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Safety Recommendation Details

Safety Recommendation R-03-002
Details
Synopsis: At 8:57 a.m., central daylight time, on May 28, 2002, an eastbound Burlington Northern Santa Fe (BNSF) coal train collided head on with a westbound BNSF intermodal train near Clarendon, Texas. Both trains had a crew of two, and all crewmembers jumped from their trains before the impact. The conductor and engineer of the coal train received critical injuries. The conductor of the intermodal train received minor injuries; the engineer of the intermodal train was fatally injured. The collision resulted in a subsequent fire that damaged or destroyed several of the locomotives and other railroad equipment. Damages exceeded $8 million.
Recommendation: The National Transportation Safety Board makes the following safety recommendations to the Federal Railroad Administration: In territory not equipped with a positive train control system, restrict the issuance of track warrant authority that contains an after-arrival requirement to trains that have stopped at the location at which they will meet the opposing train.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: CLARENDON, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA02FR007
Accident Reports: Collision of Two Burlington Northern Santa Fe Freight Trains
Report #: RAR-03-01
Accident Date: 5/28/2002
Issue Date: 6/13/2003
Date Closed: 8/6/2004
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s): Positive Train Control

Safety Recommendation History
From: NTSB
To: FRA
Date: 8/6/2004
Response: At the same meeting, the FRA indicated that it shares the Safety Board's concern regarding after-arrival orders. The FRA pointed out that it had issued Safety Directive 97-l, addressing practices to evaluate the integrity of all railroads' programs of operational tests and inspections and to ensure that safety-critical information is accurately conveyed and acknowledged for operations in direct train control territory. Included in this publication was a recommendation that railroads review their operating rules and practices pertaining to operations in non-signaled territory to determine what further enhancements in their rules and practices are warranted, including the possibility of eliminating the use of after-arrival orders. However, as the Board noted, Safety Directive 97-1 is non-binding and the use of these orders varies among the seven Class I railroads. The Canadian National/Illinois Central, Kansas City Southern, Norfolk Southern and Canadian Pacific (SOO District) currently have no restrictions on the use of after-arrival orders. FRA staff indicated that the agency was planning no further action in response to this recommendation. Given the FRA's position and the Safety Board's continued belief in the recommendation's merit, the Board has no alternative but to classify Safety Recommendation R-03-2 "Closed--Unacceptable Action."

From: FRA
To: NTSB
Date: 10/3/2003
Response: Letter Mail Controlled 1/20/2004 9:06:06 AM MC# 2030525 The Safety Board's investigation determined that the probable cause of this collision was (1) the coal train engineer's use of a cell phone during the time he should have been attending to the requirements of the track warrant his train was operating under and (2) the unexplained failure of the conductor to ensure that the engineer complied with the track warrant restrictions. The Safety Board further determined that contributing to the accident was the absence of a positive train control system that would have automatically stopped the coal train before it exceeded its authorized limits. As a result of this investigation, the Safety Board issued two safety recommendations to FRA. As the result of two major train accidents that occurred in June 1997, one on CSX Transportation, Inc., (CSX) in St. Albans, West Virginia, and the other on the Union Pacific Railroad (UP) in Devine, Texas, FRA issued Safety Directive 97-l' addressing safety practices to evaluate the integrity of all railroads' programs of operational tests and inspections and to ensure that safety-critical information is accurately conveyed and acknowledged for operations in Direct Train Control territory. Included in this publication was a recommendation that railroads review their operating rules and practices pertaining to operations in non-signalled territory to determine what further enhancements in its rules and practices were warranted, including the possibility of eliminating the use of "after arrival" orders. The following is a current status of "after arrival" orders on the seven Class I railroads. CSX had previously (December 1996) eliminated "after arrival" orders over their entire system, both in signaled and non-signaled territory. This was as a result of a head-on collision that occurred on August 20, 1996, in Smithfield, West Virginia, which involved a train that held an "after arrival" order but failed to positively identify the train to be met. UP eliminated "after arrival" orders in non-signaled territory, subsequent to the Devine, Texas, collision. In that accident, the train dispatcher failed to give the train being restricted the "after arrival" information on its track warrant. However, the UP has recently reinstated "after arrival" orders in non-signaled territory, but with the provision that the train being restricted must first be stopped at the point of 'Although termed a safety "directive", the document is non-binding and its requirements are purely elective restriction. BNSF initially took no action in response to the elimination of "after arrival orders," but subsequent to the tragic accident at Clarendon on May 28,2002, in non-signaled territory, now requires the train being restricted to be stopped at the point of restriction before the "after arrival" order may be issued. The Canadian National/Illinois Central, Kansas City Southern, Norfolk Southern and Canadian Pacific (SO0 District), currently have no restrictions on the use of "after arrival" orders. Those railroads that currently have no restrictions on the use of "after arrival orders" feel that any limitations placed on the train dispatcher's ability to freely issue movement authorities, such as "after arrival" orders, severely and unnecessarily impacts their operations and is not a judicious use of dispatcher resources. Their reasoning is that operational flexibility is diminished by forcing the train dispatcher to have to rely solely on the pace of the trains, rather than being able to operate at his/her own pace by planning the work and issuing the necessary movement authorities when the need actually arises, when he or she is not occupied doing other things. In fact, to place such a restriction on train dispatchers not only reduces flexibility but violates existing rules for train dispatchers which require them to issue instructions to trains as may be required for their safe and efficient movement, to plan as far in advance as practical, and not to delay trains unnecessarily. To require the dispatcher to wait until a train has actually arrived and is stopped at the point of restriction carries with it the undesirable side effects of blocked crossings, poor fuel conservation, air and noise pollution, excessive brake shoe wear, and crew fatigue, by extending their time on duty. FRA believes there is merit to this assertion, particularly when one takes into account that both the industry and FRA's expectations are that, like all operating rules of the railroad, those rules governing the issuance of and compliance with mandatory directives, will be strictly adhered to. "After arrival" orders are fundamentally no different from the old train order From S-A, Fixing Meeting Points for Opposing Trains, whereby a train would receive its "meet" order(s) when it left its initial terminal - meets that in most cases would not occur until many miles down the railroad. In today's dispatching environment, with the advances in communications technology, particularly on high density lines, railroad dispatching practices now permit train dispatchers to advance trains more expediently. This means that in the case of meets, these instructions are now typically given when trains are only a relatively short distance from the meeting point, which has greatly decreased the possibility of overlooking the order, since it will be almost immediately acted upon. Additionally, most railroads have an operating rule that requires crews to remind each other when approaching an area where their train is restricted, typically two miles in advance, which includes an "after arrival" order, and some even go beyond that and require crews to broadcast this information over the radio. Also, most railroads have adopted the recommendation in Safety Directive 97-l concerning track warrants in those instances in which a train meet is included in the movement authority, that the train dispatcher state "this track warrant includes a requirement to meet another train," which must be repeated back to the train dispatcher. Based on the foregoing, FRA believes that most railroads in the Nation do have sufficient operating rules and instructions already in place to address the Safety Board's concern regarding restrictions placed on the issuance of "after arrival" orders without the intrusiveness of regulatory intervention by FRA. However, we must agree that this coverage is not uniform and complete among the many railroads, especially on those railroads covered by the General Code of Operating Rules (GCOR) that utilize track warrants as a means of main track authority. While we believe that it is essential that those rules governing the issuance of and compliance with mandatory directives must be strictly adhered to by employees, we must agree with the Safety Board that this does not always occur as demonstrated by the accidents that have resulted due to human errors. This speaks of the need for FRA to continue to facilitate actions necessary within the railroad industry for the development and implementation of positive train control as the Safety Board has recommended in Safety Recommendation R-01-06. But until positive train control can be fully achieved, we need to take those steps that will decrease the risk of collisions that may occur as a result of employee error. FRA also agrees with the Safety Board's issuance of Safety Recommendation R-03-3 to Mr. Rod McCorkle, Chairman of the GCOR Committee, and for that Committee to discuss the contents of that recommendation which reads: "Add language to the track warrant rules to ensure that in territory not equipped with a positive train control system, track warrant authority that contains an after-arrival requirement is issued only to trains that have stopped at the locution at which they will meet the opposing train." (R-03-3) FRA believes that the GCOR Committee should discuss and consider the adoption of this recommendation for trackage that is not equipped with some form of automatic train stop or positive train control. Should that Committee decide to incorporate the intent of Safety Recommendation R-03-3 in their GCOR track warrant rules, this would achieve the results that the Safety Board seeks in establishing a railroad operating rule that would limit the issuance of an after-arrival requirement only to trains that have stopped at the location at which they will meet the opposing train. This would be achieved without the necessity of FRA promulgating a regulation to achieve this same objective as FRA routinely monitors dispatching practices and compliance with railroad operating rules in this area, and reserves the right to take appropriate enforcement action when it is warranted. To facilitate discussion and consideration of the Board's recommendation of this issue, I have instructed my staff to arrange a meeting with the appropriate railroad industry representatives. Should the rail industry decide not to adopt the language specified in Safety Recommendation R-03-3, FRA would then revisit Safety Recommendation R-03-2 to determine if a rule-making procedure should be initiated. It is FRA's belief that the rail industry should have the first opportunity to consider and act upon this issue before FRA would attempt to enter into rule-making. Therefore, based on the above discussion, FRA respectfully requests that the Safety Board give consideration to classifying Safety Recommendation R-03-2 as "Open-Acceptable Response," until such time as it is determined whether or not the rail industry will adopt Safety Recommendation R-03-3. I appreciate the Safety Board's excellent investigation of the circumstances involved in the collision at Clarendon, and for the careful attention given in your letter providing your rationale for the safety recommendations made to bring about improvement to railroad safety.