1996 — Feb 16, MARC 286 and Amtrak 29 Trains Collide, Fire ~Silver Spring, MD — 11

— 11  NTSB. RAR: Collision…Derailment…MARC…286…Amtrak…29…Silver Spring…, 1997.

— 11  Wikipedia. “List of Rail Accidents (1950-1999).”

 

Narrative Information

 

NTSB: “Abstract: On February 16, 1996, Maryland Rail Commuter (MARC) train 286 collided with National Railroad Passenger Corporation (Amtrak) passenger train 29 near Silver Spring, Maryland. All 3 CSXT operating crewmembers and 8 of the 20 passengers on MARC train 286 were killed in the derailment and subsequent fire.  Eleven passengers on MARC train 286 and 15 of the 182 crewmembers and passengers on Amtrak train 29 were injured.

 

“The major safety issues discussed in this report are the performance and responsibility of the MARC train 286 crewmembers, the oversight of CSXT signal system modifications, the Federal oversight of commuter rail operations, the lack of positive train separation control systems, and the adequacy of passenger car safety standards and emergency preparedness. In addition, the Safety Board examined the use of the reverser during an emergency brake application, the effectiveness of the computer-aided train dispatching recordkeeping, the crashworthiness of locomotive fuel tanks, and the contents of the CSXT and MARC operating agreement.

 

“As a result of its investigation, the Safety Board issued recommendations to the FRA, the FTA, the CSXT, the MTA/MARC, the U.S. Department of Transportation, the Federal Emergency Management Agency, the Governor and the General Assembly of Maryland, the Association of American Railroads, the Montgomery County Emergency Management Agency, the Baltimore County Emergency Management Agency, the Baltimore City Emergency Management Agency, the Metropolitan Washington Council of Governments, the Jefferson County Commissioners, the Berkeley County Commissioners, the American Short Line Railroad Association, the Brotherhood of Locomotive Engineers, the United Transportation Union, the International Brotherhood of Teamsters, and the American Public Transit Association. In addition, the Safety Board reiterated safety recommendations to the FRA, the General Electric Company, and the Electro-Motive Division of General Motors….”  (NTSB.  MARC/Amtrak Collision. 1997.)

 

“Executive Summary.

 

“About 5:39 p.m. on February 16, 1996, Maryland Rail Commuter (MARC) train 286 collided with National Railroad Passenger Corporation (Amtrak) passenger train 29 near Silver Spring, Maryland. En route from Brunswick, Maryland, to Union Station in Washington, DC, MARC train 286 was traveling under CSX Transportation Inc. (CSXT) operation and control on CSXT tracks.  MARC train 286 passed an APPROACH signal before making a station stop at Kensington, Maryland; proceeded as if the signal had been CLEAR; and, then, could not stop for the STOP signal at Georgetown Junction, where it collided with Amtrak train 29. All 3 CSXT operating crewmembers and 8 of the 20 passengers on MARC train 286 were killed in the derailment and subsequent fire. Eleven passengers on MARC train 286 and 15 of the 182 crewmembers and passengers on Amtrak train 29 were injured. Estimated damages exceeded $7.5 million.

 

“The National Transportation Safety Board determines that the probable cause of this accident was the apparent failure of the engineer and the traincrew because of multiple distractions to  operate MARC train 286 according to signal indications and the failure of the Federal Railroad Administration (FRA), the Federal Transit Administration (FTA), the Maryland Mass Transit Administration (MTA), and the CSXT to ensure that a comprehensive human factors analysis for the Brunswick Line signal modifications was conducted to identify potential sources of human error and to provide a redundant safety system that could compensate for human error.

 

“Contributing to the accident was the lack of comprehensive safety oversight on the CSXT/ MARC system to ensure the safety of the commuting public. Contributing to the severity of the accident and the loss of life was the lack of appropriate regulations to ensure adequate emergency egress features on the railroad passenger cars….”  (NTSB 1997, vii.)

 

“Accident Narrative

 

“On Friday, February 16, 1996, at 5:39 p.m., an eastbound Maryland Rail Commuter (MARC) train 286, operated by the CSX Transportation Inc. (CSXT) for the Maryland Mass Transit Administration (MTA) collided with the westbound National Railroad Passenger Corporation (Amtrak) passenger train 29, Capitol Limited… The accident occurred during a blowing snowfall near milepost (MP) BA 8.49 at a railroad location, referred to as Georgetown Junction, about 1 mile west of Silver Spring, Maryland…The snow accumulation on the ground at the accident site was 5 inches… Both trains were operating on the double main tracks owned and maintained by the CSXT.

 

“The MARC train 286 was a “push-pull” commuter train consisting of a locomotive unit on the rear end, two passenger cars, and a passenger coach cab control car in the lead. The engineer was operating the train from the cab control car in the push mode at the time of the collision. The MARC train 286 was in scheduled commuter service proceeding eastward on track 2 between Brunswick, Maryland, and Union Station, Washington, DC. The train departed Brunswick at 4:30 p.m. eastbound for a scheduled 5:30 p.m. arrival at Union Station with three CSXT operating crewmembers (an engineer, a conductor, and an assistant conductor) on board.  MARC train 286 had to make a “flag” station stop at the Kensington, Maryland, station to board two waiting passengers. The train carried 20 passengers at the time of the collision. Before MARC train 286 stopped at Kensington, the engineer on the westbound MARC train 279 stated that as the two trains passed each other on adjacent tracks, he had heard a portion of the radio communication of the MARC train 286 engineer acknowledging the wayside signal 1124-2, located about 1,000 feet west of Kensington station.

 

“The westbound Amtrak train 29, with a 2-unit locomotive and 15 cars, departed Union Station about 5:25 p.m. en route to Chicago, Illinois. The Amtrak operating crew consisted of an engineer, an assistant engineer, a conductor, and an assistant conductor. Thirteen on-board service employees, a mechanical rider who was in the second unit, and 164 passengers were also

on board the Amtrak train. The Amtrak train 29 had been routed onto track 2 from Union Station

to Georgetown Junction to pass a stopped westbound CSXT freight train that occupied track 1 east of Georgetown Junction. The engineer of Amtrak train 29 stated he was operating on a MEDIUM CLEAR signal…and was beginning to negotiate the crossover from track 2 to 1 at Georgetown Junction when the collision occurred…

 

“The locomotive event recorder of MARC train 286 indicated that the train accelerated upon departing the Kensington station, slowed for a posted speed restriction, and then accelerated again. The engineer of MARC train 286 placed the train brakes in emergency about 2.18 miles from the Kensington station at a speed of approximately 66 mph. About 11 seconds after the emergency brake application and 7 seconds before impact, the train control lever (reverser) was recorded as being moved from reverse to forward. (The locomotive had been operating in the reverse position as a pusher locomotive before this.) The impact speed with Amtrak train 29 was

about 38 mph.

 

“The collision between the lead Amtrak unit and the MARC cab control car tore away the front left quadrant of the cab control car. The fuel tank on the lead unit was ruptured in the collision and sprayed fuel on the cab control car. All three MARC cars and the MARC locomotive derailed in the accident. Both Amtrak units and the first eight cars of train 29 derailed. The derailed Amtrak equipment consisted of six material handling cars, one baggage car, and a transition-sleeper car, which was the only occupied Amtrak car to derail….”  (NTSB.  MARC/Amtrak Collision. 1997, 1-2.)

 

“The first firefighters to reach cab control car 7752 reported that the car was fully involved in fire and that they did not observe any survivors.  They made several attempts to enter the cab control car. The fire was extinguished within 10 minutes, after which the firefighters were able to enter cab control car 7752. They were later assisted by members of the Montgomery County Police Department (MCPD) in the recovery of 11 victims for coordinating the identification and notification process with the Maryland medical examiner. At 3:50 a.m. on Saturday, February 17, 1996, the last victim was recovered, and the IC turned over the accident to the MCPD. At 4 a.m. the recovery operations were secured.”  (NTSB.  MARC/Amtrak Collision. 1997, 7.)

 

“The last car in the consist, passenger coach 7709, derailed and tilted approximately 30 degrees clockwise. Its corner was depressed near the frame of the left-side rear door, which was closed. The front end of the passenger coach 7709 was lodged against the rear end of the passenger coach 7720. The truck assembly on the rear end, which was lodged against locomotive unit 73 and Amtrak locomotive unit 811, was damaged. Passenger coach 7709 had no fire damage. No emergency window exit decals were found on or near the windows. On February 29, 1996, with MARC officials present, a Safety Board investigator took several minutes, applying physical exertion, to remove the leftside front emergency exit window of passenger coach 7709. Then on March 14, a Safety Board investigator attempted unsuccessfully to remove the right-side rear emergency exit window, which was later removed by another investigator after about 3 minutes of physical exertion. (A lubricant used to install these particular emergency windows was later found to have hardened over time.)”  (NTSB.  MARC/Amtrak Collision. 1997, 17.)

 

“Pathological and Medical Information

 

“MARC Train 286–On February 17, 1996, autopsies were performed in Baltimore on the three MARC operating crewmembers and the eight MARC passengers who were fatally injured in the collision. The Maryland medical examiner recorded the postmortem examination reports.

 

“The engineer, who was found on the exterior left side of cab control car 7752, received fatal multiple injuries and generalized body burns.  The conductor, who was recovered from the aisle floor at row 10, sustained fatal multiple injuries.  The assistant conductor, who was discovered lying over a right side seat of row 9, received fatal smoke and soot inhalation and generalized body burns.  The eight passenger fatalities were also in cab control car 7752: two sustained fatal smoke and soot inhalation injuries, three received fatal smoke and soot inhalation injuries plus general body burns, one sustained fatal generalized body burns, another received fatal soot inhalation injuries and generalized body burns, and the final victim sustained fatal multiple injuries with generalized body burns….” (NTSB.  MARC/Amtrak Collision. 1997, 26.)

 

“Postaccident Actions

 

“National Transportation Safety Board—On March 12, 1996, during its investigation of this accident, the Safety Board issued the following four urgent safety recommendations…to improve the safety of the rail commuting public:

 

–to the Maryland Mass Transit Administration:

 

Install removable windows or kick panels for emergency exits in interior and exterior passageway doors. (R-96-4)

 

Install an easily accessible interior emergency quick-release mechanism adjacent to all exterior doors. (R-96-5)

 

Install retro-reflective signage on car interiors and exteriors at emergency exits that contains easily understood instructions and clearly marks all emergency exits (doors and windows).  (R-96-6)”  (NTSB.  MARC/Amtrak Collision. 1997, 36.)

 

“–and to the Federal Railroad Administration:

 

Inspect all commuter rail equipment to determine whether it has: (1) easily accessible interior emergency quickrelease mechanisms adjacent to exterior passageway doors; (2) removable windows or kick panels in interior and exterior passageway doors; and, (3) prominently displayed retro-reflective signage marking all interior and exterior emergency exits. If any commuter equipment lacks one or more of these features, take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (R-96-7)”….  (NTSB.  MARC/Amtrak Collision. 1997, 37.)

 

“Locomotive Fuel Tanks–…. The fuel tank of the Amtrak lead locomotive unit ATK 255 was almost completely separated from the unit and was found lodged against and partially underneath the left side of the unit, adjacent to its normally mounted location. The left side-plate of the tank was catastrophically ruptured open and showed substantial shredding deformation and impact striations.

 

“The circumstances suggest that the fuel tank of the lead Amtrak unit ATK 255 ruptured on impact with the MARC cab control car 7752 and that the diesel fuel therein ignited and engulfed

the cab control car. There are no regulatory requirements or industry design specifications for the locomotive fuel tanks involved in this collision…” (NTSB.  MARC/Amtrak Collision. 1997, 45.)

 

“Accident Narrative Review

 

“The APPROACH indication of signal 1124-2 required the MARC train 286 engineer to slow his train to not more than 30 mph after passing the signal and to be prepared to stop at the Georgetown Junction signal.  The collision occurred because the engineer did not operate MARC train 286 in conformity with the signal indication when he stopped at Kensington station and then proceeded towards Georgetown Junction, attaining a speed of about 66 mph. The engineer’s actions after departing the Kensington station were appropriate had signal 1124-2 been CLEAR, but his actions were inappropriate for an APPROACH aspect….” (NTSB 1997, 46.)

 

“….Disbelief was likely once he or the other crewmembers or both observed the STOP signal at Georgetown Junction. The crew would have then consumed some time trying to reconcile the restrictive STOP indication with an expected CLEAR indication, which had been the norm for them at Georgetown Junction. One of the passengers stated, “I could see the look, like bend over and check to see if something’s coming, then they jump back like in shock, then they went forward again just to double check,” which would attest to disbelief on the part of the traincrew.” (NTSB. MARC/Amtrak Collision. 1997, 46.)

 

“Traincrew Voice Recording

 

“The 35-year experience using cockpit voice recordings (CVRs) to assist in determining the cause of commercial aviation accidents has shown that evidence about the operating communications among crewmembers is frequently important in accident investigations….

 

A few years ago the FRA contemplated issuing a rule requiring voice recorders in locomotive compartments but rejected the idea because it did not consider them as a necessary safety measure.  The FRA could have included traincrew voice recording requirements in the 1993 regulations for locomotive event recorders as part of the minimum parameters to be recorded. The Safety Board, consequently, concludes that had the FRA required the recording of the train crewmembers’ voice communications, the essential details about the circumstances of this accident could have been provided. Therefore, the Safety Board believes that the FRA should amend 49 CFR Part 229 to require the recording of train crewmembers’ voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings….”  (NTSB. MARC/Amtrak Collision. 1997, 51-52.)

 

“Positive Train Separation Control Systems

 

“The Safety Board has long advocated a PTS control system and since 1970 has issued safety recommendations concerning train collision prevention…A PTS control system can prevent trains from colliding by automatically interceding in the operation of a train when an engineer does not comply with the requirements of the signal indication.

 

“Following its investigation of a head-on collision on the Burlington Northern Railroad near Ledger, Montana, the Safety Board issued in July 1993 the following safety recommendation to the FRA:

 

In conjunction with the Association of American Railroads and the Railway Progress Institute, establish a firm timetable that includes at a minimum, dates for final development of required advanced train control system hardware, dates for an implementation of a fully developed advanced train control system, and a commitment to a date for having the advanced train control system ready for installation on the general railroad system. (R-93-12)…

 

“The FRA and the railroad industry share the responsibility for the development and implementation of a PTS control system.  Under its regulatory authority, the FRA can order a railroad to install a PTS control system, and the FRA can issue emergency orders, as it did following this accident, where an unsafe condition or practice causes an emergency situation involving a hazardous death or injury….”  (NTSB. MARC/Amtrak Collision. 1997, 55.)

 

“The Safety Board has investigated numerous train collisions in which the probable cause or contributing cause was the inattention of the traincrew to wayside signals. In its investigation of the head-on collision of two freight trains near Kelso, Washington, the Safety Board attempted to determine again why one traincrew did not comply with the signal indication of an intermediate signal.  The Safety Board reported its concerns about a systemic safety issue: the adequacy of passive wayside signals to reliably capture traincrews’ attention when competing sources of attention are present, and it urged the railroad industry to recognize that human vigilance has limits and that wayside signals do not ensure safe train operations…”  (NTSB. MARC. 1997, 56)

 

Since the collision at Georgetown Junction, MARC has undertaken a project, for which the MTA has hired a consultant and provided funding, to develop and evaluate an intermittent cab signaling system (ICSS) that features both civil speed enforcement and positive train stop technology….

 

The Safety Board is encouraged by the efforts of the MTA/MARC project to develop and evaluate an ICSS; however, ICSS should only be an interim solution until a PTS control system can be fully implemented. A PTS control system is a major step for the railroad industry to provide a redundant system where an unacceptable threat to public and employee safety exists.”  (NTSB. MARC/Amtrak Collision. 1997, 57.)

 

“Passenger Car Safety Standards

 

“During the investigation of this accident, the Safety Board identified problems with emergency egress from the passenger cars that contributed to the number of fatalities….” (NTSB 1997, 58)

 

“The MTA responded in a November 7, 1996, letter that it has: 1) entered into an engineering contract for designing removable windows for emergency exits in car end and side doors….2) completed the design of a quick-release mechanism adjacent to all exterior doors with the mechanism installation to be completed in March 1997….and 3) installed luminescent interior as well as enhanced retroreflective exterior signage on all MARC cars as of August 30, 1996….

 

“The Safety Board first began addressing passenger car safety with the FRA after an accident at the Botanical Gardens station in New York, New York, in January 1975…. In June 1996, the FRA finally reacted to the concerns raised by the Safety Board, the General Accounting Office, and others and issued a notice of initiation for rulemaking on rail passenger equipment safety standards to comply with the Federal Railroad Safety Authorization Act of 1994.

 

“Current FRA regulations for passenger car safety standards are inadequate. They do not address passenger car safety standards for selfcontained emergency lighting; inspection, removal, and maintenance of emergency windows; exterior emergency door releases; interior flammability and smoke standards; and structural crashworthiness. The Safety Board is encouraged by the current FRA position in developing rulemaking and expects that the passenger car safety standards will not only address the safety of passengers in newly built passenger cars but also in existing passenger cars. The FRA indicated that the group working on the development of passenger car safety standards completed their work in December 1996, and a notice of proposed rulemaking (NPRM) is expected by the end of 1997.

 

“In addition during the investigation of this accident, the Safety Board identified several areas of safety deficiencies that should be addressed by passenger car safety standards for improved passenger safety. The identified areas are the power source of emergency lighting, the difficulty in removing emergency windows, the missing or inaccessible exterior emergency door release handles, the failure of interior materials to meet flammability and smoke standards, and the structural crashworthiness of cab control cars….”  (NTSB 1997, 60-61)

 

“After Safety Board investigators alerted MARC to the failure of the emergency lighting system, MARC projected plans to complete by late 1997 the fleetwide installation of battery pack ballasts, designed to provide power should head-end or car battery power be lost, in selected fluorescent lighting fixtures….

 

“….The Safety Board concludes that a need exists for Federal standards requiring passenger cars be equipped with reliable emergency lighting fixtures with a self-contained independent power source when the main power supply has been disrupted to ensure passengers can egress safely.  Therefore, the Safety Board believes that the FRA should require all passenger cars to contain reliable emergency lighting fixtures that are each fitted with a self-contained independent power source and incorporate the requirements into minimum passenger car safety standards….” (NTSB 1997, 62)

 

“Exterior Emergency Door Release

 

“….The Safety Board concludes that the exterior emergency door release T-handles for the MARC cars were not either in place or accessible to firefighters because no requirements for their maintenance or accessibility exist. Therefore, the Safety Board believes that the FRA should require that all exterior emergency door release mechanisms on passenger cars be functional before a passenger car is placed in revenue service, that the emergency door release mechanism be placed in a readily accessible position and marked for easy identification in emergencies and derailments, and that these requirements be incorporated into minimum passenger car safety standards….”  (NTSB 1997, 63)

 

“Interior Materials

 

“The analysis of fire debris indicated that diesel fuel from the breached fuel tank of Amtrak unit 255 sprayed into the breached opening of the MARC 286 cab control car. Positive residues were found on some passenger seats and on a sheetmetal panel near the opening. The analysis revealed that the diesel fuel played a significant role in the early fire growth within the car, and within 3 to 5 minutes after the collision based on witness testimony, flashover developed in the cab control car with the fire accelerating over the breached area because of that sprayed diesel fuel. Had diesel fuel not sprayed into the cab control car, the fire likely would not have spread as quickly as it did. For the passengers to quickly exit the car became even more critical because of the rapid growth of fire. Except for those passengers who died from blunt trauma injuries, others may have survived the accident, albeit with thermal injuries, had proper and immediate egress from the car been available. The Safety Board concludes that the catastrophic rupture of the Amtrak unit 255 fuel tank in the collision with the MARC cab control car 7752 released fuel, which sprayed into the interior of the cab control car, and resulted in the fire and at least 8 of the 11 fatalities….”   (NTSB 1997, 63)

 

“Emergency Preparedness

 

“The MCEMA[1] disaster plan did not contain procedures for responding to railroad passenger train accidents. The Safety Board concludes that the MCEMA disaster plan lacked procedures for responding to railroad passenger train accidents, such as simulating the accident response with coordinated management, which could have emphasized the importance of being familiar with passenger cars and of coordinating activities between the MCFRS, the MTA/MARC, and the CSXT. To be familiar with the means of emergency egress from a passenger train and to coordinate activities with the railroads are extremely essential procedures needed for emergency response. Therefore, the Safety Board believes that the MCEMA should develop comprehensive procedures for responding to railroad passenger train accidents and include these procedures in its disaster plan….

 

“The CSXT traincrews of MARC passenger trains had minimal guidance, compared with the Amtrak manual of on-train instructions for conductors and assistant conductors, to properly perform passenger train functions. Since the CSXT operation in 1985 of the MARC passenger service, the CSXT had not maintained a comprehensive passenger program that would provide guidance to traincrews for passenger train functions. The CSXT produced Passenger Service Bulletins as needed, but it offered little guidance on responding to passenger train emergencies. The CSXT passenger traincrews reported that they had not received any emergency training in passenger train operations and in passenger responsibility in emergencies. The Safety Board concludes that the CSXT personnel operating MARC passenger trains are not adequately trained to understand and therefore emergency response organizations unless a national effort is made to address emergency response training for railroad accidents. Consequently, the Safety Board believes that the Federal Emergency Management Agency should include in its training at the U.S. Fire Administration National Fire Academy a curriculum that addresses the needs of State and local emergency management agencies to respond to a major railroad accident and that familiarizes emergency response organizations with railroad equipment and appropriate rescue methods for railroad accidents.”  (NTSB 1997, 68-69)

 

“Conclusions

 

“….4. The MARC train 286 engineer apparently forgot the signal aspect, which required him to be prepared to stop at Georgetown Junction, due to interference caused by various events, including performing an unscheduled station stop, that occurred between the presentation of the APPROACH aspect at signal 1124-2 and the STOP signal at Georgetown Junction.

 

 

“5. Neither the conductor nor the assistant conductor while in the cab control compartment appeared to have effectively monitored the engineer’s operation of MARC train 286 and taken action to ensure the safety of the train.

 

“6. Had the Federal Railroad Administration required the recording of the train crewmembers’

voice communications, the essential details about the circumstances of this accident could

have been provided.

 

“7. Had the Federal Railroad Administration and the Federal Transit Administration required the CSX Transportation Inc. to perform a total signal system review of the proposed signal changes that included a human factors analysis within a comprehensive failure modes and effects analyses, this accident may have been prevented….

 

“8. Federal funds granted for the signal modifications on the CSXT Brunswick Line to accommodate an increase in the number of Maryland Rail Commuter trains did not ensure that the safety of the public was adequately addressed.

 

“9. Without a separate collection database specific to commuter rail inspections and accident/incidents, it is difficult for the Federal Railroad Administration to evaluate its own effectiveness of inspections and to identify problematic trends.

 

“10. The Federal Railroad Administration reliance on the need for increased vigilance of wayside signals and special actions in operating rules, such as the crew communication rule of emergency order 20, does not adequately safeguard the public.

 

“11. Had a train control system that could utilize the cab signal equipment on the Maryland Rail

Commuter cab control car been a part of the signal system on the Brunswick Line, this accident may not have occurred.

 

“12. A fully implemented positive train separation control system would have prevented this accident by recognizing that MARC train 286 was not being operated within allowable parameters, based on other authorized train operations, and would have stopped the train before it could enter into the unauthorized track area.

 

“13. The emergency egress of passengers was impeded because the passenger cars lacked readily accessible and identifiable quick-release mechanisms for the exterior doors, removable windows or kick panels in the side doors, and adequate emergency instruction signage.

 

“14. The absence of comprehensive Federal passenger car safety standards resulted in the inadequate emergency egress conditions.

 

15. A need exists for Federal standards requiring passenger cars be equipped with reliable emergency lighting fixtures with a self-contained independent power source when the main power supply has been disrupted to ensure passengers can safely egress.

 

“16. Prescribed inspection and maintenance test cycles are needed to ensure reliable operation of

emergency windows in all long-distance and commuter rail passenger cars.

 

“17. The exterior emergency door release T-handles for the MARC cars were not either in place or accessible to firefighters because no requirements for their maintenance or accessibility exist.

 

“18. The catastrophic rupture of the Amtrak unit 255 fuel tank in the collision with the MARC cab control car 7752 released fuel, which sprayed into the interior of the cab control car, and resulted in the fire and at least 8 of the 11 fatalities.

 

“19. Because other commuter passenger cars may also have interior materials that may not meet specified performance criteria for flammability and smoke emission characteristics, the safety of passengers in those cars could be at risk.

 

“20. The Federal guidelines on the flammability and smoke emissions characteristics and the testing of interior materials do not provide for the integrated use of passenger car interior materials and, as a result, are not useful in predicting the safety of the interior environment of a passenger car in a fire.

 

“21. Even though the Montgomery County Fire and Rescue Services personnel responded promptly to the emergency, they could do nothing to save any of the accident victims because passenger coach cab control car 7752 was already completely engulfed in flames when the first firefighter arrived on scene.

 

“22. The Montgomery County Emergency Management Agency disaster plan lacked procedures for responding to railroad passenger train accidents, such as simulating the accident response with coordinated management, which could have emphasized the importance of being familiar with passenger cars and of coordinating activities between the Montgomery County Fire and Rescue Services, the Maryland Rail Commuter, and the CSX Transportation Inc.

 

“23. The confusion during the initial emergency response resulted because the CSX Transportation Inc. and Maryland Rail Commuter lacked a formal emergency management plan to follow.

 

“24. The CSX Transportation Inc. personnel operating Maryland Rail Commuter passenger trains are not adequately trained to understand and, therefore, execute their responsibilities for passengers in emergencies.

 

“25. The lack of appropriate training for emergency responders in the areas of emergency planning, coordination and communications, rescue methods, inaccessible terrain along railroad property, familiarity with railroad equipment, and disaster drills may become a recurrent problem for other emergency response organizations unless a national effort is made to address emergency response training for railroad accidents….

 

“27. The Federal Railroad Administration has not addressed the use of computer-aided dispatching system records to provide information for the identification and evaluation of potential safety-related trends for corrective action.

 

“28. The CSX Transportation Inc./Maryland Rail Commuter system lacked comprehensive safety oversight to ensure the safety of the commuting public.” (NTSB 1997, 73-74)

 

Wikipedia: “February 16, 1996 – Silver Spring, Maryland, United States: The engineer of a MARC commuter train bound for Washington Union Station, either misses or ignores a stop signal and collides with outbound Amtrak train no. 29, the westbound Capitol Limited. The crash left 3 crew and 8 passengers dead aboard the MARC train. Three die of injuries suffered in the impact; but the rest are killed by smoke and flames, the fire which may have been ignited by oil pot switch heaters. This accident lead to the FRA instituting the Delay in Block Rule, and also was a major impetus for the Passenger Equipment Safety Standards regulation (49 CFR Part 238).”  (Wikipedia.  “List of Rail Accidents (1950-1999).”)

 

Sources

 

National Transportation Safety Board. Railroad Accident Report. Collision and Derailment of Maryland Rail Commuter MARC Train 286 and National Railroad Passenger Corporation Amtrak Train 29 Near Silver Spring, Maryland on February 16, 1996 (NTSB RAR-97/02).  Wash., DC: NTSB, July 3, 1997, 155 pp. At: http://www.ntsb.gov/publictn/1997/RAR9702.pdf

 

Wikipedia. “List of Rail Accidents (1950-1999).” http://en.wikipedia.org/wiki/List_of_1950-1999_rail_accidents

 

 

 

[1] Montgomery County Emergency Management Agency