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Safety Recommendation Details

Safety Recommendation R-15-006
Details
Synopsis: On Friday, August 17, 2014, at 2:28 a.m. central daylight time, southbound UP freight train MASNL collided with northbound UP freight train QNLPI at milepost (MP) 228.6 while traversing the turnout at Control Point CP-Y 229 on the UP Hoxie Subdivision in Hoxie, Arkansas.1 The track in the area transitions from a single main track to two main tracks. As a result of the collision, the engineer and the conductor from the southbound train were fatally injured, and the engineer and the conductor from the northbound train were transported to local hospitals on the day of the accident with serious injuries. About500people within a 1.5-mile radius of the derailment were evacuated. The southbound train consisted of two leading locomotives and 86 cars. The northbound train consisted of two leading locomotives and 92 cars. The lead locomotives from both trains derailed, and the second locomotive from the northbound train released diesel fuel, resulting in a fire. In total, 55 cars derailed, including 41 cars from the southbound train and 14 cars from the northbound train. The maximum authorized speed in the area is 70 mph for freight trains and 75 mph for passenger trains. Amtrak passenger trains operate over this segment of the UP Hoxie Subdivision. The maximum authorized speed through the turnout from main track no. 1 to main 2 track no. 2 is 40 mph for both freight and passenger trains. There were no temporary speed restrictions at the point of collision on the day of the accident.
Recommendation: TO THE AMERICAN PUBLIC TRANSIT ASSOCIATION, ASSOCIATION OF AMERICAN RAILROADS, AND THE AMERICAN SHORT LINE AND REGIONAL RAILROAD ASSOCIATION: Inform your members of the circumstances of this accident and the risks posed by automated inputs that reset alerter cycles. Urge your members to assess their locomotive alerter systems to (1) identify any inputs that reset the alerter cycle without intervention by crew members and (2) determine ways to eliminate such resets. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Hoxie, AR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14FR011
Accident Reports: Railroad Accident Report: Collision of Two Union Pacific Railroad Freight Trains
Report #: None
Accident Date: 8/17/2014
Issue Date: 2/4/2015
Date Closed: 8/23/2016
Addressee(s) and Addressee Status: American Public Transportation Association (Closed - Acceptable Action)
American Short Line and Regional Railroad Association (Closed - Acceptable Alternate Action)
Association of American Railroads (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: American Public Transportation Association
Date: 4/7/2016
Response: We note that you concur with the problem we identified, recognize that this vulnerability needs to be immediately addressed, and have advised yours members as requested. In a related matter, on March 17, 2016, in response to the Federal Railroad Administration’s (FRA) October 15, 2015, letter regarding Safety Recommendations R-15-4 and -5, we acknowledged that the FRA planned (1) to issue a Safety Advisory notifying railroads of the circumstances of this accident and of the risks posed by automated inputs that reset alerter cycles and (2) to encourage railroads to review the operation of their locomotive systems to ensure that no system resets the alerter warning timing cycle without direct engineer action. These actions address the intent of Safety Recommendation R-15-6, which is classified CLOSED--ACCEPTABLE ACTION.

From: American Public Transportation Association
To: NTSB
Date: 3/14/2016
Response: -From Michael P. Melaniphy, President and CEO: About APTA The American Public Transportation Association (APTA) is a non-profit international trade association of public and private member organizations, including public transit systems; high-speed intercity passenger rail agencies; planning, design, construction and finance firms; product and service providers; academic institutions; and state associations and departments of transportation. More than ninety percent of the 10.7 billion of Americans who use public transportation are served by APTA member transit systems. As the primary advocacy group for public transportation in North America, we fully appreciate and accept as our primary duty to lead the industry in moving people safely. This safety and security role is deeply imbedded in the over 100 year history1 of our organization and is exemplified as being the top goal of APTA’s Strategic Plan. Status of Recommendation R-15-6, Automated Inputs Affecting Locomotive Alerters (Urgent) As a standard practice, APTA issues alerts to our members whenever the NTSB issues safety recommendations that could be applicable to operational safety even if they are intended for a single agency rather than the industry at large. In response to your letter dated February 4 concerning NTSB R-15-6, APTA advises that it has shared the totality of letter, and its urgency, with the CEOs of all FRA regulated railroads in our membership. The letter, as well as the link to the report, was also shared with the members of our Commuter Rail Safety & Security subcommittee, including members that serve as contractors operating commuter rail service on behalf of the service provider. In this manner, we believe that we have saturated our membership with the information contained in R-15-6 and have satisfied the intent of the recommendation. In the case of recommendation R-15-6 the following broadcast email was issued to APTA members in accordance with NTSB request for urgent action: Subject: NTSB Issues Urgent Recommendation R-15-6: Dear Committee Members- The NTSB has discovered that some locomotive cab alerter systems that monitor train engineer performance receive false indications of engineer activity and reset their monitoring cycles based on this inaccurate information. By resetting the timing cycles, the alerters are prevented from providing the engineers with the visual and audio alarm as intended, nor would they set the penalty air brake application if the engineer was unresponsive. Such a situation occurred August 17, 2014 in Hoxie, AR resulting in a head-on collision between two UP freight trains. Two crew members died and two were seriously injured. The NTSB investigation found that the alerter system was continuously suppressed by receiving signals from the horn activation circuit, which was interpreted as an action being performed by the engineer. In reality, the horn was being sounded automatically by a horn sequencer unit. Here is the summary by the NTSB, for more information follow the attached URL: The safety issue we have identified during this investigation involves an onboard system (in this case the horn sequencer) that, once activated, repeatedly resets the alerter cycle without any manual intervention by a crew member. This vulnerability needs to be immediately addressed by the FRA and the industry. Therefore, the NTSB makes the following urgent safety recommendation to the American Public Transportation Association, the Association of American Railroads, and the American Short Line and Regional Railroad Association: R-15-6 (Urgent) Inform your members of the circumstances of this accident and the risks posed by automated inputs that reset alerter cycles. Urge your members to assess their locomotive alerter systems to (1) identify any inputs that reset the alerter cycle without intervention by crew members and (2) determine ways to eliminate such resets. W.P. Grizard EOM https://www.aptagateway.com/eweb/upload/201500096_Out.pdf Additional follow up action was taken by including this recommendation for discussion at the 2015 APTA Rail Safety Committee meeting held in Salt Lake City June 21, 2015. It is our contention that we have more than satisfied the Board’s recommendation and respectfully request R-15-6 to be reclassified as “Closed – Acceptable Action”.

From: NTSB
To: American Public Transportation Association
Date: 10/27/2015
Response: We expect to receive an initial response from recipients of our recommendations within 90 days after recommendations are issued, and within 30 days in the case of urgent recommendations; completing actions to address our safety recommendations usually takes recipients 3 to 5 years. Safety Recommendation R-12-36 is now over 3 years old, yet we have received no update regarding your actions to address it since your June 28, 2012, letter. We classified this recommendation “Open—Acceptable Response” on August 22, 2012, pending issuance of the recommended guidelines and standards. To date we have received no response from you regarding Safety Recommendation R-14-71 or Safety Recommendations R-15-6, -11 or -12, currently classified OPEN--AWAIT RESPONSE. Accordingly, we would appreciate receiving a prompt update regarding your actions and plans for satisfying these recommendations. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Pending your timely reply, all the recommendations will retain their current classifications. Copies of our letters issuing each of these recommendations are enclosed, as are copies of your June 28, 2012, letter regarding Safety Recommendation R 12-36 and our August 22, 2012 reply.

From: NTSB
To: Association of American Railroads
Date: 6/12/2015
Response: We are pleased that you notified the chief operating officers of your member railroads of the accident and tasked your Locomotive Committee with assessing (1) the inputs that may reset the alerter cycle without intervention by crew members and (2) ways to eliminate these types of resets. We note that you are also working to identify locomotives equipped with sequencers that pose this problem so that the owners of those locomotives can disable the repetitive sequencing. Accordingly, Safety Recommendation R-15-06 is classified CLOSED—ACCEPTABLE ACTION.

From: Association of American Railroads
To: NTSB
Date: 3/6/2015
Response: Following your recommendation, AAR notified the chief operating officers of its member railroads of the accident. AAR also tasked its Locomotive Committee with assessing the inputs that may reset the alerter cycle without intervention by crew members and ways to eliminate these types of resets. The horn sequencer in the Hoxie accident provides one such input- it activates the locomotive horn and repeats the highway crossing cadence until purposely turned off by the locomotive engineer. Until turned off, the sequencer resets the alerter cycle. On behalf of the committee, AAR is proceeding to identify those locomotives equipped with this type of sequencer. Once identified, the owners of those locomotives will be able to disable the repetitive sequencing. AAR trusts that AAR's actions fulfill the intent of Safety Recommendation R-15-06. Thus, AAR requests that the status of R-15-06 be "Closed-Acceptable Action."

From: NTSB
To: American Short Line and Regional Railroad Association
Date: 8/23/2016
Response: We note that, although your organization did not directly inform your membership of the circumstances of the Union Pacific Railroad freight train collision in Hoxie, Arkansas, you did cite a Federal Railroad Administration (FRA) safety advisory in your newsletter that recommended all freight railroads review their locomotive systems to ensure no system resets the alerter timing cycle without direct engineer action. We believe your action meets the intent of the recommendation. Accordingly, Safety Recommendation R-15-06 is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

From: American Short Line and Regional Railroad Association
To: NTSB
Date: 6/27/2016
Response: -From Linda Bauer Darr, President: Please consider this to be a response to your letter dated February 4, 2015 to Mr. Richard F. Timmons, who retired as President of the American Short Line and Regional Railroad Association as of December 31, 2014. On December 16, 2015, in response to the Federal Railroad Administration's (FRA) Safety Advisory 2015-06, ASLRRA published an article in its online newsletter, with a hot link to the FRA advisory: FRA Issues Safety Advisory Concerning locomotive Alerter Systems The Federal Railroad Administration (FRA) has issued Safety Advisory 2015-06 recommending all freight railroads review the operation of their locomotives equipped with alerters, and modify as necessary, to ensure no system resets the alerter warning timing cycle without direct engineer action, especially those equipped with horn sequencers. Click here to review the advisory. The newsletter was released to an email list of more than 5,000 individual subscribers. A copy of the newsletter is provided as an attachment to this letter. As you may recall, you and I met on December 2, 2015 and discussed the urgent safety advisory, and established ASLRRA's plan to communicate the information to our membership via newsletter. We appreciate your follow up. Please don't hesitate to let me know if anything further is needed from the Association on this matter.