NTSB: Fatal crash could have been prevented
(National Transportation Safety Board )
Investigators for the National Transportation Safety Board said today that a fatal Green Line crash in May 2008 could have been prevented if the MBTA had an automated train control system.
That finding was the unanimous conclusion of a public hearing today in Washington, D.C., where the board discussed the investigation of the rush-hour crash May 28, 2008, that killed MBTA operator Ter’rese Edmonds. Acting NTSB Chairman Mark V. Rosenker said that installing an automated or positive train control system on the Green Line would be "worth it if we can prevent accidents and loss of life and injuries."
"If technology exists and it exists on the other [MBTA] lines, why would the Green Line not have everything possible that is going to prevent the accidents from happening?" Rosenker asked. "I don’t understand that as an operator. I just don’t if the technology exists.”
MBTA General Manager Daniel A. Grabauskas has previously said it would be difficult to install an automated train control system on the antiquated Green Line because of the high volume of trolleys running through underground tunnels. During today's NTSB hearing, however, officials said technology existed to retrofit the Green Line with a failsafe computer system to control the trains and help prevent collisions. To read a summary of the board's findings, click here.
In recent months, the MBTA has begun testing such automated systems, which are far from perfect. For example, the automated train control system on the Metro in Washington, D.C., did not prevent a crash last month that killed nine people.
During today's hearing, board member Robert L. Sumwalt said he was "fairly incredulous" that prior to the crash, the MBTA did not have a formal system to check whether train operators were obeying signals and following other safety rules.
“I think it speaks to the lack of a safety culture of the organization that they did not do those things,” Sumwalt said.
Investigators also determined that Edmonds was at high risk for undiagnosed sleep apnea and may have dozed off or experienced a “micro-sleep," preventing her from pressing the brakes in the seven seconds when she could have seen a trolley stopped ahead of her. Board members said today that the MBTA lacked employee screening for sleep apnea and had an inadequate fatigue awareness program.
The accident also demonstrated the need to implement minimum construction standards of rail cars to ensure crash worthiness, according to board member of Debbie Hersman.
The Globe reported today that dozens of pages of investigative documents were released on Monday by the board. While no officials would detail a cause, documents and prior statements from investigators suggest that a driving error by Edmonds was the primary reason for the crash.
In testimony released this week, Linda Jenness was working in the rear of a Green Line train last year, slowly accelerating from a red light in Newton, when she “heard a horrific crash and felt my train being thrown.’’
“I just felt like an airplane hit me,’’ Jenness told federal investigators.
“It threw me out of the seat at first, but then I landed in the seat, and then I jumped up, and I hit my mushroom, which is the emergency brake, three times,’’ Jenness said. “It wasn’t stopping.’’
Jenness’s train had been stopped at what investigators believe was a signal that was stuck on red just west of the Waban station. The train had just started moving at the time of the crash.
The driver of the train, seated in the front car, had reacted to the red signal properly, stopping for a minute and then moving forward at no more than 10 miles per hour.
Tests later showed connections on the track that conduct electricity were rusted, which probably caused the signal to default to the red position, according to the report.
The report said the train behind, driven by Edmonds, 24, encountered a second red signal, requiring it to stop so it would not hit Jenness’s train. But Edmonds did not stop, according to crash records. She proceeded through the signal at 38 miles per hour, causing the violent rear-end collision that fatally injured Edmonds.
It remains unclear why Edmonds ignored her red signal. The records released yesterday say there were no illegal drugs or alcohol found in her system when she died. There was, however, the presence of Doxylamine, often included in over-the-counter sleep aids, in Edmonds’s urine.
Investigators did not say in the initial report whether they believed that was a factor. The drug, found in medicines such as Unisom and some versions of NyQuil, can leave people sluggish even a day after taking it, said Candy Tsourounis, professor of clinical pharmacy at the University of California at San Francisco.
“With most over-the-counter medicines, you will see some drowsiness eight, 10, 12 hours after the dose.’’ Tsourounis said.
Drugs containing the product customarily include a warning about operating heavy machinery.
The crash that killed Edmonds also injured seven other passengers, one of them critically.
Damage to the trolley cars involved in the crash was estimated at $8.6 million.
The NTSB is also investigating a second Green Line rear-end crash near Government Center that occurred May 8 this year. In that crash, an operator told authorities he was writing a text message to his girlfriend in the moments before impact.
Though both crashes seem to be the result of operator error, the MBTA’s antiquated signal system has been criticized for its lack of an automated crash-prevention system. The NTSB is expected to discuss that issue in its report today.
Other lines and other systems across the country have automated systems designed to prevent trains from coming too close to one another.
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Boston is home to two great schools of pharmacy, Mass. College of Pharmacy and Northeastern University. Couldn't the author get a quote from a professor at one of these schools instead of San Francisco?
Yeah, could have been avoided if the paid operator was doing her job.
Jack.....who cares where they got the information. Try making a valid point.
Like the DC metro? Automated signals didn't function last month & crash killed 9 people, remember?
Bottom line is, automated or not, operators need to do their jobs to keep passengers safe.
About time Grabauskas gets fired or steps down. He is a liar. Technology exists and he chose not to implement it. regardlessm the driver screwed up and if she were alive would and should be held responsible. The T drivers conveniently either run through signals or use them as excuses to hold up the trains. The whole system is crooked and needs to be fixed top to bottom, people and the equipment.
Sleep Apnea? Come on, give me a better one than that...she was probably about to text a friend when she crashed and the text not going through is why no one can prove it. That sounds more likely to me given the circumstances. Driving 100's or 1,000's of people every day is not a right because of who you know, it is a HUGE responsibility and we need qualified responsible people in the roles.
The remarks about the lack of a culture of safety at the MBTA was surprising to me. It indicates that the entire MBTA is due for a shaking up and a shaking out. Changing the culture is difficult, but it can be done with wholesale changes in management, starting at the top. On-the-job training for T management also needs to end. One bad manager training another is a recipe for mediocrity. Cross-pollination is vital to any organization. The T should be hiring from among the best managers in the country at other transit systems.
Everything is preventable in hindsight!
These articles tend to imply that automated systems have proximity sensors that activate only to prevent imminent collision. They are not nearly so high-tech. They merely respond to trip-wires on the ground (the ones that currently trigger the lights), and don't allow a train to proceed until the next segment of track is clear.
Why is this a problem? On San Francisco's MUNI, which is much like the Green Line except that it has automated train control, multiple trains aren't allowed to enter the station/open doors simultaneously, causing intolerable backups in the tunnels. (Go ahead and imagine yourself in a queue of green line trains stretching all the way from Park Street to Kenmore. Envision peering through the windshield at the CLEARLY empty station in front of you, fidgeting as the automated system waits another 45 seconds to let you go anywhere.)
The T should only install automated control on the D line, where travel speed, visibility, and longer headways might be able to justify it.
at a
COLLISION AVOIDANCE SYSTEMS exist in most new Volvos (and many other vehicles) - SO they can't be that expensive or hard to install!
So even if the 'Automated Train Control System' cannot be installed, each trolley can certainly install a Collision Avoidance System - or make them Mobile so they are only used/installed in active Trolleys. What's are we missing? WHY has no one mentioned this system?
It detects and imminent Collision and computes when the last possible moment brakes must be applied to avoid - IF Brakes are not applied, the system applies the brakes and AVOIDS COLLISIONS! Hello? This has been around for years and is cheap enough so that car makers install it in moderately priced cars (that is, not costing over $75,000). Point is that it's so worth it when 100's of peoples lives are at stake...
>> MBTA General Manager Daniel A. Grabauskas has previously said it would be difficult to install an automated train control system on the antiquated Green Line because ...
And it's NOT difficult to bury one of your own?
Come on man, this the THE 21st Century. One can do anything one wishes to do. So do it!
About lack of a safety culture, that seems a bit extreme given the slow motion speed limits on the system as a whole. The T in the past used to win all the transit safety awards according to George Sandborn. I believe the last death to a revenue passenger inside a T transit vehicle (excludes commuter rail) was 1973 (going by memory, so corrections welcome.) The Green line may not be as absolutely safe as the other lines. But with those 1-minute rush hour headways, does anyone really believe automatic train control won't create a rush hour nightmare? Every time in the past the T went to ATC, the service got worse. I remember the good old days on the red line before ATC : faster speeds and 3 minute rush hour headways. Yet during the 30 year period from 1950-1980 only one major collision and one or no collision fatalities. The ATC also produced a near collsion at Harvard, and made several other mistakes. So was it really worth the price?
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