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Safety Recommendation Details

Safety Recommendation R-17-017
Details
Synopsis: On April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 (train 89) struck a backhoe with a worker inside at milepost 15.7 near Chester, Pennsylvania. The train was authorized to operate on main track 3 (track 3) at the maximum authorized speed of 110 mph. Beginning on the morning of April 1, Amtrak had cheduled track-bed restoration?ballast vacuuming—at milepost 15.7 on track 2 on the Philadelphia to Washington Line. Track 2 had to be taken out of service between control points Baldwin (milepost 11.7) and Hook (milepost 16.8) for the 55 hour duration of the project. As train 89 approached milepost 15.7, the locomotive engineer saw equipment and workers on and near track 3 and initiated an emergency brake application. The train speed was 106 mph before the emergency brake application and 99 mph when it struck the backhoe. Two roadway workers were killed, and 39 other people were injured. Amtrak estimated property damages to be $2.5 million. The accident investigation focused on the following safety issues: roadway worker protection, communication between dispatchers and foremen, lack of job briefing, and safety management. As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, Amtrak, Brotherhood of Maintenance of Way Employees Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen. The National Transportation Safety Board also reiterates a recommendation to the Federal Railroad Administration.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Chester, PA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA16FR007
Accident Reports: Preliminary Report: Railroad DCA16FR007Amtrak Train Collision with Maintenance-of-Way Equipment, Chester, Pennsylvania​​Safety Recommendation Report: Using Technology to Protect Maintenance-of-Way Employees
Report #: RAR-17-02
Accident Date: 4/3/2016
Issue Date: 12/28/2017
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/30/2019
Response: Reiterated in the Railroad Accident Report RAR-19-02: Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train Cayce, South Carolina, February 4, 2018, adopted Jul 23, 2019, published on September 30, 2019, notation number 59351 and accident number RRD18MR003. The attached letter from the NTSB Chairman provides information about the NTSB’s July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. This letter provides information about our July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues: • The medical examination process for railroad employees. • The actions and responsibilities of the train crew handling switches. • The CSX Transportation efficiency testing program and staffing. • Operations during signal suspensions. • Implementation of a safety management system by Amtrak (National Railroad Passenger Corporation) to assess and mitigate risks for operation on host railroads. • Occupant protection in passenger railcars. Accordingly, the NTSB reiterates the following safety recommendations to the Federal Railroad Administration. Additional information regarding these reiterations can be found in the noted sections of the report. • Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) (See section 2.2.2.) • When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) (See section 2.2.2.) • Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay. (R-17-17) (See section 2.8.) • Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear. (R-18-10) (See section 2.5.) In the same report, we also classified two previously issued safety recommendations: • Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum authorized speed. (R-18-5), (classified “Closed––Unacceptable Action” in section 2.5.) • Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear. (R-18-10), (classified “Open––Unacceptable Response” in section 2.5.) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. 2.8 Government Regulation of Safety Management On August 12, 2016, the FRA published a final rule, 14 CFR Part 270, requiring the development and use of SSPPs for all passenger rail operations. Since the final rule was published, the FRA has delayed implementation seven times. On June 12, 2019, the FRA published a new notice of proposed rulemaking that would further delay the effective date of this rule past the most recent date of September 4, 2019, to a new undetermined date. In the investigation of the accident in Chester, Pennsylvania, the NTSB found that one of the challenges faced by all railroads in developing a formal SSPP has been the failure of the FRA to enact its final rule. Many of the railroads have designed their SSPP but are apprehensive about implementing their plan because of concerns that modifications will be necessary after the regulation is fully enacted. At the time of the NTSB’s report on the accident in Chester, the FRA had delayed the rule’s implementation four times. As a result, the NTSB issued Safety Recommendation R-17-17 to the FRA: Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay. (R-17-17) In the years since the rule was published, accidents have continued to occur. On April 22, 2019, pending implementation of the final rule, Safety Recommendation R-17-17 was classified Open—Unacceptable Response. The Chester accident occurred on Amtrak’s own property. However, as shown by this accident and others, Amtrak operates on host railroads throughout the United States. The system safety regulation would not be limited to Amtrak property and would be applicable to all of Amtrak’s operations, including those on host railroads. With the regulation in place, the relationship between the host railroad and Amtrak would be better defined, and Amtrak could present to the host railroads their regulatory obligations. The NTSB concludes that the repeated postponement of 49 CFR Part 270, System Safety Program by the FRA has delayed needed safety improvements for the passenger rail industry and the traveling public. Therefore, the NTSB reiterates Safety Recommendation R-17-17 to the FRA.

From: FRA
To: NTSB
Date: 9/27/2019
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA) response to the National Transportation Safety Board's (NTSB) Safety Recommendations R-19-008 through-015 and reiterations of R-16-32, R-16-35, R-16-36, and R-17-17. The NTSB issued and reiterated these safety recommendations, respectively, after its investigation of the December 18, 2017, derailment of National Railroad Passenger Corporation (Amtrak) train 501 in DuPont, Washington. Based on FRA's investigation, FRA maintains the primary cause of the Amtrak 501 derailment was the failure of the engineer and the conductor to comply with Amtrak's operating rules. Specifically, the engineer failed to prioritize attention and situational awareness to properly call out speeds and identify the wayside signals and signs. FRA also maintains that improper crewmember training was a contributing accident cause, as FRA's investigation found training for the assigned crewmembers of Amtrak 501 did not comply with Federal regulations. With these factors in mind, please find below FRA's specific responses to each safety recommendation. The NTSB reiterated this recommendation in its letter to FRA dated June 21, 2019. On August 12, 2016, FRA published a final rule requiring commuter and intercity passenger railroads to develop and implement a system safety program (SSP) to improve the safety of their operations. 19 The SSP rule is part of FRA's efforts to continuously improve rail safety and to satisfy the statutory mandate in the RSIA.2° FRA subsequently stayed the SSP final rule to address petitions for reconsideration filed by certain labor organizations and State and local transportation departments and authorities.21 On June 12, 2019, FRA issued a proposed rule to respond to the petitions.22 FRA is working diligently to issue the SSP final rule. As the SSP rule was built on existing industry practice, a systematic, risk-based safety management program is an essential safety tool for any railroad operation-regardless of whether such a program is required by Federal regulation. FRA continues to offer its technical assistance and support to any railroad or entity who chooses to continue with the implementation or maintenance of voluntary safety programs. FRA will continue to support the industry in these efforts as the rulemaking progresses through the regulatory process.

From: NTSB
To: FRA
Date: 6/24/2019
Response: Reiterated in the Railroad Accident Report RAR-19-01: Amtrak Passenger Train 501 Derailment DuPont, Washington December 18, 2017, Adopted on May 21, 2019 and published on June 24, 2019, notation number 58913 and accident number RRD18MR001. On April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 struck and killed a worker inside a backhoe at MP 15.7 near Chester, Pennsylvania (NTSB 2017). As a result of this investigation, the NTSB identified the need for Amtrak to implement a formal System Safety Program, and issued recommendations to Amtrak to take this action. One of the challenges faced by all railroads in developing a formal System Safety Program, has been the failure of the FRA to enact its final rule. Many of the railroads have designed their System Safety Program but are apprehensive about implementing their plan because of concerns that modifications will be necessary after the System Safety Program regulation is fully enacted. At the time of the NTSB’s report on the accident in Chester, the FRA had delayed the rule’s implementation four times. As a result, the NTSB issued Safety Recommendation R-17-17 to the FRA: Enact Title 49 Code of Federal Regulations Part 270, “System Safety Program,” without further delay. (R-17-17) In the 2 1/2 years since the final rule was published, the FRA has granted six extensions that have delayed this rule until its currently scheduled effective date of September 4, 2019. In the years since the rule was published, accidents have continued to occur. In addition to the accident near Chester, Pennsylvania, and the accident in DuPont, Washington, the NTSB is also investigating the February 4, 2018, accident involving Amtrak train 91, which diverted from the main track through a hand-thrown switch into a siding and collided head-on with a stationary CSX Transportation freight train in Cayce, South Carolina (NTSB 2018b). The engineer and conductor of that Amtrak train died, and 92 passengers and crewmembers were transported to medical facilities. On April 22, 2019, pending implementation of the final rule, Safety Recommendation R-17-17 was classified “Open—Unacceptable Response.” The Chester accident occurred on Amtrak’s own property. As shown by this accident and others, Amtrak operates on host railroads throughout the United States. The system safety regulation would not be limited to Amtrak property and would be applicable to all of Amtrak’s operations including those on host railroads. With the regulation in place, the relationship between the host railroad and Amtrak would be better defined and Amtrak could present to the host railroads their regulatory obligations. The NTSB concludes that the repeated postponement of 49 CFR Part 270, “System Safety Program,” has delayed needed safety improvements for the passenger rail industry, rail employees, and the traveling public. Therefore, the NTSB reiterates Safety Recommendation R-17-17.

From: NTSB
To: FRA
Date: 4/22/2019
Response: We are aware that before this recommendation was issued, you published the System Safety Rule on August 12, 2016. This rule requires that commuter and intercity passenger railroads develop and implement a system safety program to evaluate and manage safety risks. We are disappointed that, after 2 years, you have granted multiple extensions to this regulation that have delayed its effective date to September 4, 2019. In the years since the rule was published, accidents have continued to occur. In addition to the accident near Chester, Pennsylvania, we are currently investigating two railroad accidents involving Amtrak trains which may show the need for this recommendation. On February 4, 2018, southbound Amtrak train 91, diverted from the main track through a hand-thrown switch into a siding and collided head-on with a stationary CSX Transportation freight train in Cayce, South Carolina. The engineer and conductor of the Amtrak train died as a result of the collision, and 92 passengers and crewmembers on the Amtrak train were transported to medical facilities. In another accident, on December 18, 2017, southbound Amtrak train 501 derailed from a bridge near Dupont, Washington. Several passenger railcars fell off the bridge onto Interstate 5 and hit multiple highway vehicles. Three rail passengers were killed, and 57 passengers and crewmembers were injured. Additionally, 8 individuals in highway vehicles were injured. These accidents show the continuing need for all commuter and intercity passenger railroads to develop and deploy system safety programs. Pending issuance of the recommended requirement, Safety Recommendation R-17-17 is classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 5/3/2018
Response: -From Ronald L. Batory, Administrator: Since publishing the System Safety Program final rule on August 12, 2016, FRA received petitions for reconsideration from labor organizations and State and local transportation departments and authorities, including a request to stay the rule's effective date pending FRA's response to the petitions. FRA initially stayed the effective date of the final rule on February 10, 2017, and on November 30, 2017, last extended the effective date of the final rule until December 4, 2018. FRA convened a Railroad Safety Advisory Committee (RSAC) meeting on October 30, 2017, to discuss the petitions for reconsideration and comments received in response to the petitions for reconsideration. FRA is in the process of considering recent stakeholder feedback arising from the meeting to address the issues raised in the petitions. FRA respectfully asks that NTSB classify Safety Recommendation R-17-17 as "Open-Acceptable Response."

From: FRA
To: NTSB
Date: 1/11/2018
Response: -From Karl Alexy, Director, Office of Safety Analysis: Thank you for the report, Amtrak Train Collision with Maintenance-of-Way Equipment, Chester, Pennsylvania, April 3, 2016, NTSBIRAR-17102, which was sent to the Federal Railroad Administration (FRA) on December 28, 2017. In Section 5.1 of the report, NTSB issued to FRA two Safety Recommendations, R-17-17 and R-17-18, as a result of its findings. Improving safety is FRA's top priority, and FRA will continue to work to make rail shipments as safe as possible. FRA is committed to working with NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.

From: NTSB
To: FRA
Date: 12/28/2017
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On November 14, 2017, the NTSB adopted its report Amtrak Train Collision with Maintenance of Way Equipment, Chester, Pennsylvania, April 3, 2016, NTSB/RAR 17/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.