National Transportation Safety Board Special Investigation Report

Accidents Involving the Maryland Transit Administration at the Baltimore-Washington International Airport Light Rail Station

February 13, 2000 and August 15, 2000

In a special railroad investigation, the National Transportation Safety Board has determined the probable causes of two separate accidents involving the Maryland Transit Administration (MTA) at the Baltimore Washington International Airport (BWI). Although the accidents have different causes, the Board found similar safety issues were involved in both of them. Sleep apnea was identified as a factor in the accidents.

This is an abstract from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

Executive Summary

In 2000, the Maryland Transit Administration (MTA)1 experienced two similar accidents in the same location just 6 months apart. Both accidents involved the failure of an MTA light rail vehicle (LRV) train to stop at the designated stopping point at the Baltimore-Washington International Airport Light Rail Station (BWI Airport Station). In both cases, the train struck a "hydraulic bumping post" apparatus at the end of the track. The Safety Board's investigation of the two accidents indicated that, although the direct cause of each accident was different, aspects of the MTA rail transit operation common to the two accidents influenced both their outcomes. Consequently, the Safety Board developed a special investigation report to address the safety factors affecting both accidents.

The first accident occurred about 2:37 p.m. (eastern standard time) on February 13, 2000, when MTA train 24 (composed of a single LRV), en route from Baltimore to the BWI Airport struck the hydraulic bumping post at the terminus of track No. 1 at the BWI Airport Station and derailed. The force of the collision detached the bumping post from the track, and the front of the train, which was lodged against the bumping post, was elevated about 3 1/2 feet into the air. Train 24 carried 26 people (25 passengers and 1 operator), 18 of whom were injured. Five of those injured had serious injuries. The MTA estimated the cost of the accident at $924,000.

The second accident occurred about 7:14 a.m. (eastern daylight time) on August 15, 2000, when MTA train 22 (composed of two LRVs), en route from Baltimore to the BWI Airport, struck the hydraulic bumping post at the terminus of track No. 2 at the BWI Airport Station and derailed. The bumping post separated from its attachment to the track and came to rest in an inverted position. The leading LRV of the train came to rest on top of the overturned bumping post and about 4 1/4 feet up in the air. Train 22 carried 22 people (21 passengers and 1 operator), 17 of whom were injured. None had life-threatening injuries. The MTA estimated the cost of the accident at $935,000.

This special investigation report discusses the following safety issues:

The effect of sleeping disorders on the performance of LRV operators,
The adequacy of requirements governing the use of prescription and over-the-counter medications by LRV operators,
The adequacy of the event recorders.

As a result of its investigation of these accidents, the Safety Board makes recommendations to the Federal Transit Administration, all rail transit systems, and the MTA.

Conclusions

The train 24 operator failed to apply the brakes to stop his train at the Baltimore-Washington International Airport Station on February 13, 2000.
The effects of prescription pain-relieving medications and/or recent cocaine use impaired the performance of the train 24 operator on February 13, 2000.
The train 22 operator did not apply the brakes to stop his train at the Baltimore-Washington International Airport Station on August 15, 2000.
The train 22 operator was not impaired by alcohol or illegal drugs at the time of the August 15, 2000, accident.
The train 22 operator was suffering from severe obstructive sleep apnea at the time of the August 15, 2000, accident.
The chronic fatigue he was experiencing due to undiagnosed obstructive sleep apnea likely caused the train 22 operator to fall asleep as the light rail vehicle train approached the Baltimore-Washington International Airport Station on August 15, 2000.
Better education about the risks posed by sleeping disorders, the indicators and symptoms of such disorders, and the available means of detecting and treating the conditions could help transit agencies and their employees reduce the risk of safety-sensitive employees being impaired by chronic fatigue.
Because the Maryland Transit Administration did not require safety-sensitive employees to report their use of prescription and over-the-counter medications, it lacked information that could have had a bearing on the condition and performance of such employees.
Maryland Transit Administration managers and employees were confused about the requirements for reporting medication use to the Maryland Transit Administration.
In the interests of passenger safety, rail transit operators should be at least as rigorous as Federal Railroad Administration-regulated operators concerning possible sources of operator impairment.
Before the two accidents at the Baltimore-Washington International Airport Station in 2000, the Maryland Transit Administration had not successfully implemented a comprehensive system safety program plan throughout all levels of the organization; however, efforts to do so are now underway.
The Cullen-Western-Hayes WH bumping posts installed on both service tracks at the Baltimore-Washington International Airport Station were the wrong end-of-track protection devices for this location because their kinetic energy absorption capacity was inadequate for some light rail operations possible at this location and their design did not provide an adequate deceleration stopping distance for the Baltimore-Washington International Airport Station stop.
The bumping posts at the Baltimore-Washington International Airport Station struck during the February and August 2000 accidents had been improperly installed.
The event recording system in place on the Maryland Transit Administration light rail cars is inadequate to serve as a reliable accident investigation tool.

Probable Cause: February 13, 2000, BWI Accident

The Safety Board determines that the probable cause of the February 13, 2000, accident at the Baltimore-Washington International Airport rail transit station was the train 24 operator's impairment by illicit and/or prescription drugs, which caused the operator to fail to stop the train before it struck the bumping post at the terminus.

Probable Cause: August 15, 2000, BWI Accident

The Safety Board determines that the probable cause of the August 15, 2000, accident at the Baltimore-Washington International Airport rail transit station was the train 22 operator's severe fatigue, resulting from undiagnosed obstructive sleep apnea, which caused the operator to fall asleep so that he could not brake the train before it struck the bumping post at the terminus.

Safety Recommendations

As a result of its investigation of both accidents discussed in this report, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Transit Administration

Authorize and encourage rail transit systems to require their employees in safety-sensitive positions to inform the rail transit system about the employee's use of prescription and over-the-counter medications so that the rail transit system can have qualified medical personnel determine the medication's potential effects on employee performance.

To All Rail Transit Systems

Require employees in safety-sensitive positions to inform their supervisors about their use of prescription and over-the-counter medications so that qualified medical personnel may determine the medication's potential effects on employee performance, and train the employees about their responsibilities under the policy.

Ensure your fatigue educational awareness program includes the risks posed by sleeping disorders, the indicators and symptoms of such disorders, and the available means of detecting and treating them

To the Maryland Transit Administration:

Install, on all your light rail vehicles, independent event recorders that record and retain the most recent 48 hours of data, store data in nonvolatile memory, and have a back-up power source that would enable the entire recording system to function if electric power is lost to the car.

NTSB Determines Cause of Two Transit Rail Accidents at BWI Airport December 11, 2001 03:58 PM

The first accident occurred about 2:37 p.m. on February 13, 2000, when an MTA train en route from Baltimore to BWI derailed after striking a hydraulic bumping post at the end of track No.1 at the airport station. The force of the collision detached the post from the track, and the front of the train, which was lodged against the bumping post, was elevated about 3 = feet into the air. There were 25 passengers and 1 operator on board the train; 18 persons were injured.

A similar accident occurred about 7:14 a.m. on August 15, 2000, on track 2 of the BWI station. The post again separated from its attachment to the track; it came to rest in an inverted position on the track. The train's lead car landed on top of the overturned post and about 4 < feet up in the air. There were 22 passengers and 1 operator on board the train; 17 persons were injured.

In each accident, the Board noted that the operator's failure to apply the brakes resulted in the train hitting the bumping post and that, prior to the two accidents, the MTA had not successfully implemented a comprehensive system safety program plan throughout all levels of the organization. Efforts to do so are currently underway.

Major issues developed during this special investigation include the effect of sleeping disorders on the performance of light rail vehicle operators, the adequacy of regulations governing the use of prescription and over-the-counter medicines by light rail vehicle operators, and the adequacy of event recorders.

The train operator of the second accident was suffering from severe obstructive sleep apnea at the time of the accident according to the Board.

In the first accident, the Board found that the effects of prescription pain- relieving medicines and/or the recent use of cocaine impaired the performance of the train operator.

The Board identified several deficiencies with the event recorders on both accident trains, including the system's dependence on a triggering event to activate the recording system. Such a system does not provide enough information to determine how a train is being operated before an accident.

Consequently, the Board concluded that the event recording system on the MTA light rail cars is inadequate to serve as a reliable accident investigation tool. As a result of its investigation the Board recommended that the Federal Transit Administration, all rail transit rail systems and the Maryland Transit Administration:

Authorize and encourage rail transit systems to require their employees in safety-sensitive positions to inform the rail transit system about the employees' use of prescription and over-the-counter medicines so that the rail transit system can have qualified medical personnel determine the medicine's potential effects on employee performance.
Require employees in safety-sensitive positions to inform their supervisors about their use of prescription and over-the-counter medicines so that qualified medical personnel may determine the medications potential effects on employee performance, and train the employees about their responsibilities under policy.
Ensure fatigue educational awareness program includes the risks posed by sleeping disorders, the indicators and symptoms of such disorders, and the available means of detecting and treating them.
Install, on all light rail vehicles, independent event recorders that record and retain the most recent 48 hours of data, store data in nonvolatile memory, and have a back-up power source that would enable the entire recording system to function if electric power is lost to the car.

An abstract of the Board's report is available on its web site at www.ntsb.gov, under Publications. The entire report will be available on the web site in a few weeks. Printed copies will be available after that through the National Technical Information Service.