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Safety Recommendation Details

Safety Recommendation R-88-081
Details
Synopsis: ON NOVEMBER 12, 1987, NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK)/MASSACHUSETTS BAY TRANSPORTATION AUTHORITY (MBTA) COMMUTER TRAIN 8110 WAS STANDING PARTIALLY BERTHED AT THE BACK BAY STATION PLATFORM IN BOSTON, MASSACHUSETTS, WHEN IT WAS STRUCK FROM THE REAR BY AMTRAK/MBTA COMMUTER TRAIN 8114.
Recommendation: THE NTSB RECOMMENDS THAT THE NATIONAL RAILROAD PASSENGER CORPORATION: WHEN REQUIRING TRAINCREW PERSONNEL TO QUALIFY ON THE PHYSICAL CHARACTERISTICS OF A PARTICULAR TERRITORY, EITHER TRAIN THOSE PERSONNEL IN SIMULATED OPERATIONAL SITUATIONS WITH A SYSTEM THAT IMMEDIATELY INTEGRATES A TRAINEE'S RESPONSES TO POWER AND BRAKING OR PERFORM THE QUALIFYING TEST ON THE SAME TYPE OF EQUIPMENT AND IN THE ACTUAL OPERATIONAL ENVIRONMENT THAT THOSE EMPLOYEES WILL ENCOUNTER LATER.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 11/29/1988
Date Closed: 9/5/1990
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 9/5/1990
Response: As you stated, our respective staffs met on this issue and discussed it at length. In our view , no new information was offered by Amtrak and we believe that our original understanding of Amtrak's position was accurate. We continue to disagree with Amtrak's opinion that the alternate qualification procedure are "safe and appropriate." The Safety Board continues to believe that the implementation of Amtrak's stated position will allow qualification procedures to fall below the optimum procedures that are normally used. The afety Board believes that there is no acceptable substitute for qualification procedures that encompass the elements contained in this recommendation.~ Since we continue to disagree on this subject, Safety Recommendation R-88-81 will remain classified as "Closed--Unacceptable Action."

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 6/6/1990
Response: BASED ON YOUR LETTER, AMTRAK BELIEVES THE NTSB MAY HAVE MISUNDERSTOOD OUR LATEST RESPONSE TO SAFETY RECOMMENDATION R-88-81. THEREFORE, I WOULD LIKE TO RESTATE OUR POSITION: WHILE AMTRAK DOES HAVE STANDARD PROCEDURES FOR QUALIFYING EMPLOYEES ON THE PHYSICAL CHARACTERISTICS OF THE RAILROAD OVER WHICH THEY WILL OPERATE, WE WOULD LIKE TO RESERVE THE ABILITY TO MODIFY THOSE PROCEDURES SHOULD THE NEED ARISE. MODIFICATION OF QUALIFICATION PROCEDURES IS NOT DECIDED AT THE LOCAL OR DIVISION LEVEL. SUCH DECISIONS ARE MADE AT THE SYSTEM LEVEL, AND SAFETY IS OF THE UTMOST IMPORTANCE IN THE DECISION-MAKING PROCESS. WE BELIEVE THAT THE ALTERNATE PROCEDURES EMPLOYED IN THE QUALIFICATION OF EMPLOYEES ON THE REOPENING OF THE SOUTHWEST CORRIDOR WERE BOTH SAFE AND APPROPRIATE, BASED ON THE NATURE OF THE REHABILITATION PROJECT, AND THAT THEY ENSURED THAT EMPLOYEES WERE FULLY QUALIFIED ON THE PHYSICAL CHARACTERISTICS OF THE TERRITORY INVOLVED. ANY FUTURE MODIFICATION OF OUR QUALIFICATION PROCEDURE, IF IT SHOULD EVER OCCUR, WOULD BE MADE ONLY AFTER A THOROUGH EVALUATION PROCESS AND A SYSTEM LEVEL DECISION. OUR RESPECTIVE STAFFS HAVE DISCUSSED THIS ITEM AND HAVE ARRANGED A MEETING TO REVIEW OUR POSITION WITH YOU ON THIS SUBJECT. I HOPE THAT AFTER THIS MEETING WE WILL BE ABLE TO RECLASSIFY THIS TOPIC AS A CLOSED-ACCEPTABLE ACTION.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 5/11/1990
Response: Safety Recommendation R-88-81 asks that Amtrak, when requiring traincrew personnel to qualify on the physical characteristics of a particular territory, either train those personnel in simulated operational situations with a system that immediately integrates a trainee's responses to power and braking or perform the qualifying test on the same type of equipment and in the actual operational environment that those employees will encounter later. The Safety Board notes that Amtrak has not changed its position from previous responses and regrets Amtrak's position from a safety perspective, in that the railroad apparently permits its operating officers to suspend or not comply with "standard qualifying procedures." However, absent an indication that Amtrak intends to change its current operating procedures on this matter, Safety Recommendation R-88-81 has been classified as "Closed--Unacceptable Action."

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 2/28/1990
Response: AS INDICATED IN BOTH OUR PREVIOUS RESPONSES TO THIS RECOMMENDATION, THE PROCEDURES USED TO QUALIFY TRAIN CREW PRESONNEL ON THE PHYSICAL CHARACTERISTICS OF THE SOUTHWEST CORRIDOR WERE DICTATED BY THE SCOPE OF THE REHABILITATION PROJECT. AS WE POINTED OUT IN OUR INITIAL RESPONSE, WE BELIEVE THOSE PROCEDURES WERE BOTH SAFE AND APPROPRIATE, AND ENSURED TRAIN AND ENGINE PERSONNEL WERE FULLY QUALIFIED TO OPERATE TRAINS OVER THE SOUTHWEST CORRIDER. PRESENTLY, NO FURTHER PROJECTS ARE PLANNED THAT WOULD RESTRICT OUR ABILITY TO USE OUR STANDARD QUALIFYING PROCEDURES. WE EXERCISING THEIR PROPER DECISION MAKING RESPONSIBILITIES IN THE FUTURE. BE ASSURED, HOWEVER, SUCH DECISIONS ARE NOT LIGHTLY UNDER TAKEN AND WOULD BE MADE ONLY AFTER A THOROUGH REVIEW OF THE SAFETY IMPLICATIONS WE SUGGEST R-88-81 (AMTRAK'S EVALUATOR) BE CLASSED "CLOSED--ACCEPTABLE ACTION."

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 1/4/1990
Response: The Safety Board agrees with Amtrak that the Southwest Corridor is now in normal service. However, the Safety Board continues to be concerned that Amtrak, in future post-repair/rehabilitation situations, will again suspend normal qualification standards. As the Amtrak response does not address this concern, Safety Recommendation R-88-81 remains classified as "Open-- Unacceptable Action."

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 8/22/1989
Response: As previously indicated, it was the absence of freight operations on the Southwest Corridor that triggered our decision not to qualify engineers on the b.raking characteristics of freight trains. This decision was taken in relationship to the initial opening of the territory. Obviously, if freight trains begin operating over the territory in the future, engineers willreceive such training as part of their physical characteristics qualification. The Safety Board's statement that "training for passenger train braking characteristics is critical, as demonstrated by the commuter train accident that prompted Safety Recommendation R-88-81," seems to imply that the engineer of Train 8114 was not a",qqa-&ly qualified on the braki:ng characteristics of passenger trains and that this factor had a causal relationship to the accident. It is our position that the engineer was both experienced and fully qualified o:n the braking characteristics of passenger trains. To the extent that his braking procedure on the morning of the accident had a causal relationship to the accident, it had nothing to do with his qualifications on either the equipment or the territory. The Safety Board's conclusion that "the cab signals and automatic train control system we.re operating on the morning of the accident and that they were not sufficient to ensure proper braking," also leaves the impression that the engineer was less than fully qualified in braking a passenger train, and completely ignores the actual cause of the accident. Although the cab signals and automatic train control systems were operating properly on the morning of the accident, the wayside signal system was not functioning properly. It was the display of a false proceed aspect (approach) on Automatic Signal 2262-2, coupled with the engineer's failure to immediately observe a restricting cab signal aspect after passing that signal that caused him to brake his train in the manner he did. His braking procedure had absolutely nothing to do with his qualification on the equipment or the territory involved. The Safety Board recognized these facts in both its findings and probable cause, as stated in its final report on this accident. No constructive purpose is served by attempting to establish connections that the facts have clearly demonstrated do not exist. We agree with the Safety Board's view that the Southwest Corridor should not be exempted from Amtrak's general policies and procedures for qualifying train crew personnel. The procedures adopted to qualify personnel on the Southwest Corridor, as outlined in our original response, were employed as a result of the rehabilitation project and were only used for the initial reopening of the territory. Once the railroad was restored to service, normal qualification standards and procedures were reinstituted.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 7/14/1989
Response: Your letter points out that Amtrak employees are generally qualified by the methods cited by the Safety Board in Safety Recommendation R-88-81, with one exception to this general policy being the "Southwest Corridor" between Boston and Readville. The Safety Board finds no fault with Amtrak's general policies and procedures,, but we are concerned about the exception to the general practice on this "unique" section of your system. We do not agree with the reasons presenteb for using video and high-rail cars for qualifying personnel on the "Southwest Corridor" as outlined in your letter and offer our comments on each of your points of discussion. 1. The Safety Board does not agree with your assessment that the absence of freight operations in this territory eliminates the need to train operators in braking characteristics. The Safety Board believes that training for passenger train braking characteristics is critical, as demonstrated by the commuter train accident that prompted Safety Recommendatoin R-88-81. Further, we are not aware of any restriction that would prevent freight trains from operating on the Southwest Corridor. The applicIable timetable provides for freight train operation. Therefore, we do not understand why freight operations should be excluded from the qualifying procedures. 2. The Safety Boardibelieves that the cab signals and automatic train control system were operating on the morning of the accident and that they were not sufficient to ensure proper braking. When an ATC system is in place, qualifying procedures for that location should include either simulator activity or's qualifying test on the same type of equipment and in the actual operational environment. 3. The Safety Board was informed by Amtrak, the Federal Railroad Administration, and the Massachusetts Bay Transportation Authority that the track profile had been altered in both grade and alignment since the requalifying engineers and conductors had qualified. The Safety Board believes that because of the alterations, these employees should be requalified. Amtrak's policy in regard to other jurisdictions would require a "head end" requalification in similar circumstances. 4 through 9. The Safety Board is aware of the actions taken by Amtrak to provide information to personnel qualifying on the Southwest Corridor. The Safety Board pointed out in its report that it supports classroom training; however, the Safety Board continues to believe that such training should be augmented with other types of training that will allow an employee to demonstrate proficiency with the type of equipment and in the potential operating environment in which the employee is likely to operate. The Safety Board does not believe the "Southwest Corridor" should be exempted from Amtrak's general policies and procedures for qualifying traincrew' personnel. We will hold Safety Recommendation R-88-81 in an "Open--Unacceptable Action" status pending your further response.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 1/6/1989
Response: Our review of the facts of this accident convinces us that a false proceed aspect on Signal 226.2 on the day of the accident was not reported by the engineer of train 8110. It is possible, although not entirely clear, that the same type of false proceed aspect was previously observed at the same location by the same engineer and not properly reported. It has been alleged that proper reports may not have been made because engineers did not understand the effect of code change points on the cab signal system and confused malfunctioning signals with the intended function of the system, We believe that such explanations should be considered in the circumstances in which they were put forth. The use of code change points is .not unique to the Southeast Corridor or new to the Boston Division. Code change points were used at several locations on the Dorchester Branch during the years that this route was used for MBTA service between Boston and Readville. Both engineers involved in this accident regularly operated trains over that territory and were experienced in the effect of code changes. The only difference in the intended function of the signal system on the Southwest Corridor was the use of color position light aspects, not signal sequencing or code changes. Both the rules and reporting requirements governing the cab signals were unchanged and their application no different on the Southwest Corridor than on the Dorchester Branch. In summary, given the circumstances of the rehabilitation project, we believe the steps and methods used to ensure train and engine personnel were qualified on the physical characteristics of the Southwest Corridor were both appropriate and adequate.