Page:NTSB RAR-92 01.pdf/18

 brakes and reduce throttle to no greater than run 2 position, he should not increase the throttle above that position until brake release has been initiated. The locomotive engineer should make additional reductions with the automatic airbrakes, as needed, to slow or stop. After reaching the desired speed, he should release the automatic airbrake and increase throttle. When making a stop, he should reduce throttle to idle, maintain a minimum 12-psi service reduction while stopped, and make a full application of the locomotive independent brake.

Amtrak management requires that its employees be familiar with the rules and instructions that relate to their duties. If in doubt about meaning or application, they are to ask their supervisor for an explanation. Under Amtrak rules, the locomotive engineer is responsible for observance of signals and for control and regulation of train movement. He is also responsible for instructing apprentice engineers and for ensuring that they are familiar with engine duties During the accident investigation, Amtrak officials and locomotive engineers stated that the locomotive engineer of Amtrak train 66 should have instructed the apprentice engineer to start braking the train at the Pickle Factory, a landmark structure at MP 225.7. They also said that a train operating at 100 mph could not be stopped safely if braking commenced, as was reported, at the Ruggles Street station (MP 226.2). The apprentice engineer stated that he received instruction in the power braking method in the locomotive engineer training program.

—Amtrak management oversees train operations through an efficiency testing program, train riding, and day-to-day supervision of operating crews. Amtrak policy requires that operating officials make at least 100 efficiency tests for operating rues compliance per month. The goal of this program is to test every operating employee on operating rules compliance every 30 days. The Amtrak efficiency testing program is on file with the FRA.

The Safety Board found that in the 11 months preceding the accident, the entire crew of Amtrak train 66 had been tested on operating rules compliance. The locomotive engineer had been tested 27 times, including 14 times for speed and 6 times for signals, and had no reported failures. Efficiency test records indicate that during the 11 months, he had been tested in the Boston area on three occasions On November 16, 1990, he underwent a running automatic airbrake test near Back Bay station. Since entering the locomotive engineer training program, the apprentice engineer had been tested five times, including twice for speed and twice for signals, and had no reported failures.

The FRA inspects Amtrak's efficiency testing records and continuously monitors Amtrak's performance for regulatory compliance. The engineer of Amtrak train 66 testified that FRA safety inspectors had accompanied him on over-the-road trips. The FRA had also observed the performance of dispatchers operating in the centralized dispatching offices No exceptions were noted.

Meteorological Information
The National Weather Service reported that at 8:23 a.m. on December 12, 1990, Boston had a temperature of 34&deg;F and no rain or snow.

Medical and Toxicological Information
According to hospital medical records, 278 persons were transported from the accident scene, 14 were admitted and 264 were treated for minor lacerations,