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Safety Recommendation Details

Safety Recommendation R-05-010
Details
Synopsis: On October 12, 2003, about 4:38 p.m., central daylight time, westbound Northeast Illinois Regional Commuter Railroad (Metra) train 519 derailed its two locomotives and five passenger cars as it traversed a crossover from track 1 to track 2 near Control Point 48th Street in Chicago, Illinois. The train derailed at a recorded speed of about 68 mph. The maximum authorized speed through the crossover was 10 mph. There were about 375 passengers and a crew of 3 on board. As a result of the accident, 47 passengers were transported to eight local hospitals. Of these, 44 were treated and released, and 3 were admitted for observation. Damages from the accident exceeded $5 million.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require train crews to call out all signal indications over the radio, including clear signals, at all locations that are not equipped with automatic cab signals with enforcement or a positive train control system.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Chicago, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA04MR001
Accident Reports: Derailment of Northeast Illinois Regional Commuter Railroad Train 519
Report #: RAR-05-03
Accident Date: 10/12/2003
Issue Date: 11/23/2005
Date Closed: 7/19/2012
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s): Positive Train Control

Safety Recommendation History
From: NTSB
To: FRA
Date: 7/19/2012
Response: Thank you for the June 7, 2011, e-mail from Mr. Aaron Thompson, Program Analyst, and for your May 7, 2012, letter to the National Transportation Safety Board (NTSB) regarding safety recommendations that the NTSB issued to the Federal Railroad Administration (FRA). Mr. Thompson’s e-mail addressed Safety Recommendations R-02-1, R-03-12, R-05-10, and R-09-21 and -22, stated below, which were issued to the FRA as a result of four NTSB accident investigations. Safety Recommendation R-09-21 was issued as an urgent recommendation. This letter also addresses Safety Recommendations R-98-56, R-05-2, R-05-17, R-06-19, and R-06-26, stated below, which were discussed in the Secretary of Transportation’s April 12, 2011, letter submitting to Congress the report Actions on Unmet Statutory Mandates and Open Recommendations by the National Transportation Safety Board and the Department of Transportation’s Inspector General Regarding Railroad Safety, pursuant to Section 106 of the Rail Safety Improvement Act of 2008. Finally, this letter addresses Safety Recommendations R-11-6 and -7, discussed in your May 7, 2012, letter, which were issued to the FRA on January 12, 2012, as a result of our investigations of two of five recent rear-end collisions of railroad trains that occurred when crewmembers failed to operate their trains at the required restricted speed. The NTSB is aware that, on February 22, 1996, the FRA issued Emergency Order 20, and modified it in Notice No. 2 in March 1996, in response to the collision and derailment of a Maryland Transit Administration (MARC) and an Amtrak train near Silver Spring, Maryland, on February 16, 1996. This order requires that commuter and intercity passenger railroads (including public authorities providing passenger service through contracts with other railroads, and freight railroads with affected passenger service on their lines) take certain steps regarding their operations above 30 miles per hour (1) where cab signal, automatic train stop, or automatic train control protections are not present and (2) on railroads that permit passengers to occupy the leading car. Although these practices partially meet the intent of the recommendation, because the FRA has made it clear that it will take no further action to complete the recommended action, Safety Recommendation R-05-10 is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: FRA
Date: 12/1/2011
Response: CC# 201100449 was closed administratively; no response was written or mailed.

From: FRA
To: NTSB
Date: 6/7/2011
Response: CC# 201100231: - From Aaron W. Thompson, Program Analyst, Accident Analysis Branch: Please reference FRA’s report to Congress at http://www.fra.dot.gov/rrs/pages/fp_1778.shtml. Additional information is below. R-05-10: After speaking with Dennis Yachechak (OP Acting SD), it is believed FRA will take no further action with this recommendation. R-02-01: After speaking with Tom McFatlin (S&TC SD) and Ron Ries (HRX SD), it is believed FRA will take no further action with this recommendation. R-09-21: After speaking with Tom McFatlin (S&TC SD), it is believed FRA will take no further action with this recommendation. R-09-22: After speaking with Tom McFatlin (S&TC SD), it is believed FRA will take no further action with this recommendation. R-03-12: After speaking with Bob Lauby (Dep. Assoc. Administrator for Regulatory and Legislative Ops.), it is believed FRA will take no further action with this recommendation. FRA will support Amtrak’s actions regarding this recommendation.

From: FRA
To: NTSB
Date: 4/12/2011
Response: -From Ray LaHood, Secretary of the United States Department of Transportation: NTSB Classification and Actions Taken by FRA: Open – Unacceptable Response. FRA’s RSAC reviewed this recommendation, but there was significant opposition on the grounds of impracticality, radio congestion, and other factors. FRA notes that the mandate for PTC contained in the RSIA should, to a considerable extent, lead to this becoming a moot issue. FRA recognizes that the purpose of this recommendation is to ensure that personnel responsible for safe train movements are actively engaged in responding appropriately to all signals governing their movements. FRA will explore a further alternative approach in connection with resolution of this recommendation and the recommendation concerning audio and image recording (Rec. No. R-10-01, which superseded Rec. No. 07-03), if possible, refining options previously presented to and discussed in two RSAC working groups. Actions Needed to Be Taken by FRA: Determine whether an alternative solution can be implemented.

From: NTSB
To: FRA
Date: 6/2/2010
Response: MC# 2090581: The NTSB notes that within the FRA’s RSAC, both labor and management representatives expressed considerable disagreement regarding the recommendation, citing the impracticality of such a requirement, radio congestion, and other factors. The FRA points out the Railroad Safety Improvement Act (RSIA) of 2008 mandate for PTC will render this requirement moot by 2015 in areas where PTC is installed. In the meantime, the FRA will provide an alternate approach to address this recommendation and Safety Recommendation R-07-3, concerning voice recordings, by modifying a previously manageable solution discussed in two RSAC working groups. The FRA will be discussing these options informally with the NTSB in the near future. The NTSB is looking forward to meeting with the FRA to move toward a resolution in meeting the objective of both recommendations. Accordingly, pending the FRA’s implementing a requirement that train crews call out all signals, including clear, at all signal locations not equipped with ACS with enforcement or PTC, Safety Recommendation R-05-10 remains classified Open Unacceptable Response. The NTSB would like to receive a PTC coverage map in the FRA’s next update to consider the potential effect of the RSIA on this issue.

From: FRA
To: NTSB
Date: 9/2/2009
Response: Letter Mail Controlled 9/14/2009 10:35:09 AM MC# 2090581: - From Joseph C. Szabo, Administrator: The FRA’s RSAC reviewed this recommendation, but there was significant opposition from both labor and management representatives on the grounds of impracticality, radio congestion, and other factors. FRA notes that the mandate for PTC contained in the RSIA should, to a considerable extent, lead to this becoming a moot issue. The FRA wishes to emphasize those placing additional safety duties on employees, under circumstances where regular validation of performance is not feasible, may lead to disregard-not only for the specific duties in question, but potentially for more critical duties, as well. Compliance will thus become sporadic, with omissions extending both to critical procedures and less critical procedures, potentially leading to catastrophic consequences. The circumstances of the Chatsworth accident, which involved violations of Emergency Order No. 20 communication procedures that could have prevented the accident, present a good illustration of this potential. The FRA recognizes that the purpose of this recommendation is to ensure that personnel responsible for safe train movements are actively engaged in responding appropriately to all signals governing their movements. FRA will explore a further alternative approach in connection with resolution of this recommendation and the recommendation concerning voice recording (R-07-003); if possible, refining options previously presented to and discussed in two RSAC working groups. We will be discussing options with the Board, informally, in the near future. The FRA respectfully requests that NTSB classify this Safety Recommendation as Open-Acceptable Response," until such time as FRA has determined the proper alternative approach needed to fully address the intent of this recommendation.

From: NTSB
To: FRA
Date: 11/15/2006
Response: MC# 2060249: The Safety Board is aware that on February 22, 1996, the FRA issued Emergency Order 20 (EO20) and modified it in Notice No. 2 in March 1996, as a result of the collision and derailment of a Maryland Transit Administration (MARC) and an Amtrak train near Silver Spring, Maryland, on February 16, 1996. The Board notes that the FRA will request the Passenger Safety Working Group of the Railroad Safety Advisory Committee (RSAC) to include these issues in the forthcoming review of EO20. We would appreciate being informed of the timeframe for conducting this review. We further note concerns on the part of the FRA and some of the class I and commuter railroads regarding difficulties they anticipate such as airwave congestion and a loss of effectiveness of radio-transmitted messages due to the repetitious nature of this practice should the FRA require all railroads to call out all signals, including clear signal indications. The Safety Board is aware that two class I railroads (CSX and Norfolk Southern [NS]) and two commuter railroads (Virginia Railway Express and MARC, when operating on CSX and NS track) currently call out all signals and apparently have not found this practice to be problematic. Several other railroads also require train crews to call out all signals under various circumstances and conditions. The Board suggests that, as part of its review of EO20, the FRA, through its RSAC, should study the effectiveness of these railroads' procedures related to calling out all signals to determine how these railroad procedures could be applied industry wide. The Board believes that all railroads should call all signal indications, including clear at all locations except yard and terminal limits. Pending these actions being taken, Safety Recommendation R-05-10 is classified "Open-Unacceptable Response."

From: FRA
To: NTSB
Date: 5/16/2006
Response: MC# 2060249: The requirement for the locomotive engineer to call out certain information over the radio and requiring an acknowledgment from a member of the train crew, has been a practice in the railroad industry since the 1960s. The origin of this practice was primarily rooted in attempting to maintain the alertness of the train crews who were either riding in the caboose at the rear of the train, or in the body of a passenger train, by notifying them that the train was approaching a siding or station. While far from universal, in the ensuing years, additional railroads slowly embraced the concept, some even expanding it to include fixed signal aspects and indications, but again strictly for the alertness value. Eventually, however, railroads recognized that an ancillary benefit could be derived from this practice by obligating the train crew to become more vigilant in the operation of the train. By the 1980s, with the gradual elimination of cabooses on freight trains, the conductor and brakeman were now required to ride in the operating cab of the controlling locomotive, along with the engineer. Under these circumstances, signal calling was sometimes restricted to the locomotive cab, but over time railroads also continued to experiment with calling of signals on the radio. When FRA issued Emergency Order No. 20 (EO 20) in February 1996 and modified in Notice No. 2 in March 1996, FRA recognized the immediate need to ensure that signal indications were followed by train and engine crews. Since certain operating rules requiring the communication of signal indications and other information were already in place on many railroads, FRA adopted in EO 20 a rule that required a crew member located in the operating cab of a controlling locomotive, cab car, or MU car to orally communicate each wayside signal indication that required that the train be prepared to stop at the next wayside signal or that the train be prepared to pass the next wayside signal at restricted speed. A designated crewmember, whether in the operating compartment or elsewhere in the train, must then immediately acknowledge and confirm the transmission. That requirement remains in place. However, FRA did not require that this information be transmitted over the radio. If another crewmember is present in the operating compartment, or if an intercom is used, then these methods would satisfy this requirement. FRA's expectations are that in the absence of an appropriate response by the engineer to a restrictive indication that has been communicated, the designated crewmember shall take action to ensure the appropriate response. In the 10 years that this specific requirement of EO 20 has been in effect, FRA is unaware of any issues of noncompliance, or any instance of a train crewmember having to take any action to ensure that the train is being operated safely. However, by contrast, FRA sees limited value in indiscriminately broadcasting all signal aspects and indications over the radio. On a passenger train, for example, train crews may be occupied with other important duties such as collecting tickets, making change, answering passenger inquiries, adjudicating fare disputes, controlling unruly passengers, and making heat/light adjustments. With tinted windows obscuring their external view and inhibiting their ability to judge speed and the train's location, particularly at night, a crew member's ability to react quickly and appropriately to signal information is dubious at best. In the case of freight trains, all crewmembers will typically be seated in the locomotive cab or will be distracted by other duties or personal needs away from their normal positions in the cab. Second, arbitrary radio transmissions that have no practical value can actually be a detriment to safety by unnecessarily congesting the airwaves, particularly in terminal areas (as the Board notes in its accident investigation report, EO 20 has an exception for "yard and terminal limits"). Further, calling signal indications such as clear or advance approach, which require no immediate action on the part of the engineer, would be meaningless to another crew member located elsewhere in the train, since they would not be required to take any action either. Third, radio transmissions can also be interrupted ("stepped on"), thereby rendering the information incomplete or useless. Requiring separate acknowledgement of each transmission-including clear signals-would further clog the airways and would like introduce a new source of disruption to the engineer's situational awareness, particularly in the case of commuter operations where train speeds and frequent signals could result in an unacceptable communications workload. Also, with the multiplicity of channels in use today, one crew may not necessarily hear all transmissions that could affect their train. Fourth, repetitive radio transmissions lose their effectiveness over time and may become merely white noise. FRA believes that it is essential that the power of Federal regulation be reserved for truly necessary and practical requirements, lest their influence be seriously diluted. Fifth, too much information broadcast over the radio regarding train locations, speed, signal aspects an indications, etc., may create an anticipatory environment that can influence crews to act capriciously on that information. FRA's accident files contain cases that were caused by crews acting on information regarding a preceding train's location, even though railroad operating rules and Federal regulations prohibit this practice. The Board itself has noted that "communications between trains can be inconsistent," and that "radio communication between trains, because it is ad hoc, can itself lead to misunderstandings that could compromise safety." (NTSB RAR 01-01 at 35-36.) FRA does appreciate that, in the context of passenger operations subject to EO 20, it is appropriate to review the requirements for calling of signals, the present limitation to aspects more restrictive than those at issue in the Metra derailment and the practices of the railroads in designation areas where even these minimum requirements do not apply. In response to the Board's expressed concerns, FRA will request the Passenger Safety Working Group of the Railroad Safety Advisory Committee to include these issues in its forthcoming review of EO 20. However, FRA strongly believes that an indiscriminant implementation of the subject recommendation to all railroad operations is not supported by the Board's analysis, the circumstances of the Metra derailment, or other information available to FRA. Accordingly, FRA respectfully requests that the NTSB reconsider this safety recommendation, classifying Safety Recommendation R-05-10 as "Closed-Reconsidered."