND STRUCTURES, WHICH IS RESPONSIBLE FOR ALL INSPECTION AND MAINTENANCE OF TRACK, LINE EQUIPMENT AND PHYSICAL STRUCTURES AND BUILDINGS; AND ELECTRICAL, WHICH IS RESPONSIBLE FOR THE OPERATION AND MAINTENANCE OF POWER GENERATION, SIGNALS, AND COMMUNICATIONS SYSTEMS. SINCE THIS REORGANIZATION THE SIGNAL GROUP WITHIN THE ELECTRICAL DEPARTMENT HAS BEEN RESPONSIBLE FOR PROVIDING AND MAINTAINING THE REQUIRED SLOW SPEED SIGNS AND LIGHTS FOR ALL CONTRACTOR AND SKELETONIZED TRACKWORK SYSTEMWIDE. THIS INCLUDE ALL WORK REQUIRING THE ISSUANCE OF A "GENERAL ORDER" FOR TRACK WORK BEING PERFORMED BY OUTSIDE CONTRACTORS UNDER THE DIRECTION OF THE ENGINEERING AND CONSTRUCTION DEPARTMENT, AS WELL AS "SKELETONIZED" TRACK WORK PERFORMED BY THE TRACK AND STRUCTURES DEPARTMENT. IT IS THE RESPONSIBILITY OF TRACK AND STRUCTURES TO POST THE REQUIRED SPEED RESTRICTIONS FOR ALL NON-SKELETONIZED CAPITAL AND ON-GOING MAINTENANCE TRACK ACTIVITIES PERFORMED BY NYCTA PERSONNEL, SUCH AS TIE AND RAIL REPLACEMENT WORK. WE ARE CURRENTLY IN THE PROCESS OF REVIEWING THIS ENTIRE PROCEDURE BECAUSE IT CONTAINS A NUMBER OF INHERENT PROBLEMS. THESE PROBLEMS ARE DUE PRIMARILY TO THE FACT THAT THE RESPONSIBILITY FOR POSTING AND MAINTAINING THE APPROPRIATE SPEED SIGN AND SIGNAL RESTRICTIONS IS SPLIT BETWEEN TWO DEPARTMENTS, AND IS DEPENDENT UPON THE TYPE OF WORK BEING DONE AND WHO IS DOING IT. ALSO, THE LACK OF A FORMALIZED REVISION TO RULE 63(K) AS STATED IN THE RULES AND REGULATIONS PRESENTS THE POTENTIAL FOR FURTHER CONFUSION IN THAT REFERENCE TO THE FORMER MAINTENANCE OF WAY DEPARTMENT IS MADE. IT IS OUR INTENTION TO COMPLETE OUR REVIEW IN THE NEAR FUTURE AND ISSUE A NEW REVISED PROCEDURE THAT PROVIDES A CLEAR AND CONCISE SUMMARY OF WHAT THE REQUIREMENTS FOR RESTRICTED SPEED SIGNS AND SIGNALS ARE AND WHO IS RESPONSIBLE FOR THEM.