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Safety Recommendation Details

Safety Recommendation R-18-014
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 ALL CLASS I RAILROADS: Implement a process to notify and coordinate with the local and state transportation agencies responsible for highway maintenance at grade crossings as early as possible before conducting any planned maintenance work that has the potential to increase track elevation.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Open - Initial Response Received)
Canadian National Railway (Closed - Acceptable Action)
Canadian Pacific Railway (Open - Await Response)
CSX Transportation, Inc. (Open - Acceptable Response)
Kansas City Southern Railway Company (Closed - Reconsidered)
Norfolk Southern Corporation (Closed - Reconsidered)
Union Pacific (Closed - Reconsidered)
Keyword(s):

Safety Recommendation History
From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 11/28/2018
Response: -Mark A. Schulze, Vice President, Safety, Training and Operations Support: BNSF has personnel and processes in place which promote active communication and coordination with transportation agencies across its system. Included in this approach, BNSF currently has in place effective programs, instructions and communication processes to "notify and coordinate" with responsible transportation agencies regarding railroad related maintenance work that may affect grade crossings. Through these processes, BNSF routinely communicates with the appropriate transportation agencies weeks or months in advance of conducting planned maintenance work affecting grade crossings, including potential changes to elevation of track. In some instances, due to events such as unplanned maintenance or work schedule disruptions, shorter notification time frames may occur, however BNSF diligently works with its communities to promote positive communication and coordination of its maintenance activities. Based on these processes, BNSF respectfully requests that NTSB close Recommendation R-18-14 as "Closed: Acceptable Action".

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 8/28/2018
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 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 are two new recommendations issued to the BNSF Railway Company (and the other Class I railroads), which can be found on page 52 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 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.

From: NTSB
To: Canadian National Railway
Date: 6/10/2019
Response: We note that you routinely notify local and state roadway authorities prior to conducting planned maintenance work affecting grade crossings, and we believe that the verbal advance notice you typically provide allows enough time for the city or state departments of transportation to prepare for impending track work. We are pleased that you added a new provision to your company’s Track Standards Bulletin TSB 6-0-0 to direct that local and state transportation agencies that are responsible for roadway maintenance at grade crossings communicate regarding potential increases in track elevation at the crossing. Accordingly, Safety Recommendation R 18 14, is classified CLOSED--ACCEPTABLE ACTION.

From: Canadian National Railway
To: NTSB
Date: 11/28/2018
Response: -From Jean-Jacques Ruest, President and Chief Executive Officer: The railroads that operate under the CN trade name in the U.S. (collectively and individually, "CN") currently provide notice to and coordinate with appropriate road authorities when railroad or highway maintenance projects will be or are being conducted at railroad-highway grade crossings. In part to further effectuate this recommendation, effective as of October 8, 2018, CN added a new provision to its Track Standards Bulletin TSB 6-0-0 ("Railway Crossings") that provides for communication in writing with the local and state transportation agencies responsible for roadway maintenance at a grade crossing to advise them as early as possible before CN performs any maintenance work that has the potential to increase the track elevation at that crossing. CN is investigating the feasibility of automating, in whole or in part, this communication process.

From: NTSB
To: Canadian National Railway
Date: 8/28/2018
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 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 are two new recommendations issued to the Canadian National Railway Company (and the other Class I railroads), which can be found on page 52 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 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.

From: NTSB
To: Canadian Pacific Railway
Date: 8/28/2018
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 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 are two new recommendations issued to the Canadian Pacific Railway Company (and the other Class I railroads), which can be found on page 52 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 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.

From: NTSB
To: CSX Transportation, Inc.
Date: 7/22/2019
Response: Our investigation of the accident in Biloxi found that you performed regular maintenance of the tracks at the grade crossing where the accident occurred, including replacing wooden railroad ties—a procedure that raises the track level by about 1.5 inches each time it is performed. Over the years, this accumulation of track level elevations can substantially raise the railroad track above its original construction level. Moreover, even a single track elevation can have a substantial impact on grade-crossing safety. At the grade crossing where the Biloxi accident occurred, the wooden railroad ties had last been replaced in February 2014. There were 23 vehicle groundings reported at the crossing in the 3 years after the February 2014 track maintenance, compared to only 3 reported groundings for the previous 2 years, suggesting that the last track elevation substantially increased the risk of vehicle groundings on the crossing. We understand that the Mississippi Department of Transportation (MDOT) was not informed of the track maintenance that you conducted in February 2014, and, although you likely informed the city of Biloxi that you planned to carry out some railroad work that required closing the affected crossings, we found no evidence that you gave the city details about the work being done nor informed the city that the work would raise the crossings’ vertical profiles. Our Biloxi report pointed out that, although we did not know if MDOT or the city of Biloxi realized that raising the crossings’ vertical profiles could increase the risk of vehicle grounding, or if either agency would have elected to take effective countermeasures based on such knowledge, we issued this recommendation because, with better communication, MDOT and the city of Biloxi would have at least had the opportunity to consider the increased risk. We note that you have a longstanding practice of coordinating and cooperating with state and local transportation agencies to facilitate railroad and highway maintenance projects at grade crossings, as well as to notify local and state roadway authorities prior to conducting planned maintenance work that will affect grade crossings. We point out that there is always a potential for grade-crossing maintenance projects to result in “minor” track elevation increases or decreases. We note that, each year, you develop a planned track maintenance schedule that you are willing to provide to state transportation agencies upon request. We further note that you will continue to coordinate with local officials and provide them notice as far in advance as practicable of planned track maintenance work at grade crossings. Although these actions are encouraging, they do not fully satisfy the intent of this safety recommendation. Please reconsider your policy of only notifying state transportation agencies about maintenance at grade crossings upon request, and instead notify them on a regular basis. Pending that action, Safety Recommendation R-18-14, is classified OPEN--ACCEPTABLE RESPONSE.

From: CSX Transportation, Inc.
To: NTSB
Date: 11/21/2018
Response: -From Brad Spencer, Director, Track Testing: It has been CSXT's longstanding practice to coordinate and cooperate with state and local transportation agencies to facilitate both railroad and highway maintenance projects at grade crossings. While CSXT strives to maintain consistent track profile when performing such maintenance projects, there is always a potential that certain grade crossing maintenance projects may result in minor track elevation increases or decreases. In response to the specific recommendation, each year CSXT develops a planned track maintenance schedule that contains projects it intends to complete across its entire system. Upon request from a state transportation agency, CSXT is willing to implement an additional process to provide a copy of its planned track maintenance schedule for the coming year for work to be performed in that particular state. CSXT will also continue its practice of coordinating with local officials and providing them notice as far in advance as practicable of planned track maintenance work at grade crossings. CSXT will strive to provide this notice at least 30 days prior to performing such planned maintenance, understanding that in some circumstances 30 days' notice may not be feasible. Based on these actions, CSXT respectfully requests that the NTSB designate the status of R-18-14 as Closed-Acceptable Action.

From: NTSB
To: CSX Transportation, Inc.
Date: 8/28/2018
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 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 are two new recommendations issued to CSX Transportation, Inc. (and the other Class I railroads), which can be found on page 52 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 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.

From: NTSB
To: Kansas City Southern Railway Company
Date: 5/29/2019
Response: We note that you routinely notify local and state roadway authorities prior to conducting planned maintenance work affecting grade crossings, and we believe that the advance notice you typically provide allows enough time for the city or state departments of transportation to prepare for impending track work. We are pleased to learn that you already had this process in place prior to our issuing this recommendation. Accordingly, Safety Recommendation R 18-14 is classified CLOSED-RECONSIDERED.

From: Kansas City Southern Railway Company
To: NTSB
Date: 11/20/2018
Response: -From Patrick J. Ottensmeyer, President and Chief Executive Officer: When KCSR develops the next year's capital budget in the Fall of the current year, lines that will incur programmed maintenance are identified. KCSR's Engineering Department will notify each state department of transportation of the limits of the lines in that state that are to receive programmed maintenance the following year. KCSR also often issues press releases in advance of major programmed maintenance projects, providing notice to the public and to all levels of local and state government of impending work. In addition, crossing work requires closing the crossing so the crossing surface and track can be adjusted or replaced as necessary. These road closures require cooperation with the governing road authorities on detours and traffic control. Often these issues are coordinated several weeks in advance. Finally, maintenance and rehabilitation of crossings is sometimes done on an as needed basis upon request of state or local authorities. In each of these instances, governmental authorities are aware of impending track work. If any of them raise concerns to KCSR about crossing profiles, KCSR will work with the governing authorities on what may be needed to address the issue.

From: NTSB
To: Kansas City Southern Railway Company
Date: 8/28/2018
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 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 are two new recommendations issued to the Kansas City Southern Railroad Company (and the other Class I railroads), which can be found on page 52 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 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.

From: NTSB
To: Norfolk Southern Corporation
Date: 4/5/2019
Response: We note that you routinely notify local and state roadway authorities prior to conducting planned maintenance work affecting grade crossings, and we believe that the 30-day advance notice you typically provide should be enough time for the city or state departments of transportation to prepare for the impending track work. We point out that any additional advance communication between your company and the local or state departments of transportation will increase community engagement and support a successful outcome to the project. However, we are pleased that, prior to our issuing this recommendation, you already had a process in place that is consistent with the intent of Safety Recommendation R-18-14, which is classified CLOSED-RECONSIDERED.

From: Norfolk Southern Corporation
To: NTSB
Date: 10/17/2018
Response: -From Karin Stamy, General Solicitor: NS routinely notifies local and state roadway authorities prior to conducting any planned maintenance work affecting grade crossings. Notice is typically provided 30 days in advance, but shorter time frames also occur. State roadway authorities are typically notified when work is conducted at crossings involving state highways. Otherwise, the local road authority is notified. Potential elevation to track is included in those notifications where appropriate.

From: NTSB
To: Norfolk Southern Corporation
Date: 8/28/2018
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 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 are two new recommendations issued to the Norfolk Southern Corporation (and the other Class I railroads), which can be found on page 52 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 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.

From: NTSB
To: Union Pacific
Date: 5/29/2019
Response: We note that you routinely notify local and state roadway authorities prior to conducting planned maintenance work affecting grade crossings, and we believe that the 12-month advance notice you typically provide should be enough time for the city or state departments of transportation to prepare for impending track work. We are pleased that, prior to our issuing this recommendation, you already had a process in place that is consistent with the intent of Safety Recommendation R-18-14, which is classified CLOSED--RECONSIDERED.

From: Union Pacific
To: NTSB
Date: 9/13/2018
Response: -From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer: As a threshold matter, Union Pacific complies with the Federal Highway Administration’s (FHWA) Railroad-Highway Grade Crossing Handbook which requires establishing that the elevation at a crossing with approach sections meets the local state DOT highway specifications. Additionally, any time Union Pacific is planning maintenance work, it contacts the various road authorities six to twelve months in advance of all work performed. During this notification process, Union Pacific informs the road authorities the type of work that is anticipated, and whether Union Pacific expects road surface elevations to change. However, as a practical matter, many factors can disrupt both the schedule of work and/or the type of work performed based on railroad operations, weather, sub-grade conditions and road authority projects/traffic flows in the area (vehicular traffic may be rerouted based on road authority work elsewhere). As a result, the work schedule and work scope can be subject to change. In most cases, Union Pacific will seek permits or place public notifications of any crossing closures.

From: NTSB
To: Union Pacific
Date: 8/28/2018
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 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 are two new recommendations issued to the Union Pacific Railroad (and the other Class I railroads), which can be found on page 52 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 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.