Page:NTSB RAR-81-4.pdf/28

-23- passenger injuries in the FRA study. The report concluded that there was a need to "prevent leg entrapment under seats by adding a back skirt to reduce high frequency of leg injury in collisions."

Since the findings of the FRA study identified the injury—producing fixtures that are present in passenger train accidents, the Safety Board finds it difficult to understand why the FRA has not yet taken steps to require correction of these unsafe and obvious injury-producing conditions. The Safety Board reiterates to the FHA the urgent need for establishing passenger car safety standards.

Emergency Evacuation

Instructions for opening the trapdoors, which covered the steps at the side door locations, were not posted and the passengers were required to jump from the floor level of the car to the ground. The failure of Amtrak to provide adequate instructions for emergency evacuation resulted in additional passenger injuries.

Some emergency escape windows were not identified. One handle needed for removing the window stripping to effect an emergency escape was separated from the window stripping. Instructions were not posted to advise passengers that the window glass must be pulled inward to remove it. These conditions prevented the passengers from removing some of the windows and resulted in panic when the passengers smelled smoke and thought they were trapped. If adequate instructions had been displayed in the cars outlining the operation of trapdoors and emergency escape windows, the panic and the injuries sustained as a result of jumping to the ground may have been avoided.

The flagman and engineer jumped from the power car of train No. 74 when they realized that collision was imminent. This action saved their lives. However, they did not have sufficient time to warn the passengers of the impending collision. Because the conductor and a trainman were occupied in extinguishing the fire outside the second car, only one trainman was available to assist passengers in the rear of the train. No crewmen assisted the passengers in the second, third, and fourth cars.

Training and Supervision of Operator

The OW operator stated that he had been trained to apply the blocking device after copying a train order. Additionally, the operator said that he learned the improper procedure from other operators during his on-the-job training. The operator's statement indicates that other operators were following this unsafe practice, even though it was a violation of Conrail Rules for a "J" holding order. This situation at the OW tower highlights a problem with on-the-job training- if the employees used to train new employees are using improper and unsafe procedures, these methods are being taught to the new employees. Therefore, it is evident that Conrail needs to improve its overview and direct supervision of on-the-job training for operators.

Federal regulations require that Conrail make periodic tests and inspections to determine the extent of compliance with its Operating rules, timetables and special instructions by its operating employees. Records must be retained and made available to the FRA so that performance can be checked by FRA.

Conrail's training of the OW operator was inadequate because it did not assure that he was copying and delivering train orders according to the rules. The absence of supervisory monitoring during his first year of work as an operator resulted in the