Passenger Trains > NTSB: "Ineffective Safety Management" at Metro-North

NTSB Press Release
National Transportation Safety Board
Office of Public Affairs

October 28, 2014


Ineffective Safety Management a Common Theme in Five Recent Metro-North
Accidents

> WASHINGTON – In its investigation of five Metro-North accidents, the
> National Transportation Safety Board identified several recurring
> safety issues, including inadequate and ineffective track inspection
> and maintenance, extensive deferred maintenance issues, inadequate
> safety oversight, and deficiencies in passenger car crashworthiness,
> roadway worker protection procedures and organizational safety
> culture.
>
> Within an 11-month period from May 2013 through March 2014, the NTSB
> launched investigations into five significant accidents involving
> Metro North. Taken together, these accidents resulted in 6
> fatalities and 126 injuries. During the investigations, the NTSB
> found several safety management problems that were common to all of
> the accidents.
>
> "Seeing this pattern of safety issues in a single railroad is
> troubling," said NTSB Acting Chairman Christopher A. Hart. "The NTSB
> has made numerous recommendations to the railroad and the regulator
> that could have prevented or mitigated these accidents. But
> recommendations can only make a difference if the recipients of our
> recommendations act on them."
>
> The probable causes released today are for the following Metro-North
> accidents:
>
> May 17, 2013, derailment and subsequent collision in Bridgeport,
> Connecticut;

> May 28, 2013, employee fatality in West Haven, Connecticut;

> July 18, 2013, CSX derailment on Metro-North tracks in Bronx, New
> York;

> December 1, 2013, derailment in Bronx, New York; and

> March 10, 2014, employee fatality in Manhattan, New York
>
> As a result of the early findings from the five investigations, the
> NTSB initiated an in-depth special investigation of the Metro-North
> Railroad. On November 19, the Board will hold a meeting to discuss
> the numerous safety issues identified during that special
> investigation. During the meeting, investigators will discuss all
> five Metro-North accidents, examine the common elements that were
> found in each, and highlight lessons learned and the steps that have
> been taken to make rail transit safer for Metro-North passengers.
>
> The NTSB will also issue safety recommendations designed to improve
> railroad safety on Metro-North and other railroads. Early this year,
> the NTSB made safety recommendations to the Federal Railroad
> Administration and to Metro-North that address some ongoing issues.
>
> The November 19 meeting will be held in the NTSB Boardroom and
> Conference Center in Washington, DC and it is open to the public.
>
> All NTSB rail accident reports are available at

http://www.ntsb.gov/investigations/reports_rail.html

Press release at:

http://www.ntsb.gov/news/2014/141028.html

The probable cause of the fatal derailment on Dec. 1, 2013 was
ascertained to be "the engineer’s noncompliance with the 30- mph
speed restriction because he had fallen asleep due to undiagnosed
severe obstructive sleep apnea exacerbated by a recent circadian
rhythm shift required by his work schedule."

The reports cover several fatal incidents, but all point to a failure to take safety as a priority.

In the March 2014 death of an electrician, some of the work to be done was outside the limits of authority given to the track gang. And an electrician was killed at what's called an A-B switch, outside the work limits.

http://www.ntsb.gov/doclib/reports/2014/RAB1413.pdf

The CT funded bridge work at WALK had a similar issue. The "rescue boat" operator under the bridge worked a different schedule than the repair workers, and didn't have to notify the repair workers when he took breaks, went to lunch, etc.

So, on the 5pm news, Fox reported the cause of the accident as the train engineer falling asleep due to sleep apnea.

They then played a clip from a Metro-North official saying that they will make infrastructure improvements to the rail lines to prevent that from happening again in the future.

News station error or just plain stupidity - you make the call.

Daveb Wrote:
-------------------------------------------------------
> So, on the 5pm news, Fox reported the cause of the
> accident as the train engineer falling asleep due
> to sleep apnea.
>
> They then played a clip from a Metro-North
> official saying that they will make infrastructure
> improvements to the rail lines to prevent that
> from happening again in the future.
>
> News station error or just plain stupidity - you
> make the call.

Might be a little of both. Here in the NY area, the NTSB guy asserted on TV that positive train control would have prevented the accident. And the MetroNorth president said they are installing it. So this situation never happens again.

Senator Schumer also put his two cents in. Didn't say anything would recalling.

Daveb Wrote:
-------------------------------------------------------
> So, on the 5pm news, Fox reported the cause of the
> accident as the train engineer falling asleep due
> to sleep apnea.
>
> They then played a clip from a Metro-North
> official saying that they will make infrastructure
> improvements to the rail lines to prevent that
> from happening again in the future.

Metro North made the signal changes in the huts at CP12 within days that would have enforced medium speed (30 mph) via the existing cab signal system and prevented the Spuyten Duyvil accident. Amtrak had made changes like this at their most dangerous curves (Elizabeth, Back Bay, Frankford Jct., etc.).

Makes you wonder why an alleged "Speed Signal System" was not being used for the very purpose the PRR incoporated into its design (indicating appropriate speed), but there are other instances of designs undertaken in the late 1980's and early 1990's where Route Signalling philosophy was allowed to creep in. A prime example is Gate Interlocking and Harold Interlocking. Signals installed circa 1990 give a Clear aspect at Gate into the approach block for the #20 turnout joining Amtrak to the LIRR at Harold instead of the appropriate Approach Limited. The only actual limit on train speed there is the engineer adhering to the timetable special instructions.

I think Metro North was tasked by the FRA with curing about a dozen locations like this on their lines and managed to force adherence to Medium or Limited speed within a month via code changes to the control lines of the signal system and its circuits.