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Safety Recommendation Details

Safety Recommendation R-87-071
Details
Synopsis: ABOUT 8 A.M., ON NOVEMBER 12, 1987, MASSACHUSETTS BAY TRANSPORTATION AUTHORITY (MBTA) TRAIN 8114 COLLIDED WITH THE REAR END OF STANDING MBTA TRAIN 8110 ON TRACK 2 AT THE BACK BAY STATION IN BOSTON, MASSACHUSETTS, INJURING 45 PASSENGERS AND 8 CREWMEMBERS. BOTH COMMUTER TRAINS WERE OPERATED BY AMTRAK UNDER CONTRACT WITH MBTA. THE ENGINEER OF TRAIN 8114 REPORTED THAT THE LAST SIGNAL HE PASSED BEFORE THE COLLISION DISPLAYED AN "APPROACH" INDICATION. ACCORDING TO APPLICABLE OPERATING RULES, AN "APPROACH" INDICATION ALLOWS THE ENGI NEER TO PROCEED "PREPARED TO STOP AT NEXT SIGNAL." BEFORE REACHING THE NEXT SIGNAL HIS TRAIN COLLIDED WITH THE REAR OF TRAIN 8110. POSTACCIDENT SIGNAL TESTS DETERMINED THAT UNDER CERTAIN TRACK OCCUPANCY CONDITIONS, THE EASTBOUND SIGNAL ON TRACK 2 (SIGNAL 2262-2) DISPLAYED A MORE PERMISSIVE INDICA TION THAN SHOULD HAVE BEEN DISPLAYED.
Recommendation: THE NTSB RECOMMENDS THAT THE U.S. DEPARTMENT OF TRANSPORTATION: DETERMINE IF THERE ARE SIGNAL SYSTEMS IN USE ON THE NATION'S RAIL AND RAIL RAPID TRANSIT SYSTEMS DESIGNED AND CONSTRUCTED TO SIMILAR SPECIFICATIONS AS SIGNAL 2262-2 ON THE MASSACHUSETTS BAY TRANSPORTATION AUTHORITY SIGNAL SYSTEM, INSPECT ANY SIMILAR SIGNAL SYSTEMS FOUND FOR DEFECTIVE ELECTRICAL CIRCUITRY CONDITIONS, AND REMOVE THESE SIGNAL SYSTEMS FROM SERVICE UNTIL THE DEFECTIVE CONDITIONS ARE CORRECTED. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: BOSTON, MA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA88MR002
Accident Reports: Rear-End Collision of Amtrak Massachusettes Bay Transportation Authority Commuter Trains
Report #: RAR-88-05
Accident Date: 11/12/1987
Issue Date: 12/22/1987
Date Closed: 5/12/1989
Addressee(s) and Addressee Status: DOT (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: DOT
Date: 5/12/1989
Response: The Safety Board is pleased to note that UMTA has received written responses from all the rapid and light rail operators in the United States advising that the track circuit design used in Boston on the Northeast Corridor is not used on any other rapid or light rail systems. This action, coupled with the Federal Railroad Administration's earlier determination that only 15 installations of similar track circuit design were made for intercity railroads, all of which were corrected the day after the accident that prompted the Board's recommendation, satisfies the intent of this recommendation. Therefore, Safety Recommendation R-87-71 has been placed in a "Closed--Acceptable Action" status.

From: DOT
To: NTSB
Date: 11/21/1988
Response: AS WE ARE NOT A REGULATORY AGENCY, THE URBAN MASS TRANSPORTATION ADMINISTRATION 9UMTA) IMPLEMENTED THE INTENT OF THE NTSB RECOMMENDATION THROUGH A LETTER TO ALL RAPID AND LIGHT RAIL GENERAL MANAGERS, IDENTIFYING THE PROBLEM AND ASKING THEIR COOPERATION IN INSPECTING AND MODIFYING AS NECESSARY ANY SIGNAL SYSTEM FOUND TO BE OF THE DESIGN USED IN BOSTON. A COPY OF THAT LETTER IS ENCLOSED. WE HAVE NOW RECEIVED WRITTEN RESPONSES FROM ALL THE RAPID AND LIGHT RAIL OPERATORS IN THE UNITED STATES, AND HAVE BEEN GIVEN THE ASSURANCE THAT THE DESIGN USED IN BOSTON ON THE NORTHEAST CORRIDOR IS NOT USED ON ANY RAPID OR LIGHT RAIL SYSTEMS. AT YOUR REQUEST, WE HAVE ENCLOSED COPIES OF TWO TYPICAL LETTER RESPONSES FROM GENERAL MANAGERS OF TRANSIT AUTHORITIES FOR YOUR INFORMATION. WE HAVE REVIEWED EACH OF THESE RESPONSES CAREFULLY AND FIND THEM ENTIRELY ACCEPTABLE. WE BELIEVE THESE ACTIONS RESPOND FULLY TO YOUR CONCERNS AND REQUEST THAT YOU RECLASSIFY RECOMMENDATION R-87-071 "CLOSED- ACCEPTABLE ACTION."

From: NTSB
To: DOT
Date: 4/22/1988
Response:

From: DOT
To: NTSB
Date: 3/24/1988
Response: THE FEDERAL RAILROAD ADMINISTRATION (FRA) INFORMS ME THAT THE TRACK CIRCUIT DESIGN IN QUESTION WAS CORRECTED IN ALL KNOWN LOCATIONS THE DAY AFTER IT WAS DETERMINED THAT IT WAS THE CAUSE OF THE NOVEMBER 12, 1987, TRAIN ACCIDENT IN BOSTON. AS INFORMATION, THE TRACK CIRCUIT DESIGN THAT CAUSED THE ACCIDENT IS UNIQUE TO THE NORTHEAST CORRIDOR AND MORE SPECIFICALLY TO THE GENERAL AREA OF THE ACCIDENT. THE CIRCUIT IS A UNION SWITCH AND SIGNAL DESIGN, ORIGINALLY DESIGNED FOR USE IN ELECTRIFIED TERRITORY, THAT WAS APPLIED TO THIS ONE SECTION OF THE NORTHEAST CORRIDOR. NO OTHER MANUFACTURER USES THIS PARTICULAR CIRCUIT DESIGN AND WE ARE CONFIDENT THAT NO OTHER INTERCITY RAILROAD INSTALLATIONS EXIST. ONLY 15 INSTALLATIONS OF THIS CIRCUIT WERE MADE FOR INTERCITY RAILROADS AND THEY ALL WERE CORRECTED THE DAY AFTER THE ACCIDENT. WITH RESPECT TO RAPID TRANSIT, THE URBAN MASS TRANSPORTATION ADMINISTRATION'S (UMTA) OFFICE OF SAFETY WILL NOTIFY ALL UMTA GRANTEES THAT MAY HAVE THE TYPE OF SIGNAL PROBLEM COVERED IN THE NTSB REPORT. WHILE UMTA DOES NOT HAVE THE AUTHORITY TO REQUIRE THE REMOVAL, REPAIR OR REPLACEMENT OF A GRANTEE'S SIGNALIZATION EQUIPMENT DIRECTLY, THEY WILL INSTRUCT THEIR GRANTEES TO INSPECT THEIR OWN SIGNALS AND TAKE WHATEVER ACTIONS ARE NECESSARY TO ENSURE THE SAFETY OF THEIR OWN OPERATIONS. FURTHER, UMTA WILL ASK FOR A REPORT OF WHAT LOCAL INVESTIGATIONS AND ACTIONS WERE TAKEN AS A RESULT OF THE MBTA FINDINGS BY THE NTSB AND WILL CAREFULLY EVALUATE THE RESPONSE RECEIVED FOR ADEQUACY. I TRUST OUR ACTIONS WILL SATISFY THE INTENT OF YOUR RECOMMENDATION.