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Safety Recommendation Details

Safety Recommendation R-87-005
Details
Synopsis: ABOUT 8:12 A.M., EASTERN DAYLIGHT TIME, JULY 10, 1985, EAST BOUND TWO-CAR TRAIN NO. 6601 STRUCK THE REAR OF THREE-CAR TRAIN NO. 6614, WHICH WAS STANDING INOPERATIVE ON THE EAST BOUND MAIN TRACK OF THE GREATER CLEVELAND REGIONAL TRANSIT AUTHORITY (GCRTA) RED RAPID TRANSIT LINE. TRAIN NO. 6614 WAS STUCK IN A REVERSE CURVE ABOUT 900 FEET WEST OF THE WEST 98TH STREET STATION IN CLEVELAND, OHIO. THE OPERATORS AND CONDUCTORS OF BOTH TRAINS AND A TOTAL OF 46 OF THE APPROX IMATELY 400 PASSENGERS ON THE TRAINS WERE TRANSPORTED TO NEARBY HOSPITALS. TWO DAYS AFTER THE ACCIDENT, ANOTHER PASSENGER WAS ADMITTED TO THE HOSPITAL FOR A CERVICAL SPINE INJURY; THE TRAIN CREWMEMBERS AND THE OTHER PASSENGERS RE CEIVED OUTPATIENT TREATMENT FOR MINOR INJURIES. THE REAR CAR OF TRAIN NO. 6614 WAS DERAILED AND SUSTAINED REAR END STRUCTURAL DAMAGE AS A RESULT OF THE COLLISION IMPACT.
Recommendation: THE NTSB RECOMMENDS THAT THE GREATER CLEVELAND REGIONAL TRANSIT AUTHORITY: REQUIRE ABSOLUTE BLOCK OPERATION WHENEVER AUTOMATIC TRAIN CONTROL OR AUTOMATIC TRAIN STOP ARE NOT FUNCTIONAL.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Cleveland, OH, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA85RM009
Accident Reports: Rear-End Collision of Two Greater Cleveland Regional Transit Authority Red Line Rapid Transit Trains near the 98th Street Station
Report #: None
Accident Date: 7/10/1985
Issue Date: 5/11/1987
Date Closed: 9/29/1988
Addressee(s) and Addressee Status: Greater Cleveland Regional Transit Authority (Closed - Acceptable Action)
Keyword(s): Transit, Positive Train Control

Safety Recommendation History
From: NTSB
To: Greater Cleveland Regional Transit Authority
Date: 9/29/1988
Response:

From: Greater Cleveland Regional Transit Authority
To: NTSB
Date: 7/27/1988
Response: AUTHORIZED INCIDENTS, I.E., INSTRUCTED BY TOWER CONTROL SUPERVISORS, OF OPERATORS PROCEEDING THROUGH STOP ASPECTS BY "KNOCKING DOWN" SIGNALS INCLUDING CASES WHERE THEY CLOSE UP TO A DISABLED TRAIN AHEAD, ARE LOGGED BY THE TOWER CONTROL SUPERVISORS. THIS INFORMATION INCLUDES THE DATE, TIME, TRAIN NUMBER, AND REASON. TOWER LOGS ARE REVIEWED AND FOLLOWED UP ON DAILY BY THE CHIEF RAIL TRAFFIC SUPERVISOR. UNAUTHORIZED INCIDENTS ARE FOLLOWED UP WITH DISCIPLINARY ACTION (SEE EXAMPLE). IT IS OUR PROFESSIONAL JUDGMENT THAT THIS PROCEDURE PROVIDES THE MAXIMUM SAFETY. THE CHIEF RAIL TRAFFIC SUPERVISOR AND RAIL TRAFFIC SUPERVISORS CONDUCT DAILY CHECKS OF TOWER CONTROL SUPERVISORS, TO MONITOR THEIR PERFORMANCE. TOWER LOGS AND OTHER ROUTINE REPORTS ARE REVIEWED AND FOLLOWED UP ON DAILY BY THE CHIEF RAIL TRAFFIC SUPERVISOR. ALL INFORMATION IS KEPT ON FILE. IN ADDITION, RADIO COMMUNICATIONS ARE MONITORED CONSTANTLY AND RECORDED ON TAPE. TAPES ARE RETAINED FOR 2 1/2 YEARS. THE RESULTS OF THE EFFICIENCY CHECKS AND TESTS, AND OF GCRTA'S EVALUATION OF TOWER CONTROL SUPERVISORS' COMPLIANCE WITH ABSOLUTE BLOCK OPERATIONS, ARE BEING FURNISHED IN THE FORM OF EXAMPLES OF THE FOLLOWING REPORTS (ATTACHED).

From: NTSB
To: Greater Cleveland Regional Transit Authority
Date: 6/28/1988
Response:

From: Greater Cleveland Regional Transit Authority
To: NTSB
Date: 3/4/1988
Response: ABSOLUTE BLOCK OPERATION HAS ALWAYS BEEN THE RULE AT GCRTA, BUT A MORE STRINGENT POSTURE HAS BEEN ADOPTED TO INSURE COMPLIANCE WITH THIS PROCEDURE. A STRONGER EMPHASIS HAS BEEN MADE THROUGH BULLETINS, OPERATING RULES AND TRAINING TO REINFORCE UNDERSTANDING AND COMPLIANCE WITH THE PROCEDURE. PERIODIC CHECKS ARE MADE BY SUPERVISION TO INSURE COMPLIANCE AND THESE CHECKS ARE AUDITED BY RAIL OPERATIONS MANAGEMENT AND THE SAFETY DEPARTMENT. THE OPERATORS' RULE BOOK STIPULATES THAT WHENEVER AN OPERATOR APPROACHES A RED SIGNAL (A DARK SIGNAL IS ALWAYS TREATED AS A RED SIGNAL) THEY MUST STOP, REMAIN STANDING FOR THIRTY SECONDS AND THEN CALL THE TOWER CONTROL SUPERVISOR FOR INSTRUCTIONS. THE PROCEDURES THAT THE TOWER CONTROL SUPERVISOR MUST FOLLOW ARE EXPLAINED IN THE RAIL EMERGENCY PROCEDURES MANUAL. THE TOWER CONTROL SUPERVISOR CANNOT PERMIT A TRAIN TO PROCEED THROUGH A RED OR DARK SIGNAL WITHOUT FIRST DETERMINING IF THE BLOCK IS OCCUPIED BY ANOTHER TRAIN. HE OR SHE CHECKS THE MODELBOARD TRAIN CONTROL PANEL (WHEN APPLICABLE) AND ESTABLISHES RADIO CONTACT WITH THE LEADER TRAIN. IF THE BLOCK IS OCCUPIED, THE TRAIN STANDING AT THE SIGNAL IS NOT PERMITTED TO ENTER THE BLOCK EXCEPT TO ASSIST IN AN EMERGENCY SITUATION. IF IT IS DETERMINED THAT THE BLOCK IS UNOCCUPIED, THE TOWER CONTROL SUPERVISOR CAN PERMIT THE TRAIN TO PROCEED; BUT UNDER A RESTRICTIVE MOVEMENT AS EXPLAINED IN R-87-6. MAINTENANCE PERSONNEL ARE ALSO DISPATCHED TO THE AREA TO CORRECT THE PROBLEM. THE SAME CRITERIA IS ESTABLISHED WHENEVER CAB SIGNAL EQUIPMENT BECOMES DEFECTIVE. THE OPERATOR MUST STOP THEIR TRAIN IMMEDIATELY AND CALL THE TOWER CONTROL SUPERVISOR FOR INSTRUCTIONS. THE TOWER CONTROL SUPERVISOR FOLLOWS THE SAME PROCEDURE AS PREVIOUSLY MENTIONED. IF THE TRAIN CAB SIGNAL MECHANISM IS FOUND DEFECTIVE THEN THE TRAIN IS REMOVED FROM SERVICE IMMEDIATELY. SEVERAL EFFORTS ARE MADE TO INSURE COMPLIANCE WITH ABSOLUTE BLOCK OPERATIONS. RAIL SUPERVISORS MAKE AT LEAST TWO RIDE CHECKS DURING THEIR WORK SHIFT OBSERVING ALL ASPECTS OF AN OPERATORS PERFORMANCE INCLUDING PROPER SIGNAL ADHERENCE. EACH TOWER CONTROL SUPERVISOR PERFORMS AT LEAST ONE SIGNAL TEST DURING HIS OR HER WORK SHIFT. AT RANDOM HE OR SHE DELIBERATELY SET AN INTERLOCKING SIGNAL TO THE RED ASPECT AND THEN MONITORS A TRAIN OPERATOR'S ACTIONS ON THE TOWER MODELBOARD TRAIN CONTROL PANEL AND RADIO. TWICE EACH MONTH SIGNAL TESTS ARE CONDUCTED IN THE FIELD WITH AUTOMATIC SIGNALS. THESE TESTS ARE CONDUCTED BY RAIL SUPERVISORS AND SIGNAL PERSONNEL WHO SET THE SIGNAL TO RED OR DARKEN THE SIGNAL TO OBSERVE A TRAIN OPERATOR'S ACTIONS. OPERATORS THAT FAIL TO FOLLOW PROPER PROCEDURES ARE SUBJECT TO DISCIPLINARY ACTION. PASSING THROUGH A RED OR DARK SIGNAL WARRANTS AN AUTOMATIC SUSPENSION AND MANDATORY RETRAINING ON THE FIRST OFFENSE AND DISCHARGE BY THE THIRD OFFENSE. THESE PROCEDURES ARE REINFORCED THROUGH THE ANNUAL TRAINING CLASSES FOR BOTH OPERATORS AND SUPERVISORS AS WELL AS REMEDIAL TRAINING SESSIONS THROUGHOUT THE YEAR.

From: NTSB
To: Greater Cleveland Regional Transit Authority
Date: 11/25/1987
Response: