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Safety Recommendation Details

Safety Recommendation R-17-028
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 BROTHERHOOD OF MAINTENANCE OF WAY EMPLOYEES DIVISION, AMERICAN RAILWAY AND AIRWAY SUPERVISORS ASSOCIATION, BROTHERHOOD OF LOCOMOTIVE ENGINEERS AND TRAINMEN, AND BROTHERHOOD OF RAILROAD SIGNALMEN: Work with Amtrak to improve the effectiveness of all applicable safety programs.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
Mode: Railroad
Location: Chester, PA, United States
Is Reiterated: No
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: American Railway and Airway Supervisors Association (Open - Await Response)
Brotherhood of Locomotive Engineers and Trainmen (Open - Acceptable Response)
Brotherhood of Maintenance of Way Employees Division (Open - Await Response)
Brotherhood of Railroad Signalmen (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Brotherhood of Maintenance of Way Employees Division
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. Among the Safety Recommendations are three issued to Brotherhood of Maintenance of Way Employes Division, which can be found on page 70 of the report. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement the recommendation.

From: NTSB
To: American Railway and Airway Supervisors Association
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. Among the Safety Recommendations are three issued to American Railway and Airway Supervisors Association, which can be found on page 70 of the report. 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, detailing the actions you have taken or intend to take to implement the recommendations. When replying, please refer to the safety recommendations by number.

From: NTSB
To: Brotherhood of Locomotive Engineers and Trainmen
Date: 10/16/2018
Response: We note the BLET’s long history and recognize that your Amtrak General Committee of Adjustment is proactive on matters of railroad safety. We also note your concerns regarding the safety culture at Amtrak and whether Amtrak will remain committed to C3RS and similar nonpunitive safety programs. Because of your concerns, we issued these recommendations to you and three other labor unions representing employees at Amtrak, and we issued companion Safety Recommendations R-17-24 through -26 to Amtrak so you would work together to address these safety issues. We are currently reviewing a July 6, 2018, letter from Mr. Kenneth J. Hylander, Executive Vice President and Chief Safety Officer at Amtrak, providing Amtrak’s initial response to its companion recommendations. Mr. Hylander told us that Amtrak retired “optional” safety programs (such as Safe2Safer) and no longer collectively bargains participation in safety programs, but remains committed to working with labor unions to improve operational safety and to implement an SMS that includes actively engaging with them. He also said that Amtrak is committed to working with labor unions to improve and expand C3RS and similar systems to increase participation and system response time. According to Mr. Hylander, Amtrak held a number of meetings with labor unions to develop its SMS, which is scheduled for draft completion by November 2018. We note that you are concerned about introducing video cameras into locomotive cabs and the effect that will have on Amtrak’s C3RS because such confidential systems rely on nonpunitive reporting. You believe there is growing evidence that rail carriers will no longer have an incentive to participate in a confidential reporting program when they can simply monitor video recordings to analyze any operating scenario, and that most current C3RS programs do not afford confidential reporting of “real time” events, such as signal infractions that were recorded by a railroad’s dispatching equipment. We further note that you prefer a regulatory framework for recording devices that is similar to the policy we use for handling cockpit voice recorders (CVRs) when we investigate aviation accidents. We would like to clarify that the statutory restrictions in place for our use of locomotive in-cab audio and image recording devices are the same as for our use of CVRs. Further, CVR recordings are not encrypted and there are no federal laws or regulations prohibiting airlines from using the recordings as part of their flight operations quality assurance programs. We share your belief that the locomotive cab video data should not be used for punitive purposes, but we also continue to believe that routinely using this data to evaluate procedural compliance will benefit safety. We again note your long history of developing and participating in programs to improve railroad safety, the concerns that you expressed about Amtrak’s commitment to these programs, and the need for programs that monitor rule compliance to be nonpunitive to be effective. Please periodically update us on the status of your activities to satisfy these recommendations. Pending completion of those actions, Safety Recommendations R-17-28 through -30 are classified OPEN--ACCEPTABLE RESPONSE.

From: Brotherhood of Locomotive Engineers and Trainmen
To: NTSB
Date: 2/26/2018
Response: -From Dennis R. Pierce, National President: Preliminarily, let me state that collective bargaining agreements in the railroad industry – including those that involve of matters of safety - are negotiated under the terms and conditions of the Railway Labor Act at both the national and the local level. BLET has long been an advocate for voluntary collective bargaining agreement solutions to all issues that confront the railroad industry, including safety. Although BLET also is willing to seek collectively bargained solutions in response to your recommendations, I must note that history clearly shows that only those issues that both the unions and the railroads show an interest in bargaining over result in voluntary labor agreements. The BLET at the national level, and our Amtrak General Committee of Adjustment ("GCA") both have a long and well-documented history of being proactive on matters of railroad safety. With respect to Amtrak specifically, for example, the BLET was one of the founding members of the railroad's Operation Red Block ("ORB") program, which was originally designed to support a drug-and alcohol-free workplace by providing Passenger Engineers with a confidential means to mark off duty. That program was so successful that none of Amtrak's more than 1,400 locomotive engineers tested positive for drug and alcohol use in 2011, and zero Amtrak locomotive engineers tested positive for drugs and alcohol in post-accident testing between 1987 and 2012. BLET at the national level was a founding participant in creating the railroad industry's C3RS program and, on Amtrak, our GCA was one of the Labor Unions that created the Amtrak C3RS Program. C3RS on Amtrak had been so successful that the Program was expanded to include safety-critical employees of other railroads that operate over Amtrak trackage. In addition, our Amtrak GCA has been a participant in and supporter of numerous other safety initiatives Amtrak has promoted in recent decades. Of late, however, Amtrak has failed to adhere to the terms and conditions defined within the C3RS Implementing Memorandum of Understanding pertinent to disputes, and to internal bylaws established for governance of other safety committees and initiatives. Moreover, over the past year both Amtrak's and FRA's commitment to the vitality of C3RS has waned significantly, with budgetary constraints routinely cited as the primary cause of that diminished emphasis. For example, one of Amtrak's Peer Review Teams (PRT) identified 170 "corrective actions" as necessary, based on C3RS reports received. To date, those corrective actions have gone largely unaddressed. Consequently, such deviation from the fundamental purpose of the Program has resulted in a precipitous decline in both Labor leaders' and employees' faith and trust in the current Program and the true legitimacy of Amtrak's overall commitment to safety. Additionally, it remains to be seen what effect the introduction of video cameras inside the locomotive cab will have on C3RS at Amtrak. Confidential reporting systems such as C3RS – and their analogues in the aviation industry - have long relied on trust between ballast level employees and the management who supervise them. BLET is concerned and firmly believes there is growing evidence that a rail carrier such as Amtrak will no longer have an incentive to participate in a confidential reporting program when it can simply monitor video recordings anytime they want to analyze any operating scenario. Further, most current C3RS programs do not afford confidential reporting of so called "real time" events. In application, events such as signal infractions that were recorded by the railroad's dispatching equipment were not allowed to be included in the program. BLET has made efforts in the past to expand this coverage to include real time events as any close call reporting program designed to truly improve safety must include real time events. This is especially now that video surveillance and recording of all in cab events has been introduced. In previous efforts, BLET strongly advocated a regulatory framework for recording devices in the Rail Safety Advisory Committee ("RSAC") that mirrored the policy for handling cockpit voice recordings by the NTSB in examining post-accident recordings in the aviation industry. The recordings would be encrypted with NTSB being the only agency able to decrypt the audio and video recordings and only for the purposes of post-accident analysis. Continual surveillance inside the locomotive cab and confidentiality in reporting close calls in the work place are not congruent concepts. The RSAC works on a consensus basis and was not able to reach consensus on recording devices. Given the hidebound manner in which discipline is meted out in this industry, BLET questions whether Amtrak will remain committed to C3RS and similar nonpunitive safety programs. That being said, we share the Board's legitimate concern over the safety culture at Amtrak. Several successful initiatives have been undertaken, and we believe they have shown positive results in making Amtrak a safer railroad, both for its workers and for the traveling public. However, a couple of systemic factors have contributed to a diminution in the effectiveness of these efforts, in our view. One is the fact that - after more than 45 years - Amtrak has yet to receive a consistent commitment of resources from the federal government, reducing safety programs to just another line item on a budget that is forced to run on ideological vapors every year. The other is that Amtrak management, from the executive level to the field, has been in a state of disarray and turmoil for many years now. As a result, those responsible for managing today's safety programs are not the champions who created them. This makes it difficult for the workforce to see safety as anything other than a goal to which mere lip service is paid. Despite these systemic problems, the BLET remains committed to improving the effectiveness of safety programs that pertain to our Passenger Engineers. We will continue to support and devote the necessary resources to C3RS and similar efforts. And we look forward to the Federal Railroad Administration completing its rulemaking on risk reduction and system safety programs - including meaningful fatigue management programs - so that we can work to improve the safety culture on the nation's passenger railroad in a proactive and holistic manner. I thank you for the opportunity to address this key issue of concern for our membership.

From: NTSB
To: Brotherhood of Locomotive Engineers and Trainmen
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. Among the Safety Recommendations are three issued to Brotherhood of Locomotive Engineers and Trainmen, which can be found on page 70 of the report. 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, detailing the actions you have taken or intend to take to implement the recommendations. When replying, please refer to the safety recommendations by number.

From: NTSB
To: Brotherhood of Railroad Signalmen
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. Among the Safety Recommendations are three issued to Brotherhood of Railway Signalmen, which can be found on page 70 of the report. 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, detailing the actions you have taken or intend to take to implement the recommendations. When replying, please refer to the safety recommendations by number.