WASHINGTON -- After a 16-month investigation, the National Transportation Safety Board decided yesterday that the simplest of human failings caused last year's fatal collision between Amtrak and MARC trains in Silver Spring: An engineer forgot about a signal warning him to slow down.
Eleven people were killed in the Feb. 16, 1996, accident, including MARC Engineer Richard Orr and two fellow crew members. The wreck occurred when Orr's eastbound commuter train rammed into a westbound Amtrak train around 5: 39 p.m.
But while concluding that human error was the primary cause, the five-member board pointed to a broad and often complex set of safety issues that contributed to that night's events.
And for the first time, the board recommended that a train crew's conversations be recorded -- like the recordings of airline crews -- so that investigators can better understand how such accidents happen.
"If this locomotive had been traveling at 30,000 feet, it would have had a cockpit voice recorder," said NTSB Chairman James E. Hall. "We've had them in airplanes since 1965. It's been a very effective tool."
Under the scenario pieced together by federal investigators, the eastbound Maryland Rail Commuter Train 286 passed a yellow signal just before entering Kensington Station on MARC's Brunswick line in suburban Montgomery County. The signal was a warning to proceed no faster than 30 mph and be prepared to stop.
It was a distracting time for Orr and crew members. At Kensington, they had to pick up two passengers -- an unaccustomed circumstance at the little-used stop -- and were probably expecting a clear trip the rest of the way to Washington's Union Station.
After leaving Kensington, Orr apparently forgot about the earlier warning signal and accelerated to 63 mph -- too fast to avoid a head-on collision with Amtrak's westbound Capitol Limited, the NTSB said. The Amtrak train was temporarily on the eastbound track in order to bypass a stopped freight train.
NTSB investigators said that while they can't be 100 percent certain Orr forgot about the yellow signal, all the evidence points to that likelihood.
"The engineer probably identified the signal correctly but forgot it," said Bruce Magladry, an NTSB investigator. "We believe he recalled the signal he normally sees at Kensington -- clear."
Additional signal removed
Officials also noted that the crew failed to receive what might have been a critical reminder to slow down -- another signal immediately after Kensington Station that had been removed several years earlier. The removal was part of an upgrade of the signal system meant to make the line safer.
Ironically, the federal grant that made that change possible came in reaction to the Jan. 4, 1987, disaster in Chase when an Amtrak train collided into the rear of three Conrail locomotives. Authorities touted the new signal system as a safety improvement needed to handle growing MARC traffic.
Meanwhile, Orr's fellow engineers are unlikely to accept the government's version of events. Even investigators acknowledged that forgetting a signal would have been out of character for Orr, a Glen Burnie resident with a superlative 25-year record with CSX Transportation, the company that runs MARC trains on the Brunswick line.
None of the MARC crew members showed evidence of drug or alcohol use, nor was fatigue a factor, investigators found.
"Our membership won't buy into the theory that a competent engineer who was qualified and experienced would, in fact, lose his place," said William C. Walpert, vice president of the Brotherhood of Locomotive Engineers. "It would be like an airline pilot not being able to find an airport."
Safety issues noted
Nevertheless, the NTSB found much to criticize in an accident that Hall described as unusually "chock full" of safety issues. Among the contributing factors:
Inaccessible emergency exits in MARC cars that were insurmountable barriers to eight victims who died from injuries sustained not in the crash but during the fiery aftermath. That problem with windows and doors has since been corrected by the Mass Transit Administration, the panel noted.
The failure to study the "human factors" of how crews might respond when the second signal was taken out of Kensington Station. Such an analysis might have prevented the accident, the panel asserted.
Neither CSX, which runs the railroad, nor the MTA, which contracts CSX, bothered to train MARC crews on how to handle emergencies. Investigators postulated that the company's lax attitude might have stemmed from a $150 million insurance policy -- funded wholly by Maryland taxpayers -- that protects it from liability claims. The state has since required the training both of train crews and emergency rescuers.
The federal government's poor safety recordkeeping. Is there a pattern of problems for commuter rail systems? Authorities said it's hard to tell because Federal Railroad Administration records don't distinguish commuter lines from the freight lines of parent companies that offer both kinds of services.
The board issued 36 safety recommendations stemming from the accident, including the use of an on-board voice recording system.
Such recommendations can have considerable influence, but neither the industry nor government regulators are required to follow them.
Pub Date: 6/18/97