Meteorological Information At the time of the accident it was partly cloudy with good visibility. The temperature was about 70°F and winds were northeasterly at 5 mph. Survival Aspects The two trainmen in the caboose of train WA-6 were able to escape by the rear platform steps before the collision. The operating cab of the lead locomotive unit of train WA-4 was demolished by the collision, overturning of the unit, and the subsequent fire. Before the collision, the front brakeman had jumped to the ground from the cab. The engineer survived by lying on the floor of the cab before the collision; he was able to climb from the cab after the accident. Tests and Research No defects were found in the undamaged components of the cab signal apparatus of the lead locomotive unit of train WA-4. The signals at 880 were observed shortly after the accident and were found to display "stop-and-proceed" aspects for both Nos. 1 and 2 tracks. Tests performed on the signal system indicated the signals were functioning as intended before the accident. Postaccident airbrake tests were performed on the caboose and 64 of the 71 cars in train WA-4. Trainline leakage was within permissible limits. Excessive piston travel was noted on 13 cars. Maximum sight distances approaching the signals preceding the accident location were Bay, 1,980 feet; North Point, 3,829 feet; River, 4,041 feet; and 880, 1,929 feet. ANALYSIS The engineer of train WA-4 was operating his train while keeping only one unoccupied signal block between his train and train WA-6 ahead, as the trains moved northward from Bay. He evidently assumed that the signals he encountered would improve to "proceed" aspects before he reached them. As train WA-4 approached the block signal, it would change from a "stop-and-proceed" aspect to an "approach" aspect, indicating that train WA-6 had cleared the block ahead. This permitted train WA-4 to continue without stopping. Also, because the wayside signals changed to "approach" as the train approached them, the locomotive cab signals changed to "clear," which permitted the engineer to increase the train's speed to more than the medium speed. This situation had occurred successively at Bay, North Point, and River. However, as WA-4 approached signal 880 the situation changed. Train WA-6 had stopped in the signal block with its caboose just north of signal 880 due to the emergency application of the brakes. As WA-4 approached signal 880 the engineer testified that he assumed that this signal would react as the previous three had. When he realized that the signal continued to display the "stop-and-proceed" aspect and would not change, the 30 mph speed of the train was too great to permit stopping short of the signal and the rear of train WA-6. ConRail operating rules require that a train moving under an "approach" aspect be operated in such a manner that it can be stopped short of the next signal and must not exceed 30 mph. The engineer of WA-4 stated that in his opinion he was complying with the rules at Bay, North Point, and River. Approaching signal 880, although the engineer had less than half the sight distance he had had on approaching the signal at River, and slightly more than half that available to him approaching North Point, he knew the location and aspect of signal 880. It is obvious that the engineer did not comply with ConRail's rules because he approached signal 880 at a speed too great to stop short of the signal when it did not change from "stop-and-proceed." On the basis of the engineer's description of the method he employed in braking train WA-4, it is obvious that the train's brakes were being used improperly. Several brake applications had been made approaching Baltimore and it is possible that there was insufficient time between the brake actuations and the stop at Baltimore for the brake pipe to have been fully recharged. This is confirmed by the necessity to place the brake valve handle in "handle off" position to stop the train. Similarly, the train brakes were applied and released several times as train WA-4 proceeded from Bay to River and approached signal 880. Again, there was probably insufficient time for full restoration of brake pipe pressure and emergency reservoir pressure. As a result, the brake system was not fully effective when it became necessary to make an emergency stop approaching signal 880. The stopping distance required may have been substantially increased. The engineer of train WA-4 apparently did not take into account the consequences of making repeated brake applications without allowing adequate time for recharging the brake pipe. The method by which air is taken from the emergency reservoirs to help promote quick release of the brakes was discussed and demonstrated during the air brake classes of his formal training as an engineer. The training also acquainted him with the results of too frequent brake actuations without sufficient time to recharge the brake system. However, he apparently did not relate it to this situation. ConRail rules do not describe what occurs when the train brakes are used improperly nor do they detail the quickrelease action of the control valves. The braking capability of train WA-4 was further reduced by the 13 cars which were found to have long piston travel. When the engineer of train WA-4 saw the signal at Bay improve from "stop-and-proceed" to "approach," he should have released the brakes and then reduced the power to the point where the train was not accelerating so that repeated brake applications would not be required. The engineer is assigned the primary responsibility for operating the train within the speed requirements. However, by Rule 34 (See appendix A) other crewmembers are required to take the necessary action if the engineer fails to respond to conditions properly. The front brakeman of WA-4 had little experience as an operating employee, and stated that in his opinion the engineer was competent and that the train was moving at a speed which would permit it to stop short of the signal. Therefore, he had no reason to use the emergency brake valve. This and previous cases investigated by the Safety Board suggests that Rule 34, which depends upon an employee of another craft who generally has less experience and training, to overrule the judgment of an engineer, was ineffective. Neither caboose was equipped with radios, so the crewmembers were unable to communicate between the locomotive and the caboose. They were unable to ascertain conditions pertinent to the safe operation of their trains. The conductors on both trains could not effectively carry out their assigned responsibilities for the general operation of their trains. Had each caboose been equipped with a radio, and had the engineer of WA-6 informed his conductor by radio of the emergency stop, the crew of WA-4 may have heard the radio transmission and been aware of the stopped train. Communication between the engineer and conductor is necessary if the joint responsibility for safe movement of the train is to be carried out. Because of the ineffectiveness of Rule 34 as a safety backup to the engineer, it becomes even more important to enforce the requirement that the conductor exercise his responsibility for the safety of the train. The Safety Board has made recommendations to the FRA 2/ in the past regarding this issue; however, the FRA declined to make regulations which would require: "Where responsibility for safe operation of the train FRA's rationale for not regulating this facet of rail operations is contained in their response to the Safety Board's recommendation R-73-11 as follows: "Having the conductor in closer proximity to the engineer 2/ National Transportation Safety Board Railroad Accident Reports: "Collision of Two Penn Central Freight Trains at Herndon, Pennsylvania, March 12, 1972" (NTSB-RAR-73-3); "Collision of Two Texas and Pacific Freight Trains at Meeker, Louisiana May 30, 1975" (NTSB-RAR-75-9). crewmember to be in the control cab of the engine with It would have been easy for the engineer of train WA-6, who had talked to the engineer of train WA-4 only 5 minutes earlier, to have notified train WA-4 immediately that WA-6's train was in emergency and was stopping. Alternatively he could have notified the dispatcher or the operator at Bay and the transmission probably would have been heard by the crew on the locomotive of train WA-4. This would have provided additional warning to train WA-4 that signal 880 would not change from the "stop-and-proceed" aspect. If the operator at Bay had known in sufficient time, he could have notified train WA-4. A requirement to have the operator or dispatcher notify a following train when the preceding train makes an unscheduled stop, may have alerted the engineer of train WA-4 of the conditions ahead soon enough for him to take action. The method of combining the use of radio with automatic signals would produce the optimum level of safety. Whatever procedure is developed, due regard must be given to 49 CFR 220 and particularly to 49 CFR 220.51, Signal Indications. In summary, this accident happened because the engineer of train WA-4 operated the train in violation of the requirements of ConRail rule 285 which required him to approach each "stop-and-proceed" signal at such a speed that would enable him to stop the train short of the signal. Further he persisted in handling his airbrakes in a manner that degraded the capability of the system even after the stop at Baltimore which should have warned him that his procedure was faulty. Although the evidence indicates that the engineer of train WA-4 was subjected to a reasonably thorough training course for engineers, his performance on the day of the accident suggests a serious deficiency in the application of what he should have learned. This means that the instruction was faulty or the followup in the on-the-job phase and subsequent supervision was deficient. CONCLUSIONS Findings 1. 2. 3. 4. 5. 6. The engineer of WA-4 assumed that signal 880 would change to a The engineer of train WA-4 operated his train too fast to stop The numerous applications and releases of the train brakes between The front brakeman of train WA-4 did not act to apply the train's brakes, which he was authorized to do by operating rules. The conductors of each train could not properly discharge their duties from the rear ends of the trains because they had no method of communication. The front brakeman lacked the training and experience to overrule the judgment of the engineer on train WA-4; therefore Rule 34 was ineffective. Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the failure of the engineer of train WA-4 to fulfill his responsibility to properly control the speed of the train, as required by the signal indications, to insure that it could be stopped before passing signal 880. Contributing to the severity of the accident was the manner in which the engineer of train WA-4 applied and released the brakes approaching the accident point and the failure of the engineer of train WA-6 to communicate with the tower and train WA-4 when train WA-6 stopped. RECOMMENDATIONS As a result of this investigation, the National Transportation Safety Board recommended that the Consolidated Rail Corporation: "Insure that ConRail freight trains and locomotives receive proper airbrake |