NTSB DETERMINES 2007 MASSACHUSETTS BAY TRANSIT AUTHORITY RAIL ACCIDENT WAS CAUSED BY THE FAILURE TO PROVIDE SIGNAL PROTECTION FOR TRACK MAINTENANCE WORKERS

[NTSB Press Releases <NTSBPressReleases@xxxxxxxx>]

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                      NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: March 18, 2008
SB-08-11

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NTSB DETERMINES 2007 MASSACHUSETTS BAY TRANSIT AUTHORITY 
RAIL ACCIDENT WAS CAUSED BY THE FAILURE TO PROVIDE SIGNAL 
PROTECTION FOR TRACK MAINTENANCE WORKERS

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Washington, DC - The National Transportation Safety Board 
determined today that the probable cause of the collision 
involving a Massachusetts Bay Transit Authority train with a 
maintenance truck in Woburn, Massachusetts 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, January 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.  

During its investigation, the NTSB 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 accident, the Safety Board made the 
following recommendations:

To the Federal Railroad Administration:

1.      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.

2.       Require redundant signal protection, such as 
shunting, for maintenance-of-way crews who 
depend on the train dispatcher to provide 
signal protection.

3.      Revise the definition of "covered employed" 
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.  

To the Brotherhood of Maintenance of Ways Employees 
Division:

4.  Promote the prevention of alcohol and drug 
abuse by assisting your 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 website in several 
weeks.

-30-

Media Contact: Terry N. Williams, 202-314-6100 
williat@xxxxxxxx 








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