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Safety Recommendation Details

Safety Recommendation R-75-002
Details
Synopsis: AT 4:57 A.M. ON JULY 5, 1974, AMTRAK TRAIN NO. 4-C WAS OPERATI THE TRACKS OF THE ATCHISON, TOPEKA, AND SANTA FE RAILWAY COMPANY JUST EAST OF MELVERN, KANSAS. AS THE TRAIN MOVED OVER A TURNOUT LEADING FROM THE SOUTH MAIN TRACK TO A SIDING LOCATED BETWEEN THE TWO MAIN TRACKS, THE REAR 13 CARS OF THE 18-CAR TRAIN DERAILED. THE REAR SIX CARS TURNED OVER, SLID DOWN AN EMBANKMENT, AND CAME TO A STOP ON THEIR SIDES. FIFTEEN EMPLOYEES AND 87 PASSENGERS WERE INJURED AS A RESULT OF THE ACCIDENT. ONE OF THE INJURED PASSENGERS DIED SEVERAL WEEKS LATER. THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINES THAT THE PROBABLE CAUSE OF THE ACCIDENT WAS THE BROKEN CLOSURE RAIL OF THE TURNOUT LEADING FROM THE SOUTH MAIN TRACK TO THESIDING. THE INSUFFICIENT STRENGTH OF THE TRACK BOLT AND THE APPARENTSTRESSED CONDITION OF THE RAIL CONTRIBUTED TO THE CAUSE OF THE BROKEN RAIL.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL RAILROAD ADMINISTRATION: PROMULGATE REGULATIONS TO ESTABLISH MINIMUM STANDARDS FOR THE SIZE AND QUALITY OF ALL COMPONENTS USED IN THE CONSTRUCTION OF TRACK.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Melvern, KS, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: 79997
Accident Reports: Derailment of an Amtrak Train on the Tracks of the Atchison, Topeka and Santa Fe Railway Company
Report #: RAR-75-01
Accident Date: 7/5/1974
Issue Date: 2/5/1975
Date Closed: 11/10/1982
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 11/10/1982
Response: Our records show that 18 safety recommendations directly related to FRA's "Track Safety Standards" rulemaking are being held in an "Open-Unacceptable Action" status. These recommendations were issued as a result of the investigation of ten derailment accidents, a special study on broken rails, and a safety effectiveness evaluation of track standards as related to accidents involving hazardous materials shipments by rail. A listing of the accidents or studies and the associated recommendations by number is in Enclosure 1. The recommendations cover specific aspects of track safety standards such as: Track geometry, Track gauge, Quality control of track components, Rail wear limits, Effective inspection procedures-internal defects and visual, Operation on various track classifications, Application of track standards to yard tracks. We have reviewed eachof the 18 track standards-related recommendations in light of the recent amendments to 49 CFR 213 and have acted to place 17 of them in a status of "Closed-Unacceptable Action," as noted in enclosure 2. The remaining recommendation, R-74-2, has been classified as "Closed-No Longer Applicable" based on an FRA analysis of broken-rail accidents provided to the Safety Board in FRA's December 1, 1981, response to that recommendation, and on the fact that the statistics used to develop the recommendation are now outdated. The Safety Board stresses the fact that its action in closing these recommendations does not, in any way, indicate a lessening of its concern for the need for effective track safety standards. We believe that the weakening of these standards inherent in the recent amendments is not justified, and we plan to address these important issues as they arise in connection with our investigation of future accidents, and to issue recommendations regarding these issues where appropriate. The Safety Board, in closing its open safety recommendations relating to track safety, reiterates the position it took in its letter of March 29, 1982, which addressed the proposed rules that now have been adopted as amendments to the track safety standards. In those comments we stated that the weakening of the standards would derogate the needed margins of safety, and we suggested that FRA first provide clear evidence, through testing and research, that the changes to the standards would not adversely affect rail safety. We urged FRA to use available safety analysis techniques to evaluate existing standards before making modifications. We are concerned that FRA declined to apply such techniques, but instead merely took into account potential increased costs to the industry in withdrawing its earlier more rigorous proposed rulemaking. In our March 29 letter we also highlighted the inadequacy of track inspections as a finding in many track failure related accidents, the lack of testing and research to support relaxation of current standards, and the possibility and desirability of developing performance standards or track certification procedures. The Board reaffirms its position in the March 29 letter, and we emphasize the Board's concern that track safety problems will be magnified by the recent action of FRA. We urge FRA to continue its research related to track safety and to implement its findings through regulatory action and promulgation of industry guidelines to upgrade track standards.

From: FRA
To: NTSB
Date: 9/7/1982
Response: TRACK SAFETY STANDARDS, MISCELLANEOUS AMENDMENTS, PUBLISHED ON 9/7/82: THERE ARE NO CHANGES IN 49 CFR 213 SUBPART D "TRACK STRUCTURE" WHICH WOULD APPLY TO R-75-2.

From: FRA
To: NTSB
Date: 3/24/1982
Response: FRA LTR: FRA DOES NOT PLAN TO ISSUE REGULATIONS ON SIZE AND QUALITY OF COMPONENTS USED IN TRACK CONSTRUCTION. RECOMMENDED SIZE AND QUALITY OF TRACK COMPONENTS ARE FULLY ADDRESSED IN THE MANUAL FOR RAILWAY ENGINEERING. THE RAILROAD INDUSTRY HAS ADOPTED AND IMPLEMENTED THE RECOMMENDATIONS. AS NEW COMPONENTS ARE DEVELOPED FROM ONGOING RESEARCH, THE RESULTS ARE DISTRIBUTED TO THE RAILROAD INDUSTRY FOR ITS USE IN TRACK CONSTRUCTION AND MAINTENANCE.

From: NTSB
To: FRA
Date: 10/7/1981
Response: The National Transportation Safety Board has reviewed your rationale for withdrawing the Notice of Proposed Rulemaking (NPRM), "Track Safety Standards: Miscellaneous Proposed Revisions," Docket No. RST-3 1/, which was published in Notice No. 2 at 46 FR 32896 on June 25, 1981. The stated justification for this withdrawal appears to be based exclusively on the major differences in the estimates of the Federal Railroad Administration (FRA) and the Association of American Railroads (AAR) regarding the economic impact if the proposed rules are implemented. While a thorough, documented analysis of these differences by the FRA staff appears to have been warranted prior to issuing a final rule, we do not agree that withdrawal of the NPRM was warranted since this action will unnecessarily delay the implementation of previously identified necessary track improvements. It appears that to a great extent the differences in costs associated with the proposed rule relate to the perceived scope of the rule. FRA could have clarified the intended scope of the rule without resorting to an entirely new rulemaking. Since October 1971 when the then existing railroad industry standards were adopted as the FRA track safety regulations, the Safety Board has recommended improvements to correct safety problems identified in major railroad accident investigations and safety evaluation activities. Our testimony at the FRA's November 15-16, 1978 General Safety Inquiry supported the development of improved track safety requirements and our January 10, 1980 response to the NPRM supported the need for track safety regulatory improvements. In issuing the NPRM, the FRA documented the need for reducing the disproportionate number of accidents caused by track defects (16, 570 for the years 1975 through 1978 - 42 percent of the total number of train accidents), the need for eliminating ambiguities in the existing regulations, and the critical need for providing incentives for railroads to use their scarce resources in the most effective manner to eliminate safety hazards. The Safety Board is not aware of any significant improvements implemented by the railroad industry that invalidate the needs cited by the FRA in its NPRM. In 1979, the FRA employed an independent consulting firm to assess the cost impact of the proposed regulations. This assessment found that the railroad industry would incur a $47 million one-time track rehabilitation cost and a 21.18 million increase in annual operating expenses. Upon review of these findings, the FRA concluded that the anticipated economic impact upon the industry would be a 20.2 million one-time cost and a $3.5 million increase in annual operating expenses. Using the amended estimates, the FRA's cost benefit analysis showed that a $19.9 million annual savings would be realized by the railroad industry from the anticipated reduction in the numbers of rail accidents and by eliminating administrative regulatory burdens. After the extensive, documented efforts of the FRA to assess the economic impact of the proposed regulations upon the railroad industry, the Safety Board cannot understand the FRA's apparently uncritical acceptance of the AAR's contention that the one-time rehabilitation costs would be more than 42 times that FRA estimates and the increase in annual operating costs would be more than 18 times the FRA estimates when it is clear the AAR premise is different than the FRA premise underlying the rulemaking. Even taking the AAR's premise, the fact that in 1979 alone, the railroad industry reported $105 million in losses to their property due to track damage would still appear to make the proposed regulations economically feasible. 2/ The Safety Board is not in agreement with the AAR's contention that the proposed track standards would be economically infeasible. For any meaningful analysis of the economic impact and the appropriateness of the proposed regulations relative to the provisions of Executive Order 12291, all costs and benefits must be evaluated, including the property losses incurred by the public which are not reported by the railroads, railroad employee and public deaths and injuries, and other costs incurred as a result of track-caused accidents. Consequently, the Safety Board does not believe that the FRA's withdrawal action was justified on the basis of criteria established by Executive Order 12291 as indicated in Deputy Administrator Schiefelbein's June 18, 1981 letter which advised the Safety Board of the status of the FRA's track safety standards rulemaking proposal. In an August 5 letter to Secretary Lewis, the Safety Board expressed its concern that in the current DOT effort to reduce regulatory burdens, hasty and incomplete assessments of existing or proposed regulations could result in the abandonment of many necessary and justified safety improvements which have taken years of diligent and dedicated effort to develop and put into effect. Secretary Lewis' August 31, 1981 response to the Safety Board gave assurance that these areas of concern are being adequately addressed by the Department. The Safety Board believes that the FRA's withdrawal of this NPRM reflects the appropriateness of the Board's concern and urges the FRA to expedite action necessary for the implementation of final regulations designed to correct previously identified track safety problems. The FRA has the obligation to represent the safety interests of the public by establishing appropriate railroad track safety standards. Therefore, objections to proposed rulemaking to improve track safety standards must be cautiously and completely reviewed. The Safety Board believes the FRA should have proceeded with this assessment based on the NPRM which gave rise to the objections to determine not only the true cost impacts upon the railroad industry, but also the risks imposed upon the public if the track standards are not further improved. We invite your attention to the catastrophic public risks posed by transporting hazardous materials in tank cars over defective track such as occurred in the Crete, Nebraska accident in 1969 and more recently in the accidents which occurred at Belt, Montana in 1976, at Pensacola, Florida in 1977, and at Muldraugh, Kentucky in 1980. We acknowledge that the FRA's stated goal is to develop another NPRM for improving track safety regulations; however, we note that no timetable is provided within which the FRA will complete its reassessment and issue a new NPRM. The withdrawal of the existing NPRM without establishing a time certain by which the FRA will issue a new proposal necessitates the classification of all 17 outstanding recommendations made to the FRA for track safety improvements as "Open-Unacceptable Action" (see enclosed list). The Safety Board urges the FRA to establish a time certain by which its assessment will be completed and a new NPRM will be issued. Additionally, we would appreciate receiving quarterly reports concerning the status of the assessment project.

From: FRA
To: NTSB
Date: 7/6/1981
Response: FEDERAL RAILROAD ADMINISTRATION LTR: ENCLOSED WAS A COPY OF THE WITHDRAWAL NOTICE OF FRA DOCKET NO. RST-3 THAT APPEARED IN THE FEDERAL REGISTER -- THIS NOTICE DATED THURSDAY, JUNE 25, 1981, ANNOUNCES THE WITHDRAWAL OF THAT NOTICE OF PROPOSED RULEMAKING (NPRM) (44 FR 52104) PROPOSING TO AMEND THE TRACK SAFETY STANDARDS (49 CFR 213). THE SUBSTANTIAL DISCREPANCIES BETWEEN THE FIGURES FOR REHABILITATION COSTS AND THE WIDELY DIFFERING ASSESSMENT OF THE COMMENTERS CONCERNING THE NECESSITY AND IMPACT OF THE PROPOSED AMENDMENTS HAVE CAUSED THE FRA TO CONCLUDE THAT IT IS NOT PRACTICABLE TO DEVELOP AND APPROPRIATE FINAL RULE ON THE BASIS OF THIS NPRM.

From: FRA
To: NTSB
Date: 6/18/1981
Response: FEDERAL RAILROAD ADMINISTRATION LTR: THANK YOU FOR NTSB'S RECENT LETTER EXPRESSING THE BOARD'S CONCERN ABOUT FRA'S PLANNED WITHDRAWAL OF THE NOTICE OF PROPOSED RULEMAKING (NPRM) THAT PROPOSED TO REVISE AND STRENGTHEN THE CURRENT TRACK SAFETY STANDARDS (FRA DOCKET NO. RST-3). IN VIEW OF THE BOARD'S INTEREST IN THIS MATTER, YOU WILL BE FURNISHED WITH COPIES OF OUR FUTURE FEDERAL REGISTER NOTICE ON THE TRACK SAFETY STANDARDS.

From: NTSB
To: FRA
Date: 3/26/1981
Response: The Safety Board is concerned about withdrawal of the Proposed Rule Making and its implications. Since the revision of the track safety standards was begun in 1978 and the proposed revisions were published on September 6, 1979, the Safety Board believes that the FRA has had adequate time to resolve all issues. Consequently, the Board is interested in knowing what problems the FRA may have encountered and the current status of the review.

From: FRA
To: NTSB
Date: 1/16/1978
Response: FRA LTR: TO ENCOURAGE CARRIERS TO SEEK QUALITY TRACK MATERIALS, FRA IS CONSIDERING PROMULGATING PERFORMANCE ORIENTED TRACK STANDARDS. BEFORE MAKING ANY MAJOR REVISIONS OR ADDITIONS TO THE EXISTING STANDARDS, FRA WILL REVIEW THE RESULTS OF SEVERAL RESEARCH PROJECTS CURRENTLY BEING CONDUCTED. THE TITLE AND OBJECTIVE OF EACH OF THESE PROJECTS WAS PROVIDED TO THE NTSB IN FRA 4/28/76 LETTER. THE RESULTS OF THE SHORT-TERM PROJECTS ARE EXPECTED IN 1978; LONGER-TERM RESULTS SHOULD BE AVAILABLE IN 1979. IF THE DATA INDICATE THAT PERFORMANCE STANDARDS ARE COST BENEFICIAL, THEY WILL BE PROMULGATED AT THAT TIME.

From: FRA
To: NTSB
Date: 4/28/1976
Response: FRA LTR: FRA DOES NOT PLAN TO PROMULGATE DESIGN BASED STANDARDS. RESULTS OF VARIOUS RESEARCH PROJECTS SHOULD BE KNOWN BEFORE DECISION IS MADE. FURTHERMORE, THE TRACK RELATED ACCIDENT PICTURE DOES NOT INDICATE BOLD SIZE AS BEING A PROBLEM.

From: NTSB
To: FRA
Date: 8/20/1975
Response: The Safety Board believes that FRA may have some misunderstanding of the intent of this recommendation. The Safety Board in its report entitled, "Special Study of Proposed Track Safety Standards" commented in depth on the need for both performance and design-based ("size and quality") standards. (See pages 1, 2, 6, 8, and 9 in the enclosed report.) Recommendation R-75-2 is a followup to the principles advanced in that report, but in this instance the recommendation is based on a specific accident. As the Special Study observes, it is quite practical to develop and employ both performance and design-based standards. Design-based standards are available to supplement performance standards and are more conducive to simple enforcement. Complete reliance on performance standards will necessitate the use of elaborate testing machines (some of which are not yet developed) to detect noncompliance. Where a performance requirement is established, design standards known to meet performance can substitute for performance tests. This pattern is used, for example, in marine navigation light standards where the visibility distance is specified and standard size bulbs known to provide it are the basis for compliance. Design-based standards are now used by FRA in many of the Track Standards. The requirement for a certain number of bolts in a rail joint id just such a standard, yet, it is now incomplete as it does not require that bolts be of a certain size or quality. The size and quality could be determined by testing to ensure conformance within a defined performance. Then a design specification and inspection format could follow. Such a procedure could be used for all track components, not just metal components as the reply assumes. We urge your review of the Board's study of the Track Safety Standards and reconsideration of your reply to Recommendation R-75-2. We would appreciate receiving your further comments and also FRA's schedule for the promulgation of track performance standards.

From: FRA
To: NTSB
Date: 7/9/1975
Response: FRA LTR: ULTIMATELY, FRA EXPECTS TO PROMULGATE PERFORMANCE STANDARDS FOR TRACK BASED ON THE RESULTS OF CURRENT AND NEAR-TERM FUTURE RESEARCH. PROMULGATION OF STANDARDS IN TERMS OF COMPONENT SIZE AND QUALITY WOULD BE THE ANTITHESIS OF THIS APPROACH.