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Safety Recommendation Details

Safety Recommendation R-18-007
Details
Synopsis: On June 10, 2017, about 10:12 a.m. eastern daylight time, an LIRR train on main line track 3 approached five roadway workers. The foreman, followed by two employees, and the watchman at the rear were walking single file in main line track 1 in the Queens Interlocking. Another employee was walking on the right-of-way, clear of all tracks, at the same pace as the other employees. The roadway workers confirmed the watchman warned them of the approaching train, but they disagreed on when he gave the warning. Despite that, the security video showed the roadway workers made no attempt to clear the tracks. Investigators could not determine the number of seconds between the time the train’s engineer sounded the horn and the time of the accident. Three roadway workers remained in track 1, but the foreman moved into the path of the train. The train was traveling about 78 mph when the engineer applied the emergency brake just before impact.
Recommendation: TO THE METROPOLITAN TRANSPORTATION AUTHORITY: Following the completion of the audit, implement actions to correct any identified deficiencies. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Queens Village, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA17FR009
Accident Reports: Safety Recommendation Report: Train Approach Warning and Predetermined Place of Safety
Report #: RSR-18-02
Accident Date: 6/10/2017
Issue Date: 2/15/2018
Date Closed: 11/8/2019
Addressee(s) and Addressee Status: Metropolitan Transportation Authority New York City Transit (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 11/8/2019
Response: We note that you completed the recommended audit, which used video from the forward facing cameras on operating locomotives and trailing cab cars to identify roadway workers on or near the tracks. The audit showed that, with one exception, LIRR employees were properly employing the train approach warning (TAW) technique as a method for roadway worker protection (RWP). We further note that if you find any action departing from the TAW procedure, you use video from image recorders positioned on the controlling locomotives and trailing cab cars to instruct your roadway workers to be in the clear of active tracks when oncoming trains are approaching. The inspection technique you used to audit locomotive forward-facing camera video was found valuable and deemed a best practice for identifying work crews that require retraining, as well as for expanding and re-enforcing education regarding TAW and RWP. As a result of the audit, following any identified break from TAW procedures, you re-educate your workforce about the importance of RWP and the appropriate use of TAW. We further note that you also improved your RWP training, incorporating bulletins and red alerts that detail the circumstances surrounding each incident, and that you re-educate employees with respect to the appropriate use of TAW. These actions satisfy Safety Recommendations R-18-6 and -7, which are classified CLOSED--ACCEPTABLE ACTION.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 10/5/2018
Response: -From Joseph J. Lhota, Chairman: As a follow-up to the MTA's April 18, 2018 correspondence concerning the above recommendations, the MTA did conduct the audit as the National Transportation Safety Board (NTSB) recommended. The audit process incorporated the review of documents and actions taken by Long Island Rail Road (LIRR), in response to the June 10, 2017 accident which was the impetus for these recommendations. Utilizing the forward-facing video from both the lead and trailing rail cars, the .audit team identified 115 video segments where roadway workers were on or near the tracks. This video was reviewed in conjunction with a New York State Department of Transportation (NYSDOT) Public Transportation Safety Board (PTSB) Chief Investigator and a LIRR Corporate Safety Director of Regulatory Compliance. The audit findings acknowledged that LIRR employees were properly employing the train approach warning (TA W) technique as a method for roadway worker protection (R WP) as prescribed in LIRR and Federal policy, with only one exception. The details and supporting information are in the attached summary of audit findings. The audit highlighted the benefits of using forward-facing vide9 proactively. The inspection technique of periodically reviewing locomotive forward-facing camera video, was found valuable and deemed a best practice within LIRR for identifying work crews that require retraining, as well as for expanding and re-enforcing education regarding TAW and RWP. Immediately following any identified break from TA W procedure, LIRR acts to re-educate its workforce as to the importance of roadway worker protection and the appropriate use of TAW. Further, LIRR enhanced its RWP training, incorporating bulletins and red alerts detailing the circumstances surrounding each incident and re-educates employees with respect to the appropriate use of TAW. Regarding these NTSB recommendations, all audit findings have been implemented. Based on our actions, we respectfully request that these recommendations be classified as "Closed-Acceptable Action". If any additional information is required, please let us know and we will be happy to provide it.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 4/18/2018
Response: -From Joseph J. Lhota, Chairman: Concerning the above two recommendations, the MTA will conduct the audit as recommended. Specifically, the MT A Safety Management Office has partnered with the MTA Auditor General to design and conduct the audit. The Auditor General and his staff routinely audit programs and activities across the MTA family of agencies, and many of these audits have a safety focus. For this project, the MTA Chief Safety Officer will collaborate with the Auditor General to ensure that the audit fully satisfies the intent of the recommendation. Further, the Federal Railroad Administration (FRA) has reached out to offer technical assistance with the audit, and we have accepted this offer of assistance. The audit is in its early stages, and we expect that it will require approximately six months to complete. Following the audit, we will implement all necessary actions to correct any identified deficiencies. We would be pleased to provide any additional information that you require. We will keep the NTSB informed of our progress on the work outlined above.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 2/15/2018
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 13, 2018, the NTSB adopted its report Train Approach Warning and Predetermined Place of Safety, RSR-18/02, which was written as part of the investigation of a June 10, 2017, roadway worker fatality in Queens Village, New York. The details of this and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Two urgent safety recommendations are being issued to Metropolitan Transportation Authority, which can be found on page 4 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 30 days, detailing the actions you have taken or intend to take to implement these urgent recommendations. When replying, please refer to the safety recommendations by number.