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Statement on Train No. 3920 Derailment from George D. Warrington
There is nothing more important to New Jersey Transit’s Board of Directors, our staff, and Governor McGreevey -- than the safety of our customers. It is paramount.
This investigation has been, and will continue to be focused on getting at the facts – and ensuring this doesn’t happen again.
As a result of the derailment this past Monday, I launched a comprehensive investigation of the incident including a detailed review of: audiotapes of communications between the dispatching office and crew, computer downloads from train equipment, statements from the crew and passengers, training records, and other documents.
Together with the FRA and AMTRAK, NJ TRANSIT’s investigating team conducted a tear down mechanical inspection at our maintenance facility in Kearny, and staged a re-enactment of the crew’s inspection of the train that took place prior to the derailment. Working with an outside metallurgical expert, we have analyzed the performance of the wheel assembly on the Arrow III car that lost a wheel.
The full report from metallurgy studies will take at least 30 days. Absent any new information, we have been able to make a preliminary assessment -- based upon all available evidence to date -- that the train struck some form of debris enroute from Trenton. The debris strike caused the bearing seal to be damaged between the gear unit and the bearing housing. This damage and subsequent overheating caused the bearing to seize up. Later on its journey, the bearing failure led to the separation of the wheel from the axle.
However, in Edison, at Mile Post 29.7 -- Amtrak’s wayside hot wheel scanner signaled to the dispatcher that the wheel was overheating. The train stopped to enable the crew to perform an inspection of the wheels. The protocol in these instances is very clear – and is guided by both NJ TRANSIT rules and Amtrak special instructions to crews. The conductor is required to use a Tempilstik device on the bearing housing to determine whether the surface temperature has exceeded 200 degrees. Proper performance of the inspection would enable detection of impending wheel failure.
With these facts at hand to date, NJ TRANSIT will initiate a disciplinary process for the train’s conductor -- consistent with union contractual requirements -- and pursue a hearing process to determine his responsibility in the apparent failure to properly inspect the wheel condition and take corrective action. Following the hearing, if guilt is indicated, appropriate disciplinary action will be taken. Pending the outcome of the hearing, the conductor will remain out of service without pay.
In addition, all of our train crews will immediately be retrained in safety and inspection protocols within the next 60 days.
The investigating team found no evidence of material defect or concerns associated with maintenance practices. However, in the interest of absolute safety, we will take the additional precaution of downloading daily the computers on the 115 Arrow III cars that have traction motors, to monitor for any abnormalities. I have also instructed our mechanical engineering staff to look at developing a shield for the key portion of the wheel assembly to prevent further debris strikes from doing catastrophic damage.
We will continue working with the FRA until their investigation is complete and our findings are final.
Finally, the investigation found that the instructions and assistance rendered to train 3920’s passengers immediately following the derailment were inadequate. While the investigation found that the first manager was on the scene within 20 minutes and the on-board public address system was not operational following the derailment, it is clear that on-board emergency response plans and contingency protocols need to be improved.
As a result, I have directed a task force to review all aspects of customer care and communications during this event, including interviewing the customers aboard train 3920, and will announce the actions to be taken in about two weeks. The task force will thoroughly review crew size, evacuation protocols, emergency communications and passenger information on what to do in the event of an emergency. There are important lessons to be learned from this incident and we will overhaul our practices accordingly.
In conclusion, the preliminary findings of NJ TRANSIT’s investigation are that two factors contributed to the derailment of train 3920:
· A “mechanical failure” -- the result of striking debris – that ultimately separated the wheel from the axle.
· And “human error” – not detecting the impending wheel failure through established protocols.
Finally, I want to thank the Federal Railroad Administration for their leadership --- and Amtrak for their cooperation -- with the emergency response -- service recovery and participation in the investigation.