Synopsis
On June 6, 1969, a rear-end collision occurred between two
Great Northern Railway freight trains at Marysville, Washington.
It resulted in death to two, and in injury to two, members of the
train crews.
Cause
The collision was caused by the engineer of the following train
lapsing into unconsciousness and failure of the front brakeman to
maintain a lookout ahead, resulting in the following train passing
a stop-signal and colliding with the train standing on the main
track.
Location of Accident and Method of
Operation
The accident occurred on that part of the railroad extending
southward from Blaine to Everett, Wash., a distance of 85 6 miles
In that area the railroad is a single-track line over which trains
operate by timetable, train orders, and an automatic block-signal
system.
At Marysville, 79.2 miles south of Blaine, a siding and a team
track parallel the main track on the west, as shown in Plate No
1
The collision occurred on the main track, 140 feet north of the
Marysville station.
Several city streets cross the railroad at grade within the
Marysville city limits. Because of this, the maximum authorized
speed for all trains moving through Marysville is restricted to 25
m.p.h.
A 25 m.p.h. speed restriction sign for southbound trains is
adjacent to the main track, 2961 feet north of the collision
point.
Main Track
From the north, the main track is tangent approximately 2.5
miles to the collision point and 1489 feet southward The grade for
southbound trains in that area is 0.40% descending.
Time and Weather
The collision took place at 3:44 a.m., under clear weather
conditions.
Signals
Automatic signals 40.9 and 39.5, governing southbound movements
on the main track, are 2.1 miles and 3071 feet north of the
collision point, respectively. They are of the upper-quadrant
semaphore type and are approach lighted. The applicable signal
aspects, indications and names are as follows:
|
Signal |
Aspect |
Indication |
Name |
| 40.9 |
Yellow |
Proceed prepared to stop before any part of
train *** passes the next signal Trains exceeding 40 MPH must
immediately reduce to that speed |
Approach |
| 39 5 |
Red |
Stop before any part of train *** passes the
signal then proceed at restricted speed through entire
block |
Stop and Proceed |
When the block of signal 40.9 is unoccupied and the block of
signal 39.5 is occupied, signals 40.9 and 39.5 display Approach
and Stop-and-Proceed aspects, respectively, for an approaching
southbound train.
Authorized Speeds
The maximum authorized speed for freight trains between Blaine
and Everett is 60 m.p.h. It is restricted, however, to 25 m.p.h.
in the speed-restriction zone at Marysville.
Carrier's Operating Rules
34 All members of the crew in cab of engine must ***
communicate to each other by its name the indication of each
signal affecting the movement of their train *** as soon as it
becomes visible ***
804B When conditions or signals require that the train be
stopped or speed of train be reduced and the engineer or conductor
fails to take proper action to do so, or should the engineer
become incapacitated, other members of the crew must take
immediate action to stop train, using emergency brake valve if
necessary.
Train Equipment
The locomotive and caboose of Extra 725 South, the following
train involved in the accident, were equipped with
radio-telephones. The control compartment of the locomotive was
equipped with an Alertor safety control system. This is an
electronic system which includes a built-in antenna in the
engineer's seat. It is so designed that any motion by the engineer
will be detected by the antenna. A timing circuit set for 20
seconds is actuated each time the seat antenna detects motion. If
the antenna detects no motion within that 20-second period, an
audible and visual indicator calls the engineer s attention to
this fact. If the seat antenna detects no motion within the
following 10-second period, a relay contact opens, causing an
automatic application of the train brakes.
The Alertor safety control system of the locomotive of Extra
725 South was not functioning the day of the accident, due to the
system having been cut out. This matter will be explored later in
our report.
Circumstances Prior to Accident
Train Extra 675 South
Extra 675 South, a southbound local freight train, left M.V.B.
Station, 48.6 miles south of Blaine, at 12:15 a.m. the day of the
accident. Shortly before 3:20 a.m., the train, consisting of 1
road-switcher type diesel-electric unit, 3 cars and a caboose,
passed signals 40.9 and 39.5, and entered the 25 m.p.h.
speed-restriction zone at Marysville. A few minutes later, it
stopped on the main track in the block of signal 39.5, with the
rear end 3071 feet south of that signal and 140 feet north of the
Marysville station. The locomotive then moved to the siding and
the team track for switching operations, leaving its train on the
main track without any crew member providing flag protection
against following trains. The carrier's rules did not require such
protection, due to the train being stopped in automatic
block-signal territory.
Train Extra 725 South
Extra 725 South, a southbound freight train, left Vancouver, B
C , Canada at 7:05 p.m. the day before the accident. After
entering the United States and stopping at Blaine, Wash., where
the crew members dined while a customs inspection was made, the
train resumed its trip southward.
Extra 725 South, consisting of 1 road-switcher type
diesel-electric unit, 35 cars and a caboose, passed English, 7.1
miles north of Marysville, about 3:35 a.m. Soon afterward, it
neared signals 40.9 and 39.5. The engineer and front brakeman were
in the control compartment at the rear of the locomotive. The
conductor, flagman, and swing brakeman were in the caboose. The
train brakes had been tested and had functioned properly when used
en route.
The Accident
Extra 675 South
About 20 minutes after leaving its train on the main track at
Marysville, the locomotive of Extra 675 South completed switching
operations at the north end of the team track and began to push
three empty flat cars slowly southward on the siding. The engineer
and fireman were in the control compartment at the north, or rear,
end of the locomotive. The conductor, flagman, and front brakeman
were on the leading flat car in the direction of the movement.
After passing its train and the Marysville station, the
locomotive began to push the three flat cars over the Fifth Street
grade crossing located just south of the station. A few seconds
later, as the locomotive was about to move clear of the crossing,
the portion of its train standing on the main track was struck
from the rear by Extra 725 South, at 3:44 a.m. Derailed equipment
of the latter train then struck the locomotive pushing the three
flat cars, killing its engineer and fireman.
According to some of their statements, the conductor, flagman,
and front brakeman of Extra 675 South were unaware of anything
being wrong before the collision on the main track. Their other
statements, however, indicate that they had seen Extra 725 South
approaching Marysville and had thought it would stop short of
their train. In either event, the conductor, flagman, and front
brakeman jumped from the leading flat car immediately before or at
the time of the collision on the main track, and escaped
injury.
Extra 725 South
This train was moving on an ascending grade at 35 m.p.h. as
indicated by the speed-recording tape, as it neared English, 7.1
miles north of Marysville. It then entered the descending grade on
which the collision occurred, and passed English while moving
about 45 m.p.h. and increasing speed.
The engineer stated that he had not noticed any fumes in the
locomotive control compartment while en route from Vancouver, and
that he had been alert and feeling well until shortly after his
train passed English. At that time, according to his statements,
he "blacked out." Although the investigation revealed information
indicating otherwise, the engineer said he vaguely recalled having
seen a "yellow block" (signal 40.9) in the distance before
becoming fully unconscious, and having moved the throttle from Run
8 to Run 5 or 6 position for controlling the speed properly in the
block of signal 40.9. He further said that he could not remember
anything else leading up to the accident, except for a vague
recollection that he saw the train ahead and applied his brakes in
emergency a moment or two before the collision.
The speed tape shows Extra 725 South continued to increase
speed after the engineer allegedly lapsed into unconsciousness. It
was moving about 60 m.p.h. when it passed signal 40.9, which
indicated Approach. The train had increased speed to 62 m.p.h.
when it passed signal 39.5, which indicated Stop-and-Proceed, and
entered the 25 m.p.h. speed-restriction zone at Marysville
Approximately 30 seconds after passing signal 39.5 and entering
the speed-restriction zone, Extra 725 South collided with the
train standing on the main track while moving at 63 m.p.h.
The front brakeman of Extra 725 South stated that because of a
nauseous feeling caused by fumes in the locomotive control
compartment, he rode with his head out the window on the left side
of the compartment and looked back at the cars as his train moved
on the tangent track in approach to signals 40.9 and 39.5, and the
collision point. In essence, the front brakeman's other statements
are that (a) he and the engineer had called the indications of
some signals to each other while en route from Vancouver (b) he
did nor see signals 40.9 and 39.5 or hear the engineer call the
indications of those signals (c) he had no knowledge of the
engineer's condition nearing Marysville (d) he had taken no
exception to the excessive speed at which his train moved after
entering the Marysville speed-restriction zone, and (e) he was
unaware of anything wrong until just before the collision, when he
looked ahead and saw the caboose of Extra 675 South standing on
the main track a short distance ahead.
The conductor, flagman and swing brakeman of Extra 725 South
were in the caboose as their train approached Marysville. The
swing brakeman was holding a radio conversation with a yardmaster
located at a point south of Marysville. According to their
statements, none of the crew members on the caboose (a) saw either
signal 40.9 or 39.5 (b) took any exception to the excessive speed
at which his train entered and moved in the 25 m.p.h.
speed-restriction zone at Marysville or (c) was aware of anything
wrong before the brakes of his train applied in emergency before
or at the time of the collision.
Damages
Extra 675 South
The caboose of this train was derailed and destroyed. The
impact propelled the three cars ahead of the caboose 1135 feet
southward on the main track, without derailing or damaging them.
The locomotive was struck by derailed equipment of Extra 725
South, while moving slowly southward on the siding at the south
edge of the Fifth Street crossing. It derailed, stopping upright
on and in line with the siding structure about 80 feet south of
the crossing. The engine hood was torn off and the engine was
somewhat damaged. The control compartment was crushed, as a result
of a derailed gondola car stopping on top of it. The photo on the
cover page shows the extent of damage to the
locomotive.
Extra 725 South
The locomotive and first 20 cars of this train were derailed.
The locomotive overturned onto its left side. It stopped at a
40-degree angle to, and with one end across, the main track about
450 feet south of the collision point. The derailed cars stopped
in various positions on or near the structures of the main track,
siding and team track, as shown in Plates No 2 and No 3
Of the derailed equipment, the locomotive and 11 cars were
destroyed; 6 cars heavily damaged, and 3 cars slightly
damaged.
Marysville Station
The southern half of the station was struck by derailed
equipment and was virtually destroyed. The station was
unoccupied.
Damage Cost
According to the carrier's estimate, the cost of damages to
train equipment and track structures was $319,810
Casualties
Extra 675 South
The engineer was killed as a result of multiple compound skull
fractures. The fireman was also killed, by crushing injuries to
his head and chest. The engineer and fireman were found near their
locomotive, on the ground between the siding and team
track.
Extra 725 South
The front brakeman suffered a concussion and internal injuries.
The engineer sustained bruises, and lacerations of the right
arm.
Post-Accident Examinations and Tests
Signals
Signals 40.9 and 39.5 were tested after the accident and were
found to be functioning properly.
View
Tests revealed that signal 40.9 is not visible from a
southbound locomotive in the area where the engineer
of
PLATE NO 2
|
Extra 725 South |
| |
|
|
|
1st |
car - NP |
60582 |
|
2nd |
car - GATX |
74447 |
|
3rd |
car - NP |
7189 |
|
4th |
car - PLC |
16221 |
|
5th |
car - NP |
42296 |
|
6th |
car - NP |
8411 |
|
7th |
car - NP |
15459 |
|
8th |
car - NP |
41926 |
|
9th |
car - ARR |
11510 |
|
10th |
car - HP |
6409 |
|
11th |
car - SF |
692174 |
|
12th |
car - WP |
2824 |
|
13th |
car - PRR |
611110 |
|
14th |
car - GN |
15341 |
|
15th |
car - EJE |
62031 |
|
16th |
car - GN |
200155 |
|
17th |
car - PC |
557260 |
|
18th |
car - REWX |
64461 |
|
19th |
car - GN |
78493 |
|
20th |
car - GN |
78501 |
PLATE NO. 3
Extra 725 South approached from right. Locomotive of that train
is under gondola car at left. Locomotive of Extra 675 South is under
wreckage at center.
Extra 725 South allegedly lapsed into unconsciousness, due to
track curvature and trees alongside the railroad. The locomotive
must reach a point more than two miles farther southward before the
signal comes into view, indicating that the engineer's vague
recollection of having seen a "yellow block" (signal 40.9) before
becoming completely unconscious was erroneous.
Locomotive of Extra 725 South
Examination of this locomotive soon after the accident found
the throttle in Run 8 position, indicating that the engineer's
vague recollection of having moved the throttle to Run 5 or 6
position before becoming completely unconscious was also
erroneous. The reverser of the locomotive was found in forward
position; the independent brake valve in release position; the
emergency brake valve on the left side of the control compartment
in closed position; the cutout cock of the Alertor safety control
system in cutout position; a broken seal attached to the aforesaid
cutout cock, and a plastic covered foam-rubber seat pad belonging
to the engineer. The automatic brake valve was found in emergency
position, indicating that the engineer may have moved the brake
valve to that position immediately before the collision, as
alleged.
Alertor Safety Control System
This system was removed from the locomotive of Extra 725 South,
installed in the control compartment of a similar locomotive, and
tested. The system functioned properly after it was cut-in on the
test locomotive. It was also tested with the engineer's
foam-rubber seat pad in use. In some of the latter tests, the pad
interfered with the seat antenna's ability to detect normal motion
of the employee at the controls. In those cases, the employee was
required to move in an unusual manner to nullify the Alertor
system action, i.e. prevent the system from applying the brakes
automatically.
Hours of Service
Extra 675 South
All the crew members of this train had been on duty 14 hours 44
minutes at the time of the accident, after having been off duty 9
hours 15 minutes.
Extra 725 South
All the crew members of this train had been on duty 10 hours 14
minutes at the time of the accident, after having been off duty 11
hours 20 minutes at Vancouver.
Best information available indicates all the crew members had
motel rooms for their layover at Vancouver, and had slept there
before reporting on duty for the accident trip. The engineer
stated he had eight hours sleep before reporting for duty, and had
felt fully rested at that time.
Engineer and Front Brakeman of Extra 725
South
The front brakeman, age 22, was first employed by the carrier
in May 1969, after passing physical and rules examinations. His
record was clear.
The engineer, age 66, was first employed by the carrier as a
fireman in 1945, and was promoted to engineer in November 1961
after passing a mechanical examination. His service record
indicates he last passed a physical examination by the carrier on
July 8, 1968, and an operating rules examination on January 22,
1969. It further indicates he was subjected to disciplinary action
by the carrier in (a) September 1964, for responsibility in
connection with a side collision involving a cut of cars in a
yard, and (b) March 1969, for failure to stop a train before
passing a stop-signal.
Post-Accident Medical Examinations
The front brakeman of Extra 725 South refused to undergo a
blood test after the accident.
Examination of the engineer of Extra 725 South by the carrier's
physician revealed that his heart and neurological conditions were
normal, and that his blood was negative for alcohol and sugar
content.
In connection with his physical condition, the engineer stated
he could not recall ever having "blacked out" before the day of
the accident, but there was a possibility he had done so without
knowing it. He further stated that some time shortly before
undergoing the carrier's medical examination on July 8, 1968, he
went to a private physician for a complete examination, indicating
that he had felt some concern about his physical condition.
According to the engineer, the examination by his personal doctor
revealed that he had a minor diabetic condition. As a result, he
was given a prescription calling for him to take one Orinase
tablet every day. He said that he followed the prescription
faithfully, and had taken an Orinase tablet before reporting on
duty for the accident trip.
Apparently the carrier's examination on July 8, 1968, detected
no diabetic condition of the engineer. He stated that he did not
inform the carrier's physician about his recent examination by a
private doctor; the diabetic condition disclosed by that
examination, or the medication he was taking daily.
Condition of Alertor Safety Control
System
Before Accident Trip
The engineer of Extra 725 South operated locomotive 725 on his
northward trip to Vancouver. He stated that the Alertor system was
inoperative during that trip, for some undetermined reason, and
that he found it was still inoperative after the locomotive left
the Vancouver engine-house for its return trip southward. A
bulletin of the carrier requires an engineer finding an Alertor
safety control system defective to report such finding by wire to
the division superintendent from the first available point of
communication. The engineer said he did not make the aforesaid
required wire report after finding the Alertor system to be
inoperative on the northward trip to Vancouver, or after leaving
the Vancouver engine house for the southward trip. He further said
that after completing the northward trip, he did not submit a
locomotive inspection report showing the Alertor system was
inoperative and in need of repair, as required under such
circumstances.
According to the carrier's engine house
records, the Alertor
system of locomotive 725 was cut in, sealed, tested and found to
be functioning properly before the locomotive was dispatched for
its northward trip to Vancouver. The records further indicate the
Alertor system was tested again at the Vancouver engine house and
found to be functioning properly, before the locomotive was
dispatched for its southward, or accident, trip.
After the accident, the engineer of Extra 725 South was charged
with manslaughter for the deaths of the engineer and fireman of
Extra 675 South. A trial by jury in the Snohomish County Superior
Court of the State of Washington found him guilty of this charge.
The conviction was based on criminal negligence, fox cutting out
the Alertor safety control system of his
locomotive.
Conclusions
Extra 675 South
-
The rear portion of this train was standing on the main track
at Marysville in accordance with applicable rules and regulations
of the carrier, under protection afforded by the Approach and
Stop-and-Proceed indications of signals 40.9 and 39.5,
respectively. None of the crew members was providing flag
protection against following trains, due to such protection not
being required under the carrier's rules.
Extra 725 South
-
Considering the speed (62 m.p.h.) at which this train entered
the 25 m.p.h. speed-restriction zone at Marysville, and the
relatively short distance (2961 feet) between the southward
speed-restriction sign and the collision point, the crew members
on the caboose probably could not have stopped their train short
of a collision had they taken action to apply the brakes in
emergency after the train entered the speed-restriction zone at
excessive speed.
-
The aforesaid crew members lack of concern for compliance with
the speed restriction imposed on trains at Marysville apparently
contributed to the severity of the accident. Had they felt proper
concern when the train neared and entered the speed-restriction
zone without reducing speed, and promptly attempted to establish
radio communication with the engineer, the crew members in the
caboose might have alerted themselves to the necessity of applying
the train brakes in emergency. If they had then taken such action,
it is possible the train would have decreased speed materially
before the collision, lessening the accident consequences with the
possibility of the enginemen of Extra 675 South escaping fatal
injuries.
-
A significant causal factor in the accident was failure of the
front brakeman of Extra 725 South to maintain a lookout ahead as
his train approached signals 40.9 and 39.5, and to call the
indications of those signals to the engineer as required by the
carrier's rules. Considering that the engineer noticed no fumes in
the locomotive control compartment; that if the front brakeman was
feeling nauseous as alleged, he could have refreshed himself just
as well by looking ahead from his open side window as by looking
back; that the train was moving on tangent track in approach to
signals 40.9 and 39.5, and the collision point; that the front
brakeman merely had to look ahead occasionally to see the
indications of those signals; that calling the indications of
those signals to the engineer required no great effort by the
front brakeman, whether or not he was feeling nauseous, and that
safety of a train movement requires a diligent lookout ahead be
maintained, the reason given by the front brakeman for not
maintaining a lookout ahead and seeing the indications of signal
40.9 and 39.5 lacks validity. Consequently, it is concluded that
for some unjustifiable reason the front brakeman neglected to
maintain a lookout ahead while approaching signals 40.9 and 39.5.
Had he maintained such a lookout, he would have seen the engineer
was not complying with the indications of those signals and
realized the necessity of taking action to stop the train, as
required by the rules. Thus, he might have averted the
accident.
-
Extra 725 South left Vancouver with the Alertor safety control
system of the locomotive inoperative, due to being cutout. From
all indications, this system was functioning properly when the
engineer took charge of the locomotive at the Vancouver engine house, as evidenced by
engine house employee work reports;
the lack of any wire or locomotive inspection report by the
engineer that the system was malfunctioning or inoperative, and by
tests conducted after the accident. Hence, it appears that the
engineer cutout the Alertor system some time after leaving the
Vancouver engine house, possibly due to his privately-owned rubber
seat pad interfering with the ability of the system's seat antenna
to detect motion, and to the engineer wanting to prevent the
system from causing undesired brake applications resulting from
the seat antenna's inability to detect motion.
The inoperative Alertor safety control system was a significant
contributing factor in the accident, as the engineer evidently was
motionless in his seat for a considerable period of time while his
train approached the collision point. Had the Alertor system not
been cutout, it would have detected the engineer's lack of motion
in approach to signal 40.9 and stopped the train by applying its
brakes automatically, averting the accident.
-
Since the investigation revealed nothing in contradiction to
the statements of the engineer of Extra 725 South that he had
eight hours sleep before going on duty at Vancouver and had been
alert until shortly after his train passed English, there is no
support for an assumption that he fell asleep at the controls.
Thus, it is concluded he "blacked out," as claimed, resulting in
his inability to operate his train in accordance with the
indications of signals 40.9 and 39.5, and to avoid the collision.
The incapacitation of the engineer was the primary cause of the
accident.
The investigation revealed that about 12 months before the
accident a medical examination by a private physician found the
engineer had a minor diabetic condition. It further revealed the
carrier's medical examination conducted about 11 months before the
accident apparently did not find that the engineer had a diabetic
condition, and the engineer did not inform the carrier's physician
about the results of the previous medical examination. As a result
of the examination by his personal physician, the engineer was
given a prescription calling for him to take one Orinase tablet
daily. He followed the prescription faithfully, taking one Orinase
tablet the afternoon of the day he reported on duty for the
accident trip Under the circumstances, it would appear that the
engineer became incapacitated while approaching the collision
point because of adverse affects from the medication he was taking
for control of his diabetic condition.
That the consumption of Orinase can cause physical
incapacitation is evidenced by a Federal Aviation Administration
regulation which prohibits pilots on active duty from taking such
medication. It is further evidenced by our Accident Investigation
Report No 4142, concerning a collision involving a passenger train
engineer who had a diabetic condition and was taking Orinase
tablets for medication. In that case, the engineer suddenly lapsed
into unconsciousness after entering a siding to meet an opposing
train, resulting in his train failing to stop short of the other
end of the siding, and colliding with the opposing train.
-
The circumstances involved in this accident serve well to
illustrate the necessity of all crew members assuming and sharing
equal responsibility for the safety of their train, to prevent an
accident in the event one of the crew members fails to take proper
action under conditions requiring the train to stop or reduce
speed.
Recommendations*
It is recommended that:
-
All line-haul railroad carriers prohibit engineers taking
Orinase for medication, or any other medication susceptible to
producing serious side effects, from service on locomotives
engaged in line-haul operations.
-
All railroad carriers having locomotives equipped with Alertor
safety control systems or similar systems, issue instructions
prohibiting enginemen's of privately-owned seat cushions that
might affect proper functioning of the safety control systems.
Such instructions would be conducive to eliminating the
possibility of an engineman cutting out an Alertor system being
adversely affected by his privately-owned seat cushion, due to
believing the system is in defective condition.
-
The Burlington Northern, Inc take measures to ensure that
supervisory officials are informed of every case in which a
locomotive arrives at an engine house with a broken seal of a
cutout cock or similar valve, so that such officials may exercise
appropriate supervision over the use of sealed cutout cocks or
valves.
-
The railroad industry undertake a comprehensive study of the
serious safety problem caused by neglect or failure of enginemen
to operate trains in accordance with signal indications, speed
restrictions, train orders, operating rules, etc., and by failure
of other crew members to take appropriate action for the safety of
their trains when enginemen neglect or fail to do so.
|
