Passenger Trains > Lest we forget: the Ricky Gates Wreck and sloppy Govern

On this date in 1987: Conrail engines running light run through a signal and collide with an Amtrak train at Gunpow (Chase, MD) on the Northeast Corridor, killing 16. Conrail engineer Ricky Gates was later
found to be using marijuana and watching TV at the time of the
accident. The incident will lead directly to the licensing and drug
testing of locomotive engineers.
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Even at that time, after the horrific wreck, marijuana and drug
advocates tried to emphasize that tests done on Gates and his brakeman
did not verify that Gates was under the influence. Some so-called
experts will say anything in the name of their own cause.

But the real reason why the tests did not establish "influence" was
sloppiness at the Civil Aeromedical Institute, the U.S. Transportation
Department's drug-testing lab. Its failure to provide an accurate test
was attributed to the poor skills of one technician, who not only did a
bad job of testing, but used up all of the blood sample in doing so:
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Testing Debacle: Federal Lab Studying Train, Airline Crashes Fabricated Its Findings --- Higher-Ups Were Warned, But FAA Unit Continued To Provide Phony Results --- Squandering a Blood Sample

by Walt Bogdanich Staff Reporter of The Wall Street Journal
The Wall Street Journal, 07/31/1987

Last January, at a Federal Aviation Administration laboratory in Oklahoma City, two men worked long into the night, finishing just before dawn. Their job was important: to tell the nation whether drug use was a factor in the worst railroad accident in Amtrak's history.

Along with an assistant, the lab's supervisor, 52-year-old biochemist Delbert Lacefield, was trying to test the blood of a railroad engineer involved in the Jan. 4 train crash just outside Baltimore that left 16 people dead and about 170 injured.

Their work hadn't gone well. For months, unbeknown to his superiors, Mr. Lacefield had been fabricating test data in other train-crash investigations, reporting results of blood tests that had never been performed. Now, with top government officials swarming over the Amtrak case, the lab supervisor knew that he had to produce.

But there was a problem: Neither Mr. Lacefield nor anyone else in the lab knew how to use the sophisticated equipment needed to perform such a test. The assistant would later say that he felt like someone "who had to learn to fly an aircraft already in operation."

Mr. Lacefield went ahead, but his fuzzy test report led the Federal Railroad Administration to investigate his operation, the Civil Aeromedical Institute, or CAMI, the premier drug-testing lab of the U.S. Transportation Department. (Both the FAA and the railroad administration are Transportation Department units.)

Investigators found that CAMI's forensic toxicology department had fabricated the results of 17 train-wreck blood tests during a nine-month period last year. Transportation officials stress that in the case of the fatal Amtrak crash in Chase, Md., the results weren't phony, just sloppy. In fact, Federal Railroad Administrator John H. Riley, whose agency began using CAMI for post-accident testing in February 1986, boasts that his internal-control system, although flawed, worked because it turned up the lab's shortcomings.

But according to internal government investigative files and interviews with lab experts, problems at the lab were far worse than transportation officials have publicly admitted. Moreover, though some government supervisory personnel were informed of the deficiencies nearly a year ago, corrective action wasn't taken until the Amtrak disaster focused attention on the problems.

CAMI's work was so shoddy that accident investigators say they will never be sure whether drug use by the engineer played a role in the Amtrak tragedy. Moreover, investigators now wonder about the accuracy of hundreds of post-accident lab tests that CAMI performed on airplane crews over 20 years.

The case raises a number of other questions as well: Why did federal transportation officials give such an important task to an unqualified laboratory? How could widespread evidence of the lab's dishonesty and incompetence go undetected month after month? And what does the episode suggest about the U.S. government's ability to run a large-scale drug-testing program? Later this year the Transportation Department is scheduled to begin random testing of up to 30,000 of its employees.

In retrospect, there is little doubt that fraud and incompetence at CAMI could have been detected well before the Amtrak accident. The situation was so bad that lab technologist Mary Miller would later tell investigators that during her pre-employment job interviews last year at CAMI she "was twice approached by employees concerning questionable practices," including the reporting of phony test results.

In fact, three of the lab's four laboratory technologists say that they complained -- without result -- to Mr. Lacefield's supervisor about such problems as failed testing methodologies, outdated procedures and a lack of quality control.

At hearings held by a House subcommittee on transportation, the chairman, Rep. Thomas A. Luken of Ohio, called the government's casual supervision of CAMI "shocking," particularly in light of the Reagan administration's plans to embark "willy-nilly" on the testing of Transportation Department employees. Mr. Riley, the railroad administrator, cautioned against overreacting. He argued that calling off "the alcohol and drug program because of Del Lacefield is the rough equivalent of using Jim Bakker as a reason not to pray." But Mr. Riley and Rep. Luken did agree on the need for national certification of laboratories to weed out the good from the bad. Currently, only a few states regulate drug-testing labs -- a process that laboratory experts say would have uncovered CAMI's problems much sooner.

In the case of the Amtrak crash test, CAMI's workers reached different conclusions using improperly calibrated equipment, then promptly lost the computer data backing their findings. Worse yet, they squandered the entire blood sample taken soon after the accident from train engineer Ricky Gates. With no blood left, retesting by a competent lab couldn't be done.

Mr. Gates's urine tested positive for marijuana, but lab experts say that without the more precise blood test, there is no way of knowing whether Mr. Gates was drug impaired at the time he pulled his Conrail engine in front of an Amtrak train carrying about 600 people at 105 miles an hour.

The botched analysis also means that the government can't use blood-test results in its prosecution of Mr. Gates, who faces 16 counts of manslaughter as a result of the crash.

CAMI's big lie began to unravel within days of the Amtrak crash, according to railroad administration records. Recognizing the unusually high level of public interest in the accident, railroad administrators made a point of reviewing test procedures with Mr. Lacefield before lab analysis began. Even so, transportation officials in Washington found Mr. Lacefield's eventual report imprecise, and the lab later admitted that documentation for its findings was gone. ("I have a confession to make . . . ," Mr. Lacefield said in broaching the subject to investigators.)

But a major break in the case came on Feb. 6. Two railroad administration officials called Oklahoma City to ask Mr. Lacefield about terminology he had used to report blood-test results in the Amtrak case and in other cases. Because Mr. Lacefield wasn't available, the officials talked instead to laboratory chemist Ron W. Beckel. They then heard what they call the "startling" news that Mr. Beckel, whom they thought had been preparing blood for the tests, had not done so. Recounting this conversation in a memo, one of the officials said that from "the tenor of the conversation and Mr. Beckel's careful choice of words" he inferred that Mr. Beckel had no knowledge of Mr. Lacefield's having done blood work either.

The next Monday, railroad officials flew to Oklahoma, where they reviewed CAMI's files and interviewed lab workers. Soon after, the Transportation Department's inspector general was called in to investigate and his findings were turned over to the U.S. attorney's office.

As part of a plea bargain, Mr. Lacefield, who no longer works for the government, pleaded guilty to three felony counts of providing false information to a federal agency. He was sentenced July 23 in federal court in Oklahoma City to two years' probation and was ordered to perform eight hours of community-service work a week for one year. FAA spokesman John Leyden, who says he knows nothing about higher-ups ignoring warnings of the lab's deficiencies, says that none of Mr. Lacefield's supervisors has been disciplined.

After the fraud was exposed, the railroad administration received what one of its officials calls "a considerable amount of credit" inside government for breaking the case. But some laboratory experts say that the episode never would have occurred if the railroad administration had used better judgment in selecting a lab and the FAA had more closely monitored its lab's performance.

Railroad administration officials say that they chose CAMI because it was part of the Department of Transportation and therefore a known quantity. Its forensic toxicology lab had conducted tests on cockpit crews involved in most serious U.S. plane crashes, and the National Transportation Safety Board had often considered its results in attempting to determine the cause of crashes. (CAMI also does general aviation research unconnected with its forensic toxicology lab.)

In the absence of a national certification program for drug-testing laboratories, a Transportation Department facility was preferable to selecting "an unknownprobably a low-bid outside contractor," Mr. Riley, the railroad administrator, says.

Although transportation officials say that CAMI was selected because of its top reputation, government accident investigators told The Wall Street Journal that CAMI's airplane work sometimes contradicted the findings of other labs. "That should have triggered the attention of management," says an accident investigator. "It was an island unto itself."

Richard Prouty, the chief forensic toxicologist with the medical examiner's office in Oklahoma City, recalls an incident several years ago when his lab results differed from CAMI's. "We got one set of values on subject A and B, and CAMI got a set of values on A and B that were essentially reversed," Mr. Prouty says. After retesting, he adds, CAMI's error was "demonstrated conclusively."

An FAA official says that specimens from the same subject may differ because of contamination or deterioration, so it isn't unusual for two labs to report different test results on the same individual. But a laboratory expert who has seen CAMI's work says that discrepancies were so "substantial that they raise the issue of who was right and who was wrong." This expert cites the case of a 1984 airplane crash near Laredo, Texas. CAMI reported that the pilot had a blood alcohol level of .406, while a nearby hospital found only about a quarter of that amount. It would be "virtually impossible," the expert says, to fly a plane with the alcohol level reported by CAMI.

The railroad administration picked CAMI to run its post-accident program knowing that the facility lacked a device called a gas chromatograph/mass spectrometer that is needed for sophisticated blood testing. CAMI promised that it would subcontract blood tests out to a nearby non-government laboratory, but it never made good on that promise. None of its employees knew how to extract a test sample from blood plasma, a necessary first step before an outside lab can analyze the fluid.

Under pressure to produce results, Mr. Lacefield decided on his own to fabricate data. Investigators, still puzzled by his motives, speculate that the biochemist was eager to demonstrate competence in a sophisticated technology, got in over his head and falsified data to cover up. Mr. Lacefield, whom acquaintances describe as short, chubby and affable, had worked at CAMI for 21 years. Financial gain didn't figure in his actions; the railroad contract was simply another assignment handed to his lab. Mr. Lacefield declined to comment.

The situation didn't improve when CAMI finally obtained a gas chromatograph/mass spectrometer in late 1986. CAMI began using the device immediately -- even though according to John W. Melchner, the Transportation Department's inspector general, "it can take as long as two years to develop a good feel for how to use the instrument."

Patricia A. Roberts, a CAMI technologist, told investigators that the new instrument "had some design and engineering problems" and that therefore its findings weren't "consistent enough for us to have confidence in our results." It was apparently while trying to use the instrument that Mr. Lacefield and his assistant squandered the Conrail engineer's blood sample.

Mr. Riley, the railroad administrator, defends his agency's selection of CAMI, saying that much research went into the decision. "Assuring program integrity was a key issue for us from day one," he says. He also notes that the FAA was hired "lock, stock and barrel" to run the technical side of the program and was supposed to oversee the lab's activities.

But quality control was practically nonexistent at the laboratory, government records show. In June 1986, the Armed Forces Institute of Pathology reported to FAA officials that CAMI's forensic toxicology laboratory lacked certain safeguards, and it urged that the lab undergo proficiency testing by an outside group. These suggestions were ignored, and the railroad administration says that the FAA never informed it of the findings.

CAMI's own employees tried to alert authorities to the lab's incompetence. Medical technologist Claudia Ryan said in a sworn statement that she mentioned the "lack of quality control and outdated procedures" to one of Mr. Lacefield's supervisors but "was rebuffed. Therefore," she added, "I did not approach {him} with information concerning the falsification of reports."

Meanwhile, CAMI continued to run a sloppy shop. Following a Long Island Rail Road crash in New York City last December, CAMI incorrectly reported that a railroad worker's blood had tested positive for alcohol. The report was withdrawn before any action was taken because investigators concluded that the employee hadn't been drinking, government investigative files show. The laboratory attributed the mistake to a testing error. In an unrelated admission, Mr. Lacefield told the inspector general that CAMI workers had at times improperly cleansed test vials.

The railroad administration says that it doesn't know of a single railroad worker who was actually accused of using drugs or alcohol because of a false-positive test. Transportation officials say that in each case where leftover blood permitted retesting of CAMI's work, the error proved to be a false negative -- that is, CAMI hadn't detected drug use when it was present. To critics, though, this is hardly reassuring. "Do we want junkies driving our trains?" asks a laboratory investigator. "What's the point of the program?"

After the fraud was exposed, transportation officials temporarily reassigned Robert Dille, CAMI's overall manager. The forensic lab has been shut down, and all post-accident rail and airline testing has been transferred to a non-government laboratory in Utah. The department's future random drug testing will be done by laboratories approved by the Department of Defense, which government officials believe has more expertise than the FAA.

Nevertheless, as more people call for drug and even AIDS testing, Rep. Lukens says that CAMI should serve as a sobering example. "We have to worry about having some way of assuring the public that these {labs} are following standards," he says. "No one wants to see careers shattered and innocent lives ruined" by shoddy lab work.

Anyone recall an "unsubstantiated" report from the scene of a television set being thrown from the cab into the river shortly after the incident? Redskins vs the 49ers that day.

Pullman Wrote:
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> Anyone recall an "unsubstantiated" report from the
> scene of a television set being thrown from the
> cab into the river shortly after the incident?
> Redskins vs the 49ers that day.
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...Sure do!

Also reports that the warning horn on Gates's Conrail engine had been disabled by somebody peeing into it, so it would not have sounded when he passed the red signal...not that it would have made that much difference, at the speed he was going.

Interesting to note the author of that Wall Street Journal article appears to be the same reporter who now is exposing the "cozy" relationship between the railroad industry and its regulators for the New York Times.

I think some of what he has written in the Times stories is right-on, though some of it has been a bit over the top.

Pullman Wrote:
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> Anyone recall an "unsubstantiated" report from the
> scene of a television set being thrown from the
> cab into the river shortly after the incident?
> Redskins vs the 49ers that day.
I remember THAT report well. Actually, if I recall correctly, the Redskins were playing the NY Giants that afternoon. (Giants went on to demolish the skins and win the Super Bowl!).

My wife would agree that watching sports on TV constitutes serious impairment.

Whatever Gates' condition, and however it was engendered, there existed automated means to keep this accident from happening -- but they weren't used.

They weren't just unused, they were removed...before the wreck, Amtrak took out the stub-end escape track at the interlocking, to save the cost of maintenance on a switch deemed redundant...had the interlocking been in its original PRR configuration, Ricky Gates would have plowed into a pile of gravel away from the other main tracks...

The crossing that was at Ebenezer Rd. in Chase, Md was one of my favorite haunts.

I remember that it was a beautiful Sunday afternoon. I was driving out there after dinner. Mom always had dinner ready promptly at 12:00 noon on Sundays after church. I was heading Eastbound along Eastern Blvd. in front of the Martin Marietta plant in Middle River, Md. when I looked over to my left and noticed an Amtrak train not moving. I thought that was rather peculiar, but never really gave it a second thought. After all, it could have had mechanical problems or the crew may have outlawed. I drove East about another mile almost reaching Carroll Island Rd., when all Hell broke loose. The traffic was at a standstill and as I sat there, emergency vehicles of every sort and from every jurisdiction were passing my car. At that time, I only had a base station scanner, so I did not know what had happened immediately. It was only after I had managed to get to a service station, that I found out about the wreck.

At that time, I was a member of the Baltimore City Auxilliary Police Unit. I could have badged my way past the the blockade on Old Eastern Ave. But, I decided not to do so. I thought that too many people would only create more confusion and possibly hinder the rescue operations.

I then turned around and took Martin Blvd. over to Rte 40. Heading East on Rte 40, I found the Ebenezer Rd. intersection blockaded there as well. Only residents and emergency vehicles were allowed to proceed. I drove further East until I reached Edgewood Rd. I turned right and drove to the bridge that went over the tracks at Edgewood, Md. When I got there, there were several other railfans there as well. We stayed there, hoping to get a glimpse of any railroad emergency equipment that may have been heading to the crash site. After about two hours, I decided to leave because I was getting cold and hungry. After driving back to Rte 40 and heading West, I stopped at a little bar & grill. Naturally, the televisions were tuned to live reports from the wreck site. It seemed everyone in the place were in awe of the helicopter shots showing the seriousness of the crash. I remember some of the ladies there were crying as we watched people being pulled from the wreckage. By this time it was about five or six o'clock. I decided to call it a day and went home. The memories of that day will stay with me always.

Here is a link to photos of the crash and a commentary.

http://www.michaeljdavis.com/amtrak.htm

Okay, I just recently learned the *real* cause of the Chase, MD accident. Not that any of this excuses Ricky Gates and his train crew, or is meant to.

In 1982, Conrail decided to cease electric freight operation on Amtrak's NEC -- mostly because the rebate of access fees had run out. When the NEC was transferred to Amtrak in 1977, Amtrak "paid" for it by letting Conrail use it for free until the payments totaled the agreed purchase price. In 1982, CR had to start paying.

Now, all the electric locos (and in fact every loco operating on the NEC) had both cab signals and enforcement in those days. But since CR was going to be retiring the electrics, and they didn't want to continue maintaining two pools of motive power, they asked the FRA to exempt CR locos from the need to have cab signal enforcement. FRA agreed, and CR locos were changed to an arrangement where the cab signal displayed and there was an annunciator bell or whistle, but no penalty brake application.

It was THAT decision that made the Chase accident possible. Five years earlier, the locomotives would have been stopped by a penalty brake application after passing the first red signal.

FRA has since reversed itself, and locos operating on the NEC today must have enforced cab signals. But that won't recover the lives of 27 Amtrak passengers.

rresor you are absolutly correct. In addition, the Conrail management at Bayview and Harrisburg (and probably elsewhere) condonned the disabling of the cab signal whistle because it was too loud and annoying. The cab signal enunciator was a brass air whistle that shrieked in the cab. The engineers would put duct tape around the whistles to shut them up. The whistles in all three engines were taped.

Blaming this accident on drug use was a sham.

I will never forget sitting on the sofa watching the game when the special report broke in with the aerial picture. Hey that looks like Gunpow....then the phone rang. Lucky for me I didn't have to be there until later after the people were all out.

Ugly mess, I'd been to many freight wrecks but passenger wrecks are terrible. The thing that got me the most was the signs of normal activity stopped in mid stream. Belongings, the two pizza boxes with the half eaten pizza sitting on the floor....

rresor Wrote:

> FRA has since reversed itself, and locos operating on the NEC today must have enforced cab signals.

Still true today? I ride the NEC about once a year.

Wasn't the death toll reduced because the first car in the train, which was totally flattened, was closed and not carrying any passengers?