PB96-916302NTSB/RAR-96/02

NATIONALTRANSPORTATIONSAFETYBOARD

WASHINGTON, DC 20594

RAILROAD ACCIDENT REPORT

DERAILMENT OF AMTRAK TRAIN 49ON CONRAIL TRACKAGENEAR BATAVIA, NEW YORK, ON AUGUST 3, 1994

6721

Abstract: On August 3, 1994, westbound Amtrak (National Railroad Passenger Corporation)train 49 derailed on Conrail (Consolidated Rail Corporation) trackage at milepost 406.7 nearBatavia, New York. Ten crewmembers and 108 passengers sustained injuries.

The major safety issues included in this report are the lack of Federal and industry guidelines forflattened rail head conditions and the integrity of passenger car seats. The report also discussesthe timeliness and adequacy of emergency response services.

As a result of its investigation, the National Transportation Safety Board issued safetyrecommendations to the Federal Railroad Administration, the National Railroad PassengerCorporation, the Association of American Railroads, and the American Short Line RailroadAssociation.

The National Transportation Safety Board is an independent Federal agency dedicated to promotingaviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967,the agency is mandated by Congress through the Independent Safety Board Act of 1974 toinvestigate transportation accidents, determine the probable causes of the accidents, issue safetyrecommendations, study transportation safety issues, and evaluate the safety effectiveness ofgovernment agencies involved in transportation. The Safety Board makes public its actions anddecisions through accident reports, safety studies, special investigation reports, safetyrecommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety BoardPublic Inquiries Section, RE-51490 L'Enfant Plaza, SWWashington, DC 20594(202) 382-6735

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(703) 487-4600

DERAILMENT OF AMTRAK TRAIN 49

ON CONRAIL TRACKAGE

NEAR BATAVIA, NEW YORK

AUGUST 3, 1994

RAILROAD ACCIDENT REPORT

Adopted: July 11, 1996Notation 6721

NATIONALTRANSPORTATION

SAFETY BOARD

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iii

CONTENTS

EXECUTIVE SUMMARY ........................................................................................................... v

INVESTIGATION

Accident .......................................................................................................................................... 1Injuries............................................................................................................................................. 5Damages .......................................................................................................................................... 7Personnel Information ..................................................................................................................... 7Train Information ............................................................................................................................ 8Operations ....................................................................................................................................... 8Track and Signals ............................................................................................................................ 8Rail Defects ................................................................................................................................... 10Meteorological Information .......................................................................................................... 11Pathological, Medical, and Toxicological Information................................................................. 11Survival Aspects............................................................................................................................ 11Disaster Preparedness.................................................................................................................... 13Postaccident Tests ......................................................................................................................... 13

Rail Heads ............................................................................................................................... 13Signals ..................................................................................................................................... 14Material Handling Car 1500.................................................................................................... 14Dynamic Interaction between Material Handling Car 1500 and Rail Head............................ 19Metallurgical ........................................................................................................................... 23

ANALYSIS

General .......................................................................................................................................... 25Accident ........................................................................................................................................ 25Rail Structure................................................................................................................................. 25Wheel and Rail Dynamics............................................................................................................. 26Track and Rail Inspection.............................................................................................................. 27Flattened Rail Definition Standards .............................................................................................. 28Rail and Material Handling Car 1500 Dynamics .......................................................................... 30Survival Aspects............................................................................................................................ 31

iv

CONCLUSIONS ......................................................................................................................... 32

PROBABLE CAUSE .................................................................................................................. 33

RECOMMENDATIONS ............................................................................................................ 33

APPENDIXES

Appendix A--Investigation and Hearing ................................................................................. 37Appendix B--Material Handling Car Characteristics.............................................................. 39Appendix C—Acronyms Used in this Report......................................................................... 41

v

About 3:44 a.m. on August 3, 1994,Amtrak (National Railroad PassengerCorporation) train 49, the Lake ShoreLimited, en route from New York, NewYork, to Chicago, Illinois, was travelingwestbound about 79 mph on Conrail(Consolidated Rail Corporation) trackagewhen it derailed at milepost 406.7 nearBatavia, New York. No fatal injuries weresustained; 108 passengers and 10 crew-members were injured.

The National Transportation SafetyBoard determines that the probable cause ofthe derailment was the fact that Federal andindustry guidelines do not currently addressflattened rail head conditions, due to aninsufficient understanding of the risk thatflattened rail poses to train operation.

The major safety issues discussed in thisreport are the lack of Federal and industryguidelines for flattened rail head conditionsand the integrity of passenger car seats. Thereport also discusses the timeliness andadequacy of the emergency responseservices.

As a result of its investigation of thisaccident, the National Transportation SafetyBoard makes recommendations to theFederal Railroad Administration, theNational Railroad Passenger Corporation,the Association of American Railroads, andthe American Short Line RailroadAssociation.

EXECUTIVE SUMMARY

1

INVESTIGATION

The Accident

Amtrak (National Railroad PassengerCorporation) passenger train 49, theLake Shore Limited, was a regularlyscheduled westbound train that traveledfrom New York, New York, to Chicago,Illinois. (See figure 1.) The trainconsisted of 2 locomotive units, 2material handling cars (MHCs), 1baggage car, 12 passenger cars, and 1baggage/dormitory car. Before the trainleft Albany, New York, its operatingcrew received a list of speed restrictionsfor their trip. The crewmembersinspected the locomotive unit consist,reviewed the cab defect and inspectioncards, and checked the radio. They alsodid a mandatory road air brake test, byapplying and releasing the train airbrakes. The crew found no problem withthe locomotive consist or the air brakes.

Train 49 left Albany at 10:46 p.m. onAugust 2, 1994, and reached Rochester,New York, by early morning on August3. It left Rochester about 3:13 a.m.; andat 3:27 a.m., it passed over a draggingequipment and train defect detector,which did not detect any defects. (Seefigure 2.) About 3:42 a.m., it reachedmilepost (MP) 403.7, the point where theinitial derailment1 occurred. The train

1At the initial derailment, two wheels of the

train left the track, but the train continued on.The general derailment happened 3 miles and 2minutes 15 seconds later, when several moretrain cars derailed and the train could no longerproceed. The initial derailment as it occurred wasnot witnessed, nor was the train crew aware of it.

continued west and passed the head endof a Conrail (Consolidated Rail Cor-poration) freight train at MP 406.45. Thefreight train on the adjacent track, mainline track 1, was also moving west.According to both the Conrail trainengineer and conductor, sparks andgravel were coming from the undersideof either the second or third car behindthe locomotive units of train 49. Thecrew of the freight train attempted toalert the crew of train 49 by radio.

No response was received from theinitial attempt. Train 49 responded to thesecond attempt, but the generalderailment at MP 406.7 occurred almostsimultaneously. At the time, train 49 hada clear (proceed) signal indication andwas traveling, according to the eventrecorder, about 79 mph. The eventrecorder data strip also indicated that theemergency brakes were initiated by atrain line separation after the generalderailment had occurred.

Fourteen cars of the 18-car consisthad derailed. The two locomotive unitsand the first seven cars remained on theright-of-way within the track structureafter the derailment. The locomotiveunits and the second and third cars didnot derail, and only the lead trucks of thefirst, fourth, and fifth cars derailed.

,“ ,/iti

(..,

2

Signal Bridge/i

f x Area where Conrailtrain crew sawtrain 49 i Track 1

fi

EDestroyed switch Track 2

‘t- uI I

14 3 miles‘7”2mi’e+

M.P. 406.7 M.P. 403.7General derailment Initial derailment

M.P. 386.5Defect detector

Not to scale

Figure 2 — Profile of defect detector and initial and general derailment sites.

:x .&$-i., .;=>: ~,z .& :% .,.+ ~ +<~,, AL,,%,., ~, ,,, -;”

N#i?~~gii~gyf!;,:iw$g+j 4EnlfiNQ0;i ,::,q’;~~;f~Qn%tibnx*%&*:~, ,g<<, *,&As.~.’&~.~,

,, ,., ,..> . s ,- ?-,, ~ ,, ,,, --., ,,

1;%?.,..,. .n. $,.v~- .-,.

Engine 374 Upright2 Engine 207 Upright3 Material handling car 1500 Upright, lead truck off4 Material handling car 1505 Upright5 Baggage car 1162 Upright6 Coach car 4705 Upright, lead truck off7 Coach car 4602 Upright, lead truck off8 Coach car 4728 Upright, both trucks off9 Lounge car 28021 Upright, both trucks off

M.P. 407.36

10 Dome coach car 9411 On side, over bank11 Diner car 8503 On side, over bank12 \ Coach car 4007 On side, over bank13 Coach car 4716 On side, over bank14 Coach car 4640 On side, over bank15 I Sleeper car 2430 I Upright, over bank16 Sleeper car 2433 Upright, over bank17 Sleeper car 2056 Upright, over bank18 I Dormitory car BD1621 I Upright

A

‘Signal Bridge

)

Not to scale. — — . - .

Figure 5 – Location of cars after accident.

8

supervisory school, a 4-week foremanschool, and a 1-week track inspectionschool.

Train Information

The Amtrak Lake Shore Limited wasa consolidation of trains 449 and 49,which were combined at Albany for thetrip to Chicago. Trains 449 and 49 hadoriginated at the South Hampton StreetYard in Boston, Massachusetts, and atthe Sunneyside Yard on Long Island,New York, respectively. Train 449 hadconsisted of the two locomotive unitsand the first seven cars of the Lake ShoreLimited. These locomotives had their airbrakes tested and inspected on the daybefore the derailment when still part oftrain 449. Train 49 had included the carsthat became the last eight cars on theLake Shore Limited. Mechanicalpersonnel had tested and inspected theair brakes on August 2 at 5:50 a.m.When train 49 arrived at Albany, eight ofits cars and dome car 9411 were addedto the end of train 449 to form theconsist of the Lake Shore Limited. Afterthe two trains were combined, mechan-ical personnel, in accordance with 49CFR 232.12(b), did a 1,000-mileinspection, and no defects were noted.

Operations

The accident track was a section ofthe Chicago line of the Albany division,which was governed by the signalindications of the traffic control signalsystem, supplemented by bulletins,timetable special instructions, NORACoperating rules, and radio communi-cations. Conrail owned the track, andAmtrak had trackage rights to operatepassenger trains over it. Over 45-million

gross tons of freight were transported onmain line track 2 in 1993.

The train dispatcher for the Albanydivision was in Selkirk, New York, andoperated the Chicago line territoryremotely under a traffic control system.The trains were routed and controlled onthe main tracks by automatic and controlpoint signals. According to the timetable,train 49 was limited at Batavia to a speedof 79 mph. The engineer was operatingthe train under Amtrak Air Brake andTrain Handling Rules and Instructionsfor passenger train operations.

Track and Signals

The accident track was designated asFederal Railroad Administration (FRA)class 5 track, and the maximum speedfor a passenger train, under 49 CFR213.9, was 90 mph. However, FRAregulations do not allow any train tooperate at speeds greater than 80 mphunless the train is equipped withautomatic cab signals or automatic trainstop or train control systems. Since theConrail Rochester to Buffalo main linewas not equipped with either of thesystems, the Conrail timetable limitedpassenger trains to a maximum speed of79 mph. No other operational speedrestrictions were in effect for main linetrack 2 on the day of the derailment.

The derailment areas had two mainline tracks. Main line track 1 was northof main line track 2. The tracks, spaced13 to 13.5 feet apart, ran from east towest. The numbering of the milepostsincreased also from east to west. Thetrack gradient between the initial point

9

of derailment (POD), MP 403.7, and MP405.1 was 0.25 percent ascending,followed by a 0.14-percent descendinggrade to the general POD at MP 406.7.The initial POD was in a 1o 0' curve tothe right (westward) on main line track2.

Main line track 2 was constructed of140-pound RE (American RailroadEngineering Association), controlcooled, continuous welded rail. Manu-factured by United States Steel, it wasclassified as an “A” rail,2 heat numberCH D 27080A26, and installed new in1977. The rail at the initial POD wasfastened to wooden crossties with doubleshoulder tie plates (1:40 cant) with twoplate-holding spikes and two rail-holdingspikes per tie plate.

According to 49 CFR 213.233, class5 track must be inspected twice a week.Between July 5 and the day before theaccident, the Conrail track inspector hadinspected the track between MPs 356and 407 nine times from a high-railvehicle. He had noted the followingtrack defects: 24 bolt defects in joints, amissing frog bolt, a wide-gage location,and 2 cross level variations. Each defectwas reported as being corrected the same

2“A” rails are rolled from the topmost

portions of ingots cast from the open hearth steel-making process. During earlier times, railroadsgenerally restricted the use of “A” rail to yard orside tracks because of a tendency for inclusionsand impurities to congregate in the top of aningot. Conrail had not restricted the placement of“A” rails because in 1977, when the subject railwas manufactured and installed, the clean steel-making processes were in use. During the last 5years, newly manufactured “A” rails havedisappeared entirely because rails are now manu-factured using a continuous casting process.

day as noted, and not one of the noteddefects was in the area of MP 403.7.

Figure 7 — View of normaland flattened rail heads.

FRA track inspectors randomlyaccompany Conrail track inspectors toobserve track inspections. An FRA trackinspector had accompanied the Conrailtrack inspector, riding a high-railvehicle, 9 days before the August 3derailment. They found flattened railhead3 (see figure 7) at MP 403.7. TheConrail track inspector stated that theythought the flattened rail head mightconstitute a track geometry defect.4 Aftermeasuring the track for compliance withthe track geometry requirements for class5 track, the inspectors found that

3The head is the running surface of the rail; a

flattened head is one that has acquired adepression.

4When an inspector finds a track defect, hemust take, according to CFR 213.9, one of twoimmediate actions: either have the defect repair-ed or lower the track class number, thus loweringthe maximum operating speed of a train.

10

the track met the standards, and no otherexceptions were noted. They stopped atother areas without noting any defects.

Sperry Rail Service conducted aninternal rail defect inspection for Conrailon June 27, 1994. No rail defects werenoted in the initial POD area at MP403.7.

Main line track 2 had its last trackgeometry test 2 months before theaccident on June 6, 1994. One FRAreportable defect was noted betweenMPs 403 and 408. This defect at MP405.72 consisted of a cross levelvariation (height level between two rails)of 1.37 inches on tangent track. TheFRA allowable tolerance for class 5track cross level variation is 1.0 inch.The defect was corrected on June 8,when a section of rail was replacedbecause of a flattened rail head.

The geometry test in the spanbetween MPs 403 and 408 revealed fivedeviations from Conrail standards: fourcross level variations (from 0.78 to 0.87inch, with 0.75 inch as the threshold forclass 5 variance) and one cross levelvariation in a spiral to the curve (0.68inch, with 0.5 inch as the threshold forclass 5 variance in a spiral). However,the deviations were not FRA defects.Conrail categorizes such deviations aslevel 1, which do not require immediateattention.

The most recent major maintenanceprojects were tie replacement from MPs401.6 to 405.8, track surfacing betweenMPs 402.8 and 405.9, and rail grindingfrom MPs 382.0 to 435.8 on July 21 and26 and September 13, 1993, respectively.No record of unscheduled maintenance

that was performed in the derailmentarea was reported.

Signal test records before theaccident indicated no anomalies, and thesystem was functioning as intended. Allrequired FRA signal tests were currentand complete.

Rail Defects

Rail defects are addressed in theFRA track safety standards under 49CFR 213.113. The standards identifysuch rail defects as transverse fissures,compound fissures, detail fractures,engine burns, damaged rails, defectivewelds, horizontal or vertical split heads,split web or web separations, and cracksor ordinary breaks. Inspectors find thesedefects by either visual or electronicinspection, and various remedial actionsare prescribed to reduce the effect of adefect on the safety of train operations.The FRA track safety standards definedamaged rail as rail that has sustaineddamage from one of three causes: awreck; broken, flat, or unbalancedwheels; or slipping wheels. No definitionaddresses a flattened rail head.

Because a flattened rail is neitherdefined as nor considered a rail defect,no category was provided within theConrail track inspector’s form on whichto record the findings of his inspection.The track inspector, according to hisstatement, had recorded observed flat-tened rail head conditions on the otherside of his report forms as a reference forsubsequent inspections. He said that hehad first identified the flattened rail atMP 403.7 as engine burn since it did notfit any identified category.

11

The Sperry Rail Service Rail DefectManual, used as a reference by railroadtrack departments, does not contain adefinition of a flattened rail head.However, it states that a crushed railhead is a "flattening of several inches ofthe head usually accompanied by acrushing down of the metal, but with nocracking under the head." The origin isusually a soft spot in the steel of thehead. The crushed rail head grows whenheavy loads go over it, and the faster thatthe heavy load is traveling, the more thedepth of the crushing increases. Themanual goes on to state that a crushedhead is not a serious defect, but isgenerally removed from high speed trackbecause it can cause rough riding ofequipment and concentrated load defects(rail fracture) may develop from impact.

Conrail has a program for replacingworn curve rail. The flattened rail nearthe initial POD was not considered to beworn rail and was not reported to thesupervisor as part of this worn railprogram.

Meteorological Information

At the time of the accident, the skieswere cloudy, visibility was about 5 mileswith some fog, winds were calm,temperature was about 69 oF, and dewpoint was 67 oF with 90 percenthumidity.

Pathological, Medical, andToxicological Information

No fatal injuries were sustained inthe accident. The injured included 108passengers and 10 crewmembers whowere either treated at and released fromor admitted to one of five local hospitals.The 93 people who were treated and

released from hospitals sustainedbruises, abrasions, and small lacerations.The 25 passengers who were admittedsustained extremity and rib fractures,back injuries, internal injuries, andconcussions.

FRA regulations required theoperating crewmembers of train 49 tosubmit blood and urine specimens fortoxicological testing; the test resultswere negative.

Survival Aspects

The Heritage class dome coach 9411had seats that rotated and reclined (seefigure 8), which differed from all theother seats in the train cars. Each backframe was attached to its pan frame bytwo 12-inch-long tapered metal braces.During the derailment, the pan framesremained attached to the pedestals, andthe pedestals remained anchored to thefloor tracks and sidewalls. However, 20back frames, including the back cush-ions, separated from the pan frames,exposing the metal braces. (See figure9.) No car occupants reported beinginjured by these braces.

Some passengers reported that theyhad no difficulty in evacuating the cars;others, however, said that the evacuationwas difficult. Several passengers in thecars that had turned on their sides statedthat they had trouble reaching the exposedside windows. Other passengers said thatthey could not open the heavy car-enddoors. Darkness, the steep embankment,and the awkward position of the cars wereother reasons attributed to a difficultevacuation.

Disaster Preparedness

The GCEMC initiated the GeneseeCounty mass casualty incident plan forthis accident. The plan was to provideguidelines for orderly and efficientresponse procedures to incidents that taxnormal day-to-day response. The lastdisaster drill, according to the GCEMC,had been in September 1993 and sim-ulated a hazardous material spill accidentin which five fatalities and two injuriesoccurred at a rest stop on an interstatehighway.

In October 1994 at the New YorkState Fire Academy, Amtrak presentedto emergency response agencies its 3-hour training course, which includeshow emergency responders shouldinteract with Amtrak crewmembers,what emergency responders shouldknow about Amtrak equipment, and howto evacuate Amtrak trains. GeneseeCounty emergency response agenciesparticipated in this training. In April andMay 1995, Amtrak provided passengercars for use in disaster drills in fivecommunities near the site of the Bataviaderailment.

Postaccident Tests

Rail Heads — The south rail was thehigh rail in the accident curve. The headof the south rail at the initial POD wasflattened in several places (see figure10), most significantly just to the east,where the head was flattened for a lengthof 38 inches for a maximum depth of0.43 inch on the high side of the curve.(See figure 11.) At the same spot was amark, which appeared to be a wheelflange (see figure 12) mark on top of therail head, dropping off onto the crossties

and ballast and leading to the generalPOD. (See figure 13.)

Figure 10 — Flattened rail headat initial POD (looking east).

In the flattened rail head area, the topof the head had flowed outward (mush-roomed) toward both the gage and fieldsides 5 of the rail head, resulting in anincrease in the width of the head and alow spot in the running surface. Thehead material spread a greater amounttoward the field side of the rail (amaximum amount of more than 0.5 inch

5The gage side is between the running railsand is adjacent to the wheel flange. The fieldside is opposite the gage side.

13

The head of the south rail was alsoflattened in about 12 other locations east

Figure 11 — Flattened rail headafter removal.

beyond the field side of the head) thantoward the gage side (about 0.15 inch).The maximum width of the head in theflattened area, as measured in the SafetyBoard materials laboratory, was 3.695inches. The typical maximum headwidth of the rail was about 2.815 inches.(The rail head width and height is 3.0and 7.31 inches, respectively, for a new140-pound RE rail section.) The follow-ing table lists the south rail field mea-surements from the initial POD to 15feet 10 inches east of the POD:

Location

MP 403.7 (POD)

4 feet 6 incheseast*

9 feet O inches east

11 feet 8 incheseast

15 feet 10 incheseast

Rail HeadWidth

(inches)

3.0

3.62

3.0

3.0

3.0

1

Corresponds with center of flattened rail

14

RailHeight(inches)

7.28

6.79

7.13

7.22

7.26

section.

of the initial POD. One such location offlattened rail head was at MP 402.79,where the track alignment was in a 1028’curve. The flattened rail head was on thehigh side rail of the curve and appearedto be marked by a wheel flange. Thefollowing table lists the observed railhead measurements:

Location

mark on rail head

flattened head(maximum)

Rail HeadWidth

(inches)

2.98

3.17

RailHeight(inches)

7,09

7.02

The Safety Board did track geometrymeasurements with the track in theloaded and static conditions. The crosslevel variation at the flattened rail headat the initial POD in the loaded conditionwas 1.125 inches. The maximum allow-able deviation for class 5 track is 1 inchunder 49 CFR 213.63.

Signals — Postaccident signal testingwas completed on August 8, 1994, inaccordance with FRA requirements. Noexceptions were noted.

Material Handling Car 1500 — The firstand second cars behind the locomotiveconsist were the empty MHC 1500 andthe half-loaded MHC 1505, respectively.(The car weight light and with maximumcargo load is 76,700 and 177,000pounds, respectively.) These cars werepainted steel gray with Amtrak stripingand logos.

P

.

FlangeDepth

T~Gage Side

Side +,

Head Point ofRail: Web Measurement

Bas Tie Plate of Gage(Double-shoulder)+

I r % 41 ; I

!k ~~‘ I TrackII1,1 Spike ~~

Wood Crosstie

Figure 12 — Wheel/Rail interface.

Figure 14 — Material handling car of 1500-series.

1 Truck Frame 12 Friction Snubber

2 Equalizer Beams 13 Lateral Bumper

3 Equalizer Springs 14 Package Tread Brake

4 Pedestal Tie Bar 15 Disc Brakes

5 Roller Bearing Adapter 16 Bolster Anchor Assembly

6 Central Bearing 17 Locking Center Pin

7 Truck Bolster 18 Vertical Wear Sleeve

8 Secondary Coil Springs 19 Equalizer Spring Seat

9 Rubber Sandwich 20 Bolster Spring Seat Assembly10 Vertical Shock Absorber 21 Insulation Pad11 Lateral Shock Absorber 22 Wheel and Axle Assembly

Figure 15 — Truck of material handling car 1500.

18

20

final test was also organized by theSafety Board and was conducted by theResearch and Test Department of theAAR Transportation Test Center (TTC)in Pueblo, Colorado, between November7 and 10, 1995. This test physicallyreplicated the dynamics of the flattenedrail head being traversed by MHC 1500.7

According to the consulting firm,MHC 1500 lost vertical wheel load nearthe initial POD because of the flattenedrail head. The narrowing of track gagedue to flattened rail head resulted in anincrease of lateral wheel forces. The firmconcluded that these two factors in unionwould be sufficient to cause thederailment.

In addition, the consulting firmconducted simulations comparing thedynamic vehicle performance of anempty MHC 1500 at 70 mph with thefollowing: an empty trailer-on-flat-car(TOFC) at 50 and 70 mph, a loadedTOFC at 50 and 70 mph, a loaded and anempty hopper at 50 mph, and anAmcoach car at 70 mph. The resultswere preliminary in nature; however,these results indicated that the emptyMHC and the empty TOFC were moresusceptible than the other cars to losingvertical wheel load when the flattenedrail head was traversed.

In February 1995, a team of threeTTC vehicle/track interaction dynamicsengineers at the Amtrak Beech Groveshop facility inspected MHC 1500 tofactor the condition of the car into thecomputer model. Amtrak and repre-

7The second and third tests were conducted in

partnership with Amtrak, Conrail, the AAR, andthe FRA.

sentatives of the truck manufacturerwere present while the team examinedthe car. MHC 1500 was not in the samecondition as at the time of thederailment, and the trucks inspectedwere not the same trucks that wereinstalled at the time of the derailment.The car had been released and returnedfor service. AAR in its initial reportnoted the following:

• The B-end left side bolster anchor rodwas misadjusted, causing the bolster torub on its keeper and to have a potentialfor vertical and lateral suspensionbinding.

• The car body leaned to the left.

• The bolster springs on both ends of thecar had more shims on the right side ofthe car than on the left side.

• The B-end left side bearing gap wasalmost completely closed up and showedsigns of frequent rubbing between thebolster and truck frame. Wear surfaces atthe other three side bearings showedlittle signs of rubbing.

• Fatigue cracks were developing wheresome of the secondary verticalsuspension friction dampers weremounted to the side sill. This conditionmight be a sign of binding in thedampers causing excess forcetransmission into the body.

• Several axle journal boxes werebinding in the truck frame pedestal jaws.

• The B-end bolster was offset to theright so that the right side lateral stopwas almost in contact and showed signs

21

of frequent rubbing. The left side stopshowed no sign of contact or rubbing.

• The wheel profile measurements fromthe derailed axles showed a ridge in thegage corner of both wheels of the secondaxle.

Amtrak and the truck manufacturerconsidered the conditions noted by theTTC team to be still within design toler-ances. The car had been in servicesuccessfully for some months after theaccident.

The AAR, in participation with theSafety Board and the parties to theinvestigation, oversaw additional com-puter modeling in August 1995. TheTTC initial computer modeling verifiedto a great extent the Amtrak consultingfirm’s results; however, the TTC did notagree with all of the conclusions. TheAmtrak consultant concluded that thelateral wheel force was sufficient tocause derailment, but the TTC believedthat the lateral force predicted was notsufficient to cause flange climb. TheTTC thought that an extreme componentfailure, such as the truck failing to rotatefor the curve, would be necessary tocause a derailment. An actual field testwas proposed to determine whether theAAR NUCARS model reasonablypredicted the actual on-track perfor-mance of MHC 1500. Therefore, theTTC installed the accident rail in its owntest tracks and secured MHC 1500 toreplicate the dynamics of the accident.Then, the TTC conducted the followingtests between November 7 and 10, 1995:

• Twist and Roll: The TTC measuredthe suspension dynamics of the test carover known track perturbations and

compared the results with the computermodel parameters.

• Steady State Curving: The TTCmeasured truck rotations and otherdynamic characteristics of MHC 1500 ina 7.5- and 5-degree curve.

• Flattened Rail Head: The TTCmeasured the response of MHC 1500over the flattened rail from the accidentsite.

• Balloon Track: The TTC measuredtruck rotations and other dynamiccharacteristics of the car on the curvedtrack.

These test results correlated rela-tively well with the NUCARS simula-tions.

During flattened rail head tests,minor wheel unloading occurred at 50mph in the lead axle, and a morepronounced wheel unloading occurred at55 mph. The trailing axle wheel seemedin the video to be unloaded, but thecomputer data indicated a positivevertical force in the downward direction.Further calculations revealed that themaximum unloading occurred approxi-mately 4 to 4.5 feet from the flattenedrail, corresponding with the Safety BoardPOD measurement in Batavia. At thatpoint, the contact position sensorindicated that the wheel flange wasforced away from the rail. The tests wereterminated at 55 mph.

The AAR engineer suggested that therail "fell away" from the wheel becauseof the inertia of the wheel andsuspension, and when it came back incontact with the wheel, it caused a

22

1. The wheel is in normal contact with the rail

2. The wheel is air borne as the rail “falls away” from the wheel.

3. The wheel strikes the rail at the far side of the flattened area.

4. The wheel is again air borne due to the rebounding effect.

5. The wheel is in normal contact with the rail.

Figure 17 — Movement of wheel on flattened rail head.

relatively large vertical force that createda "bouncing" effect. Figure 17 illustratesthe sequence.

The AAR engineer had noticed in hisinspection of MHC 1500 that the car bodyleaned to the left. A leaning car body candecrease side bearing clearance and causeincreased turning friction in the truck as itattempts to steer through a curve. Tosimulate this condition at the test track, ashim was welded onto the side bearing onthe low-rail side. The resulting side bear-ing clearance8 on the modified truck was

8A side bearing is intended to control the roll

dynamics of the car. Side bearing clearanceallows the truck of a rail car to swivel freely toadjust to changes in the rail. Absence of sidebearing clearance increases friction force in the

approximately zero, which creates morefriction in the side bearing and makes itmore difficult for the truck to turn.

The results of the tests with the trucksshimmed closely corresponded with theresults of the test without the shims. Thedata from the second set of tests showedgreater wheel unloading and a greatertotal moment around the center pin. Thetrucks, however, did not lock.

During the second set of tests, at 60mph, the video image of the trailing axleshowed the flange riding on the gagecorner of the rail. The tests wereterminated at this time because snow

side bearing and decreases the ability of the truckto swivel.

23

began falling, which changed the frictioncoefficients between rail and wheel.

Metallurgical — The Safety Boardmaterials laboratory examined theflattened area and the adjacent section ofthe rail before the TTC tests were con-ducted. An ultrasonic test of the railshowed no identifiable internal defects.

After the TTC tests were performed,the materials laboratory examined twoadditional sections of the rail. Onesection was from the center of theflattened area, and the other, withoutflattening, was from an area near the firstsection. The shape of the base and webof the rail on both sections appeared toclosely conform with the specified shapeof a new 140-pound RE rail. However,the section without flattening containedwear to the gage side and to the top ofthe head, and the section from the centerof the flattened area was shown to havesubstantial deformation, as previouslydocumented. Figure 7 shows an approx-imate outline of the shape of a new 140-

pound RE rail superimposed on the headof the flattened rail section. Most of thelateral deformation of the rail, as indi-cated in this figure, was toward the fieldside. Also, more vertical (downward)deformation was on the field side of thehead than on the gage side.

Approximately 60 hardness measure-ments were taken on a grid patternthroughout the head portion of each railsection. These measurements generallyranged from 60 to 64 HRA (about 223 to262 Brinell). Within about 0.375 inch ofthe head surface of the section from theflattened area, the hardness was higher,up to a maximum measured value of69.6 HRA (345 Brinell). A thinner layerof increased hardness was also notedadjacent to the head on the other section,up to a maximum hardness of 66.6 HRA(304 Brinell). Standard rail manu-factured in the 1970s has a typicalhardness of 250 Brinell.

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General

The investigation by the Safety Boarddetermined that the members of theoperating crew of train 49 were qualifiedfor their duties and were operating thetrain properly. The crewmembers wererested in accordance with applicableregulations, and the on-board servicecrewmembers performed their dutiescorrectly.

The signal system had been recentlyinspected, and preaccident tests had notrevealed any defects. The signal eventrecorder indicated that the signal systemhad been interrupted at 03:43:58 a.m.,when the train derailed and struck thesupporting structure of the signal bridge.The investigation by the Safety Boarddetermined that the signal system had nodeficiencies, had functioned as intendedat the time of the derailment, and hadbeen clearly visible to the train crew.Train 49 was operating on a clear signalindication as intended. In addition, theweather did not affect the visibility ofthe signal aspects and was not a factor inthe derailment.

Therefore, the Safety Boardconcludes that the operation of train 49,the performance of the operating and on-board service crews, the signal system,and the weather were not factors in thederailment.

The 118 injured passengers andcrewmembers were removed from thederailment site within 1 hour 16 minutes.

All severely injured people were givenpriority attention. Therefore, the SafetyBoard concludes that the localemergency response personnel reactedpromptly and acted effectively at thederailment site.

Accident

The track structure between the initialand general PODs was marked by theflange of a wheel, indicating that at leastone car was derailed. Other marks werealso found near other flattened railbefore the initial POD, indicating thatwheel lift or some degree of dynamicinstability between the track and a traincar may have occurred. To correlate themarks with a particular car or with theAmtrak train as a whole, however, wasnot possible. The Safety Board alsodetermined that neither the equipmentnor the track deviated from the FRA anddesign specifications. The investigation,therefore, focused on the interactionbetween the flattened rail head at theinitial POD, MP 403.7, and MHC 1500.

Rail Structure

The determination that the initialPOD was at MP 403.7 was based on thetwo wheel flange marks on the gage sideof the rail head that began about 22 feeteast of the POD and continued westwardon the rail head for about 34.8 feetbefore leading to the field side. Themarks indicate that at this point, the

ANALYSIS

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wheel dropped off the rail and struck thetie plates 42.4 feet later. The same markscontinued for about 3 miles until theyreached the general POD at MP 406.7.

The rail head was flattened forapproximately 38 inches, starting about4.6 feet east of the POD, and thedepression was 0.43 inch at its deepestpoint. The Safety Board concentrated itsinvestigation on this depression and theseries of other flattened rail heads andwheel/flange marks east of the initialPOD to determine what part, if any, therail and track structure had in theaccident.

Wheel and Rail Dynamics

The TTC of the AAR replicated thewheel/rail dynamics between MHC 1500and a segment of the flattened railremoved from the accident track. Thesetests were electronically monitored forvertical/horizontal loads and real-timevideo recording of the wheel/railinterface at various speeds. The TTCinstalled the flattened rail in its highspeed test track in a 0' 50" curve.

Safety Board investigators observedthe video monitor showing the wheel/railinterface at various running speeds withMHC 1500 in a nominally modifiedcondition, as well as in its increased sidebearing friction condition. Investigatorsnoted that when the car was travelingbetween 55 and 60 mph, a space wasbetween the trailing wheel of the leadtruck and the rail surface when the carwent over the depression. The wheelthen dropped to the rail surface andrebounded for a short time beforereturning to the running surface of therail. The contact position sensors of the

instrumented wheels indicated that aflange had been in contact with the railfor between 2 and 2.5 feet at theflattened rail head. The sensors alsoshowed that the flange had had two verybrief periods of rail contact in the 10 feetpast the flattened rail head. The sensors,thus, validated the importance of themarks that the Safety Board had notedon the gage face of the rail after thetesting. What the investigators saw onthe video monitor was generallyconsistent with what the Safety Boardhad found at the initial POD and with theresults of the computer simulationsperformed by Amtrak and the AAR.

In addition, the Safety Board found anarea further east of the initial POD wherethe rail head was flattened and therunning surface was marked by a wheelflange. The rail head was not flattened asseverely as it was at the POD; but it stillevidenced wheel lift.

Safety Board investigators analyzedall of the evidence available in thisderailment. The results of the variouscomputer simulations and field tests donot conclusively predict that a flangeclimb derailment would take place at thePOD that was identified at the accidentscene. However, the test results doindicate that extreme wheel unloadingand flange contact was at the flattenedrail just before the POD, which are twoconditions that must be present for aflange climb derailment to occur.Therefore, the Safety Board concludesthat the simulations and field testscorroborate the location of the initialPOD and confirm that the flattened railhead allowed the wheel to lose contactwith the rail.

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Track and Rail Inspection

Title 49 CFR 213.233 required thatmain line track 2 be inspected twiceweekly. The Safety Board investigationdetermined that two inspections of thetrack in the Batavia area had been doneby the Conrail track inspector within the6 days before the derailment. On July 29,1994, the Conrail track inspectorperformed his last inspection of the trackbefore the August 3 derailment andnoted no exceptions on his inspectionreport.

The FRA randomly assigned aninspector to observe the Conrail trackinspector's practices during aninspection. On July 25, 1994, during aroutine joint track inspection, an FRAtrack inspector and the Conrail trackinspector rode together on a high-railvehicle. The inspectors stopped atseveral locations, including the sectionof track near MP 403.7. They found theflattened rail condition at what was tobecome the initial POD. They examinedthe rails at that location and found thecondition to be within track geometryspecifications.

The Safety Board investigationdetermined that both the carrier and theFRA inspectors were experienced andhad knowledge of the existing standardsfor track defects. The Safety Board,therefore, concludes that the trackinspections were being performed asintended by the carrier and by the FRAand that the flattened rail condition atMP 403.7 had been detected before thederailment occurred.

Under FRA track safety standards aflattened rail head is neither defined asnor considered a rail defect. The Conrail

track inspector had recorded theobserved flattened rail head on the otherside of his report forms because nocategory was provided within the form torecord these observations. He used thisrecord as a reference for subsequentinspections. As he told Safety Boardinvestigators, he had first identified theflattened rail at MP 403.7 as engine burnsince it did not fit any identificationcategory. Because flattened rail head wasnot defined as or considered an FRA raildefect and because the industry had noidentification for flattened rail head, theFRA and Conrail track inspectors, whenthey noted the flattened rail conditionduring their joint inspection, had noguidance to follow for a potentiallydangerous situation. The Safety Boardconcludes that the FRA has not providedthe guidance on what size or type offlattened rail head is potentially hazardousto train operations that would allow trackinspectors to take corrective action.Consequently, the inspectors could onlyexamine the area of the flattened railhead for a track gage or cross levelviolation of the track geometrystandards. The Safety Board, therefore,concludes that the flattened rail head atthe initial POD was not considered adefect because it did not meet thedefinition of an existing rail defect andthe track geometry did not meet defectspecifications.

During the postaccident investigation,the cross level variation of the track atthe center of the flattened rail head nearthe initial POD was 1.125 inches, whichwould have been considered a trackgeometry defect requiring repair or thereclassification of the track to FRA class4. Had the track been repaired byleveling the geometry defect, the

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flattened rail condition would haveremained in the track. The flattened railstill being in the track would havecaused the geometry to vary again fromthe wheel pounding over the railirregularity and would have caused apotential for wheel lift. Had the trackbeen reclassified, the maximum speedfor a passenger train on the track wouldhave been lowered to 80 mph.Nevertheless, the speed of train 49would not have been affected becausethe train was governed by the Conrailmaximum allowable timetable speed of79 mph for passenger trains.Consequently, the Safety Boardconcludes that the track geometry defectfound after the derailment at the initialPOD was not a contributing factor in thederailment.

Flattened Rail DefinitionStandards

The Conrail division engineer whoafter the accident had accumulated dataabout flattened rail estimated that 30.72miles of the 300 miles of rail betweenSelkirk (near Albany) and Bay View,New York, (near Buffalo, New York) is“A” rail, which is the type of rail thatseems to be subject to flattening.

The flattened rail head found in thisaccident is not unique to Conrail. TheAAR examined rail in 1994 from theChicago & North Western (CNW) andfrom the Canadian National (CN)railroads that exhibited physical andchemical properties that were similar tothe properties of the flattened rail headfrom the Batavia derailment. These railswere manufactured in the 1970s; theCNW rail was an “A” rail. (A CNW andCN review of other rails suggested “A”

rails were more likely to have thisflattened head condition.) Rolling loadtests on the CN rail, performed by theAAR, disclosed that after 2 millioncycles of impact simulation, no internalfatigue defects developed. The AARconcluded that these flattened railconditions tended not to be structurallydestructive. As a remedy for the railcondition, the CNW placed a speedrestriction on its track, and the CNattempted to weld and grind the affectedareas. The industry, however, has notdetermined the best long-term remedialaction.

The chief engineer of Conrail, whoalso was the president of the AmericanRailway Engineering Association,1 toldthe Safety Board that flattened rail headshad not been discussed to any extentwith other railroads, other than beingreported on at various committees, withthe CNW experience being thepredominant incident.

The Safety Board is concerned aboutthe incidents of flattened rail on Conrail,CNW, and CN tracks because theyindicate that this condition may occurelsewhere and, thus, threaten the safetyof train operations. The Safety Boardrecognizes that some time would berequired to collect and analyze data toascertain the cause of flattened rail andthe extent of the potential hazard. Safety-enhancing steps, however, could be

1 The engineering body of the North

American railroad industry, which presents aforum for discussion and development ofstandards of recommended practices for railroadmaintenance and design. Its members are railroadengineers and other qualified individuals whoserve on various organization committees.

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taken in the interim. The FRA couldissue technical bulletins for its inspectorsthat provide them with an interim aide indetermining the hazard posed byflattened rail conditions. A bulletin couldexplain the circumstances of thisaccident and offer guidelines based onsuch information as the speed and typeof a train and its operating area.Therefore, the Safety Board believes thatthe FRA should develop, not later thanDecember 31, 1996, an interim technicalbulletin authorizing track inspectors totake corrective action to prevent thepotential hazard of flattened rail headconditions to train operations.

The Conrail division engineeraccumulated data on removed flattenedrail to determine whether he couldestablish any correlation between thelikelihood of rail being flattened and itsweight, curvature, or classification. Hefound that “A” rails had the highestpercentage of flattening, with the highestnumber of occurrences in curves of 1degree or less. (The flattened rail head inthis accident was no exception to hisfindings; the “A” rail was in a 1-degreecurve.)

The Safety Board materials laboratorydid not find any metallurgical defects inthe flattened rail head from the POD.Although the reason for the flatteningcannot be conclusively determined, therail seemed to have much in commonwith other rail that has developedflattened rail head: it was an “A” railmanufactured in the 1970s that had beenheavily used in terms of tonnage andhigh axle loads. Additional research is

needed on flattened rail head todetermine the type of rail that is likely toflatten, the conditions that will cause itto flatten, and the risk posed by theflattening. The Safety Board believesthat the FRA should conduct appropriateresearch and develop a data base that canbe used to assess the risk posed byflattened rail heads. In addition, theSafety Board believes that the AAR andthe American Short Line RailroadAssociation, in conjunction, shouldassist the FRA in developing the database.

As a result of the Safety Board’sinvestigation, Conrail devised a workingdefinition of flattened rail head whenconsidering flattened rail replacement.Conrail defined it as rail head that has adepression that is at least 12 inches longand 0.25 inch deep. The chief engineerstated that this definition is arbitrary andhad been chosen as a starting point. Thedefinition would be more valuable if itwere based on an understanding of thecorrelation between risk and degree offlattening. However, both the FRA andthe industry lack the necessary data. TheSafety Board concludes that the FRAtrack safety standards fail to addressflattened rail head condition risks suchas found in this accident. Therefore, theSafety Board believes that the FRAshould develop guidelines, using the datacompiled about the risk of flattened railheads, for track inspectors to use toidentify rail head that may be hazardousto train operations and also regulationsto ensure that corrective action is takenwhen such flattened rail head conditionshave been identified.

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Rail and Material Handling Car1500 Dynamics

The TTC as part of its on-tracksimulation tests of the dynamicinteraction between the track and MHC1500 noted several irregularities;however, none were serious enough tobe considered defects. The irregularitiesindicated normal wear and tear, and theywere used to devise a more accuraterepresentation of the car for thecomputer simulation. MHC 1500 hadbeen repaired and released back intoservice up to that time. However, theseanomalous conditions had not beenpreviously reported and might have beenof some significance to the performanceof the car in its dynamic interaction withthe rail.

The detailed inspection of the car bythe Safety Board, both at the site of theaccident and at the Amtrak shop beforethe car was repaired, did not reveal anyconditions that either caused orcontributed to the accident. On October13, 1994, the trucks were disassembledand measured at the Amtrak BeechGrove shop, and the car truck frames andparts were found to be withinspecification.

During testing at the TTC, a 0.025-inch shim was tack welded into the leadleft side bearing gap, completely fillingthe gap. As a consequence, some of theweight of the car shifted from the centerbowl to the side bearing, causing afriction increase when the trucks slewed.The attempt to modify the behavior ofthe car during the dynamic testing at theTTC had no significant effect on theperformance of the car.

MHC 1500 had no history ofperformance, maintenance, or repairproblems, either before or after theaccident, and the car had accumulatedabout 200,000 miles annually withoutincident. Consequently, the Safety Boardconcludes that even though the rail in theflattened area met FRA requirementswhen inspected before the accident andMHC 1500 had no design deficiencies,the dynamic interaction of the car withthe flattened rail head initiated thederailment sequence.

The analysis of the engineeringconsulting firm contracted by Amtrakindicated that lightly loaded or shorterwheel base cars, such as MHCs or emptyTOFCs, have a greater tendency to initiatewheel lift as they transverse over flattenedrail head than do longer wheel base orheavier cars. Flattened rail may be ahazard to all trains and could cause cars inboth freight and passenger trains to derail.

The materials laboratory of the SafetyBoard examined both broken brake discsfrom MHC 1500. Not all of the fracturesurface could be examined because someof the fracture surface was obliteratedand other pieces of the fracture surfacewere missing. The remaining material onboth discs exhibited typical features ofoverstress separations. No indications ofpreexisting cracks were in any of thepieces examined.

Investigators examined the truck,brake cylinders, and brake calipers forany indication of strike damage from aloose brake disc. No marks were foundon these components that would beconsistent with a loose brake disc. Thus,no evidence was found to support the

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theory of a broken brake disc occurringbefore the accident. The Safety Board,therefore, concludes that the brake discsof MHC 1500 broke as a result of theforces of derailment and were not causalto the derailment.

Survival Aspects

No occupant of the Heritage dome carreported being injured by the 12-inch-long metal seat back braces that were

exposed when the frames of the car seatsseparated. The Safety Board concludes,however, that these exposed metal seatback braces in dome coach car 9411were a potential hazard for passengerswhen that car overturned. Therefore, theSafety Board believes that Amtrakshould install, in all Heritage coachdome cars in its possession, a positivelocking feature that will prevent theseparation of the car seat backs from theseat back braces.

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CONCLUSIONS

1. The operation of train 49, theperformance of the operating andon-board service crews, thesignal system, and the weatherwere not factors in thederailment.

2. The local emergency responsepersonnel reacted promptly andacted effectively at the derail-ment site.

3. The simulations and field testscorroborate the location of theinitial point of derailment andconfirm that the flattened railhead allowed the wheel to losecontact with the rail.

4. The track inspections were beingperformed as intended by thecarrier and by the FederalRailroad Administration, and theflattened rail condition atmilepost 403.7 had been detectedbefore the derailment occurred.

5. The FRA has not provided theguidance on what size or type offlattened rail head is potentiallyhazardous to train operations thatwould allow track inspectors totake corrective action.

6. The flattened rail head at theinitial point of derailment wasnot considered a defect because itdid not meet the definition of anexisting rail defect and the trackgeometry did not meet defectspecifications.

7. The track geometry defect foundafter the derailment at the initialpoint of derailment was not acontributing factor in thederailment.

8. The Federal Railroad Admin-istration track safety standardsfail to address flattened rail headcondition risks, such as found inthis accident.

9. The rail in the flattened area metthe Federal Railroad Administra-tion requirements when inspectedbefore the accident, and materialhandling car 1500 had no designdeficiencies.

10. The derailment occurred becauseof the dynamic interaction ofmaterial handling car 1500 andthe flattened rail head.

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11. The brake discs of materialhandling car 1500 broke as aresult of the forces of derailmentand were not causal to thederailment.

12. The exposed metal seat backbraces in dome coach car 9411were a potential hazard forpassengers when that caroverturned.

PROBABLE CAUSE

The National Transportation SafetyBoard determines that the probable causeof the derailment was the fact thatFederal and industry guidelines do not

currently address flattened rail headconditions, due to an insufficient unders-tanding of the risk that flattened railposes to train operations.

RECOMMENDATIONS

As a result of its investigation, theNational Transportation Safety Boardmakes the following recommendations:

--to the Federal Railroad Admin-istration:

Develop not later than December31, 1996, an interim technicalbulletin authorizing track in-spectors to take corrective actionto prevent the potential hazard offlattened rail head conditions totrain operations. (Class II, PriorityAction)(R-96-12)

Conduct appropriate research anddevelop a data base that can beused to assess the risk posed byflattened rail heads. (Class II,Priority Action)(R-96-13)

Develop guidelines, using the datacompiled about the risk offlattened rail heads, for track in-spectors to use in identifying railhead that may be hazardous totrain operations and also reg-ulations to ensure that correctiveaction is taken when such flattenedrail head conditions have beenidentified. (Class II, PriorityAction)(R-96-14)

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--to the National Railroad PassengerCorporation:

Install, in all Heritage coach domecars in its possession, a positivelocking feature that will preventthe separation of the car seat backsfrom the seat back braces. (ClassII, Priority Action)(R-96-15)

--to the Association of AmericanRailroads:

Inform its membership of thecircumstances of this accident.(Class II, Priority Action)(R-96-16)

Assist the Federal RailroadAdministration, in conjunctionwith the American Short LineRailroad Association, in developing

a data base that can be used toassess the risk posed by flattenedrail heads. (Class II, PriorityAction)(R-96-17)

--to the American Short Line RailroadAssociation:

Inform its membership of thecircumstances of this accident.(Class II, Priority Action)(R-96-18)

Assist the Federal RailroadAdministration, in conjunctionwith the Association of AmericanRailroads, in developing a database that can be used to assess therisk posed by flattened rail heads.(Class II, Priority Action)(R-96-19)

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BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALLChairman

ROBERT T. FRANCIS IIVice Chairman

JOHN A. HAMMERSCHMIDTMember

JOHN J. GOGLIAMember

GEORGE W. BLACK, JR.Member

July 11, 1996

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APPENDIX A

Investigation and Hearing

The National Transportation Safety Board was notified at 5:21 a.m. on August 3, 1994, ofthe derailment of Amtrak (National Railroad Passenger Corporation) train 49, the Lake ShoreLimited, on Conrail (Consolidated Rail Corporation) trackage near Batavia, New York. Theinvestigator-in-charge and other members of the Safety Board investigative team were dispatchedfrom the headquarters in Washington, DC. Investigative groups studied operations, track, signals,mechanical, survival factors, and human performance.

The Association of American Railroads, Brotherhood of Locomotive Engineers,Consolidated Rail Corporation, National Railroad Passenger Corporation, New York StateDepartment of Transportation, and U.S. Department of Transportation Federal RailroadAdministration assisted in the Safety Board investigation.

Safety Board staff conducted a deposition hearing as part of its investigation onDecember 14, 1995, at which six witnesses testified.

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APPENDIX B

Material Handling Car Characteristics

The following are the general characteristics of an MHC:

Length between Pulling Face of Coupler 64 feet 03.50 inches

Maximum Width over Grab Irons 8 feet 10.25 inches

Maximum Height 13 feet 06.25 inches

Distance between Truck Centers 41 feet 03.00 inches

Truck Wheel base 8 feet 06.00 inches

Distance Centerline of Trucks to Coupler 11 feet 06.25 inches

Car Construction Material carbon steel

Minimum Turning Radii 250 feet (22.7 degrees)

Coupler Type H tightlock

Draft Gear dresser type WM-6-DPB

Wheel Size and Type 36-inch diameter class B

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APPENDIX C

Acronyms Used in this Publication

AAR Association of American Railroads

Amtrak National Railroad Passenger Corporation

Conrail Consolidated Rail Corporation

CN Canadian National Railroad

CNW Chicago & North Western Railroad

FRA Federal Railroad Administration

GCECC Genessee Country Emergency Communication Center

GCEMC Genessee County Emergency Management Coordinator

MHC material handling car

MP milepost

NORAC Northeast Operating Rules Advisory Committee

NYS New York State

POD point of derailment

TOFC trailer on flat car

TTC Transportation Test Center