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Safety Recommendation Details

Safety Recommendation R-03-021
Details
Synopsis: On Tuesday, April 23, 2002, about 8:10 a.m. Pacific daylight time, eastbound Burlington Northern Santa Fe Railway (BNSF) freight train PLACCLO3-22 collided head on with standing westbound Southern California Regional Rail Authority (Metrolink) passenger train 809 on the No. 2 track at Control Point Atwood in Placentia, California. Emergency response agencies reported that 162 persons were transported to local hospitals. There were two fatalities. Damage was estimated at $4.6 million.
Recommendation: The National Transportation Safety Board makes the following safety recommendation to the FRA: Revise the language of 49 Code of Federal Regulations 238.113(a)(1) to reflect that appropriate exterior instructional signage describing the emergency removal procedure be required at emergency windows on all levels of a multiple-level passenger railcar.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Exceeds Recommended Action
Mode: Railroad
Location: Placentia, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA02MR004
Accident Reports: Collision of Burlington Northern Santa Fe Freight Train With Metrolink Passenger Train
Report #: RAR-03-04
Accident Date: 4/23/2002
Issue Date: 11/6/2003
Date Closed: 10/3/2008
Addressee(s) and Addressee Status: FRA (Closed - Exceeds Recommended Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 10/3/2008
Response: At the time of this accident, 49 CFR 223.9(d)(2) required each passenger car window intended for emergency extrication of passengers to be marked with a retroreflective, unique, and easily recognizable symbol or other clear marking and understandable window-access instructions to aid emergency responders. Although Metrolink passengers in the intermediate level seating area did exit through an emergency window, no windows on the intermediate level had been designated for rescue access, nor were they required to be; consequently, no instructions about how to gain access to the intermediate level had been posted. Rescue access windows permit emergency responders to gain access to passengers in the seating area without requiring movement through an interior door or to another level of the car. The Safety Board’s recommendation highlighted the fact that several related concerns were not specifically addressed in the FRA’s regulations. One of the concerns arising from the accident was the specification of the minimum number and locations of windows intended for emergency responder access to passenger cars, as 49 CFR 223.9(d)(2) addressed only marking and instruction requirements and did not provide any express requirement that rescue access windows be present. A second prominent issue concerned specifying minimum numbers and locations of emergency window exits on any level of a multilevel passenger car not just on main levels. The Safety Board notes that on February 1, 2008, the FRA published amendments to 49 CFR Parts 223 and 228, Passenger Train Emergency Systems and Emergency Communication, Emergency Egress, and Rescue Access; both became effective April 1, 2008. The final rule added a new section to the Passenger Equipment Safety Standards, Section 238.114(a)(2), Rescue Access Windows; Multi-level passenger cars-main levels, which requires a minimum of two rescue windowsone rescue access window located in each side of the car entirely within 15 feet of the car's centerline. The Board also notes that Section 238.114(a)(3) requires any level other than a main level used for passenger seating in a multilevel passenger car, such as an intermediate level, to have a minimum of two rescue access windows in each seating area. The final rule contains Section 238.114(d), Markings, which requires that rescue access windows be marked with retroreflective material, with a uniquely recognizable symbol, sign, or other conspicuous marking to identify access instructions for removing the window. While the marking requirement addresses the intent of the recommendation, the FRA’s actions and the work of the Railroad Safety Advisory Committee (RSAC) establishing the minimum number and locations of windows intended for emergency responder access, including levels other than the main level, go above and beyond what the Safety Board recommended; accordingly, Safety Recommendation R-03-21 is classified Closed Exceeds Recommended Action.

From: NTSB
To: FRA
Date: 4/1/2008
Response:

From: NTSB
To: FRA
Date: 10/31/2006
Response: Notation 7590A: The National Transportation Safety Board has reviewed the Federal Railroad Administration’s (FRA’s) notice of proposed rulemaking (NPRM), "Passenger Train Emergency Systems," Docket No. FRA-2006-25273, that was published at 71 FR 50276 on August 24, 2006. The Safety Board notes that the NPRM addresses the Board’s Safety Recommendation R-03-¬21. On April 23, 2002, a BNSF Railway freight train collided head on with a standing Southern California Regional Rail Authority (Metrolink) passenger train in Placentia, California. There were two fatalities, and emergency response agencies reported that 162 persons were transported to local hospitals. Collision damage blocked the rear stairway connecting the intermediate-level seating area with the upper- and lower-level seating areas of the Metrolink cab car. The rear door of the cab car was also blocked, essentially isolating passengers in the intermediate level. Fortunately, the passengers were not incapacitated, and they were able to remove the emergency windows that had instructional signage and pull rings on the inside. Removal of the windows from the outside would have been more difficult due to a lack of exterior instructional signage for first responders at the intermediate-level emergency access windows. As a result of its investigation of the Placentia accident, the Safety Board recommended that the Federal Railroad Administration: R-03-21 Revise the language of 49 Code of Federal Regulations [CFR] 238.113(a)(1) to reflect that appropriate exterior instructional signage describing the emergency removal procedure be required at emergency windows on all levels of a multiple-level passenger railcar. Safety Recommendation R-03-21 is currently classified "Open – Acceptable Response." The Safety Board notes that although current regulations address marking and instructions for "each window intended for emergency access by emergency responders for extrication of passengers," the regulations do not provide any express requirements that such rescue access windows exist. The Safety Board notes that the proposed regulations for 49 CFR 238.114, "Rescue access windows," will contain explicit requirements for numbers and locations of rescue access windows on all levels of a multi-level passenger railcar and requirements for instructions and marking of such windows. Therefore, the Safety Board considers the proposed requirements to be consistent with the intent of Safety Recommendation R-03-21. The NPRM adds a new section: §238.117 "Emergency communications." This section requires that existing and new Tier I passenger cars be equipped with a public address system and that new Tier I passenger cars be equipped with an intercom (i.e. two-way) emergency communication system. Current FRA emergency communication system requirements apply only to Tier II passenger cars. The Safety Board supports the extension of these requirements to embrace both Tier I and Tier II passenger cars. The NPRM also adds a new section: §238.118 "Emergency roof access." The section would require that all new passenger cars, both Tier I and Tier II, have a minimum of two emergency roof-access locations. Existing Tier I passenger cars would not be subject to the proposed requirement, while existing Tier II passenger cars would continue to be subject to the existing requirement of one emergency roof access location. The Safety Board supports the proposed requirements for emergency roof access. The Safety Board appreciates the opportunity to comment on this proposed rulemaking.

From: NTSB
To: FRA
Date: 6/2/2004
Response: Safety Board staff participated in the FRA's September 2003 Railroad Safety Advisory Committee (RSAC) meeting on passenger safety. The RSAC working group's Emergency Preparedness Task Force was formed to address the Board's recommendation, as well as high-priority topics related to systems, procedures, and equipment. The Board notes that its recommendation raised questions that RSAC believes require further examination, such as addressing confusion regarding the minimum number and locations of windows intended for emergency egress, including those on each level of a multiple-level car. Because of the confusion regarding the minimum number and locations of windows, the FRA has issued a letter to all passenger railroads to address these issues until a long-term solution is accomplished. Pending the conclusion of the FRA's RSAC Emergency Preparedness Task Force and implementation of signage describing emergency removal procedures at emergency windows on all levels of a multiple-level passenger railcar, Safety Recommendation R-03-21 is classified "Open--Acceptable Response."

From: FRA
To: NTSB
Date: 2/20/2004
Response: Letter Mail Controlled 3/2/2004 3:01:24 PM MC# 2040106 Currently, FRA is reviewing and considering the necessity of making amendments to its safety standards for passenger trains, or taking other appropriate actions, through FRA's Railroad Safety Advisory Committee (RSAC). On September 9, 2003, FRA began this effort by holding the first meeting of RSAC's Passenger Safety Working Group. We thank the Safety Board for its participation in the Working Group. Subsequently, at the November 2003 meeting of the Working Group, the issue that the Board raises was included in the issues that the Working Group will address under the category of Emergency Preparedness (systems, procedures, and equipment) and assigned as a top priority. This and related issues, identified in part below, will be discussed at the first meeting of the Working Group's Emergency Preparedness Task Force later this month. FRA notes that our existing passenger train safety regulations do require that windows intended for emergency responder access on every level of a multiple-level passenger car be clearly marked and that clear and understandable instructions for their removal be posted at or near the windows on the car's exterior. Specifically, 49 C.F.R. 223.9(d)(2) cross-referenced in 49 C.F.R. 9: 238.113(c), requires each passenger railroad to ensure that: Each window intended for emergency access by emergency responders for extrication of passengers is marked with a retroreflective, unique, and easily recognizable symbol or other clear marking. Each such railroad shall post clear and understandable window- access instructions either at each such window or at each end of the car. Accordingly, a railroad is required to clearly mark, and post clear and understandable access instructions for, each window intended for emergency access by emergency responders, even if such window is not on a main level of a multiple-level car. FRA has sent a letter to passenger railroads (copy enclosed) to make this clear and remove any confusion that may exist. Nonetheless, there are several issues related to the concern raised by the Safety Board which are not specifically provided for in our passenger train safety regulations. One is specifying minimum numbers and locations of windows intended for emergency access to cars by emergency responders, as 49 C.F.R. 5 223.9(d)(2) addresses only marking and instructions requirements. Another issue is specifying minimum numbers and locations of emergency window exits for egress by train occupants from any level of a multiple-level car. As the Safety Board is aware, 49 C.F.R. 5 238.113 specifies minimum numbers and locations of emergency window exits for emergency egress by train occupants from sleeping compartments and main levels of a passenger car. Yet, this section does not apply to general passenger seating in a level of a passenger car that is principally used for passage between the door exits and passenger seating areas, or between passenger seating areas. FRA is reconsidering the appropriateness of not applying the emergency window exits requirements in such a situation. Both of these and other related issues will be discussed at the Emergency Preparedness Task Force meeting. Until such time as FRA has concluded consideration of the need for enhancements to existing requirements, we respectfully request that the Safety Board consider classifying Safety Recommendation R-03-21 as "Open--Acceptable Response," and again welcome the Safety Board's participation in this initiative.