The MBTA team that investigated the case has concluded that the dispatcher didn't keep the proper blocking in place to provide signal protection for the area of track the maintenance crew was working upon. In addition, the railroad workers neglected to provide a shunting device to safeguard the segment of track involved. NTSB has stated that the accident could have been avoided had many of the railroad employees would have performed the important duties required of them. The adherence to simple safety precautions would have kept lives from being lost.
The accident occurred when the train engineer running the train headed southward thought he had a distinct indication of a clearance signal as he left a curve traveling sixty-two miles per hour. The train engineer attempted to use the emergency braking system of the train. Also, the shunting device was not in place to add to the protection for the workers. By the time the collision occurred the train was traveling at forty-four miles per hour. Two out of the six maintenance workers that were involved in the accident perished. Two other employees received serious injuries resulting from the train accident.
The NTSB found that the train dispatcher took out the block on the area of track on which the crew was working. This caused the train engineer of train 322 to think he had complete clearance when he approached the track area where the work was taking place. The track foreman was found to have neglected to follow safety procedures by providing the shunting device for the track area. This act would have kept the side signals red no matter what the dispatcher did. The track engineer who died from the accident was found to have marijuana in his system.
Due to the negligent behavior of the employees involved in the accident the Safety Board has developed a list of precautions to follow in the future. These precautions were suggested to the Federal Railroad Administration:
- Brief railroads on the necessity to inspect their dispatching systems and procedural operations to be sure that safety measures are implemented to give protection and prevent anyone from removing necessary protection for railroad workers receiving track occupancy authority.
- Always demand redundant signal protection, for example shunting, for railroad workers relying on train dispatchers to provide the appropriate signal protection.
- Edit the definition for "covered employees" under 49 C.F.R. Part 219 for the congressionally required alcohol and drug testing programs. It needs to include all employees and agents working on jobs that require a high level of safety precautions. This is outlined within 49 C.F.R. Sections 209.301 and 209.303.
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In addition, the Safety Board recommended that the Brotherhood of Maintenance of Ways Employees Division needs to be proactive in stopping drug and alcohol use. This can be done through helping members to be aware, educated, and to be given treatment options.