Feds fault NJ Transit crew for fatal train mishap

[Jtgshu]

Correct so the key out procedure when stopped should work, till about 5 mph when door will try to close, hence the foot.
You would still not lose a doorlight.

Not quite.........even if the loco was in bypass, the cars will try to close the doors themselves once they started moving, that is the "no motion" system. This is also why sometimes doors in a particular car will not open at a random station stop, because the car thinks its still moving, not allowing the doors to open.

However, the "no motion" system does not override the sensitive strip system which when there is an object stuck in the door, it reopens. that is the sensitive strip system.

So, even if the crew was totally incompetitent, and the brakeman gave the engineer 2 to go, and all the doors were wide open and people were unloading, these systems would NOT be over riden - they would still work - the doors would close in each car once the car sensed motion, and if someone was in the door, it would bounce back open once it felt the resistance of something (person, object, etc). This would give that unfortunate person an opportunity to either get their body parts back on the train, or get the rest of the way off the train. And with the breakneck acceleration of a '40 with 5 cars (that what this train was in bradley beach) it would give the person a handful of seconds to react.

Only MUs allow there to be a door open with a key in the panel and allow the engineer to draw traction power. All of the other comets (2, 3, 4, 5), and im ASSUMING the MLs do not allow ANY doors to be open and the engineer draw traction power, unless in bypass. Once the train starts rolling, you cannot open a door, and if you managed to (say with the emergency handle on a C5) the engineer would loose his door light, and traction power. If the locomotive was in end door bypass, the end door could be left open, with or without a key in the panel, however, as soon as the car started rolling and the car sensed the movement, the car would try to close the door itself, that is the no-motion system.

Again, its not as "cut and dry" as the newspapers are making it out to be. I still FIRMLY believe that the victim tried to get back on the train after it started moving, fell off, and was injured/killed that way. Again, the actions of the crew, in particular the brakeman, might have been a factor, but not the only factor.

[Sirsonic]

I must say that I like the statement that had the brakeman been at the rear door, she would have seen what was going on. This statement makes it clear that at a minimum the writers of the report have never actually been on the rail cars involved. Looking out the window of a CLOSED door, there is no way to see 85 feet ahead along the train.

[Sirsonic]

I was led to believe that the equipment involved was configured in a way that allowed the bypass switches to be in bypass & the seal still be intact.

That was the standard operating procedure of the mechanical department for a long time. Seal the equipment so that when the Engineer inevitably has to go into bypass, he doesn't have to brake the seal. That way, the mech dept doesn't have to come out to reseal the equipment constantly, like they do now.

I thought that the engineer was required to check the seals.

That is part of the pre-movement inspection. Of course, not everybody does that. At a glance, the seals can look sealed and actually be broken. I guess that is all up to the Engineer and how far they want to go. I am comfortable with the way I do it.

This is why I would recomend that should the switches need to be placed in bypass for any reason, including operating with Comet I equipment, that the seals be broken and totally removed. If the switches are to be left in normal, they should be pulled as tight as possible so it is not possible to place them in bypass without breaking the seals.

[Nasadowsk]

Sirsonic - that's how a seal is supposed to work!!!! The point of it is you see it gone when the switch is moved out of the normal position.

[DutchRailnut]

What strikes me as odd on NJT is engineers would not screw with Cabsignal or ATC seals but have no problem tweaking the door bypass switch till it overrides.
As for Company rules and FRA rules any safety seal violation is a de-certifyable offense, so how come you guys tread one different over another ??? in my eyes your RFE's must be total morons., and not respect their job.

Read point 5 of following federal rule:

TITLE 49--TRANSPORTATION



CHAPTER II--FEDERAL RAILROAD ADMINISTRATION, DEPARTMENT OF

TRANSPORTATION



PART 240_QUALIFICATION AND CERTIFICATION OF LOCOMOTIVE ENGINEERS--Table

of Contents



Subpart D_Administration of the Certification Programs



Sec. 240.305 Prohibited conduct.



After December 31, 1991,

(a) It shall be unlawful to:

(1) Operate a locomotive or train past a signal indication,

excluding a hand or a radio signal indication or a switch, that requires

a complete stop before passing it; or

(2) Operate a locomotive or train at a speed which exceeds the

maximum authorized limit by at least 10 miles per hour. Where restricted

speed is in effect, only those violations of the conditional clause of

restricted speed rules (i.e., the clause that requires stopping within

one half of the locomotive engineer's range of vision), or the

operational equivalent thereof, which cause reportable accidents or

incidents under part 225 of this chapter, shall be considered instances

of failure to adhere to this section; or

(3) Operate a locomotive or train without adhering to procedures for

the safe use of train or engine brakes when



[[Page 756]]



the procedures are required for compliance with the initial terminal,

intermediate terminal, or transfer train and yard test provisions of 49

CFR part 232 or when the procedures are required for compliance with the

class 1, class 1A, class II, or running brake test provisions of 49 CFR

part 238;

(4) Fail to comply with any mandatory directive concerning the

movement of a locomotive or train by occupying main track or a segment

of main track without proper authority or permission;

(5) Fail to comply with prohibitions against tampering with

locomotive mounted safety devices, or knowingly operate or permit to be

operated a train with an unauthorized disabled safety device in the

controlling locomotive. (See 49 CFR part 218, subpart D, and appendix C

to part 218); (6) Be a Designated Supervisor of Locomotive Engineers, a certified

locomotive engineer pilot or an instructor engineer who is monitoring,

piloting or instructing a locomotive engineer and fails to take

appropriate action to prevent a violation of paragraphs (a)(1) through

(a)(5) of this section. Appropriate action does not mean that a

supervisor, pilot or instructor must prevent a violation from occurring

at all costs; the duty may be met by warning an engineer of a potential

or foreseeable violation. A Designated Supervisor of Locomotive

Engineers will not be held culpable under this section when this

monitoring event is conducted as part of the railroad's operational

compliance tests as defined in Sec. Sec. 217.9 and 240.303 of this

chapter.

(b) Each locomotive engineer who has received a certificate required

under this part shall:

(1) Have that certificate in his or her possession while on duty as

an engineer; and

(2) Display that certificate upon the receipt of a request to do so

from

(i) A representative of the Federal Railroad Administration,

(ii) An officer of the issuing railroad, or

(iii) An officer of another railroad when operating a locomotive or

train in joint operations territory.

(c) Any locomotive engineer who is notified or called to operate a

locomotive or train and such operation would cause the locomotive

engineer to exceed certificate limitations, set forth in accordance with

subpart B of this part, shall immediately notify the railroad that he or

she is not qualified to perform that anticipated service and it shall be

unlawful for the railroad to require such service.

(d) During the duration of any certification interval, a locomotive

engineer who has a current certificate from more than one railroad shall

immediately notify the other certifying railroad(s) if he or she is

denied recertification by a railroad or has his or her certification

revoked by a railroad.

(e) Nothing in this section shall be deemed to alter a certified

locomotive engineer's duty to comply with other provisions of this

chapter concerning railroad safety.



[56 FR 28254, June 19, 1991, as amended at 58 FR 19004, Apr. 9, 1993; 64

FR 60993, Nov. 8, 1999]

[Jtgshu]

Again, its not as "cut and dry" as its being made out to be..........

http://www.app.com/apps/pbcs.dll/articl ... 10334/1004

Report: Train that dragged man to death had defect

By Larry Higgs • STAFF WRITER • January 1, 2008


The train that dragged John D'Agostino to his death on Nov. 21, 2006, in Bradley Beach had a defect that NJ Transit employees had reported three times in the four days before the fatal accident, according to a federal report about the accident.

The defect involved an indicator light in the locomotive, which would have told the crew that one of the doors on the train was still open. D'Agostino, 49, a native of Neptune, was pinned when a train door closed on him as he was getting off the train in Bradley Beach. The door failed to re-open, and he was dragged to his death.

In the December Federal Railroad Administration report about the accident is a listing of three incidents in which the PCS (Pneumatic Control System) indicator light in locomotive No. 4116 operated normally when the train stopped at stations with high-level platforms on the North Jersey Coast Line, but didn't work when it stopped at stations with low-level platforms.

Information downloaded from the locomotive's event recorder, which is like the black box in an airliner, showed that on the morning of the accident, the light worked normally in stations with high-level platforms, such as Red Bank and Asbury Park, but stopped functioning at stations with low platforms, such as Little Silver, Allenhurst and Bradley Beach, according to the report.

The report also shows that the problem was reported to NJ Transit once on Nov. 17 by train crews and twice more on Nov. 20.

NJ Transit and FRA officials blamed the accident on the crew, and accused the engineer of operating the train with a bypass switch on, which would have allowed the locomotive to draw power to move even if a door were open.

In an interview with the FRA, according to the report, the engineer denied moving the bypass switch out of its normal position.

If the PCS light was off when the bypass switch was in its normal position, the light would indicate an open door on the train and the locomotive would not receive power to move the train, said Patrick Reilly, general chairman of United Transportation Union Local 60, which represents NJ Transit assistant conductors and conductors.

Reilly is a former inspector and accident investigator with the FRA and National Surface Transportation Board. He brought concerns about the train doors and safety equipment to NJ Transit's board of trustees last July.

"Something was wrong with that equipment. The FRA and the carrier (NJ Transit) came to the conclusion that the doors were in bypass, but there was an electrical problem," Reilly said. "That train should have never gone out."

Had the light functioned the way it should have, with the bypass switch in normal position, the light would have gone off, meaning a door was still open, and the train wouldn't have been able to move, he said.

Unlike a check engine light in a car, which comes on to indicate a problem, the PCS light instead lights up when the train doors are closed and turns off when they are open, Reilly said. When the light is off, and a door is open, the locomotive can't take power to move, if it is functioning properly, he said.

"It was reported three times (prior to the accident)," Reilly said. "The (bypass) switch was in the normal mode and there was some kind of malfunction when the train was in low-level (station) mode. It was not working as intended."

According to the FRA report, on Nov. 17, the locomotive and rail cars were used on train No. 2348 to Hoboken, and on the return trip to Dover, the report said, there was "no PCS at high or low platforms."

That same day, when the locomotive and cars were used on train No. 2311 west, there was "no PCS at low-level platforms," the report said.

On Nov. 20, the locomotive and rail cars were used on train No. 2311 on the Coast Line and "no PCS at low platforms" was again reported, the FRA report said. The train set ran east to Long Branch as train No. 4388 and "no low-level PCS" was reported.

The locomotive and cars returned to Bay Head and then were sent to Long Branch, and then to East Matawan to rescue passengers on a train that struck a woman.

D'Agostino was riding on that train.

"Once an engineer reports a problem (with equipment) it has to be addressed or corrected," Reilly said. "Nothing shows it was addressed."

NJ Transit officials declined to comment, because information about the PCS light problem with the train set being reported prior to the accident was not in the copy of the report the agency received from the FRA.

"It's not something we've seen," said Dan Stessel, NJ Transit spokesman.

FRA officials said in an e-mail Monday that they don't consider that defect to mean there is a larger problem with equipment.

"FRA did not and does not consider this to be an indication of a larger or systemic mechanical problem, since the equipment was in end door bypass position for several days prior to the fatality as evidenced by the locomotive event recorder," said Warren Flateau, FRA spokesman.

He said that by design, the PCS light will not illuminate when the end doors are open, the end door bypass switch is on and the train is stopping at a station with a low platform.

The PCS light will illuminate when the center doors, which are used for high-level platforms, are open unless the center door bypass switch is in the bypass position, Flateau said. Only the end door bypass switch was in the bypass position, while the center door bypass switch was in the normal position, he said.

However, Reilly said that the bypass switch was put in the bypass position when a different crew moved the locomotive and cars from Spring Lake to Bay Head after the accident on the morning of Nov. 21.

An interesting quote from the article

"FRA did not and does not consider this to be an indication of a larger or systemic mechanical problem, since the equipment was in end door bypass position for several days prior to the fatality as evidenced by the locomotive event recorder," said Warren Flateau, FRA spokesman.

As per the CFR rule so kindly referenced above by Dutch, whos to say the engineer knew he was in end door bypass? The switches are simple toggle switches - and can easily be moved and flipped around (its a tiny lock nut kinda thing holding the toggle in place, it could easy vibrate - they often do on the Comet 5s, or at least used to). Even if he didn't break the seal and it looked sealed in Normal, it was in bypass, as evidenced by the event recorder. According to the article,the engineer also couldn't rely on the PCS light because it wasn't coming on at low level stations. Now, thats already strike two against the engineer, and he didn't do anything knowingly wrong.....

If according to Mr. Reilly, the equipment was physically put in end door bypass on the move to Bay Head by the crew moving the equipment after the fatality, what was it in before?

However, Reilly said that the bypass switch was put in the bypass position when a different crew moved the locomotive and cars from Spring Lake to Bay Head after the accident on the morning of Nov. 21

Makes you wonder, don't it?

[Uzi-Cat]

What strikes me as odd on NJT is engineers would not screw with Cabsignal or ATC seals but have no problem tweaking the door bypass switch till it overrides.

It isn't the engineers that are tweaking the seals. Once the seal is applied, you can't loosen them, only tighten them. They work sort of like a zip tie. It is when they are applied by mechanical, that they are put on in such a loose fashion that the switch can be operated without breaking the seals. I know many many engineers who tighten the seal up when they see that. There are some that don't care either. The best thing to do is to completely remove the seal when you break it.

[Sirsonic]

The bypass switches are only small toggle switches. To properly seal them there is supposed to be a cover placed over the switch, and then a seal applied to the closed cover. In order to operate the switch the seal must be broken and then the cover lifted to allow the switch to be placed in bypass. If the cover is down, it is not possible for the switch to be in bypass as the cover knocks the switch back down to the normal position (bypass is up).

The problem at the time was that most of the switches had no cover, so in an a vain attempt to make it look like the switch was effectively sealed, when it was not, they placed a seal below the bypass switch, even though the switch needed to be moved UP to be put in the bypass position. Also, the bypass position is not very far from the normal position. In normal the switch may be at 90 degrees, and in bypass the switch is at 75 degrees, so without physically touching the switch, which is still sealed, it would be impossible to know what position it was in.

While all of the door bypass switches have now had covers installed so they operate properly, the mechanical dept continues to seal the switches so loosely that it is possible to lift the covers and place the switches in bypass without breaking the seals. This is why I say if you need to place the doors in bypass totally remove the seals and if you need them in normal, tighten the seals as tight as possible.

The way things were done up until this incident, as I described above, were done with the full knowledge, and therefore consent as they never objected, of both NJT management and the FRA.

[thebigc]

What strikes me as odd on NJT is engineers would not screw with Cabsignal or ATC seals but have no problem tweaking the door bypass switch till it overrides.

It isn't the engineers that are tweaking the seals. Once the seal is applied, you can't loosen them, only tighten them. They work sort of like a zip tie. It is when they are applied by mechanical, that they are put on in such a loose fashion that the switch can be operated without breaking the seals. I know many many engineers who tighten the seal up when they see that. There are some that don't care either. The best thing to do is to completely remove the seal when you break it.

Those orange plastic seals with the tabs on them are a joke. Just get a key between the seal and the switch and twist; they loosen right up. Then when you're done doing what you're doing, you can tighten the seal back up.

[DutchRailnut]

Joke or not but since the event is noted on the event recorder any engineer playing loose with the rules is asking for decertification as per FRA rules.

[Sirsonic]

If he knowingly disabled the safety device, or knowingly operated it while it was disabled, then he is subject to decertification. If, however, due to poor design and a total lack of maintenance it is possible to reasonably believe the switch has not been tampered with when it has, the CFR has not been violated as it was not KNOWINGLY done.

[DutchRailnut]

Sirsonic I am sure there is a rule for engineers to check seals and if properly applied,, the knowingly part kicks in when event recorder says the device was activated, who's watch was it on.
Personaly from statements made here by NJT people I still say your RFE's are a bunch of total morons.

[Sirsonic]

The engineer is required to inspect, visually, any seals in the cab (and cab signal cut-out seals wherever they are located). If during a visual inspection the switch appears to be properly positioned and sealed, no further inspection is required. If the switch is in fact in bypass when it appears to be in normal, the engineer is not responsible. The engineer would only be responsible if he had placed the switch in bypass or if a reasonable person would have looked at the switch and thought that it was not in the normal position and/or the seal was missing or broken.

From what I have heard while the engineer was dismissed by NJT, he was not decertified. For those who dont know, you can be fired and decertified by your employer for one offense. If you are decertified, you may not be certified as a locomotive engineer by any other railroad during that period.

I will not comment at this time on the quality of NJT supervision, although my thoughts on that are well known...

[Jtgshu]

Sirsonic I am sure there is a rule for engineers to check seals and if properly applied,, the knowingly part kicks in when event recorder says the device was activated, who's watch was it on.

So whos watch was it on considering the equipment in this instance was in bypass, according to the recorder, for DAYS before the incident? Did the engineer in the Bradley Beach incident KNOW it was in bypass? That is the question...and therefore, should he be fired as a result of it????

What about every other engineer who operated that equipment and every mechanical person who tested/inspected that equipment? If it was done days prior, is the engineer boarding at that instant KNOWINGLY operating it in bypass??????? if the equipment seal is "properly applied" and sealed, its ASSUMED (yes, i know i know) that its SEALED in the proper position. Not to say that the position shouldn't be double checked, but you wouldn't see the ATC controls sealed in cutout............

I wish that all the bypass switches in all the locos and cars would be replaced with the "light switch" type switches that are on MUs. Very easy to see if its in bypass or not, cover not required, no chance for a "wandering" and loosening of the toggle switch from away from the vertical position, etc. The switch is either "off" meaning normal operation, or "on" meaning bypass position.

[ryanov]

Jt: Sure it wasn't you?

I'm not trying to point a finger here, but if the expected behavior is no door light if the switch is in bypass, and the engineer was expecting a door light, wouldn't a troubleshooting step be to make sure the switch was in the right position?

Though, I'm guessing if 4 crews reported a problem that could have been solved by flipping the switch to normal (which is what it sounds like, anyway), that someone would have figured that out. So perhaps it really did appear to be in Normal.

FYI, everyone: cut-and-dried
http://www.wsu.edu/~brians/errors/cutanddry.html