Missed Procedures Caused Fatal 2007 Train Crash, NTSB Rules
The National Transportation Safety Board determined on Tuesday that the probable cause of the collision involving a Massachusetts Bay Transit Authority train with a maintenance truck in Woburn, Mass., was the failure of the train dispatcher to maintain blocking that provided signal protection for the track segment occupied by the maintenance-of-way work crew, and the failure of the work crew to apply a shunting device that would have provided redundant signal protection for their track segment.
"This tragic accident occurred because several employees of the railroad failed to do a very important part of their job," said NTSB Chairman Mark V. Rosenker. "Simply stated, following required safety procedures would have saved lives in this accident."
On Tuesday, Jan. 9, 2007, passenger train 322, operated by the Massachusetts Bay Commuter Railroad, struck a track maintenance vehicle. The train engineer, operating the southbound train, had a clear signal indication as he exited a curve at 62 mph. When he saw the track maintenance vehicle, the engineer initiated emergency braking. The train speed had decreased to 44 mph when the collision occurred. Two of the six maintenance employees were killed and two seriously injured. Contributing to the accident was the railroad's failure to ensure that its maintenance-of-way work crew applied shunting devices as required, NTSB said.
During its investigation, the board discovered that the train dispatcher removed the block on the track segment where the crew was working, thus clearing the signals for train 322 to enter into the track segment. The investigation also revealed that the track foreman failed to follow procedures and apply a shunting device to the track segment which would have held the wayside signals red regardless of the dispatcher's actions. Additionally, the track engineer, who was fatally injured, tested positive for marijuana.
As a result of this incident, NTSB made the following recommendations to the Federal Railroad Administration:
- Advise railroads of the need to examine their train dispatching systems and procedures to ensure that appropriate safety redundancies are in place for establishing protection and preventing undesired removal of protection for roadway workers receiving track occupancy authority.
- Require redundant signal protection, such as shunting, for maintenance-of-way crews who depend on the train dispatcher to provide signal protection.
- Revise the definition of "covered employee" under 49 C.F.R. Part 219 for purposes of congressionally mandated alcohol and controlled substances testing programs to encompass all employees and agents performing safety sensitive functions, as described in 49 C.F.R. Sections 209.301 and 209.303.
Additionally, the board recommended that the Brotherhood of Maintenance of Ways Employees Division promote the prevention of alcohol and drug abuse by assisting its members in addressing awareness, education, and treatment options. A synopsis of the Board's reports, including the probable cause and recommendations, are available on the NTSB's website, www.ntsb.gov, under "Board Meetings." The Board's full reports will be available on the site in several weeks.