(The following article by Matthew L. Wald was posted on the New York Times website on November 29.)
WASHINGTON — To prevent train wrecks like one in January that killed nine people and forced thousands from their homes for days in Graniteville, S.C., railroads should equip tens of thousands of switches in the United States with devices that will “compellingly capture the attention of employees,” the National Transportation Safety Board said Tuesday.
In the Graniteville wreck, a crew put a train on a siding at the end of the work day and left a switch aligned so that the next train through also went into the siding.
The collision punctured a chlorine tank car, and the gas killed nine people, two of them as they slept.
The tracks in the Graniteville area, near Aiken, S.C., were “dark,” meaning that they had no electronic signals that would have allowed a dispatcher to realize that the first crew had forgotten to reset the switch. About 40 percent of the rail network is dark.
The second train, which was moving at 47 miles an hour in a 49-mile-an-hour zone, would have needed half a mile to stop but had less than an eighth of a mile, investigators said.
The engineer, who died in a hospital from chlorine inhalation, was doomed before he got there, they said.
A strobe light like those carried on some school buses, or a radio device that sent signals to beepers or cellphones, might have reminded the first crew to reset the switch when leaving the train for the night, investigators said.
Members of the crew, coming to the end of a 12-hour workday, had a taxi waiting to take them back to their depot and were anxious about finishing before their work hours would violate federal rules, investigators said.
They strayed from the normal pattern of resetting the switch as they moved the train to the next siding, because they were leaving the train in a siding they had not planned to use.
As a result, resetting the switch was “now not part of a natural task sequence,” said one investigator, Robert Chipkevitch.
Debbie Hersman, a member of the safety board who accompanied the investigators to the scene in January, said that the Federal Railroad Administration had proposed fines for failing to reset switches, but questioned the effect.
“Do we think these things are going to change operating behavior?” she asked.
In fact, the freight railroads recognized the problem even before the Graniteville crash on Jan. 6.
The previous October, the Union Pacific and the Burlington Northern-Santa Fe railroads adopted new requirements for train crews when they released their track warrants, which is the railroad equivalent of closing a flight plan, reporting that the trip is complete. Each required that the crew report the position of each switch.
In the January accident, the crew violated a rule of their railroad, Norfolk Southern, by failing to have a job briefing that listed the tasks to be performed at the stop in Graniteville.
While the Graniteville accident had particularly severe consequences, killing six people working the night shift in a factory by the tracks, a truck driver asleep in his cab and a man asleep in his bed, crashes caused by misaligned switches are common.
The board also recommended that railroads put tankers with materials that turn to poison gas, including chlorine and anhydrous ammonia, toward the rear of the train, where they would pose less danger, and reduce speeds through populated areas, to minimize impact forces.
The safety board also called for protective masks to be used in emergencies by train crews transporting hazardous materials.