About 6:28 a.m. on Saturday, November 23, 1996, eastbound National Railroad Passenger Corporation (Amtrak) train No. 12 derailed while crossing Portal Bridge, a swing bridge spanning the Hackensack River in Secaucus, New Jersey. When the train derailed, it sideswiped Amtrak train No. 79, which was crossing the bridge in the opposite direction on an adjacent track. All 12 cars of train No. 12 derailed, with both locomotives, 1 material handling car, and the 3 head passenger coaches coming to rest at the bottom of an embankment at the east end of the bridge. Train No. 79 sustained damage but was able to stop with the entire train intact and on the rails some distance west of Portal Bridge. No fatalities resulted from the accident, but 42 passengers and crewmembers aboard train No. 12 were injured, as was 1 passenger aboard train No. 79. Estimated cost of the damaged train, track, and signal equipment and site cleanup exceeded $3.6 million.
The National Transportation Safety Board determines that the probable cause of the accident was the failure of Amtrak management to foster an environment that promoted adequate inspection, maintenance, and repair of the miter rail assemblies on Portal Bridge and to permanently correct defects in the miter rail side bars that were discovered 10 months before the accident. Contributing to the accident were (1) the failure of the Federal Railroad Administration to develop track inspection standards for special trackwork and to periodically inspect such track as part of its oversight responsibilities and (2) Amtrak's removal of the miter rail position detection circuitry without installing replacement circuitry or implementing procedures to compensate for the loss of this safety-critical system.
The two primary safety issues discussed in this report are: (1) Amtrak management oversight of the inspection, maintenance, and repair of the miter rail assemblies on Portal Bridge; and (2) the effectiveness of Amtrak's emergency notification procedures. The Safety Board also examined the effectiveness of Amtrak locomotive event recorders in capturing critical operational data.
As a result of its investigation of this accident, the Safety Board makes safety recommendations to Amtrak, to the Federal Railroad Administration, to the Association of American Railroads, and to the American Short Line Railroad Association.
As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:
To the National Railroad Passenger Corporation (Amtrak):
Perform a comprehensive stress analysis of the design of any miter rail assembly currently in use or intended for use on Portal Bridge to identify critical areas of high cyclic stress. Ensure that the miter rail design adequately accommodates these cyclic loads. (R-97-49)
Continue to monitor the safety of special trackwork on your movable bridges and ensure that your special inspections are adequate and of sufficient frequency to detect failures or potential failures involving all components of all your special trackwork. Develop and put procedures in place to ensure that any failures or potential failures that are noted during these inspections are corrected before they develop into safety hazards. (R-97-50)
Ensure that current or future miter rail installations on Portal Bridge are equipped with a miter rail position detection/indication system that provides the maximum protection possible and that is interlocked with other bridge systems to prevent the bridge from being opened or cleared for train traffic until the position of the miter rails can be confirmed to be safe. (R-97-51)
Review the training of your police dispatchers and ensure that dispatchers are trained to correctly identify all Amtrak locations to emergency response agencies. (R-97-52)
Perform a thorough test of the entire recording system on every locomotive equipped with an event recorder to ensure that cab signal data records can be easily and positively identified and evaluated. (R-97-53)
Conduct a comprehensive internal management review of the circumstances of this accident to determine why several layers of Amtrak management failed to act in a timely fashion to correct a known hazardous condition on Portal Bridge. Make the management or procedural changes necessary to ensure that conditions affecting the safety of rail operations are given the highest priority. (R-97-54)
To the Federal Railroad Administration:
Inform the railroad industry that traction motor current is not a valid indicator of throttle position, and the requirement to record throttle position contained in 49 Code of Federal Regulations 229.5(g) cannot be met by recording traction motor current. Ensure that all operators currently using traction motor current as a substitute for throttle position modify their event recording systems to monitor and record throttle position directly. (R-97-55)
Pending the results of your Railroad Safety Advisory Committee Event Recorder Working Group and your implementation of suitable requirements concerning event recorder system maintenance, require that microprocessor-based event recorders equipped to perform self-tests be subject to the testing and inspection procedures currently applicable to all other types of event recorders. (R-97-56)
Expand the scope of your track safety standards to include special trackwork such as movable miter rails and ensure that the condition and operation of special trackwork are included, when appropriate, in all Federal Railroad Administration track inspections. (R-97-57)
Provide, in full or summary form, the results of the Federal Railroad Administration movable bridges survey to all railroads and rail rapid transit agencies. (R-97-58)
To the Association of American Railroads:
Pending the results of the Federal Railroad Administration (FRA) Railroad Safety Advisory Committee Event Recorder Working Group and the FRA's implementation of suitable requirements concerning event recorder system maintenance, advise your member railroads of the need to test and inspect all microprocessor-based event recorders equipped to perform self-tests in accordance with those procedures outlined in 49 Code of Federal Regulations 229.25(e)(2), which currently apply to all other types of recorders, to confirm proper event recorder function. (R-97-59)
To the American Short Line Railroad Association:
Pending the results of the Federal Railroad Administration (FRA) Railroad Safety Advisory Committee Event Recorder Working Group and the FRA's implementation of suitable requirements concerning event recorder system maintenance, advise your member railroads of the need to test and inspect all microprocessor-based event recorders equipped to perform self-tests in accordance with those procedures outlined in 49 Code of Federal Regulations 229.25(e)(2), which currently apply to all other types of recorders, to confirm proper event recorder function. (R-97-60)