• Feds fault NJ Transit crew for fatal train mishap

  • Discussion related to New Jersey Transit rail and light rail operations.
Discussion related to New Jersey Transit rail and light rail operations.

Moderators: Tadman, nick11a, Kaback9, ACeInTheHole

  by Jtgshu
 
A more indepth article in the Asbury Park Press

http://www.app.com/apps/pbcs.dll/articl ... S/71228003
Train crew at fault in fatal accident, federal agency finds
By Larry Higgs • STAFF WRITER • December 28, 2007

A federal investigation into the 2006 accident that claimed the life of a former Neptune man, who was dragged by the train he was getting off in Bradley Beach, blamed the accident on the train crew and cited NJ Transit for a rule violation.

The Federal Railroad Administration determined that John D'Agostino, 49, was pinned by his left shoulder and arm after a train car door closed on him. Because the early morning train's "end door bypass switch" was on, automatic detection of the passenger's plight was nullified.

FRA tests of the rail car with the bypass switch off — as it should normally be — showed the door would have reopened like an elevator door does when it bumped D'Agostino, and the train wouldn't have had power to move.

The accident occurred shortly after 2:15 a.m. Nov. 21, 2006, at the Bradley Beach station on the North Jersey Coast Line. D'Agostino was returning from Turkey to a Thanksgiving family reunion.

NJ Transit will be cited by the FRA for allowing the train to be operated with the bypass switch on and could face a fine up to $27,000.

The report also concluded that "had the assistant conductor been at the required location, the passenger caught in the door would have been seen and the accident would not have occurred."

The assistant conductor was supposed to be in the rear vestibule of the last car of the "working portion of the train" or in the last open door of the rearmost car of the three occupied cars of the five-car train, the report said.

The assistant conductor told an FRA investigator that she couldn't get to that position in time because she was opening trap doors to stairs on rail cars so passengers could get off on the low level platform, the report said. Instead, she took
up a position at a door on the second car in order to get the doors open by the time the train reached Bradley Beach, she said.

The report also said she failed to observe a red light on the side and inside of car 5514, "indicating a door was not closed" and failed to see D'Agostino was stuck .

Blame for entire crew
The engineer was faulted for failure to determine that the bypass switch in the locomotive was in the "on" position and not noticing that lights indicating a door was open weren't working, the report said.

The report also blamed the train conductor for failing to notice that the assistant conductor wasn't in the right position on the train.

NJ Transit conducted its own investigation and fired the train crew, which appealed that decision. The case is before a federal mediation board.

D'Agostino had initially been aboard an NJ Transit train that struck a woman on the tracks near Matawan. A "rescue" train was sent from Bay Head to transport the remaining passengers from that train, which remained in place as authorities investigated that first accident.

NJ Transit officials issued a brief statement on the FRA report.

"We don't comment on details that are pending litigation; however, this report confirms the conclusion of NJ Transit's investigation," said Penny Bassett-Hackett, a commuter agency spokeswoman.

Don Greer, the attorney representing the D'Agostino family, which is suing NJ Transit, said he is waiting for a copy of the report. The case was assigned to a court-appointed mediator in November, he said.

"It is disturbing to note the assistant conductor was not in the right place, but more disturbing to note the bypass switch (was on)," Greer said. "From what I've gathered, it seems the rescue train was understaffed."

Patrick Reilly, the general chairman of United Transportation Union Local 60, which represents NJ Transit conductors and assistant conductors, challenged the report's conclusions. Reilly had questioned the safety of rail car doors at an NJ Transit board meeting in July. The FRA conducted a second door test of the train in August.

"I find several items with the FRA report that are unaddressed," said Reilly, a retired investigator for the National Transportation Safety Board and the FRA.

Among issues he raised at the July meeting were that the bypass switch may have been on without the train crew knowing it was activated. The FRA report notes that bypass switches can be turned on without breaking a seal over those switches.
It also says that red indicator lights on a door control panel for doors three and four in car 5515 had burned-out bulbs when tested on the day the fatality occurred.

The next day, Nov. 22, 2006, a FRA safety advisory recommended that NJ Transit "assess the rules, instructions and procedures used to ensure that a train will not depart a station until all passengers successfully board or alight from a train and ensure compliance with such rules and regulations."

Rule revisions, reminders
After the accident, NJ Transit issued four rule revisions and reminders about when and how the bypass switch was to be used. Those rule changes could count in NJ Transit's favor when it comes time to determine the size of any fine.

That part of the case is still open, said Warren Flateau, FRA spokesman. NJ Transit can make a case for a lower fine through an attorney presenting evidence on the carrier's behalf, he said.

"A settlement conference can address system-wide issues and what NJ Transit has done to ensure it won't happen again," Flateau said.

The fine is a statutory cap and isn't intended as a punishment, he said.

"The FRA can't say 'We'll fine you a million dollars' — we don't have the authority," Flateau said. "Our focus isn't exacting punishment; that's what tort (civil) cases are for."

The FRA investigation into the accident included a test of the locomotive and five passenger cars involved in the fatality. Two tests were done on the doors on the day of the accident and in August.

The test on Car 5515 revealed that the doors operated as they are supposed to when different-sized objects, including a foot, were placed in the way and the bypass switch was off or in the normal position. The only exception was when a three-quarter-inch piece of wood was placed in the door. It closed and the locomotive was able to draw power to move, the report said.
Again, its not as cut and dry as this article makes it out to be, but thats expected in a newspaper, they aren't going to get into all the boring technical concepts, faults, etc. But as usual, Mr. Higgs seems to have done his research and developed a pretty decent article.

Just one clarification that can be confusing in the artcile. The end doors, NO MATTER THE POSITION OF THE BYPASS SWITCH, in Normal or Bypass, will "bounce back" when there is an object in the door. That is the sensitive strip system, and a totally seperate system. So even if the doors bypass switch was in bypass, if there was an object in the door, the door would have reopened. However, the bypass system would allow the engineer to draw power if the door was opened in any way. As refenced in the article, the doors worked, except for a 3/4 inch piece of wood, which allowed the locomotive to draw power, and showed a door closed indication with that object still in the door.

Now, put all your fingers together and straighten out your fingers, so you have a flat surface (not a fist, fingers flat, as if on a table) and measure that. For MOST people that will be under 3/4 of an inch. Think about it.......

Im not trying to put the blame on the victim here, however, the incident is not as cut and dry (IMO) as its being made out to be. A LOT of things COULD have happened. While the bypass switch might have been a factor, there is a good chance it wasn't the only factor. Same with the actions of the crew. they could have been a factor, but not the only factor. When an incident like this happens a LOT of stars have to come into alignment. Unfortunately for Mr. D'Agostino, and the train crew, that night, they did.

  by thebigc
 
I especially like the part about the AC not "observing" the platform. They tell us we have to have our face pressed to the window to "observe" the platform. And what exactly can you see, anyway? Nothing, in relation to your train, really.

Did the engineer put the doors in bypass and not tell the Conductor? Or were they already in bypass?

Think its easy being a Conductor? This person got canned because he wasn't watching the AC every step of the way, apparently, and possibly for something the engineer did.

And thanks again to our mechanical dept, beyond reproach as usual.

  by Jtgshu
 
thebigc wrote:I especially like the part about the AC not "observing" the platform. They tell us we have to have our face pressed to the window to "observe" the platform. And what exactly can you see, anyway? Nothing, in relation to your train, really.

Did the engineer put the doors in bypass and not tell the Conductor? Or were they already in bypass?

Think its easy being a Conductor? This person got canned because he wasn't watching the AC every step of the way, apparently, and possibly for something the engineer did.

And thanks again to our mechanical dept, beyond reproach as usual.
As far as I know BigC, the door switches on the diesel were sealed...........now, were they in the proper position when they were sealed and the paperwork signed off on the loco..........?

  by peak-layover
 
Correct me if I'm wrong, but I remember hearing that when this first happened that it was his coat that was caught in the door. Going back to the 3/4 inch thing, most coats are not 3/4 of an inch when they are compressed. The man could have easily become stuck and the doors would not have sensed it. That is a terrible excuse on the part of the investigators.

I really feel for the crew involved in this. It was speculated before that the results of the investigation would result in the finger being pointed at the crew. My heart goes out to them.

  by Nasadowsk
 
<i>And thanks again to our mechanical dept, beyond reproach as usual.</i>

Yeah no kidding. Does the MMC ever get found at fault _for anything_? I remember even in the infamous ground brush on the Arrow incident, somehow, it wasn't the MMC's fault...

  by DutchRailnut
 
Door lights are part of daily inspection and should be fixed at any inspection point, it has nothing to do with MMC.
Blame that one on the Electrician that signed the daily inspection.

  by thebigc
 
DutchRailnut wrote:Door lights are part of daily inspection and should be fixed at any inspection point, it has nothing to do with MMC.
Blame that one on the Electrician that signed the daily inspection.
I'm alluding to the fact that the doors had to be put into bypass. Which is something that occurs all too often.

  by ryanov
 
As a passenger, I hear of engineers unable to get door lights all the time. Eventually, I hear that they've checked all the doors and that the train was put into bypass. I know I thought that practice was over after the incident on the M&E, but apparently not.

What is a shame is that this crew got hit with it, like they're the only ones to run in bypass. Anyone who's ever ridden NJT knows that's not out of the oridinary.

  by DutchRailnut
 
On MNCR to put a train in door bypass the crew needs permission from dispatcher and each door needs to be checked before moving the train at each station.
Cutting out any safety device is not only FRA but also a company rule violation on MNCR.
Maybe the practice just got a bit out of hand on NJT ???

  by Uzi-Cat
 
Wow, door lights on the end door panel not working? The 3/4" piece of wood being caught in the door and the engine can still take power? That isn't supposed to happen. I can't remember when I had a train where all the door panels lights were working. That is why the process of closing the train doors is so painful now. It take much longer now since the brakeman is watching everything close from the outside and then watch his door close and then observe lights... Sounds like NJT doesn't want you to rely on lights. I guess that is sort of like how they don't want you to rely on the blue handbrake applied light. It all boils down to the crew bearing the final responsibility no matter what happens.

At least the Asbury Park Press article attempts to present the whole story, or at least a good portion of it. If you only read that first article, you come away with a totally different opinion. How fair to the train crew is that.

At least now, the local 60 has a real General Chairman who isn't afraid to defend his members.

  by nick11a
 
Geez, sounds like the are just trying to rush this one off on the crew whether or not they were entirely responsible..... and the story most definitely does not seem that cut and dry.

Unfortunately, it is guilty until proven innocent, and there just wasn't enough evidence to prove them innocent. In fact, most of the evidence is circumstancial.

Oh well, a man is dead, a crew is fired, NJT is fined a token amount and faces a possible lawsuit, and crews will continue to have to take responsibilty for FAULTY equipment that more often than not "does not work as intended." Wonderful....

  by Grump
 
nick11a wrote:Geez, sounds like the are just trying to rush this one off on the crew whether or not they were entirely responsible..... and the story most definitely does not seem that cut and dry.

Unfortunately, it is guilty until proven innocent, and there just wasn't enough evidence to prove them innocent. In fact, most of the evidence is circumstancial.
Welcome to the railroad.

  by thebigc
 
Scott, comparing the blue handbrake light and the door open lights on each car is a bit apple-orangeish, don't you think? One is a convenience feature and the other is a definite safety device, IMO. And you'd only need that little blue light once per trip while you'd rely on the red ones for the entire trip. But in one aspect you're right; NJT doesn't want us to rely on the door lights so they don't have to get fixed in a priority fashion. Like anything else around here.