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NTSB DETERMINES ENGINEER'S FAILURE TO OBSERVE AND RESPOND TO RED SIGNAL CAUSED 2008 CHATSWORTH ACCIDENT; RECORDERS IN CABS RECOMMENDED



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                      NTSB PRESS RELEASE

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National Transportation Safety Board

Washington, DC 20594

 

FOR IMMEDIATE RELEASE: January 21, 2010

SB-10-01

 

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NTSB DETERMINES ENGINEER'S FAILURE TO OBSERVE AND RESPOND TO

RED SIGNAL CAUSED 2008 CHATSWORTH ACCIDENT; RECORDERS IN

CABS RECOMMENDED

 

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Washington, DC - The National Transportation Safety Board

determined today that the 2008 rail accident in Chatsworth,

California, 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.  "For the

transportation industry, this accident demonstrates that we

must find a way to wrap our arms around the pervasive

problem of transportation operators using wireless devices

while on the job, whether that job is driving a bus, flying

an airplane, or operating a train," NTSB Chairman Deborah A.

P. Hersman said.

 

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.  "This accident shows us once again that the

safety redundancy of PTC is needed now," Hersman said.  "It

can and will save lives even when operators ignore safety

rules or simply make mistakes."

 

With the completion of this accident investigation, the NTSB

made two recommendations to the Federal Railroad

Administration:

      

1.    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.

 

2.    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 Board's full

report will be available on the website in several weeks.

 

# # #

 

NTSB Media Contact:

Terry N. Williams

(202)314-6100 

williat@xxxxxxxx

 

   

 

 

 

 

 

 

 

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