美国_RAR0304

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Collision of Burlington Northern Santa Fe Freight Train With Metrolink Passenger Train Placentia, California April 23, 2002

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Railroad Accident Report

NTSB/RAR-03/04

PB2003-916304

Notation 7590

Railroad Accident Report

Collision of Burlington Northern Santa Fe Freight Train With

Metrolink Passenger Train

Placentia, California

April 23, 2002

NTSB/RAR-03/04 PB2003-916304

National Transportation Safety Board

Notation 7590

490 L’Enfant Plaza, S.W.

Adopted October 7, 2003

Washington, D.C. 20594

National Transportation Safety Board. 2003. Collision of Burlington Northern Santa Fe Freight Train With Metrolink Passenger Train Placentia, California, April 23, 2002. Railroad Accident Report NTSB/RAR-03/04. Washington, DC.

Abstract: On Tuesday, April 23, 2002, about 8:10 a.m. Pacific daylight time, eastbound Burlington Northern Santa Fe Railway freight train PLACCLO3-22 collided head on with standing westbound Southern California Regional Rail Authority passenger train 809 on the No. 2 track at Control Point Atwood in Placentia, California. Emergency response agencies reported that 162 persons were transported to local hospitals. There were two fatalities. Damage was estimated at $4.6 million.

The safety issues discussed in this report are the attentiveness of the Burlington Northern Santa Fe train crew, the signal awareness form procedures for the Burlington Northern Santa Fe, passenger car survival factors, and the absence of positive train control systems.

As a result of its investigation, the National Transportation Safety Board issued safety recommendations to the Federal Railroad Administration, the Burlington Northern Santa Fe Railway Company, and the Association of American Railroads. The Board also reiterated a previously issued safety recommendation to the Federal Railroad Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, 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 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

Recent publications are available in their entirety on the Web at . Other information about available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2003-916304 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

References

References

Factual Information

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Railroad Accident Report

〔图〕BNSF and METROLINK TracksLos AngelesPSanHobartBernardinoROUTE OFBNSF 5340RiversideSan Juan CapistranoBastaACCIDENT SITEM

Figure 1. Accident location.

Between Hobart Yard and CP Atwood, the BNSF railroad is multiple-track territory with either two or three tracks. Trains may be operated in either direction on any of the tracks. The train dispatcher requests routes, and the traffic control system $^{5}$ moves track switches and displays signal aspects $^{6}$ to crews who operate their trains on the designated routes. BNSF 5340 changed tracks several times between Hobart Yard and Fullerton Junction as it negotiated the morning train traffic consisting of Metrolink and Amtrak trains.

At 7:32 a.m., the Metrolink crew, now operating their train as Metrolink 809, departed Riverside on their fourth trip of the day, heading for San Juan Capistrano. On this trip, the train was configured with the locomotive on the rear and the cab car on the front. The engineer was operating the train from a control compartment in the cab car. Approaching CP Atwood westbound, Metrolink 809 received a diverging clear signal to leave BNSF tracks and enter the Metrolink Olive Subdivision. (See table 1.)

Factual Information

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Railroad Accident Report

Table 1. BNSF Track No. 2 signals as displayed at time of accident.

Train BNSF 5340 was moving toward CP Atwood from the west. The engineer recalled that as he approached Basta, which is at MP$^{7}$ 163.0 (about 7 miles from C.P. Atwood), he received a signal that required him to slow his train to 30 mph, which he did. He said that he then noted that the next signal displayed approach but changed to clear before the train reached it. He then resumed normal operating speed.

The BNSF crewmembers said they were engaged in a conversation about previous employment; they had both worked at the same oil refinery before beginning their railroad careers. The BNSF 5340 conductor said that he called aloud the signal at MP 42.31—the signal before the signal at CP Atwood—as clear (refer to table 1) and that the engineer repeated “clear.” According to the transcript of an interview that BNSF officials conducted with the conductor and engineer of BNSF 5340, the engineer acknowledged that he heard the conductor call out “clear” and that he “confirmed it.” In a Safety Board interview, the engineer said that he did not see the signal. “My conductor called it before we went under it; by the time I looked up, we were past it.” Both crewmembers said they approached CP Atwood thinking they were operating on a clear signal and that they thus were not required to stop or even slow the train. (According to data from signal system data loggers, the signal at MP 42.31 was displaying approach at the time BNSF 5340 passed.)

Both BNSF 5309 crewmembers said that just before the train reached CP Atwood, they realized that signal 4EA (MP 40.71) was showing stop.$^{8}$ The train was traveling about 49 mph at the time. (See figure 2.) They said they noticed Metrolink train 809 on the same track heading toward them, and the engineer placed the train brakes in emergency. The Metrolink 809 engineer said he was slowing the train preparing to go through a switch at 25 mph when he saw the freight train coming toward his train on the same track. He also placed his train in emergency, left the control compartment, and ran back through the lower level of the car warning passengers to brace themselves.

Factual Information

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〔图〕NTSB Drawing(not to scale)Cab CarPointRestofNOTE: BNSF striking freight train not shownSAN BERNARDINOOOOOMP 40.39ImpactP

Figure 2. Signal System Layout

Factual Information

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Railroad Accident Report

As the freight train slowed, the conductor jumped clear of the locomotive at approximately 25 to 30 mph. Soon after, the engineer also jumped clear. The train was traveling about 23 mph when it collided head on with the standing Metrolink train about 1,630 feet past signal 4EA.

A security surveillance video camera at a commercial storage facility adjacent to CP Atwood captured a portion of the collision on tape. The tape shows Metrolink 809 coming to a complete stop with the trailing (third) Metrolink passenger car standing in the center of the video camera view. After being stopped for about 12 seconds, Metrolink 809 is propelled backward as BNSF 5340 makes contact. The BNSF 5340 lead locomotive comes to rest in the center of the video image after both trains have stopped. Based on the known length of the Metrolink passenger cars and of BNSF locomotive 5340, the easterly movement of Metrolink 809 during impact was calculated to be about 243 feet. (See figure 3.)

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Figure 3. Aerial photo of accident scene (courtesy Orange County Sheriff's Department).

Factual Information

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Railroad Accident Report

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Figure 4. Damaged stairway in Metrolink cab car.

〔图〕NKME634\n

Figure 5. Damaged exterior of Metrolink cab car.

Factual Information

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Railroad Accident Report

Emergency responders indicated that while passengers in the aft intermediate level of the coach were slightly delayed in exiting the railcar because of the damaged door, the passengers told responders that they were not injured or entrapped in any way. These passengers were also reported to have instructed the emergency responders to attend to the more seriously injured persons on the train until resources were available to assist them in exiting the car.

Emergency responders found two passengers who were showing minimal or no signs of life lying in the aisle of the upper deck of the lead Metrolink railcar. After a medical triage assessment was performed, one of these injured passengers, a 48-year-old male, was immediately transported by ambulance. The passenger expired in route and was pronounced dead upon arrival at the hospital. The other passenger, a 59-year-old male, was later pronounced dead at the scene.

Emergency response agency and medical facility records indicated that 264 persons on board the two trains were medically triaged at the scene. A total of 102 persons in the medical triage count were identified as “uninjured.” In addition, one firefighter experienced dehydration at the scene and was transported to a local medical facility, which raised the medical triage count to 265 persons (which included the on-scene fatality). Of the 265 persons in the medical triage count, 162 persons received emergency transportation for medical assessment and/or treatment at local hospitals. This included 157 Metrolink passengers, 2 Metrolink crewmembers, 2 BNSF crewmembers, and the 1 injured firefighter. (See figure 6.)

〔图〕METROLINK5340\n

Figure 6. Emergency responders treating accident victims.

Factual Information

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Railroad Accident Report

Table 2. Injuries

Notations in several passengers' medical records indicated that they had informed the medical staff that one of the Metrolink train crewmembers in the cab car attempted to warn passengers of the impending collision just before the impact. The notations also indicated that several of those passengers were able to place themselves in positions or locations that they felt might have helped to reduce their injuries.

A review of the pathology reports on the two fatalities indicated that both persons received severe blunt impact trauma injuries to the chest and upper abdomen. These two fatally injured persons were found near seats 58 and 61 and 66 and 70, respectively, on the upper level of the lead railcar. They were apparently sitting next to each other on the right side of the aisle (relative to the direction of travel) in seats numbered 60 and 61, with both persons facing the direction of travel. (See figures 7 and 8.) These seats are about in the middle of the railcar and are a paired seating set arranged in an opposing (face-to-face) layout with another paired seating set (seat numbers 56 and 57), with a workstation table between them. The workstation table was found to have been pushed forward relative to its normal service location and was partially resting against the seatback of the opposite seat pair set. Although the table pedestal had not fully separated from its attachment to the floor, its attachment joint with the floor was bent and partially separated.$^{13}$ No one was identified as having been occupying seats 56 or 57 at the time of the collision.

Factual Information

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Railroad Accident Report

〔图〕3332353437363938o|qe_4140434245444746DIRECTION OF TRAVEL4948TableTable51505352555457565958Table6160636267666564706971687

Figure 7. Seating layout of the upper-deck level of the Metrolink cab car. (Fatally injured passengers were seated in seats 60 and 61 at workstation table.)

Factual Information

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Railroad Accident Report

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Figure 8. Photograph depicting a simulation of the positions of the two fatally injured passengers relative to an exemplar workstation table. (The passengers were facing the direction of travel.)

Damage

Metrolink cars 634 and 113 derailed and sustained substantial crush damage. Metrolink estimated monetary damage at $4.6 million. BNSF locomotive unit 5340 sustained damage to the front end. BNSF estimated monetary damage to be $25,000.

Switch No. 3 on BNSF track No. 2 was damaged as a result of being run through (subjected to train movement that conflicted with the route for which the switch was lined) by the freight train. BNSF engineering personnel estimated the total track, structures, and signal equipment damages at $6,400.00. This figure included costs for the installation of a new switch point and stock rail.

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