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Safety Recommendation Details

Safety Recommendation R-19-006
Details
Synopsis: On June 27, 2017, at 11:18 p.m. eastern daylight time, two CSX Transportation (CSX) employees (conductor and conductor trainee) were struck and killed by southbound Amtrak (National Railroad Passenger Corporation) train P175 at Amtrak milepost (MP) 134.5 in Ivy City, a small neighborhood in Northeast Washington, DC.1 The two employees were on the track walking toward the front of their southbound train after inspecting a railcar with elevated temperature reported by a track-side detector. Their backs were to the approaching southbound Amtrak train when they were struck. At the time of the accident, the sky was clear; visibility was 10 miles, and the temperature was 64°F. Additional ambient lighting was provided by a nearby Amtrak maintenance yard.
Recommendation: TO CSX TRANSPORTATION AND THE NATIONAL RAILROAD PASSENGER CORPORATION: Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: Ivy City, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA17MR010
Accident Reports: Preliminary Report Railroad: Employee Fatalities – CSX/AmtrakRailroad Accident Brief: CSX Transportation Employee Fatalities at Ivy City Washington, DC
Report #: RAB-19-01
Accident Date: 6/27/2017
Issue Date: 4/9/2019
Date Closed:
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Open - Initial Response Received)
CSX Transportation, Inc. (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 5/22/2019
Response: -From Richard H. Anderson, President and Chief Executive Officer: For Amtrak owned territory, Amtrak maintains an existing prohibition against employees fouling tracks via the following NORAC General Rule V: Fouling a track may be necessary in the pe1fonnance of railroad work. Employees must expect the movement of trains, locomotives, or other on-track equipment at any time, on any track, in either direction. Employees must maintain a vigilant lookout for and detect the approach of a train, locomotive or other railroad equipment moving in either direction. Proper safeguards for the job classification needing protection must be in place before fouling any track. Furthermore, Amtrak took action in August of 2017 to revise the N01theast Corridor Employee Timetable. An excerpt of the revision is below: 714-S4. ADJACENT FOREIGN RAILROAD CONTACT INFORMATION – EMERGENCY COMMUNICATIONS When a train emergency occurs on Amtrak's property, the Engineer or Conductor of the train in emergency must transmit an emergency broadcast on the appropriate foreign railroad radio channel listed below (if available) when operating at locations adjacent to their trackage in the manner of the following example: "Emergency, Emergency, Emergency. Train TV-24 engine 6605 is in emergency moving east on Amtrak's No. 2 track at MP 78. " Following this emergency broadcast, the Engineer or Conductor must immediately return to the appropriate Amtrak radio channel. Once notified of a train in emergency, the Dispatcher (or Operator) must contact the appropriate foreign railroad Dispatcher on the commercial landline number listed to ensure protection is provided for the emergency condition. Once the emergency condition no longer exists, the foreign railroad Dispatcher must again be notified so protection can be lifted. The full text of the Timetable which includes line specific contact information is enclosed for reference purposes. Amtrak looks forward to working with our host railroads to implement similar standards. I trust that the information contained within this letter is sufficient to address the open recommendations noted above. If additional information 1s required, please contact Theresa Impastato.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 4/9/2019
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 assist victims and their family members affected by major transportation disasters. We are providing the following information to urge your organization to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about NTSB and our recommendation process, please see the attached one-page summary. On March 25, 2019, the NTSB adopted its report, CSX Transportation Employee Fatality at Ivy City, Washington, DC, June 17, 2017, NTSB/RAB-19/01. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issue: • Better communication could be used to protect employees who find it necessary to occupy another railroad’s active tracks. Accordingly, the NTSB makes the following safety recommendation to Amtrak. Additional information regarding this recommendation can be found in the noted section of the report. • Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads. (R-19-006) (See Safety Issue section) 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 this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-006). We encourage you to submit your response to correspondence@ntsb.gov. If your reply 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: CSX Transportation, Inc.
Date: 4/9/2019
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 assist victims and their family members affected by major transportation disasters. We are providing the following information to urge your organization to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about NTSB and our recommendation process, please see the attached one-page summary. On March 25, 2019, the NTSB adopted its report, CSX Transportation Employee Fatality at Ivy City, Washington, DC, June 17, 2017, NTSB/RAB-19/01. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issue: • Better communication could be used to protect employees who find it necessary to occupy another railroad’s active tracks. Accordingly, the NTSB makes the following safety recommendation to CSX Transportation. Additional information regarding this recommendation can be found in the noted section of the report. • Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads. (R-19-006) (See Safety Issue section) 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 this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-006). We encourage you to submit your response to correspondence@ntsb.gov. If your reply 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.