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Safety Recommendation Details

Safety Recommendation R-18-003
Details
Synopsis: The National Transportation Safety Board (NTSB) launched investigative teams to two very similar accidents within 13 weeks of one another. In both accidents, the engineers failed to stop their trains before reaching the end of a terminating track at a station. The September 29, 2016, accident on the New Jersey Transit commuter railroad at Hoboken, New Jersey, killed one person, injured 100, and resulted in major damage to the passenger station. The January 4, 2017, accident on the Long Island Rail Road (a subsidiary of Metropolitan Transportation Authority) at the Atlantic Terminal in Brooklyn, New York, injured 108 people. As the NTSB investigations progressed, it became apparent that these accidents had almost identical probable causes and safety issues. The NTSB also realized that these safety issues were not unique to these two properties, but exist throughout the United States at many intercity passenger and commuter passenger train terminals. The NTSB is issuing two new safety recommendations to the Federal Railroad Administration and two new safety recommendations to New Jersey Transit and the Metropolitan Transportation Authority. In addition, the NTSB is reiterating two safety recommendations to the Federal Railroad Administration.
Recommendation: TO NEW JERSEY TRANSIT AND METROPOLITAN TRANSPORTATION AUTHORITY: Review and revise the hazard management portion of your system safety program plans to ensure that they document previous incidents and use them when identifying and assessing operational hazards.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Hoboken, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA16MR011
Accident Reports: PRELIMINARY REPORT: RAILROAD DCA16MR011Railroad Accident Brief: New Jersey Transit Train Strikes Wall in Hoboken Terminal
Report #: SIR-18-01
Accident Date: 9/29/2016
Issue Date: 2/14/2018
Date Closed:
Addressee(s) and Addressee Status: Metropolitan Transportation Authority New York City Transit (Open - Acceptable Response)
New Jersey Transit Corporation (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: New Jersey Transit Corporation
To: NTSB
Date: 5/7/2018
Response: -From Kevin S. Corbett, Executive Director: NJ TRANSIT's 2011 Rail System Safety Program Plan (SSPP) was in effect at the time of the September 29, 2016 accident. NJ TRANSIT's SSPP followed the guidelines of the American Public Transportation Association (APTA) Manual for the Development of System Safety Program Plans for Commuter Railroads (manual). That manual was developed by the commuter rail industry jointly with the Federal Railroad Administration (FRA) and the U.S. Department of Transportation, to improve overall safety on commuter railroads. Prior to the Hoboken accident, the manual was last revised in 2006 to provide adjustments needed to better align the practice of system safety with the modal characteristics of the industry, and the unique operational context of each commuter rail system. After the accident, NJ TRANSIT revised and updated its SSPP in January 2018. More recently, in response to NTSB recommendation No. R-18-003, NJ TRANSIT revised the Hazard Management section of its Rail SSPP to include a more comprehensive, eight-step process to assessing risk. (See pages 12-19 of attached SSPP.) As a result, in the future, assessing risk will be a more collaborative effort, requiring the formation of post-accident investigation teams. Many individuals within NJ TRANSIT's Office of System Safety's Rail Division Field Ops Unit are USDOT Transportation Safety and Security Program qualified. Nevertheless, to ensure that each individual responsible for leading Risk Assessments (as described in the SSPP) is prepared to properly take the lead, they will be provided with more comprehensive, in-depth training. Additionally, the Risk Assessment process will now require the review of prior incidents and accidents. The post-accident investigation teams formed will review records from previous accidents to assist with their conclusions.

From: NTSB
To: New Jersey Transit Corporation
Date: 2/14/2018
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 February 6, 2018, the NTSB adopted its report End-of-Track Collisions at Terminal Stations, Hoboken, New Jersey, September 29, 2016, and Atlantic Terminal, Brooklyn, New York, January 4, 2017, SIR-18/01. The details of this special investigation report 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 two issued to New Jersey Transit, which can be found on page 41 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 these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 11/8/2019
Response: In issuing this recommendation, we recognized that the LIRR had voluntarily implemented an SSPP prior to the accident, and that the LIRR used an audit process to evaluate and improve the program. However, when investigating the two accidents, we did not find evidence that you have a formal hazard analysis for trains operating into a terminal track, despite having experienced earlier accidents where trains had struck the end bumping post. Although these previous accidents were significantly less severe than the accidents discussed in our report, they established that the hazard existed and another accident could occur. We concluded that the LIRR SSPP was ineffective in identifying operational hazards associated with operating trains into terminal tracks. Although the LIRR’s SSPP included hazard management, it did not recognize the unacceptable risk of an end-of-track collision. Further, you relied on standard operating procedures and locomotive engineers’ compliance with operating rules (such as speed restrictions) to prevent a collision; however, in the Atlantic Terminal accident, the engineer was impaired due to fatigue and failed to effectively control the train. This single-point failure resulted in catastrophic damage and injuries. We concluded that the use of operating rules and procedures to mitigate end-of-track collisions was an inadequate method for preventing these accidents because it failed to eliminate the possibility of a single-point failure. We understand that the LIRR implemented its SSPP in 1986, and that the SSPP has been regularly audited by third parties, updated by the railroad, and certified and recertified by the New York Public Transportation Safety Board. We note that you plan to ensure that, where necessary, your SSPPs and related controlling documents will be revised in accordance with this recommendation. However, you did not provide any information on changes made to your SSPP to address the shortcomings we found in our investigations, such as a formal hazard analysis for trains operating into a terminal track, including experience from earlier accidents where trains had struck the end bumping post, or susceptibility to single-point failures due to reliance solely on standard operating procedures and compliance with operating rules by a locomotive engineer who might be impaired. Please tell us what revisions you have made to your SSPP to address the specific limitations found in our investigation. Pending that information, Safety Recommendation R-18-3 is classified OPEN--ACCEPTABLE RESPONSE.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 4/18/2018
Response: -From Joseph J. Lhota, Chairman: As you know, the LIRR implemented its System Safety Program Plan in 1986, and it has been regularly audited by third parties, updated by the railroad, and, in more recent years, certified and recertified by the New York Public Transportation Safety Board. This is also the case for MetroNorth Railroad and New York City Transit, both of which also maintain SSPPs. Going forward, the MTA will work with its agencies to ensure that, where necessary, the SSPPs and related controlling documents are revised in accordance with the above recommendations.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 2/14/2018
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 February 6, 2018, the NTSB adopted its report End-of-Track Collisions at Terminal Stations, Hoboken, New Jersey, September 29, 2016, and Atlantic Terminal, Brooklyn, New York, January 4, 2017, SIR-18/01. The details of this special investigation report 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 two issued to Metropolitan Transportation Authority, which can be found on page 41 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 these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.