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Safety Recommendation Details

Safety Recommendation R-02-012
Details
Synopsis: These recommendations address the determination and designation of maximum authorized train speeds with sufficient safety margins to ensure that a train can be stopped by the air brake system alone. The recommendations are derived from the Safety Board's investigation of the January 30, 2000, derailment of CSX Transportation (CSXT) coal train V986-26 near Bloomington, Maryland, and are consistent with the evidence we found and the analysis we performed. As a result of this investigation, the Safety Board has issued five safety recommendations, two of which are addressed to all class I railroads. Information supporting the recommendations is discussed below. The Safety Board would appreciate a response from you within 90 days addressing the actions you have taken or intend to take to implement our recommendations.
Recommendation: The NTSB recommends that all class I railroads and CSX Transportation, Inc.: Establish procedures to revise steep-grade maximum authorized speeds as necessary.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Bloomington, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ATL00FR003
Accident Reports: Derailment of CSX Transportation Coal Train V986-26
Report #: RAR-02-02
Accident Date: 1/30/2000
Issue Date: 3/21/2002
Date Closed: 12/13/2006
Addressee(s) and Addressee Status: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Closed - Acceptable Action)
Canadian National Railway (Closed - Acceptable Action)
Canadian Pacific Railway (Closed - Acceptable Action)
CSX Transportation, Inc. (Closed - Acceptable Action)
Kansas City Southern Railway Company (Closed - Acceptable Action)
Norfolk Southern Corporation (Closed - Acceptable Action)
Union Pacific (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Canadian Pacific Railway
Date: 8/9/2002
Response: The Safety Board notes that the CPR has introduced a risk assessment and management policy and protocol, through which road managers can evaluate and revise, as necessary, descending grade speeds should train handling procedures pose a questionable risk. This policy fulfills the objective of the Board's recommendation; consequently, Safety Recommendation R-02-12 has been classified "Closed--Acceptable Action."

From: Canadian Pacific Railway
To: NTSB
Date: 6/21/2002
Response: Letter Mail Controlled 06/26/2002 7:33:27 AM MC# 2020636 In April 2001, as required by Safety Management System (SMS) regulations in Canada, CPR introduced a risk assessment and management policy and protocol. The policy requires a risk assessment to be performed whenever a safety concern is identified. The assessment includes identifying and implementing appropriate mitigating actions to eliminate or reduce risks. To ascertain the safety of heavy and mountain grade train performance, Road Managers are required to perform proficiency tests, on-job evaluations, train rides and locomotive event recorder downloads. Road Managers evaluate whether descending grade speed restrictions are appropriate and safe, and look to see that all related train handling procedures are being complied with. If a work practice or procedure poses questionable safety risks, or if there is an occurrence, the manager is required to perform a risk assessment. Through this formal risk evaluation process, descending grade speeds can be revised as necessary. If you are interested in receiving copies of CPR's risk assessment policy or protocol, we would be pleased to provide it. I trust that this response adequately addresses your recommendations.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 9/26/2002
Response: The Safety Board notes that the BNSF has an internal policy to evaluate annually maximum speeds on mountainous grades to ensure, in accordance with the revised federal power brake regulations, that trains can be stopped with the air brake alone. These evaluations are conducted on trackage where the grade is 1.7 percent or greater. The evaluations include such items as crew proficiency, protocol for the handling of rear of train devices, train handling procedures, and handling of exceptions. We appreciate receiving copies of representative pages from one of BNSF's most complex heavy grade territories, Southern California Division, Cajon Subdivision. We note that instructions are included specifying the maximum allowable total brake pipe reduction (18 psi for trains under 135 train per operative brake (TOB) and 14 psi for 135 TOB and greater) to provide for additional margin of safety for stopping trains with air brakes alone. We also note that operating instructions proscribe initiating emergency braking and stopping the train in the event speed exceeds 5 mph above the maximum authorized speed. The BNSF's policy with respect to mountainous grade operations is in line with the objective of Safety Recommendation R-02-11, which is classified "Closed--Acceptable Action." The Safety Board further notes that the BNSF has a process in place, which, in the event of changes in operations due to such factors as track configuration, equipment, or new technologies, will prompt an evaluation and possible revisions to maximum authorized speeds. This process is responsive to Safety Recommendation R-02-12, which is also classified "Closed--Acceptable Action."

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 8/8/2002
Response: Letter Mail Controlled 08/19/2002 5:07:09 PM MC# 2020771 Historically, both the former Burlington Northern Railroad and former Santa Fe Railroad had extensive experience in train operations on steep (heavy) grades. This experience resulted in an ingrained respect for the effect of gravity on train operations. While dynamic brakes were long recognized as a valuable tool in controlling train speed on heavy grades, neither railroad developed a reliance on dynamic brakes as the primary braking system in determining appropriate maximum operating speed. Burlington Northern Santa Fe Railroad has had an internal policy to perform annual mountain (heavy) grade evaluations for many years. These evaluations are conducted on trackage where the grade is 1.7% or greater. The evaluations include such items as: crew proficiency, protocol for handling of rear of train devices, train handling procedures and handling of exceptions. These evaluations revealed significant differences in the handling characteristics for trains of differing tons per operative brake (TOB). In order to establish objective guidelines and consistent safe operating practices for all engineers operating in heavy grade territories, in 1996, Burlington Northern Santa Fe evaluated the relationship between track gradient and air-braking power as it relates to brake shoe/wheel heating and heat dissipation. BNSF used a combination of computer simulation and field testing validation to develop a set of guidelines or matrix for determining maximum safe operating speeds for trains with specified TOB. This included determining absolute maximum TOB for trains on specified track segments to ensure that the primary train speed control device, automatic air brakes, are sufficient to stop a train while recognizing the effects of thermal loading on the wheels and brake shoes. The evaluation performed by BNSF was validated with an independent consulting firm, Rail Sciences. This analysis lead to the development of the current operating instructions provided to locomotive engineers in our heavy grade territories in BNSF Timetable and Special Instructions documents. Representative pages from one of our most complex heavy grade territories, Southern California Division, Cajon Subdivision, is attached for your review and represents the application of the analysis. Further instructions are included specifying the maximum allowable total brake pipe reduction, 18 psi for trains under 135 TOB and 14 psi for 135 TOB and greater, to provide for additional margin of safety for stopping trains with air brakes alone. In addition, operating instructions proscribe initiating emergency braking and stopping train in the event speed exceeds 5 mph above maximum authorized. Revision of the maximum authorized speeds may be required due to changes in track configuration, equipment or new technologies. BNSF RR has developed a process that ensures appropriate evaluation will be completed and revision of speeds accomplished when for any reason a change in operations is proposed that is not covered by current instructions.

From: NTSB
To: Canadian National Railway
Date: 7/31/2003
Response: The Safety Board notes that the CN has reviewed its downgrade operations and has determined that trains can be stopped by the use of the air brake system alone. The Board further notes that the CN will reassess these operations and revise them as necessary following incidents, problem reports, the addition of new lines, or significant changes in operations. These actions are fully responsive to Safety Recommendations R-02-11 and -12, which are classified "Closed-Acceptable Action."

From: Canadian National Railway
To: NTSB
Date: 4/17/2003
Response: CN is pleased to advise that the railroad has reviewed its downgrade operations and had determined that trains can be stopped by use of air brake system alone. The will be reassessed and revised as necessary following incidents, problem reports, when new lines are added or upon significant changes in operations.

From: NTSB
To: Norfolk Southern Corporation
Date: 5/31/2005
Response: The Safety Board appreciates receiving copies of the NS speed tables for the mountainous grade territory on the NS system. The Board notes that NS's Research and Test Department identified all steep grades on its system. The department also calculated the maximum authorized speeds that a train could safely traverse the section of track and stop by the use of the train's air brakes system alone (in accordance with the Federal Railroad Administration's definition of a heavy grade; namely, an average grade of 1 percent or greater over a distance of 3 continuous miles or an average grade of 2 percent or greater over a distance of 2 continuous miles). The NS Rules for Equipment Operation and Handling (NS-1), Rule L-241, was revised to include guidelines and instructions based on the NS Research and Test Department's analysis that specifies that the maximum allowable speed a train may attain while descending a steep grade without having the required number of effective dynamic brake axles (EDBA) is 15 mph. The revised rule also states that the engineer must not make an automatic brake pipe reduction greater than 18 pounds per square inch for a distance of 2 miles or more to avoid brake fade. The Safety Board notes that NS will provide its employees with the necessary training to comply with the regulations and will monitor crews for compliance. As NS's policy with respect to mountainous grade operations has met the objective of the Board's recommendation, Safety Recommendation R-02-11 is classified "Closed--Acceptable Action." The Safety Board further notes that the NS has a process in place to ensure that instructions reflect current operations and technology. These will continue to be evaluated and, if necessary, speeds and train handling procedures will be revised. This process is responsive to Safety Recommendations R-02-12, which is also classified "Closed--Acceptable Action."

From: Norfolk Southern Corporation
To: NTSB
Date: 1/19/2005
Response: In accordance with the Federal Railroad Administration's definition of a Heavy Grade, namely, an average grade of one percent or greater over a distance of three continuous miles or an average grade of two percent or greater over a distance of two continuous miles. Norfolk Southern's Research and Test Department identified all steep grades on our System and calculated the maximum authorized speeds that a train could safely traverse the section of track and stop by the use of the train's air brakes system. · To address the Board's recommendations, Rule L-241 [l], copy attached, specifies that the maximum allowable speed a train may attain while descending a steep grade without having the required number of Effective Dynamic Brake Axles (EDBA) is 15 MPH. Furthermore, the Engineer must not make an automatic brake pipe reduction greater than 18 PSI for a distance of two (2) miles or more to avoid brake fade. Norfolk Southern will provide its employees with the necessary training to ensure they have the knowledge to properly perform the task. In addition, NS will monitor its crews for compliance and performance with the steep-grade instructions through operational efficiency checks, train rides, Engineers Annual Monitoring, and event recorder data. Any deficiencies will be addressed to promote proper understanding and compliance. To ensure that our instructions reflect current operations and technology, Norfolk Southern will continue to evaluate and, if necessary, revise speeds and train handling procedures as they pertain to steep-grade operations. FRA Brake System Safety Standards, 49 CFR Part 232, Norfolk Southern's NS-1, Rules for Equipment Operation and Handling, and the new NS Rule, L-241 [1], provide locomotive engineers with succinct operating instructions to enhance train handling and safety of operations when descending steep grades

From: NTSB
To: Norfolk Southern Corporation
Date: 3/3/2004
Response: The Safety Board has issued several rail safety recommendations (R-99-34, R-00-12, R-02-2, R-02-6, R-02-11, R-02-12, and H-02-12) to NS as a result of various Safety Board railroad accident investigations. With the exception of R-99-34, the Board has not received a response from NS regarding these recommendations. The Safety Board is interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. That is why we monitor the implementation of our recommendations. The Board would appreciate being informed of what action, if any, has been taken or is planned to implement Safety Recommendations R-00-12, R-02-2, R-02-6, R-02-11, R-02-12, and H-02-12.

From: NTSB
To: Norfolk Southern Corporation
Date: 7/1/2003
Response: The Safety Board is interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. That is why we monitor the implementation of our recommendations. The Board would appreciate being informed of what action, if any, has been taken or is planned to implement Safety Recommendations R-00-12, R-02-6, R-02-11, and R-02-12. And, again, as progress is made toward achieving the goal of R-99-34, we would appreciate being updated. Copies of the original recommendation letters are enclosed for your reference.

From: NTSB
To: Union Pacific
Date: 5/28/2003
Response: The Safety Board notes that the UP's System Special Instructions have been revised, and our review of these documents, in particular Item 8, Descending Grades, indicates that the objective of the Board's recommendations have been met. Based on these revisions regarding steep-grade maximum authorized speeds, Safety Recommendations R-02-11 and -12 are classified "Closed--Acceptable Action."

From: Union Pacific
To: NTSB
Date: 2/27/2003
Response: Letter Mail Controlled 3/11/2003 11:04:28 AM MC# 2030140 Union Pacific had rules and instructions implemented prior to the Kelso, CA derailment on January 12, 1997. Following the Kelso derailment, these rules were reviewed, analyzed, revised and implemented. The revisions encompass Safety recommendation R-02-12. We have identified the areas of steep grade property and have revised and maximized train speeds regarding the air brake and the dynamic brake down these grades. Union Railroad Revised System Special Instructions, effective Sunday April 2, 2000 covers this requirement in Item 8. Descending Grades. In addition, each steep grade subdivision has restrictions addressing steep-grade authorized speeds in the special instruction under SI-12 Tonnage Restrictions in the Union Pacific Timetable page for the subdivision.

From: NTSB
To: CSX Transportation, Inc.
Date: 1/12/2005
Response: The Safety Board notes that CSXT contracted Rail Sciences, Inc., to evaluate maximum speeds on mountainous grades to ensure, in accordance with the revised Federal power brake regulation (Part 232), that trains can be stopped with air brakes alone. These evaluations are conducted on trackage where the grade is 1 percent or greater over a distance of 3 continuous miles. The Board appreciates receiving copies of the speed tables for the four mountainous grade subdivisions on CSXT's territory. These tables, along with operating instructions, have been incorporated into the CSX Air Brake/Train Handling Rules. Train speed is based on tonnage and dynamic brake axles for stopping trains by the use of the air brake alone. CSXT's policy with respect to mountainous grade operations has met the objective of Safety Recommendation R-02-11, which is classified "Closed-Acceptable Action." The Safety Board further notes that changes in operations due to such factors as track configuration, equipment, or new technologies continually prompt CSXT to revise, as necessary, maximum authorized speeds; in other words, the new Federal power brake rules require the computation of maximum authorized speeds or the recomputation of those speeds if there are operational changes such as increased train tonnage. This process is responsive to Safety Recommendations R-02-12, which is also classified "Closed--Acceptable Action."

From: CSX Transportation, Inc.
To: NTSB
Date: 6/18/2004
Response: CSX has made the following revisions to our steep-grade maximum speed operations. These revisions are the result of recommendations R-02-11 and R-02-12 identified by the NTSB from the CSX derailment of train V986-26 near Bloomington, Maryland on January 30, 2000. As outlined in the CSX letter to the NTSB on May 20, 2002 the CSX Power Brake Task Force identified all heavy grades that average one percent or greater for a distance of three miles. These grades, along with operating instructions, have been incorporated into the CSX Air Brake / Train Handling Rules. Train speed is based on tonnage and dynamic brake axles that ensure trains can be stopped by the use of the air brake alone. The NTSB has previously been furnished copies of the speed / tonnage graphs along with the analytical criteria. Additionally, CSX continues to evaluate train operation in heavy grade territory where new track configuration, equipment or technology may be required. Examples include: CSX has contracted the internationally known consulting firm Rail Science to evaluate the braking affects of assisted power located in the body of unit coal trains on CSX's Keystone Subdivision. Potentially, CSX will be operating Union Pacific western coal trains to our Coal Dumping Facilities located in Baltimore, Maryland. Secondly, Rail Science is also evaluating what in train forces exist should 30 powered dynamic brake axles exist in head end operation descending heavy grade. CSX will continue to evaluate heavy grade operation and make the necessary changes as required. Should you need additional information, please contact me at your convenience.

From: NTSB
To: CSX Transportation, Inc.
Date: 8/26/2002
Response: CSXT anticipates that the Power Brake Task Force, described above, will also result in speed and special instruction changes. CSXT also plans to complete these actions by the third quarter of 2002. Further, CSXT intends to systematically review speeds on the individual territories as new train operations or new equipment is introduced. Accordingly, Safety Recommendation R-02-12 is classified "Open--Acceptable Response" pending completion of CSXT's action to establish procedures as recommended. Again we would appreciate notification when action has been completed.

From: CSX Transportation, Inc.
To: NTSB
Date: 5/6/2002
Response: Letter Mail Controlled 05/20/2002 7:47:49 PM MC# 2020526 Based on the conclusion of work by the Power Brake Task Force, CSX intends to make any necessary speed and special instruction changes. We anticipate completing that work by the third quarter of 2002. CSX also intends to systematically review speeds on the individual territories as new train operations or new equipment is introduced. Please let me know if you need additional information or if we may be of further assistance

From: NTSB
To: Kansas City Southern Railway Company
Date: 11/28/2006
Response: The Safety Board notes KCSR’s intent to review steep-grade procedures on a regular basis following line additions, major operational changes, reports of problems, recurring systemic issues, and other incidents. This plan satisfies the intent of the recommendation; accordingly, Safety Recommendation R-02-12 is classified Closed Acceptable Action.

From: Kansas City Southern Railway Company
To: NTSB
Date: 4/20/2006
Response: Letter Mail Controlled 4/20/2006 9:25:36 AM MC# 2060205: Per our discussion in earlier conversations regarding our findings regarding a series of tests to ensure proper downgrade operations on heavy tonnage trains is favorable. The KCSR is pleased to announce that we have reviewed our downgrade operations and have determined that our heavy tonnage trains can be stopped by the use of their air brake system alone. These findings will be reviewed on a regular basis as a result to incidents, reports of problems, reoccurring systemic issues, line additions, and or major operations changes.

From: NTSB
To: Kansas City Southern Railway Company
Date: 1/27/2003
Response: With the exception of R-99-25, mentioned above, the Safety Board has received no information from KCS regarding these recommendations. (We note that Safety Recommendation H-02-12 was only recently issued). The Board is interested in knowing whether and how its recommendations are implemented, both to ensure that the public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all our recommendations. We would appreciate receiving information from you regarding actions taken or planned to implement these recommendations. Please address your response to Mr. John A. Hammerschmidt, Acting Chairman, National Transportation Safety Board, and refer to the recommendations by number in your response. Copies of the recommendation letters are enclosed for your reference.