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Safety Recommendation Details

Safety Recommendation R-85-083
Details
Synopsis: ABOUT 10:45 A.M. ON JULY 23, 1984, NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK) TRAINS NOS. 151 AND 168 COLLIDED HEAD-ON ON AMTRAK'S HELL GATE LINE IN THE ASTORIA SECTION OF QUEENS, NEW YORK, NEW YORK. TRAIN NO. 151 WAS BEING OPERATED BY TRAIN ORDER AUTHORITY WESTBOUND ON THE NO. 2 MAIN TRACK BETWEEN MARKET INTERLOCKING AND THE EAST END OF GATE INTERLOCKING. TRAIN NO. 168 WAS SUPPOSED TO HAVE BEEN STOPPED AND HELD AT THE HOME SIGNAL ON THE NO. 2 TRACK AT THE WEST END OF GATE INTERLOCKING FOR THE ARRIVAL OF TRAIN NO. 151. HOWEVER, TRAIN NO. 168 DID NOT STOP AT THE HOME SIGNAL BUT CONTINUED PAST GATE INTERLOCKING. THE TWO TRAINS COLLIDED ABOUT 1.1 MILES EAST OF GATE INTERLOCKING. ONE PASSENGER WAS KILLED; 129 PASSENGERS, 8 AMTRAK OPERATING CREWMEMBERS, AND 3 AMTRAK SERVICE ATTENDANTS WERE INJURED. PROPERTY DAMAGE WAS ESTIMATED BY AMTRAK TO HAVE BEEN $3,199,000.
Recommendation: THE NTSB RECOMMENDS THAT THE NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): DEVELOP AN OPERATING RULES VERIFICATION PROCEDURE THAT WILL REQUIRE EMPLOYEES TO DEMONSTRATE THAT THEY UNDERSTAND THE MEANING OF THE RULES AND CAN PROPERLY DERIVE AND APPLY THE CORRECT RULES FOR USE IN EMERGENCY CIRCUMSTANCES.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: New York, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA84AR014
Accident Reports: Head On Collision of National Railroad Passenger Corporation (Amtrak) Passenger Trains Nos. 151 and 168
Report #: RAR-85-09
Accident Date: 7/23/1984
Issue Date: 8/5/1985
Date Closed: 6/25/1992
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 6/25/1992
Response: Safety Recommendation R-85-83 asked that Amtrak develop an operating rules verification procedure that will require employees to demonstrate that they understand the meaning of the rules and can properly derive and apply the correct rules for use in emergency circumstances. The Safety Board is pleased to learn that Amtrak has instituted procedures during annual testing that will ensure that incorrect responses to test questions are discussed so the concept is understood before ending the test. The biannual division rule audits will also provide necessary followup for incorrect responses during rules examinations. In addition, the quarterly "ride-along" program skill monitoring program should prove an excellent vehicle for identifying areas requiring corrective action. Because of your efforts, Safety Recommendation R-85-83 has been classified "Closed--Acceptable Action."

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 1/24/1992
Response: AMTRAK STATES THAT IT HAS INSTITUTED PROCEDURES DURING ANNUAL TESTING WHICH WILL ENSURE THAT INCORRECT RESPONSES TO TEST QUESTIONS ARE DISCUSSED TO ENSURE THE CONCEPT IS UNDERSTOOD BEFORE ENDING THE TEST. THEY ALSO HAVE A QUARTERLY "RIDE-ALONG" PROGRAM SKILL MONITORING PROGRAM TO IDENTIFY DEFICIENT AREAS NEEDING CORRECTIVE ACTION. BI-ANNUAL DIVISION RULE AUDITS PROVIDE FOLLOW-UP FOR INCORRECT RESPONSES DURING RULES EXAMINATION.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 8/9/1988
Response: The Board notes that Amtrak has now hired a consultant to act as a moderator for the development of joint labor/management training programs and that committees are now being formed to outline priority training areas. The Board would appreciate being informed of the anticipated timeframe for implementing these training programs. In the meantime, Safety Recommendation R-85-83 will remain in an "Open--Acceptable Action" status. The following Safety Recommendation R-85-13 was issued as a result of the Board's investigation of the derailment of Amtrak train No. 81, The Silver Star, at Kittrell, North Carolina, on March 5, 1984.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 4/19/1988
Response: IN ADDITION TO CHANGES MADE IN AMTRAK'S OPERATING RULES REQUALIFICATION PROGRAM, EXPANDED CLASS TIME AND WRITTEN EXAMINATIONS, AMTRAK HAS RECENTLY RETAINED A CONSULTANT TO ACT AS A MODERATOR FOR THE DEVELOPMENT OF JOINT LABOR/MANAGEMENT TRAINING PROGRAMS. THIS DEMONSTRATION PROJECT IS PARTIALLY FUNDED BY THE FRA AND IS INTENDED TO ENHANCE AND VERIFY EMPLOYEE UNDERSTANDING OF SAFETY AND OPERATING RULES. COMMITTEES ARE NOW BEING FORMED WITH LABOR AND MANAGEMENT PERSONNEL TO OUTLINE PRIORITY TRAINING AREAS WITHIN BUDGETARY CONSTRAINTS.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 9/22/1987
Response: AMTRAK HAS RECEIVED A FRA GRANT IN THE AMOUNT OF $196,000 TO IMPLEMENT A JOINT LABOR/MANAGEMENT SAFETY TRAINING PROGRAM. A MAJOR PART OF THIS EFFORT WILL BE THE DEVELOPMENT OF AN INTERACTIVE COMPUTER TRAINING PROGRAM FOR OPERATING PERSONNEL. AMTRAK IS CURRENTLY IN THE PROCESS OF ARRANGING FOR THE SERVICES OF AN ILLINOIS-BASED CONSULTANT WHO HAS HAD SEVERAL YEARS OF EXPERIENCE WITH SUCH PROGRAMS. THIS PROGRAM WILL BE IMPLEMENTED IN EARLY FALL AND OPERATIONAL DURING 1988.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 7/13/1987
Response: Amtrak's ongoing efforts to develop and implement a computer/video disc training program remains responsive to the intent of the recommendation. Pending a further progress report on this new training concept, Safety Recommendation R-85-83 will be held in an "Open--Acceptable Action" status. The following Safety Recommendations, R-83-22, -25, and -26, were issued following the Board's investigation of the Amtrak derailment at Emerson, Iowa, on June 15, 1982.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 3/19/1987
Response: AMTRAK WILL BE RECEIVING A $197,000 TRAINING GRANT FROM THE FRA. THE IMPLEMENTING CONTRACT IS IN ITS FINAL REVIEW STAGES AND WILL BE SIGNED IN THE NEAR FUTURE. AT THAT TIME, WE WILL BE STARTING A 12-MONTH PROGRAM TO DEVELOP SOME IN TERACTION VIDEO DISC TRAINING PROGRAMS UNDER A JOINT LABOR MANAGEMENT TEAM APPROACH. ONE OF THE PROGRAMS DEVELOPED WILL BE AN OPERATING RULES UNIT. THIS NEW TRAINING CONCEPT WILL ENABLE EMPLOYEES TO DEMONSTRATE THEIR UNDERSTANDING OF THE PARTICULAR PROGRAM, AND IT IS EXPECTED TO BE A DEFINITE AID IN ALL AREAS OF SAFETY, MOFW, OPERATING AND HAZARDOUS MATERIAL TRAINING PROGRAMS.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 10/1/1986
Response: The Safety Board appreciates the additional information regarding Amtrak's plans to implement a computer/video disk training program, and we note the four principal areas on which this training program will focus. The Board notes further that while no formal action has been taken by the Federal Railroad Administration (FRA) on Amtrak's application for a grant to implement this training program, the application is still active and Amtrak intends to implement the program within 30 days of receiving the FRA grant. Pending notification that the grant has been received and the training program has been implemented, Safety Recommendation will be held in an "Open--Acceptable Action" status. Your efforts to respond to our Safety Recommendation are appreciated.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 8/20/1986
Response: AS OF THIS DATE, THE FRA IS STILL CONSIDERING AMTRAK'S AP PLICATION FOR THE GRANT TO HELP IN ACQUIRING COMPUTER/VIDEO DISK PROGRAMS. NO FORMAL ACTION HAS BEEN TAKEN BY THE FRA, BUT IT IS STILL ACTIVE. WE EXPECT TO IMPLEMENT THIS PROGRAM WITHIN 30 DAYS OF RECEIVING THE GRANT. THE PROGRAM WILL FOCUS ON FOUR PRINCIPAL AREAS: 1) MAINTENANCE-OF-WAY SAFETY TRAINING; 2) OPERATING RULES PROGRAM, 3) HANDLING EMERGENCY SITUATIONS; 4) ENVIRONMENTAL ISSUES PROGRAM.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 6/30/1986
Response: The Safety Board appreciates receiving copies of the lesson plans and written examinations for the various employees and notes that with some of the questions employees are placed in operating-type situations that require the employees to demonstrate the application of pertinent operating rules. While the Board commends Amtrak for including this type question in the operating rules examination, this in itself does not fulfill the intent of the Board's recommendation. We do note further, however, that Amtrak has applied for and expects to receive a grant from the Federal Railroad Administration for training purposes using computer/video disk programs to test employees' understanding of the rules. The Board believes that this concept is in line with the intent of the recommendation, and we would appreciate receiving more information including the timeframe for implementing the program and the types of video disk programs to be used. In the meantime, Safety Recommendation R-85-83 will remain in an "Open--Acceptable Action" status. The Board also notes Amtrak's implementation of the "System Qualification and Information System." Based on your response, it appears that this system will be an important management tool in retrieving pertinent employee information.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 4/29/1986
Response: ENCLOSED ARE COPIES OF LESSON PLANS AND WRITTEN EXAMS, AS REQUESTED IN YOUR FEBRUARY 19, 1986, LETTER. CHANGES TO AMTRAK'S REQUALIFICATION PROGRAM INCLUDE AN EXPANDED NUMBER OF DAYS FOR SUPERVISION: TRANSPORTATION - 3 DAYS ANNUALLY INSTEAD OF 1; ENGINEERING - 2 DAYS ANNUALLY INSTEAD OF 1. AMTRAK HAS APPLIED FOR AND EXPECTS TO RECEIVE A $197,000 GRANT FROM THE FRA IN ORDER TO DO SAFETY AND RULES TRAINING USING A JOINT MANAGEMENT/LABOR DEVELOPMENT CONCEPT. WE EXPECT TO USE INTERACTIVE COMPUTER/VIDEO DISK PROGRAMS WHICH WILL HELP ENABLE US TO DEMONSTRATE OUR EMPLOYEES TRULY UNDERSTAND THE OPERATING RULES. REGARDING EFFICIENCY TESTS, EFFECTIVE AUGUST 1985, AMTRAK IMPLEMENTED A NEW SYSTEM DESIGNED TO MORE EFFECTIVELY MANAGE OUR OPERATIONAL TESTS AND INSPECTION PROGRAM. TITLED, "SYSTEM QUALIFICATION AND INFORMATION SYSTEM" (SQIS), THIS SYSTEM MAINTAINS, IN A COMPUTER DATA BASE, EMPLOYEE HISTORY RECORDS, DISCIPLINE RECORDS, QUALIFICATION RECORDS, AND RECORDS OF OPERATIONAL AND EFFICIENCY TESTING. DATA IS INPUTTED CONSTANTLY ON A DIVISIONAL LEVEL. INFORMATION CAN BE RETRIEVED IN DIFFERENT FORMATS AND CAN PROVIDE DETAILED INFORMATION IN SUCH AREAS AS NUMBER OF TESTS ON A SPECIFIC RULE, IDENTITY OF EMPLOYEES NOT TESTED OVER A GIVEN PERIOD OF TIME, AND IDENTITY OF EMPLOYEES FAILING A SPECIFIC RULE. TO DATE THE SYSTEM IS OPERATIONAL ON ALL CORRIDOR DIVISIONS AND IS ABLE TO MONITOR TRAIN AND ENGINE EMPLOYEES (BOTH AMTRAK AND FOREIGN CARRIERS), TRAIN DISPATCHERS, AND BLOCK OPERATORS. OUR NEXT STEPS WILL BE TO IMPLEMENT THE SYSTEM ON OFF-CORRIDOR DIVISIONS AND TO ESTABLISH A DATA BASE FOR M/W DEPARTMENT EMPLOYEES. WE DO NOT ANTICIPATE ANY FURTHER CHANGES TO THESE PROGRAMS AT THIS TIME.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 2/19/1986
Response: The Board notes that as a result of the July 1984 accident Amtrak has modified its instruction and testing procedures to place greater emphasis on the application of critical safety rules in the operating environment and accordingly has restructured its written examination. The Board would appreciate receiving a copy of these procedures and an example of the type of written examination that is now being given. The Board notes also that Amtrak is considering further modifications to its requalification program and is reviewing its current efficiency testing program. The Board would appreciate being kept apprised of any contemplated changes to these programs. Pending further response, Safety Recommendation R-85-83 will be held in an "Open--Acceptable Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 11/4/1985
Response: BEGINNING JANUARY 1, 1984, AMTRAK MODIFIED ITS ANNUAL OPERATING RULES REQUALIFICATION PROGRAM TO MAKE CERTAIN THAT OUR METHOD OF INSTRUCTION AND TESTING WAS DIRECTED AT ENSURING EMPLOYEES NOT ONLY "KNOW THE RULES," BUT UNDERSTAND THE INTENT AND APPLICATION OF THE RULES IN ACTUAL OPERATING SITUATIONS. AFTER THE COLLISION OF TRAINS 168 AND 151 IN JULY 1984, WE REVIEWED THE STRUCTURE AND CONTENT OF OUR OPERATING RULES CLASSES. AS A RESULT OF THAT REVIEW, WE AGAIN MODIFIED OUR INSTRUCTION AND TESTING PROCEDURES TO PLACE EVEN GREATER EMPHASIS ON THE APPLICATION OF CRITICAL SAFETY RULES IN THE OPERATING ENVIRONMENT. TO ACHIEVE THIS GOAL OUR RULES EXAMINER SPENDS A SIGNIFICANT PORTION OF THE INSTRUCTION PERIOD REVIEWING EXAMPLES OF SAFETY-RELATED OPERATING SITUATIONS. FURTHER, WE HAVE INCREASED THE NUMBER OF SITUATION AND DIAGRAM QUESTIONS ON THE WRITTEN EXAMINATION TO APPROXIMATELY 40% OF THE TOTAL QUESTIONS. AMTRAK BELIEVES THAT OUR PRESENT POLICY OF INSTRUCTION AND EXAMINATIONS IS ADEQUATE TO ENSURE OUR EMPLOYEES CAN DEMONSTRATE THE ABILITY TO SELECT AND APPLY THE CORRECT RULES IN EMERGENCY SITUATIONS. HOWEVER, WE ARE CONSIDERING FURTHER MODIFICATIONS TO OUR PRESENT REQUALIFICATION PROGRAM, INCLUDING THE POSSIBILITY OF LENGTHENING THE INSTRUCTION PERIOD AND EXAMINATION. WE ARE ALSO REVIEWING OUR CURRENT EFFICIENCY TESTING PROGRAM TO DETERMINE HOW ITS EFFECTIVENESS CAN BE INCREASED.