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Safety Recommendation Details

Safety Recommendation R-77-025
Details
Synopsis: ABOUT 9:15 P.M., ON OCTOBER 19, 1976, AT NEW HAVEN, INDIANA, N & WESTERN RAILWAY COMPANY (N&W) FREIGHT TRAIN EXTRA 1376 WEST COLLIDED HEAD-ON WITH N&W YARD LOCOMOTIVE UNIT NO. 3363, WHICH WAS PULLING 55 FREIGHT CARS. ONE LOCOMOTIVE UNIT, A CABOOSE, AND ONE CAROF EXTRA 1376 WEST, AND THE YARD LOCOMOTIVE AND ONE CAR WERE DERAILED. THE BRAKEMAN ON THE LOCOMOTIVE OF EXTRA 1376 WEST WAS KILLED AND FOUR CREWMEMBERS WERE INJURED. THE ESTIMATED COST OF DAMAGE WAS $168,400.
Recommendation: THE NTSB RECOMMENDS THAT THE NORFOLK & WESTERN RAILWAY COMPANY: ESTABLISH POLICY AND PROCEDURES THAT WILL INSURE THAT ALL TRAINS ARE OPERATED IN COMPLIANCE WITH THE COMPANY'S RULES AND THE FEDERAL POWER BRAKE REGULATIONS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: New Haven, IN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: 80174
Accident Reports: Head On Collision of Two Norfolk Western Railway Company Freight Trains
Report #: RAR-77-06
Accident Date: 10/19/1976
Issue Date: 8/10/1977
Date Closed: 7/1/1986
Addressee(s) and Addressee Status: Norfolk and Western Railway Company (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: Norfolk and Western Railway Company
To: NTSB
Date: 7/1/1986
Response: THIS IS ACTUALLY A FOLLOWUP LETTER DATED 7/1/86 AND THE FOLLOWING IS A HISTORY OF PREVIOUS CORRESPONDENCE: NORFOLK AND WESTERN'S RESPONSE OF 11/21/77; NTSB'S ACKNOWLEDGEMENT LETTER OF 12/21/77.

From: NTSB
To: Norfolk and Western Railway Company
Date: 7/1/1986
Response: On November 21, 1977, the N&W responded to the Board's Safety Recommendation and indicated that in addition to the comprehensive program for newly hired employees in the Operating Department and the compulsory annual rules classes, an Air Brake Instruction Car tours the system continually presenting programs on air brake equipment and rules concerning air brake tests and train operation. While the Safety Board acknowledged receipt of N&W's November 21, 1977 letter, the Board never commented directly on N&W's response. Based on the comments in the November 21, 1977 letter and in view of the time that has elapsed since the issuance of this Safety Recommendation during which the Safety Board has not been made aware that this problem has reoccurred on the N&W, Safety Recommendation R-77-25 has been placed in a "Closed-Acceptable Action" status.

From: NTSB
To: Norfolk and Western Railway Company
Date: 12/21/1977
Response: Your letter has been forwarded to the Bureau of Accident Investigation for review. You will be advised of the results of the review in the near future.

From: Norfolk and Western Railway Company
To: NTSB
Date: 11/21/1977
Response: We have policies and procedures that are intended to secure compliance with our rules. There is a comprehensive program for newly hired employees in the Operating Department, and compulsory annual rules classes are held for all employees whose activities are governed by the Operating Rules. In addition, there is an Air Brake Instruction Car which tours the System continually, presenting programs to familiarize Trainmen, Enginemen, Yardmasters, and Mechanical Department personnel with functions of air brake equipment and rules concerning air brake tests and train operations. To follow up on these instruction programs, each month our supervisors on all divisions and terminals make efficiency tests and observations to monitor compliance with our rules. Regardless of how effective training, rules instruction, or efficiency testing programs may be, human factors cannot be entirely eliminated from rules compliance. Ultimate responsibility for obedience to the rules rests with the individual employee because it isn't possible to constantly oversee the on-duty activities of all employees. The Conductor, Engineman, and Rear Trainman of the westbound train involved in the accident at New Haven had, respectively, 31, 36, and 24 years of railroad experience. The Rear Trainman had been a promoted Conductor for 18 years. They weren't beginners. It is apparent that had the crewmembers of this train acted on compliance with our rules and Federal Power Brake Regulations, when the seven cars were added to the rear of the train at North Findlay, the uncoupled air hose between the second and third cars of the pickup would have been immediately detected. This could have been accomplished without an air gauge or caboose at the rear because both our rules and Federal regulations require that brakes on each freight car added to a train to be inspected for proper application and release, and brake operation on a train's last car be observed to be sure the Engineman can control brakes on all cars.