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PB92-916301
NTSB/RAR-92/01

NATIONAL
TRANSPORTATION
SAFETY
BOARD

WASHINGTON, D.C. 20594

 

RAILROAD ACCIDENT REPORT

 

DERAILMENT AND COLLISION OF
AMTRAK PASSENGER TRAIN 66 WITH
MBTA COMMUTER TRAIN 906
AT BACK BAY STATION
BOSTON, MASSACHUSETTS
DECEMBER 12, 1990

NTSB RAR-92-01 cover image.jpg

US GOVERNMENT PRINTING OFFICE 1990 0-942 855



The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous material ssafety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports. safety studies, special investigation reports, safety recommendations, and statistical reviews.

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NATIONAL
TRANSPORTATION
SAFETY BOARD


WASHINGTON. D.C. 20594


RAILROAD ACCIDENT REPORT


ADOPTED:FEBRUARY 25, 1992

NOTATION 5434A


Abstract: At 8 23 a m on December 12, 1990, National Railroad Passenger Corporation (Amtrak) passenger train 66, consisting of a two-unit locomotive, two material handling cars, five passenger cars, one dining car, and two baggage cars, derailed and struck Massachusetts Bay Transit Authority (MBTA) commuter train 906, consisting of one locomotive, six passenger cars, and one control car, as both trains entered Back Bay station in Boston. Massachusetts

In this report the following safety issues are discussed: tram operations and speed limits, locomotive engineer training and Federal Railroad Administration certification, and locomotive event recorder data

As a result of its investigation, the Safety Board made recommendations addressing these issues to the National Railroad Passenger Corporation, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, and the United Transportation Union



CONTENTS

EXECUTIVE SUMMARY v
INVESTIGATION 1
The Accident 7
Injuries 7
Damages 8
Crew Information 8
MBTA Train 906 8
Amtrak Train 66 8
Train Information 9
MBTA Train 906 9
Amtrak Train 66 9
Tunnel. Signal, and Track Information 10
Tunnel 10
Signals 10
Track 10
Post Acident Track Examination 10
Operations information 11
Operating Procedures 11
Amtrak Train 66 11
Management Oversight 12
Meteorological Information 12
Medical and Toxicological Information 12
Fire 13
Survival Aspects 13
Emergency Response 13
Passenger Evacuation 13
META Train 906 Crew 14
Amtrak Train 66 Crew 14
MBTA Train 906 Exits 15
Amtrak Train 66 Exits 15
Emergency Preparedness 15
Tests and Research 19
Speed Indicator Test 19
Maintenance Records 19
Locomotive Airbrake Valve Tests 19
Event Recorder Information 19
Event Recorder Tests 20
Sto ping Distance Simulation Tests 22
Braking Speed Simulation Tests 24
Amtrak's Postaccident Actions 24
Locomotive Engineer Training 25
Sources of Information 25
Program Organization 25
Classroom Training Phase 25
Physical Characteristics Familiarization 26
Simulator Training Phase 27
On-the—Job Training Phase 27
Final Evaluation of Apprentices 28
Program Administration 28
Development and Evolution of the Program 29
Engineers'and Apprentice Engineers‘ Concerns: 29
FRA Engineer Certification 29
Event Recorder Regulations 30
ANALYSIS
General 30
The Accident 31
Advance Warning Devices 32
Brake Inspections and Test 33
Instructing Engrneer's and Apprentice's Performance Before Derailment 33
Locomotive Engineer Training and FRA Qualification 35
Locomotive Engineer Training Program 35
Amtrak Locomotive Engineer Training Deficiencies 35
Training and Qualification on the IIT Simulator 37
Training and Qualifications for instructing Engineers 38
Sources of Engineer Training Program Deficiencies 38
FRA Locomotive Engineer certification Requirements 39
Locomotive Event Recorders 39
Survival Aspects and Emergency Response 40
CONCLUSIONS
Findings 40
Probable Cause 41
RECOMMENDATIONS 41
APPENDIXES
Appendix A—Investigation and Hearing/Deposition 43
Appendix B—Personnel Information 45
Appendix C—Outline of Locomotive Engineer Training Program 47
Appendix D—Apprentice Performance valuation Farm to Be Completed by Instructing Engineers 55



EXECUTIVE SUMMARY

At 8:23 am. on December 12, 1990, National Railroad Passenger Corporation (Amtrak) passenger train 66, consisting of a two-unit locomotive. two material handling cars, five passenger cars, one dining car. and two baggage cars, derailed and struck Massachusetts Bay Transit Authority (MBTA) commuter train 906, consisting of one locomotive, six passenger cars, and one control car, as both trains entered Back Bay station in Boston, Massachusetts

Operated by an apprentice engineer, Amtrak train 66 was traveling 76 mph, within a 30-mph speed restriction, on a 9" 30' curve when it derailed and struck META train 906 on the adjacent track. A fire ignited after the collision. On Amtrak train 66, 7 crewmembers and 43 passengers sustained injuries, on MBTA train 906, Screwmembers and 391 passengers were injured, and 7 firefighters sustained injuries Estimated damage exceeded $12.5 million

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the apprentice locomotive engineer to reduce speed in sufficient time to negotiate the curve into Back Bay station as a result of inadequate supervision provided by the locomotive engineer. Contributing to the accident was Amtrak‘s failure to provide adequate quality control oversight for its locomotive engineer training program, including the adequacy of selection and training for apprentices an selection and training of engineers who serve as supervisors to apprentices during on—the-job training Also contributing to the accident was Amtrak's failure to have advance warning devices for a speed reduction for the curve entering Back Bay station

The safety issues discussed in this report are:

  • train operations and speed limits,and
  • locomotive engineer training and Federal Railroad Administration certification, and
  • locomotive event recorder data

As a result of its investigation, the Safety Board made recommendations addressing these issues to the National Railroad Passenger Corporation, the Federal Railroad Administration, the Brotherhood of Locomotive Engineers, and the United Transportation Union.

This work is in the public domain in the United States because it is a work of the United States federal government (see 17 U.S.C. 105).