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Safety Recommendation Details

Safety Recommendation R-18-011
Details
Synopsis: On March 7, 2017, a 2016 Van Hool motorcoach, operated by ECHO Transportation and occupied by a driver and 49 passengers, was traveling northbound on Main Street in Biloxi, Mississippi. The motorcoach stopped in advance of a highway–railroad grade crossing on Main Street that had a high vertical profile. The crossing warning system was not in active mode when the motorcoach approached, stopped, and then moved onto the railroad tracks. As the driver attempted to drive over the crossing, the frame of the motorcoach came into contact with the pavement, and the vehicle became stuck on the crossing. An eastbound freight train operated by CSX Transportation was approaching the crossing. The grade crossing warning system activated when the train was about 29 seconds away. As soon as he became aware of the approaching train, the motorcoach driver opened the vehicle’s loading door and told the passengers to evacuate. The train engineer put the train into emergency about 502 feet west of the crossing. About 14 seconds later, the train struck the left side of the motorcoach, pushing it 259 feet down the tracks before coming to a stop, with the motorcoach still in contact with the lead locomotive. Four motorcoach passengers died, the driver and 37 passengers sustained injuries, and 8 passengers were uninjured. The investigation focused on the safety issues of high-profile grade crossings and emergency egress and extrication. As a result of this investigation, the National Transportation Safety Board (NTSB) makes new safety recommendations to the Federal Highway Administration, Federal Railroad Administration, Mississippi Department of Transportation, City of Biloxi, American Association of State Highway and Transportation Officials, American Railway Engineering and Maintenance-of-Way Association, Association of American Railroads, American Short Line and Regional Railroad Association, and Class I railroads. The NTSB reiterates and reclassifies one recommendation to the Federal Motor Carrier Safety Administration.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Assist the Federal Highway Administration (FHWA) in developing specific criteria to establish when an existing grade crossing should be reconstructed, closed, or otherwise have the risk posed by its unsafe vertical profile comprehensively mitigated, to be incorporated into the FHWA Railroad-Highway Grade Crossing Handbook.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: Biloxi, MS, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY17MH010
Accident Reports: Preliminary Report: Highway HWY17MH010​Collision Between Freight Train and Charter Motorcoach at High-Profile Highway–Railroad Grade Crossing Biloxi, Mississippi March 7, 2017
Report #: HAR-18-01
Accident Date: 3/7/2017
Issue Date: 8/28/2018
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: FRA
To: NTSB
Date: 7/31/2019
Response: -From Ronald L. Batory, Administrator: The NTSB issued Safety Recommendation R-18-11 based on a determination that the probable cause of the March 1 7, 2017, accident was the failure of CSX Transportation and the City of Biloxi "to coordinate and take action to improve the safety of the Main Street grade crossing, a high vertical profile crossing on which motor vehicles were known to ground frequently .. .. " FRA disagrees with this NTSB probable cause determination. FRA investigated the accident and independently concluded that the accident was caused by the motor coach driver's inattentiveness to highway-rail grade crossing signs as the motor coach driver continued through a clearly marked low ground clearance area and then humped the crossing with a long wheelbase vehicle. Consistent with the facts outlined in the NTSB' s accident report, FRA' s investigation found that the crossing was well-marked with warning signs. Additional signs were present, indicating that the crossing was a humped crossing, and therefore not suitable for long wheelbase vehicles. FRA' s investigation further revealed that the signs were placed to ensure that once noticed, a vehicle could detour without issue. FRA's review of the motor coach driver's performance showed several areas of concern. During a post-accident interview with the driver, he stated that as he approached the Main Street crossing, he saw the low ground clearance sign, but was distracted by a car on Esters Boulevard (a nearby intersecting street). The driver indicated that he raised the motor coach with the kneeling feature (an electrically controlled air-operated system that adjusts the ground-to-first-step height to allow passengers to get on and off the motor coach more easily) and proceeded to approach the highway-rail grade crossing, despite the low clearance warning sign that he acknowledged seeing. As he attempted to drive the motor coach over the crossing, it became stuck on the crossing. Based on the time the motor coach became stuck and when the collision occurred, more than 5 minutes elapsed; however, the passengers did not begin to evacuate until about one minute before the collision, after a passenger alerted the driver that a train was approaching and he saw the lights of the approaching train. At no point after the motor coach became stuck on the crossing did the driver call 911 or the 1-800 number posted on the blue Emergency Notification System (ENS) signs posted on the crossing signal masts to alert the railroad dispatcher to stop the train. Considering this evidence, FRA maintains that the motor coach driver's inattentiveness to the advance warning signs, and proceeding through a clearly marked low ground clearance area with a humped crossing while operating a long wheelbase vehicle, led to the accident. The driver's failure to call 911, the 1-800 number posted on the ENS signs, or immediately evacuate the passengers is concerning to FRA. To address Safety Recommendation R-18-11 and FRA's concerns, FRA has worked with FHWA to revise the Railroad-Highway Grade Crossing Handbook to incorporate specific criteria that should be considered when determining whether to close or reconstruct an existing grade crossing. Additionally, FRA met with FHW A representatives several times to discuss this issue and provided FHW A with numerous technical resources for addressing the related Safety Recommendations addressed to FHW A (NTSB Safety Recommendations H-18-23 through -25). Those technical resources include instructions on identifying vertical profile locations, a document describing LiDAR-based grade crossing surveys, a Florida Department of Transportation Standards document, as well as the following FRA materials: • FRA Compilation of State Laws and Regulations Affecting Highway-Rail Grade Crossings (2013); • FRA Guide to Crossing Consolidation and Closure (1994); • FRA Crossing Consolidation Guidelines (2009); and • FRA Accident Investigation Report HQ-2017-1192. Further, on April 25, 2019, FRA sent letters to all State Departments of Transportation (DOT) explaining the circumstances of the Biloxi accident, and asking each State DOT3 to relay the facts of this accident and assist in education and training efforts on how to recognize low ground clearance highway-grade crossings, and what should be done immediately if a vehicle becomes stuck on one. A sample letter is attached. As FRA believes we have fulfilled the intent of Safety Recommendation R-18-11, the agency will take no further action on the recommendation, and we respectfully request that the NTSB close the recommendation. I appreciate your continued interest in railroad safety issues. If FRA can provide further information or assistance, please contact Mr. Karl Alexy, Associate Administrator for Railroad Safety and Chief Safety Officer.

From: FRA
To: NTSB
Date: 8/31/2018
Response: -From Karl Alexy, Deputy Associate Administrator: Thank you for the report Collision Between Freight Train and Charter Motorcoach at High Profile Highway-Railroad Grade Crossing, which was sent to the Federal Railroad Administration (FRA) on August 28, 2018. In the "Recommendations" section of the report, the National Transportation Safety Board (NTSB) issued Safety Recommendation R-18-11 to FRA. 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 the 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: 8/28/2018
Response: On August 7, 2018, the NTSB adopted its report Collision Between Freight Train and Charter Motorcoach at High-Profile Highway–Railroad Grade Crossing, Biloxi, Mississippi, March 7, 2017, NTSB/HAR 18/01. The details of the investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at www.ntsb.gov. Among the safety recommendations is one new recommendation issued to the Federal Railroad Administration, which can be found on page 51 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. When replying, please refer to the safety recommendation by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 10 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.