NTSB Conclusions on the June, 2011 CZ truck collision

[afigg]

The NTSB board held a hearing today on the June 24, 2011 truck collision with the California Zephyr in Nevada that killed 6. The primary conclusion is that driver inattention and poorly maintained brakes on the truck led to the collision. The final report won't be published for several weeks, but there is a statement of the conclusions and findings.

NTSB Press Release

NTSB Animation of the accident reconstruction and timeline.

Five page summary of the conclusions of the investigation with recommendations

Some of the conclusions:

3. The accident could have been avoided had the truck driver been more attentive and responsive to the visual cues available to him or had the brakes on the truck been in adjustment and operational.

4. The driver was capable of seeing the flashing lights and descending gate at the grade crossing.

,,

9. Because the Nevada Highway Patrol did not follow the pushrod stroke measurement procedure described in the Commercial Vehicle Safety Alliance out-of-service criteria, it is not possible to make a definitive statement regarding the number of brakes that were out of adjustment on the accident truck.

10. A tow truck company that responded to the accident scene "backed-off" the brakes during vehicle recovery operations, thereby destroying evidence and precluding further brake measurements.

11. John Davis Trucking used improper brake maintenance procedures by manually adjusting the automatic slack adjusters, disabling the antilock braking system on the trailers, failing to maintain brakes in adjustment, equipping two axles with mismatched and incorrectly sized brake chambers, and operating with 11 of the 16 brake drums in service worn beyond specified limits.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of the Miriam, Nevada, accident was the truck driver’s delayed braking, and the failure of John Davis Trucking to adequately maintain the brakes on the accident truck. Contributing to the number of fatalities and severity of injuries was insufficient passenger railcar side impact strength.

In short: John Davis Trucking's insurance company is going to have to pay up.

Some of the recommendations:

To the Federal Railroad Administration:

9. Develop side impact crashworthiness standards (including performance validation) for passenger railcars that provide a measurable improvement compared to the current regulation for minimizing encroachment to and loss of railcar occupant survival space.

10. Once the side impact crashworthiness standards are developed in Safety Recommendation 9, revise 49 Code of Federal Regulations 238.217, "Movement of Passenger Equipment With Other Than Power," to require that new passenger railcars be built to these standards.

11. Require that passenger railcar doors be designed to prevent fire and smoke from traveling between railcars.

Ok, so how strong do the cars have to be for adequate side impact crashworthiness?

 

[Devil's Advocate]

Here's an embedded version of video...

http://www.youtube.com/watch?v=dUwYrPhgiS4

The primary conclusion is that driver inattention and poorly maintained brakes on the truck led to the collision.

I'm sure what the NTSB meant to say was that this was an highly emotional tragedy and that assigning actual blame is best left to future generations after several decades of inconsolable mourning as the status quo continues to take its toll on lives and property without any end in sight. I wonder if there's a point at which Amtrak can simply no longer afford insurance for the massive repair bills and legal troubles serious commercial truck accidents can result in.

The driver was capable of seeing the flashing lights and descending gate at the grade crossing.

It's kind of hard to imagine how he didn't see or hear anything long before breaking unless he was blind, deaf, and unconscious. Then again, whether he thought he could beat the train or was simply too self absorbed to even notice it is beside the point to me.

John Davis Trucking used improper brake maintenance procedures by…

Manually adjusting the automatic slack adjusters

Disabling the antilock braking system on the trailers

Failing to maintain brakes in adjustment

Equipping two axles with mismatched and incorrectly sized brake chambers

Operating with 11 of the 16 brake drums in service worn beyond specified limits

Sounds like your average family owned heavy haul trucking company to me. Broken, busted, and rusted. You can't expect these trucking companies to follow the rules unless the likelihood of being caught and the severity of the punishment is high enough to substantially outweigh any financial benefit for ignoring the rules.

Contributing to the number of fatalities and severity of injuries was insufficient passenger railcar side impact strength.

Get ready for passenger rail cars so heavily reinforced that even the worst commercial truck drivers in the country can't maim or kill your loved ones while they're riding in them. Unfortunately these new cars will also require double the cost, double the weight, double the motive power, and have a top speed half that of the current models.

In short: John Davis Trucking's insurance company is going to have to pay up.

Unless I am mistaken this is in not a legally binding decision. John Davis Trucking company will likely declare bankruptcy if they lose their legal case and no matter the result their insurance company is only obligated to pay a tiny fraction of the actual damage and harm caused by their incompetent staff.

 

[Swadian Hardcore]

Very interesting video. These animated accident videos tell a lot about what happened.

 

[amtrakwolverine]

As I posted on another forum How do they expect to build a railcar that can withstand a side impact from a runaway 18 wheeler going say 80MPH downhill and slamming into the side of the passenger car and expecting everyone to walk away. If it could even be done the railcars would be so heavy no locomotive could pull them.

 

[dabrilloman]

Kind of eerie...I was watching the video and just as the truck gets to the bend in the road in the video I hear a train whistle. I thought it was a bit strange as the reast of the video was silent. It took me a moment to realize the train whistle was coming through my window right next to my desk!

 

[Ryan]

Very interesting video. These animated accident videos tell a lot about what happened.

Agreed - I find it utterly amazing that the truck driver was so oblivious to what was going on around him that he literally drove into the side of a train that was right in front of him.

Sad.

 

[afigg]

As I posted on another forum How do they expect to build a railcar that can withstand a side impact from a runaway 18 wheeler going say 80MPH downhill and slamming into the side of the passenger car and expecting everyone to walk away. If it could even be done the railcars would be so heavy no locomotive could pull them.

If you look at the reconstruction video, the truck was driving at an estimated 58 mph and had braked to 26 mph at the moment of impact.. The train was moving forward at 77 mph when the truck hit at an angle, so the collision speed was greater than 26 mph. The detailed assessment of the collision speeds and forces should be in the final report.

Read the side impact crashworthiness recommendation more carefully. In this case, the front of the truck struck the transform, but the empty trailers swung around and hit the Superliner behind the transdorm. That second Superliner car was destroyed as well by the impact and subsequent fire that spread from the transdorm. The 3rd Superliner in the consist suffered serious smoke and heat damage, The engineering design question to ask is whether the cars can be designed to provide greater protection to the passengers against side impacts and fires to improve the chances of survival. Could the second Superliner have had stronger side walls so the swinging trailers did not do as much damage and have had improved protection against the spread of fire and smoke?

The NTSB is recommending that the FRA "Develop side impact crashworthiness standards (including performance validation) for passenger railcars that provide a measurable improvement compared to the current regulation for minimizing encroachment to and loss of railcar occupant survival space." Not to make the cars impact proof.

 

[Guest]

... and poorly maintained brakes on the truck led to the collision.

3. ... or had the brakes on the truck been in adjustment and operational.

11. John Davis Trucking used improper brake maintenance procedures by manually adjusting the automatic slack adjusters, disabling the antilock braking system on the trailers, failing to maintain brakes in adjustment, equipping two axles with mismatched and incorrectly sized brake chambers, and operating with 11 of the 16 brake drums in service worn beyond specified limits.

..., and the failure of John Davis Trucking to adequately maintain the brakes on the accident truck..

So, it was mostly bad brakes on the truck ????

 

[Ryan]

No, it was mostly the truck driver not applying those brakes until 27 seconds after the red lights started flashing (and after he had passed a warning sign and painted marks on the pavement).

 

[Paulus]

The problem with the NTSB's crash worthiness standards suggestion is that it will simply add weight and expense that is counterproductive for most train accidents and generally useless; this type of accident is pretty rare.

 

[Guest]

No, it was mostly the truck driver not applying those brakes until 27 seconds after the red lights started flashing (and after he had passed a warning sign and painted marks on the pavement).

All I get, is that the brakes locked at 27 seconds, not that he first applied his bad brakes at that time. I would think that if the anti-lock system had not be disabled, they would not have locked even at that point, and the truck would have slowed even further. Would he have slowed to zero with good brakes, I have no idea.

 

[SP&S]

Very interesting video. These animated accident videos tell a lot about what happened.

Agreed - I find it utterly amazing that the truck driver was so oblivious to what was going on around him that he literally drove into the side of a train that was right in front of him.

Sad.

Amazing? I don't know. Years ago I knew somebody who managed to walk into the side of a moving streetcar. The ability of mankind to ignore the obvious knows no bounds.

 

[zephyr17]

Very interesting video. These animated accident videos tell a lot about what happened.

Agreed - I find it utterly amazing that the truck driver was so oblivious to what was going on around him that he literally drove into the side of a train that was right in front of him.

Sad.

Amazing? I don't know. Years ago I knew somebody who managed to walk into the side of a moving streetcar. The ability of mankind to ignore the obvious knows no bounds.

I second that. I saw someone run into the side of a bus once myself.

 

[Ryan]

No, it was mostly the truck driver not applying those brakes until 27 seconds after the red lights started flashing (and after he had passed a warning sign and painted marks on the pavement).

All I get, is that the brakes locked at 27 seconds, not that he first applied his bad brakes at that time. I would think that if the anti-lock system had not be disabled, they would not have locked even at that point, and the truck would have slowed even further. Would he have slowed to zero with good brakes, I have no idea.

Try watching the speed of the truck. It remains constant at 58 MPH until the truck driver snaps back to reality, realizes there's a train in front of him and locks the brakes up 6 seconds before the collision.

 

[alanh]

Seems that I've read that a high percentage of grade collision are actually a vehicle driving into the side of a train that's already occupying the crossing.

 

[George Harris]

Try watching the speed of the truck. It remains constant at 58 MPH until the truck driver snaps back to reality, realizes there's a train in front of him and locks the brakes up 6 seconds before the collision.

Read the text with the simulation. It is probably, but not necessarily certain that the truck's speed was a constant 58 mph, but that speed was derived, not measured or from any direct recording of the speed. Here is how it was said that the truck speed in the simulation was derived:

The speed of the accident truck was calculated during a 5-second period when the truck was visible on the forward-facing video recorded by the locomotive. The video was analyzed to determine the position of both the locomotive and the truck as a function of time, which allowed the speed of the vehicles to be calculated. The speed of the truck was assumed constant until the point of brake application, which was estimated from the tire marks leading to the point of collision.

 

[Ryan]

OK???

He still didn't hit the brakes until long after the lights started flashing and the collision was immanent.

 

[George Harris]

OK???

He still didn't hit the brakes until long after the lights started flashing and the collision was immanent.

Not arguing that point at all. Good brakes, bad brakes, or no brakes, it still was the truck driver's fault so far as I am concerned. If he is running around with bad brakes, it could just have well been some carload of people on the road that he ran over. Just making a comment on the extent of what was known. Whether the guy was trying to speed up or slow down, we will never know.

 

[user 1215]

I don't think the outcome of this accident would have been much better had ALL brakes been perfectly functional. It really seems like 100% driver inattention to me.

 

[Swadian Hardcore]

Very interesting video. These animated accident videos tell a lot about what happened.

Agreed - I find it utterly amazing that the truck driver was so oblivious to what was going on around him that he literally drove into the side of a train that was right in front of him.

Sad.

Amazing? I don't know. Years ago I knew somebody who managed to walk into the side of a moving streetcar. The ability of mankind to ignore the obvious knows no bounds.

I second that. I saw someone run into the side of a bus once myself.

Same with that woman that tried to walk across subway tracks to the train on the opposite track and obviously fell off the high-level platform.

 

[chakk]

The earlier analyses that I read on the NTSB website many months ago suggested that if the brakes had been applied six seconds earlier than they were, the truck would have come to a stop just before hitting the side of the train. But then again, it also would have hit the train farther back in the consist (if it did still hit the train), possibly leading to more passenger injuries. Truck driver inattention (compounded by the ineffective brakes on some of the trailers) were the primary reasons for the collision.

Very sad. I had ridden many times between Winnemucca and Reno with the Amtrak conductor who died in the accident. She was the ultimate professional.