A collision of errors on the R2 is detailed

A potentially lethal mix of human error and inadequate warning systems loomed large in the head-on crash of two SEPTA trains in Montgomery County last summer, newly released federal documents show.

The July 1, 2006, accident in Abington Township derailed four cars and injured 38 passengers and all six crew members.

The National Transportation Safety Board, which is investigating, has yet to announce a cause, affix blame or prescribe remedies. But records made public by the NTSB hold plenty of fodder:

A rookie engineer who ran his southbound train on the R2 line through at least one stop signal, broke a rail switch, and continued unaware down the track.

An alarm that SEPTA's control center did not heed.

A dispatcher so harried that urgent calls from one train went unanswered for more than a minute.

The absence of a train-control mechanism that would have prevented the crash.

Heroism also emerges.

Michaeline Dunaj, now 28, the northbound train's engineer, sensed the danger and pulled to a halt. Her instincts lessened the impact, averting worse injuries or deaths.

"She probably saved a lot of lives," said lawyer James McEldrew, a Philadelphia rail-law specialist who is suing SEPTA on behalf of Dunaj's two crewmates.

SEPTA officials acknowledge, and are addressing, the lapses found by the NTSB.

Dispatchers have been retrained and software upgrades ordered to make sure stop-signal breaches are not missed, said Patrick Nowakowski, SEPTA's chief operations officer. The agency has also stepped up installation of automatic train-control devices on the tracks where the crash occurred.

SEPTA has fired Silvino Alexander, 36, the southbound engineer, for running the stop signal. He is appealing the loss of his engineer's license, said Richard Dixon, general chairman of the Brotherhood of Locomotive Engineers and Trainmen Division 7.

Dunaj, two conductors, and two assistant conductors remain off the job because of their injuries, Dixon said.

At least one conductor and an assistant conductor are suing SEPTA in Philadelphia Common Pleas Court, alleging that negligence caused their injuries. More litigation is expected from other crew members. SEPTA officials knew of no passenger lawsuits.

SEPTA, through its lawyers, has denied any liability.

Alexander had been a SEPTA engineer for two weeks. The southbound run that Saturday from Warminster was his fifth solo trip.

Dunaj had 11 months of experience. She set off from Suburban Station on the R2 line to Warminster, a route she had often traveled.

For six miles, between Warminster and Roslyn, the R2 is a single-track line. Trains headed in opposite directions have to share the same rails.

Just north of Willow Grove, a stretch of track known as a siding veers off and runs parallel to the main track. Sidings allow one train to pull over and the other to pass.

On previous runs, signals and switches had directed Alexander onto the siding. This time, they were set for him to sit on the main track and wait for the northbound train to pull onto the siding.

Dunaj was running seven minutes late. She was just reaching Roslyn, where two tracks narrowed to one.

Data recorded by SEPTA showed Alexander under a red stop signal at the siding. But his train ran past it, breaking a switch set to guide Dunaj's train onto the siding.

Alexander later claimed he had received an "approach" signal - three vertical lights, a yellow over two reds. The NTSB noted that the signal there had only two lights.

The breach came at 2:49 p.m., eight minutes after Alexander left Warminster.

It set off an alarm in SEPTA's Center City control room, where dispatchers peer into computer screens and numbered train symbols flash across a panoramic display board showing various lines.

It was bad timing for dispatcher Donald Stieber.

Twenty minutes into his shift, he was working two dispatch desks, covering for a colleague on break. His back was turned when the beeping alarm went off at his desk.

SEPTA dispatchers told the NTSB that alarms go off almost hourly, rarely for a true emergency. Often they shut them off, only later reading the details on their screens.

"We'll just, you know, acknowledge the alarms [and] look at them when we can," Stieber told the NTSB.

Records showed he did just that when the alarm from the siding sounded. Two days later, he told the NTSB that he couldn't remember getting it.

"I may have," he said.

A maintenance worker at Tabor Junction tied him up 90 seconds on the phone at his absent colleague's desk.

For much of that time, Dunaj was trying to reach him by radio.

North of Roslyn Station, Dunaj saw a green signal as she rolled toward Crestmont, a small stop before Willow Grove.

Then she hit her brakes.

The green suddenly had changed to a red "stop and proceed" signal. Going from green to red was something she had never encountered.

The change had been triggered automatically by Alexander's gaffe up the track. Dunaj had no way of knowing that. But she had a feeling, and she wasn't going anywhere without checking with her dispatcher.

"It was just an instinct," she later told the NTSB.

She tried to radio Stieber three times. No answer.

And so she sat.

Finally, Dunaj got through.

"I was explaining to [the dispatcher] that I think it's a dangerous situation because we are on a single track," she told the NTSB.

She thought she had heard him say to go ahead.

Dunaj put her hands on the throttle and the brake, and the train began to move.

In the control room, SEPTA's computer was confused.

When Alexander had broken the switch, the software logically - but wrongly - assumed the train on the tracks just south of the switch was Dunaj's. So the dispatcher's screen showed her northbound train there.

Alexander's train was supposed to be parked beside the siding. That's where the computer depicted it.

Such was the image Stieber would have seen of the R2 line when Dunaj's call summoned him back to his desk. The only hint of trouble was the colored symbol depicting Alexander's train; it had shifted from red to orange.

The orange color, the NTSB report said, meant that the software recognized that Alexander should have been on the main track next to the siding. At the same time, the computer found no indication the train was actually there.

Alexander's southbound train had, in fact, already arrived at Crestmont.

Around the next bend, on the same track, sat Dunaj's northbound train.

Because of that, Alexander should have seen a red stop signal at Crestmont. He told the NTSB that it had been yellow - an assertion SEPTA disputes.

But even under a yellow, his top speed should have been 30 m.p.h. An event recorder showed him hitting 39 m.p.h. as he rounded the curve and saw, to his horror, Dunaj's train in his path.

He told the NTSB that he had "put the train in full emergency," but knew he couldn't stop.

Cursing, he ran into the first car, telling passengers to brace themselves.

Dunaj had gone but two feet when she saw headlights rounding the curve.

Her conductor, William Keyte, also caught the flash of metal coming toward them. "I screamed at her, you know, 'It's coming at us. Get the hell out of the way.' "

They yelled for passengers to move to the rear, or sit down and hold on.

Dunaj tried to reach passengers in the second car, but "I didn't make it."

Alexander's train struck them at 11 m.p.h.

Dunaj was knocked off her feet; Keyte landed in the fourth or fifth seat of the car. He got up, ran to the radio, and called in the emergency.

On the southbound train, conductor Kimberlie Fields fell and slid under the seats. Assistant conductor Shawn Chamberlain flipped backward over a seat.

People were screaming.

The NTSB has not said when its findings and recommendations will be issued. But SEPTA isn't waiting.

It has retrained dispatchers on handling alerts.

By 2009, the R2 Warminster line should have control devices that automatically slow or stop trains that disobey signals or speed limits.

And SEPTA has ordered software to distinguish signal violations from other alarms. They will appear as computer-screen pop-ups - accompanied by a human voice repeating, "Signal overrun."