National Transportation Safety Board

“ On the trip, the apprentice engineer employed the power braking method that was taught in the locomotive engineer training program. This braking method, described in Amtrak's instructions on operations and train handling, is preferred for a mixed-equipment consist and provides a smoother stop for the passengers. It entails stopping or slowing the train by applying the automatic airbrakes on all cars, while keeping the locomotive under power and the locomotive independent brakes released. The objective is to first minimize the train slack by applying the brakes on all cars. ”

“ Of SP’s road fleet of 2,100 units, 1,800 units, according to the chief mechanical officer, are equipped with dynamic brakes. SP locomotives are designed such that when the train brakes are applied in emergency, an interlock will nullify the dynamic braking. According to SP’s chief mechanical officer, the system is designed in this manner "...to prevent train handling problems in the case of a break in two [a separation of two cars] and to prevent wheel slide because of excessive braking which would be the combination of the electric [dynamic] braking and the independent brake...." ”

“ Train resistance will vary with the type of cars, train make-up, and train length and weather. On heavier grades the majority of the grade retarding force comes from the dynamic brake and the train air brake.
The locomotive engineer, the helper engineer, the road foreman of engines, and the general road foreman all testified that they considered rule 61.E.1 to be a recommended general guideline or an option rather than a requirement. Testimony also indicates that engineers have routinely gone beyond the 50 percent reduction. ”

“ The rule requires railroads to have a formal process for evaluating prospective locomotive engineers and to determine their train operation competency before permitting them to operate equipment. Under the regulations, railroads must also conform to FRA-approved training programs for prospective locomotive engineer candidates, employ standard methods to identify qualified engineers, and monitor engineers' performance. If a railroad hires qualified persons as locomotive engineers or employs another entity to conduct training on its behalf, that railroad may elect not to have a training program. ”

“ A motorist who routinely travels on a highway that parallels the railroad tracks for some distance and normally sees trains at that time of the morning testified that she observed "...one train...going a lot faster than some I had normally seen before." The motorist, who estimated that the highway was about 1⁄4 to 1⁄2 mile from the tracks, also testified that the train was engulfed in what she assumed to be smoke, which she described as light blue in color. The helper brakeman testified that after the helper engineer placed the brakes in emergency. ”

“ When we change our tapes in the morning we do tape checks. With that we've added where we would tell the time that it is when we do it. That is with the crash phone, and that's at the request of the ramp control supervisor and airport rescue and fire-fighting -- fire chief to help them until they can come up withfurther procedures for times.
MR. WENTWORTH: Is there any procedure for the controller to call an entity other than the Airport Authority or the crash/fire/rescue station on the airport in the event of an off-base or off-airport accident? ”

“ Speed/distance calculations show that about 40 seconds elapsed as Amtrak train 66 traveled from the usual braking location to the point at which the event recorder indicates the full-service application was made. Why the engineer did not take action to slow the train during this time is not certain. Forty seconds is more than the time needed to instruct the apprentice to make a brake application and to cross the cab from the fireman's seat to the engineer's position, if necessary, to accomplish any brake application instructions that were not promptly executed. ”

“ The automatic speed control system, which functions in signalized territory, is connected to the locomotive cab signal, it is independent of and not connected to the locomotive's speedometer and event recorder. If the locomotive engineer fails to reduce speed to the authorized level in cab signal territory, the speed control automatically triggers a brake application to slow and stop the train Signal 226 2 at Ruggles Street was not coded to provide the 30-mph speed restriction at MP 227. ”

“ Upon receipt of the document in the Los Angeles office, a billing clerk entered the bill of lading information into SP’s computer system; information that would later be used to prepare the train (tonnage) profile. [4] According to SP’s director of system clerical operations, there are two methods available to the billing clerk to enter bill of lading information into the computer when a unit train [5] is involved. He testified, "One is where the only thing that you show is the total shipment weight, the cumulative weight of all cars and not the individual weights of each car. ”

“ Under Amtrak rules, the locomotive engineer is responsible for observance of signals and for control and regulation of train movement. He is also responsible for instructing apprentice engineers and for ensuring that they are familiar with engine duties During the accident investigation, Amtrak officials and locomotive engineers stated that the locomotive engineer of Amtrak train 66 should have instructed the apprentice engineer to start braking the train at the Pickle Factory, a landmark structure at MP 225.7. ”

“ Railroad
the means by which the shipping weights were determined for the shipment of the trona laden hopper cars; the dispatching of locomotives without operable dynamic brakes on mountain gradients; the information received by the road engineer regarding the weight of the train and the number of operable dynamic brakes; the communication between the road and helper engineers regarding the operation of the train, and communication with the dispatcher; the engineer’s training program, which did not adequately address emergency situations ”

“ The paragraph also states that the inspections should include the following items: aircraft markings; airworthiness, registration, and crewmember certificates; air traffic compliance; taxi and ramp and passenger enplaning/deplaning procedures; baggage and cargo (especially hazardous cargo) ; and compliance with the pilot-in-command age 60 policy, which states that a flight crewmember is prohibited from acting as pilot-in-command if he or she has reached age 60.
According to the FAA, the only "R" item required for Korean Air is one annual ramp inspection. ”

“ The other 50 percent was devoted to efficiency testing of other operating rules. According to the road foreman, there was no set policy on the number of efficiency tests to be made on grade operations or through the use of radar. With respect to train rides, the road foreman testified that he would ride with each engineer at least once or twice a year or more if the engineer was experiencing problems. ”

“ Flight crews should be trained in operations involving these conditions before being assigned line duties. Flight crews should make operational use of a risk assessment tool or checklist to identify approach and landing hazards. Appropriate procedures should be implemented to mitigate the risks. Operators should develop and implement constant angle, stabilized approach procedures to assist crews during approach operations. Operators should develop and implement a policy for the use of appropriate levels of automation of navigation and approach aids for the approach being flown. ”

“ We realized that there is -- there is the potential for being too close to topics being employed in the same organization. However, we feel that that is more than adequately balanced by the fact that we can maintain a work force of fresh, current people who are -- are capable of evaluating today's current issues in air traffic. ”

“ Helper engineer will observe speed indicator while running and remind road engineer of speed requirements if necessary. If helper engineer is unable to communicate with road engineer and if train continues to operate in excess of maximum allowable speed, helper engineer will take necessary action to stop train. ”

“ THE WITNESS: After any significant or after all accidents or significant incidents we always review the matter to make appropriate changes. After the 801 we have implemented the CRS system. As shown by the first -- our first witness today, the briefing procedures have been modified. This new modified checklist for the briefing includes -- excuse me, not includes but it is centered around the Jefferson approach chart. CFIT accident prevention concept has been introduced, and more specific training on crew duty divisions. ”

“ Freight trains handling cars with single capacity brakes (*) , with tonnage exceeding 80 tons per operative brake, must not exceed 45 mph, except maximum speed must not exceed: (1) 25 mph; or (2) 20 mph in grade territories as designated by Superintendent by milepost locations under appropriate subdivision.
*Loaded cars with empty-load brakes are to be considered the equivalent of one and one-half (11⁄2) cars in determining tons per operative brake. ”

“ Signals.—Trains on the single mainline track are governed by a traffic control system using colored lights on wayside signals. An inspection of the signal equipment in the area of the derailment was conducted on May 13, 1989. The inspection revealed no problems with the signal system.
Train Information
At the time of the accident, Extra 7551 East consisted of, from front to rear, 4 road locomotive units (SP 8278, SP 7551, SP 7549, and SP 9340) , 69 open-top hopper cars loaded with trona, and 2 helper locomotive units (SP 8317 and SP 7443) . ”

“ The head-end engineer of Extra 7551 East testified that he had never been trained on procedures concerning the reversing of engines, had never received instruction concerning the effects of extended brake application on the deterioration of brake shoes, had never received instruction regarding train handling while receiving helper engine assistance, and had never been placed in an emergency situation during simulator training. ”

“ It is ballasted to the concrete tunnel floor with 24-inch deep crushed rock Near the POD, the north rail is fitted with an operative wheel-flange lubricator about 750 feet west of the curve.
The MBTA owns the track, and Amtrak maintains it for trains operating at speeds up to 100 mph. Amtrak performs scheduled track inspections twice weekly, at intervals of at least 1 day, and does daily walking inspections of concrete ties. In May 1990, the Federal Railroad Administration (FRA) had inspected the track and noted no defects in the derailment area. ”

“ The test train carried no passengers. To simulate the stopping distance, the investigators used information recovered from the Pulse event recorder and provided during witness testimony. When stopping the train from speeds [6] of 103 to 108 mph, the automatic airbrakes, with the independent brake released, were applied 4,950 to 4,400 feet [7] before a mark that indicated the POD. Test results showed that Amtrak train 66 would have been moving 76 to 80 mph at the POD.
Figure 8.—Event recorder data recovered from Amtrak train 66. ”

“ I've been employed by the Federal Aviation Administration in air traffic control for 27 years. I held journeyman air traffic control positions in three FAA terminals, held later post of training specialist, first-line supervisor, was manager of two air traffic facilities, including the tower in Newark, New Jersey. ”

“ The locomotive engineer stated that the MBTA train 906 was almost stopped on track 1, moving about 5 to 10 mph, at the time of the accident He was standing at the controls in the cab, felt the collision, and was knocked to the floor Not knowing exactly what had happened, he made an emergency radio call to the dispatcher. ”

“ I have 27 years of experienceair traffic control, including six operational air traffic control facilities both in the en route and the terminal environment, positions as a supervisor, staff support specialist, Washington headquarters and regional. ”

“ During that time, he also acquired train-handling proficiency, judgment, and other necessary operating skills under the supervision of experienced engineers who provided individualized attention. Moreover, when engineers began working in passenger service, they had usually become experienced in operating other kinds of trains before advancing to higher speed equipment. ”

“ At 8 23 am in the Boston train dispatcher's office, the Centralized Electrical and Traffic Control (CETC) system illuminated a “track occupied" light (TOL) for track 3 at Back Bay station. The dispatcher stated that before the TOL illuminated,
Figure 2.—Diagram of Amtrak train 66 speed and distance travelled. ”

“ In spite of the efforts of the Flight Safety Foundation, the many individuals, some of whom are in this room today, and in spite of what we've now discovered about controlled flight into terrain accidents worldwide, they still continue to occur. Just ponder that. They still occur.
I believe that industry needs some degree of compulsion to take more effective action. It's not enough at the moment to have awareness and voluntary action. ”

“ In short, the retainers provide the engineer with braking capability while the air brake system is being recharged. ↑ Typically, when a company rule (in this case an airbrake rule) indicates that the superintendent will prescribe certain operating parameters, the superintendent will accomplish this through instructions in the timetable or by special bulletins. ↑ Tonnage (or tons) per operative brake is computed by dividing the gross trailing tons by the number of cars in the train. The weight of the locomotives is not included in the gross trailing tons. ”