WASHINGTON -- Amtrak crews' failure to connect a train's air brake system properly -- and then to test the brakes adequately -- caused an April 1991 collision with a Conrail freight train in Chase, the National Transportation Safety Board said yesterday.
The board blamed "Amtrak's failure to provide adequate training and oversight" as a contributing cause of the accident.
Two Amtrak crewmen were hurt when they jumped from the northbound string of four locomotives just before the train slammed into the middle of a 121-car Conrail coal train that was switching tracks south of the Gunpowder River bridge in northeast Baltimore County.
"This could easily have been a fully loaded passenger train," said Susan M. Coughlin, acting chairman of the safety board. "The mix was certainly there for a much more catastrophic accident than what we witnessed."
The crash was dubbed "Chase II" because it happened about 100 yards from the spot where the marijuana-smoking crew of a Conrail train ran a signal into the path of the Amtrak Colonial in January 1987. Sixteen people were killed and more than 170 were injured in the collision. But safety board and Amtrak officials agreed that the location, 16 miles north of Baltimore, was a coincidence.
The April 12, 1991, accident occurred as Amtrak Extra 390 North -- a diesel locomotive towing three electric engines from Washington to Philadelphia for repairs -- was midway through its journey. The three electric locomotives weren't running so they weren't pumping air into the reserve tanks of their air brake systems, safety board investigators said.
The problems began when a maintenance crew foreman at Washington's Ivy City shop near Union Station failed to hook up the diesel engine's air brake system correctly to the brake system of the electric locomotives, investigators said.
Then the train's operating crew botched a required test of the air brakes and failed to detect that the system wasn't working. The crew didn't even notice that the third electric locomotive's brake system had sprung an air leak strong enough "to blow your toupee off," said investigator Russell Quimby.
As the string of locomotives sped north at 80 mph, each time the train slowed or stopped.
Finally, when the Amtrak train was signaled to stop near Chase to let the Conrail train cross the main track, the air reserve was exhausted. Ninety seconds before the crash, the Amtrak engineer radioed that the brakes were gone and he couldn't stop. But it was too late.
The lead Amtrak locomotive plowed into the 65th car of the coal train at 3:09 a.m. A total of seven cars and locomotives derailed, and $800,000 damage was done, investigators said.
Amtrak quickly fired Mike Flynn, the foreman responsible for the faulty air brake hookup, but he later took advantage of his union seniority to take a job as a pipefitter, said R. Clifford Black IV, an Amtrak spokesman. Mr. Flynn is "no longer involved in supervising those who put together trains, and he's working out fine as a pipefitter," Mr. Black said.
The safety board praised Amtrak for taking "prompt action" to revise procedures after the crash. The railroad now requires two air brake tests before every departure, special training for crew members who work on the brake systems, reduced speeds on moves of locomotives and other safeguards.