January 22, 2010

NTSB: Metrolink crash caused by texting operator

The National Transportation Safety Board (NTSB) determined that the 2008 rail accident in Chatsworth, Calif., involving a Metrolink commuter train and a Union Pacific freight train, was caused by the Metrolink engineer's prohibited use of a wireless device while he was operating the train.

The engineer failed to respond appropriately to a red signal at Control Point Topanga because he was engaged in text messaging at the time, the NTSB said.

The September 12, 2008 head-on collision resulted in 25 fatalities and more than 100 injuries. As a result of its findings, the NTSB recommended that the Federal government require audio and image recorders in the cabs of all locomotives and in cab car operating compartments.

According to records from the wireless provider, on the day of the accident, while on duty, both the Metrolink engineer and the Union Pacific conductor used wireless devices to send and receive text messages. The engineer also made non-business related voice calls while on duty.

Although Metrolink prohibits its engineers from using wireless devices while operating a train, the privacy afforded by the locomotive cab, once the train leaves a station, makes it difficult for violations of operating rules to be discovered through ordinary management supervision or efficiency testing, the NTSB noted. On previous occasions, the Metrolink engineer also had allowed unauthorized persons to join him in the locomotive cab and even operate the train.

The NTSB also cited the lack of a positive train control system (PTC) as a contributing factor in the accident. A positive train control system would have stopped the Metrolink train short of the red signal, thus preventing the accident.

With the completion of this accident investigation, the NTSB made two recommendations to the Federal Railroad Administration:    

  • Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and system-wide performance monitoring programs.
  • Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety.

A summary of the findings of the Board's report is available on the NTSB's Website at: http://ntsb.gov/Publictn/2010/RAR1001.htm. The  full report will be available on the Website in several weeks.

 

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