A New Jersey commuter train ran through a red signal and slammed into another train last year because an engineer concealed a disease that apparently left him unable to distinguish between the colors of signals, the National Transportation Safety Board reported Tuesday.
The engineer, John J. DeCurtis, 59, had successfully hidden his diabetes-related condition from railroad officials, even paying for laser eye surgery himself rather than turning in an insurance claim. And a doctor who examined DeCurtis for his annual railroad physical almost a year before the February 1996 crash used an incorrect test for colorblindness that allowed him to slip through, the board said.
DeCurtis was killed in the wreck, along with one of his passengers and the engineer of the other train. A total of 158 were injured.
NTSB Chairman James E. Hall and other board members expressed concern that federal regulations are not more specific about eye tests for engineers, who must be able to distinguish among green, yellow and red signals.
Federal Railroad Administration spokesman David Bolger said Tuesday that new engineer vision and hearing standards will be included in rules on engineer certification, which are due to be proposed in July. Current standards say engineers must have "the ability to recognize and distinguish between the colors of signals" but do not specify how they are to be tested.
Speculation initially had centered on fatigue and problems with the signal system, both of which had no connection to the wreck, according to the board. Investigators said there was no evidence fatigue was a factor; in fact, they said, there is evidence DeCurtis was attentive to the signal _ three red lights in a vertical row _ but unable to see what color they were.
In the final analysis, the cause of the wreck was uncovered in an unglamorous review of 10 years of medical records, many of which had apparently been falsified by DeCurtis. He had consistently asserted on medical forms that he was taking no medication and was seeing no other doctors.
According to Burt Simon, senior human-factors investigator for the board, the break came when investigators discovered a single 1987 medical report with a reference to sugar in DeCurtis' urine.
The investigators then discovered that DeCurtis had seen two other doctors _ a primary-care doctor who had prescribed the drug Glucotrol to control high blood-sugar levels and an eye surgeon who had treated DeCurtis since April 1995 for diabetic retinopathy. That disease damages blood vessels in the retina and frequently causes permanent vision loss.
Mitch Gerber, the first full-time physician hired by the board, said DeCurtis already had lost a large portion of the central vision in his left eye and was having trouble with his right eye.
"If he looked directly at something, it would be invisible to him," Gerber said, adding that he had a "permanently reduced ability to determine color."
The board's report said DeCurtis had complained to a doctor of "smoke" in his right eye just three weeks before the accident and had undergone additional laser surgery two weeks before the wreck.
The investigators said that as DeCurtis' Hoboken-bound train approached a red signal at Secaucus, he apparently saw it as yellow and had begun accelerating before applying emergency brakes just seconds before colliding with an outbound commuter train. The outbound train had been given the signal to proceed past DeCurtis on another line.
Asked why DeCurtis would go to such lengths to hide his condition, Simon said he apparently wanted to keep his $70,000 annual salary rather than being reassigned to a job that might pay no more than $40,000 a year, or go on disability retirement at $25,000 a year.
"We believe it may have had to do with his financial condition," Simon said. "We can't be sure."
The board also listed as a "contributing" cause of the wreck the use of "an eye examination not intended to measure color discrimination" by Ralph S. D'Agostino of Newark, who performed DeCurtis' annual physical in February 1995 under contract to New Jersey Transit Authority.
After DeCurtis failed a portion of a colorblindness test called the Dvorine Pseudo-Isochromatic Plates Test, D'Agostino then tried to confirm the results with the Dvorine Nomenclature Test, which DeCurtis passed. However, the board said that test is intended only to determine if a person knows the name of colors, not whether he or she is colorblind.
D'Agostino's office said he was out Tuesday, and he did not return a message left with the office.
Jim Dunn, the board's investigator-in-charge at Secaucus, said New Jersey Transit has now tested all 250 of its engineers for colorblindness and all have met minimum standards.
Shirley DeLibero, executive director of New Jersey Transit, noted that the railroad had taken numerous safety steps since the wreck, including a commitment to install equipment to stop a train if an engineer misses a signal. She said the railroad also had implemented new eye-exam standards that go "above and beyond" federal regulations.
_ Information from New York Times was used in this report.