PUBLIC TRANSPORTATION SAFETY BOARD RAIL ABBREVIATED REPORT … · 2009-11-19 · 1 PUBLIC TRANSPORTATION SAFETY BOARD RAIL ABBREVIATED REPORT FORM On Friday, December 26, 2008, at

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PUBLIC TRANSPORTATION SAFETY BOARDRAIL ABBREVIATED REPORT FORM

On Friday, December 26, 2008, at approximately 6:27 a.m., eastbound NYCT Staten IslandRailway (SIR) train #26 was driven past the line-ending stop signal and struck the bumper blockat Tottenville Station. The train dislodged the bumper block, traveled off the end of the railsderailing onto the right-of-way. The train consisted of four, R-44 coach cars being operated by acrew consisting of an engineer and a conductor; neither employee claimed injury. Damageassessment to the track, the signal system and the car equipment was over $550,000.

Non revenue train #26 departed St. George Terminal at 5:55 a.m. for Tottenville Station where itwas to be positioned for westbound passenger service during the morning rush. The crew hadbeen on duty for approximately four hours and fifteen minutes prior to the derailment. The eventdata recorder from the lead car (#420) indicated that the trip from St. George to Tottenville wasas expected. The data further indicated that train #26 switched from automatic train control(ATC) to terminal mode as it entered the interlocking west of Tottenville Station at 6:24:09 a.m.At this point, train #26 was traveling about 10 MPH when the engineer placed the mastercontroller into the braking range slowing the train further to 5 MPH. After slowing to 5 MPH, train#26 passed through a required Safety Stop, in violation of SIR Operating Rule 9.33 which statesthat “…all Tottenville trains must come to a complete stop at the stop marker, and then proceedno faster than 5 MPH into the station.”

Subsequently at this point, the event recorderconfirmed that the train’s controller was movedinto a power setting and the train began toslowly accelerate. Approximately 38 secondslater, as the train reached a speed of 16 MPHand while the master controller was still in apower setting, the train’s brakes went into apenalty brake application when the trainpassed a station signal indicating stop(violation of SIR Operating Rule12.13). Thecollision speed of approximately 16 MPH wasrecorded as the brake pipe pressure rapidlydropped indicating an emergency brakeapplication. Post accident investigationdetermined that the emergency brake

application occurred when the automatic coupler sheared at impact with the bumper block,rupturing the brake pipe.

PTSB Case

10042

Property Name

NYCT –Staten Island Railway

Accident Date

December 26, 2008

Injuries

0

Fatalities

0

Accident Type

Collision

Accident Cause

Operator Fatigue

Location

Tottenville Station

Borough, City, Village, Town

Staten Island

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The bumper block’s anchor bolts were sheared off and the block components became wedgedunder the lead car which continued approximately 60 feet past the end of the running rails, downan incline, stopping at the shoreline of the Arthur Kill creek (see photo above). Car #402’sfronttruck was resting upon a marine retaining wall and the car body was adjacent to the station’shandicapped access ramp. The rear end of car #402 remained on the station track #2; at aboutthe position where the bumper block used to be.

The engineer and conductor of train #26 were taken to the NYCT Medical Assessment Center forpost incident drug and alcohol testing. Testing was administered within the required NYCT timelimit of two hours and the results were negative. NYCT's Maintenance of Way Derailment Teamand Department of Car Equipment Emergency Response team assisted SIR in the recoveryoperations at Tottenville. To re-rail car #402, the area beneath the car had to be built up,creating a ramp to pull the two lead cars up and back onto the tracks. The re-railing operationwas reported complete and without incident at 6:04 p.m.

Work Assignment

The engineer and the conductor were crew members assigned to job“Relief 1”which is a weeklywork assignment that covers the regular days off for SIR Run A, Run B, and partial Run F. Relief1 has regular days off on Tuesday and Wednesday and the start times vary according to the Run.Since the day prior to the accident was a holiday, Relief 1’s scheduled was pushed forwardto8:41 a.m., to 4:53 p.m. and then back to their normal report time of 1:41 a.m. on Friday morning.Staten Island Railway Operating rule 3.17, requires train operators to get at least 8 hours restbetween assignments. The schedule alteration was permissible; providing 8 hours and 48minutes of down time between runs.

Post Accident Statements

Both the engineer and the conductor made voluntary written statements regarding theirinvolvement in this accident. The engineer admitted not getting enough rest in the eight plushours between runs while off duty on the evening before the accident. The engineer admitted tobeing tired from the Holiday. She further stated that she used poor judgment and was unable tomake the proper safety stop (prior to Tottenville Station). The conductor’s written statement said that she was riding in the back of the train and noticed they were traveling at a higher rate ofspeed then normal while approaching the Tottenville Station. The conductor further stated thatshe attempted to pull the emergency brake cord, but pulled the train’s horn handle by mistake.(Note: The emergency brake cord and the train’s horn cord look similar and reside in closeproximity.)

Damage

The head car (#402) experienced significant damage to the #1 end bonnet and the automatic-coupler and electric portion which were sheared off the draft gear assembly. The #1 anti-climberwas also damaged. There was significant damage to the undercar equipment on car #402which included the #1 HVAC compressor/condenser units, the air brake compressor and thepropulsion group box. The #1 truck frame sustained structural damage and was scrapped. Therear bulk head inside the operator’s cab behind the engineer buckled and a piece of the bumper block punctured the cab floor opening an approximate 1 foot wide gash under the engineer’s seat. The B-side frame (left) structure on car #402 was also significantly damaged by the impactwith the station handicap ramp. The remaining three cars in the train had no reported damage.

Staten Island Railway Operating Rules Violations

Staten Island Railway Operating Rules state that eastbound trains that travel the length of thesystem without stopping are required to make a full safety stop (Rule 9.33) at a posted stop

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marker just prior to entering the Tottenville Station, and then to proceed into the station at aspeed no greater than 5 MPH. Based on analysis of the data obtained from the data logger, theengineer slowed the train down to 5 mph before taking power again and did not make therequired safety stop, accelerating to a speed of 16 MPH; well above the 5 MPH limit imposed byRule 9.33. Furthermore, the train passed a station signal indicating stop (violation of OperatingRule 12.13) just prior to striking the bumper block and derailing.

This is the second major incident involving the engineer. In 2007, the engineer was involved insingle car derailment while making a yard move at the Clifton Maintenance Shop, for which theengineer received a 4 day suspension. The conductor failed in her duties to take the necessaryactions to stop the train when the conductor felt the engineer is operating in the train in an unsafemanner; violating SIR Operating Rules 9.18 and 9.19.

For their actions on the morning of December 26, 2008, the engineer and the conductor wereboth taken out of service. The engineer was charged with several SIR Operating Rules violationsand, pending any further postponements, a decision is due. The conductor was charged with asingle Operating Rules violation and as the result of a hearing held in January 2009, the chargesagainst the conductor were substantiated and, after considering the facts, the conductor was re-trained and re-instructed on the equipment’s nomenclature, function, and proper train handling procedures.

Weather

Weather conditions at the time of the accident were mostly cloudy with temperature of 28degrees. The accident took place in the morning darkness prior to sunrise, which was at 7:15a.m. PTSB does not believe weather to be a contributing cause to this accident.

Corrective Actions

In January of 2009, the Operations Department issued an Operational ModificationsMemorandum to the Transportation and Mechanical Departments in response to issues broughtto light in the Tottenville derailment. The corrective actions include measures to:

Paint the horn handle in the R-44 operating cabs acontrasting color to distinguish it from the redemergency brake valve handle (see Photo #2);

Establish an additional stop eastbound at the AtlanticStation and westbound at the east portal of the St.George tunnel, in order to give the crew more time inan emergency; and

Revise its work schedule assignments for the reliefcrews covering the weekly assignments for the latenight F-Run resulting in a minimum turn around timegreater than 11 hours Photo #2 –New contrasting cord arrangement in

R 44 cabs.

CONCLUSION

The Public Transportation Safety Board staff finds that the most probable cause of this collisionwas the failure of the train operator to comply with Staten Island Railway Operating Rules due tofatigue. The Public Transportation Safety Board staff has reviewed the corrective actions takenby the NYCT and Staten Island Railway Operations Department makes no furtherrecommendations.

Investigated by

Robert Maraldo

Approved

Jerry Shook

Date

March 4, 2009