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Safety Recommendation Details

Safety Recommendation R-85-084
Details
Synopsis: ABOUT 10:45 A.M. ON JULY 23, 1984, NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK) TRAINS NOS. 151 AND 168 COLLIDED HEAD-ON ON AMTRAK'S HELL GATE LINE IN THE ASTORIA SECTION OF QUEENS, NEW YORK, NEW YORK. TRAIN NO. 151 WAS BEING OPERATED BY TRAIN ORDER AUTHORITY WESTBOUND ON THE NO. 2 MAIN TRACK BETWEEN MARKET INTERLOCKING AND THE EAST END OF GATE INTERLOCKING. TRAIN NO. 168 WAS SUPPOSED TO HAVE BEEN STOPPED AND HELD AT THE HOME SIGNAL ON THE NO. 2 TRACK AT THE WEST END OF GATE INTERLOCKING FOR THE ARRIVAL OF TRAIN NO. 151. HOWEVER, TRAIN NO. 168 DID NOT STOP AT THE HOME SIGNAL BUT CONTINUED PAST GATE INTERLOCKING. THE TWO TRAINS COLLIDED ABOUT 1.1 MILES EAST OF GATE INTERLOCKING. ONE PASSENGER WAS KILLED; 129 PASSENGERS, 8 AMTRAK OPERATING CREWMEMBERS, AND 3 AMTRAK SERVICE ATTENDANTS WERE INJURED. PROPERTY DAMAGE WAS ESTIMATED BY AMTRAK TO HAVE BEEN $3,199,000.
Recommendation: THE NTSB RECOMMENDS THAT THE ASSOCIATION OF AMERICAN RAIL ROADS: REVIEW MEMBER RAILROADS' CURRENT METHODS OF CONDUCTING OPERATING RULES CLASSES AND ADMINISTERING TESTS FOR DEFICIENCIES AND DEVELOP MODEL INSTRUCTION AND TESTING PROCEDURES THAT WILL REQUIRE EMPLOYEES TO DEMONSTRATE THAT THEY NOT ONLY KNOW THE WORDING OF THE OPERATING RULES BUT THAT THEY UNDERSTAND HOW THE RULES ARE TO BE APPLIED BOTH IN NORMAL AND EMERGENCY OPERATING CONDITIONS. DISSEMINATE THE MODEL PROGRAM TO MEMBER RAILROADS AND ENCOURAGE THEM TO ADOPT THE PROGRAM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: New York, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA84AR014
Accident Reports: Head On Collision of National Railroad Passenger Corporation (Amtrak) Passenger Trains Nos. 151 and 168
Report #: RAR-85-09
Accident Date: 7/23/1984
Issue Date: 8/5/1985
Date Closed: 4/19/1993
Addressee(s) and Addressee Status: Association of American Railroads (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Association of American Railroads
Date: 4/19/1993
Response: THE BOARD IS PLEASED THAT THE AAR HAS ANALYZED RULES TRAINING & ENFORCEMENT ON NINE MAJOR RAILROADS SINCE OUR LAST CORRESPONDENCE ON 7/25/88. BY DOING SO, THE AAR HAS DEMONSTRATED AN ONGOING COMMITMENT TO THE SPIRIT OF THIS RECOMMENDATION. WE AGREE THAT YOUR RAILROADS' CURRENT METHODS OF CONDUCTING & ADMINISTERING TESTS DEMONSTRATE A COMMITMENT TO PROFESSIONALISM. THE BOARD IS ALSO PLEASED TO NOTE THAT NONE OF THE SURVEY SUBJECT NOW ALLOW EMPLOYEES TO CORRECT THEIR RULES EXAMS BEFORE GRADES ARE RECORDED. THESE AGGRESSIVE RULES PROGRAMS HAVE ADDRESSED THE CONCERNS EXPRESSED BY THE BOARD. THE TRAINING, TESTING, & CERTIFICATION REQUIREMENTS OF THE FRA ENGINEER CERTIFICATION PROGRAM ARE ALSO HAVING A POSITIVE IMPACT ON OPERATING RULES PROGRAMS. CONSEQUENTLY, THE BOARD HAS CLASSIFIED R-85-84 "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: Association of American Railroads
To: NTSB
Date: 2/16/1993
Response: EDWIN HARPER - PRESIDENT: AAR'S OPERATING RULES COMMITTEE HAS ANALYZED RULES TRAINING AND ENFORCEMENT ON NINE MAJOR RAILROAD AND FINDS THAT WHILE PARTICULAR ASPECTS OF EACH PROGRAM DIFFER, MANDATORY PERIODIC RULES TESTING IS REQUIRED ON EIGHT AND THE NINTH REQUIRES A CLEAR ACCURATE DEMONSTRATION OF RULES COMPREHENSION ON ITS ORALLY-ADMINISTERED TEST. IN ADDITION, UNDER 49CFR PART 240, FRA'S ENGINEER CERTIFICATION PROGRAM REQUIREMENTS ARE MORE STRINGENT THAN THAT OF OTHER EMPLOYEES. THIS SURVEY DEMONSTRATES THE INDUSTRY'S COMMITMENT TO RULES TRAINING AND ENFORCEMENT AND ASKS THAT THE RECOMMENDATION BE CLOSED.

From: NTSB
To: Association of American Railroads
Date: 7/25/1988
Response: While the Safety Board is pleased to note that the Association of American Railroads (AAR) is continuing to bring the subject of operating rules instruction to the attention of the railroad industry, the Board finds it difficult to reach the conclusion that the railroads are providing quality rules instruction for their employees based on the questions posed to and the answers received from the representatives of eight United States railroads at the May 4, 1988, meeting of the AAR's Operating Rules Committee. Our accident investigations continue to indicate otherwise. Furthermore, the Board sees no meaningful information gained from the questionnaire that was presented to the railroad representatives. The Board will elaborate on this position as we address some of the specific questions posed. The Board notes the affirmative answers to the question, "Are exam scores used to determine qualification?" Board accident investigations, and most recently the Board's ongoing investigation of the October 12, 1987, Amtrak accident at Russell, Iowa, have revealed that, on some railroads, employees are permitted to take the rules examination, review it and correct their mistakes before the grade is recorded. Consequently, this score in no way reflects an employee's understanding of the rules. In our prior correspondence, the Board expressed concern that the previously developed minimal standards contained no specific testing procedures that would require each participant to demonstrate a thorough understanding of the information given during the training. The results to date of the above mentioned ongoing accident investigation underscore this concern of the Safety Board. We also previously expressed concern that while instruction had been alluded to in a number of the minimal standards, there was no specific standard requiring that adequate instruction time be provided. The responses by the railroad representatives only reinforce the Board's concern that there has been no discussion on the quantitative aspect of rules instruction. Board accident investigations have revealed far too often a lack of or inadequate refresher training programs, which is indicative of the industry's failure to quantify rules instruction. The Board does not agree that this questionnaire can be termed "...an in-depth followup...to determine... if the minimal guidelines are being met...," as was suggested in our September 27, 1987, letter. We would suggest that further and closer observation of actual rules classes and testing procedures would be more indicative of an "indepth followup." While the AAR considers the Board's comments, Safety Recommendation R-85-84 will continue to be held in an "Open--Acceptable Alternate Action" status. After reviewing the questions posed to the railroad representatives, the Safety Board notes a broader and more general concern. Accident investigation experience has shown us that an effective training program must reach beyond classroom instruction. Your questionnaire seemingly evaluates rules instruction program soley from the standpoint of classroom coverage and we see little benefit in that kind of a review. There are a number of other factors that, if not emphasized, can undermine or negate the effectiveness of a rules instruction program, including, but not limited to: 1. lack of followup on-the-job supervision; 2. supervision which ignores or takes no action with respect to rules violations; and 3. lack of meaningful disciplinary action for rules violations. If train crews understand that they will rarely, if ever, encounter a supervisor during a tour of duty or perceive that supervision is more concerned with the expedited movement of trains and consequently ignores or condones violations of rules, the employees are sent a mixed message that casts doubt on the credibility and applicability of the entire rules system. Also, if an employee understands that he will be reinstated within a few days after having been suspended for a rules violation, there is no incentive for the employee to adhere to operating rules, let alone learn them thoroughly in the first place. Conversely, if a train crew understands that they will routinely encounter supervisory personnel and that supervisory personnel are consistent in citing rules violations with appropriate meaningful disciplinary action, there is an incentive for employees to understand and follow those operating rules. Put another way, the testing procedures of an effective rules program should extend beyond the classroom to the operating environment so that employees are consistently monitored and checked on their knowledge and adherence to operating rules. The Board found in its investigation of the accident at Pine Bluff, Arkansas, on June 9, 1985, that management provided only part-time rules enforcement efforts by an inadequate supervisory staff, an inconsistent policy of rules enforcement and discipline, and a tendency toward leniency which mitigated the effect of discipline. In short, the Board believes there are a number of factors, in addition to the minimal standards previously developed, that the AAR should look at and take into consideration in determining the overall effectiveness of the rules instruction programs in the railroad industry.

From: Association of American Railroads
To: NTSB
Date: 5/18/1988
Response: ON MAY 4, 1988, THE AAR'S OPERATING RULES COMMITTEE REVIEWED YOUR LETTER OF SEPTEMBER 23, 1987, PERTAINING TO NTSB RECOMMENDATION R-85-84. THE REPRESENTATIVES OF 8 UNITED STATES RAILROADS WHICH REPRESENT 60% OF THE U.S. RAIL MILEAGE ANSWERED QUESTIONS RELATING TO RULES INSTRUCTION. A BRIEF SUMMARY OF THOSE RESPONSES IS ATTACHED. WE BELIEVE THESE RESPONSES INDICATE THAT RAILROADS PROVIDE QUALITY RULES INSTRUCTION FOR THEIR EMPLOYEES. ALSO, A CONSCIENTIOUS EFFORT IS BEING MADE TO INCULCATE UNDERSTANDING OF RULES APPLICATION IN THE SPIRIT OF THE GUIDELINES DEVELOPED AND DISTRIBUTED EARLIER.

From: NTSB
To: Association of American Railroads
Date: 9/23/1987
Response: The Safety Board appreciates receiving a copy of Vice President Johnston's letter of December 23, 1986, to the Chief Operating Officers regarding the "Minimal Guidelines for Rules Classes and Testing Procedures" that were adopted and approved at the October 1986 meeting of the Association of American Railroads Operating Rules Committee. Safety Board staff in attendance found the meeting to be very productive in terms of initiating constructive dialogue with the industry on the issue of training. Since there have never been minimum industry standards in the area of training, the Board considers this effort to be a significant breakthrough in the treatment of operating rules language, interpretation, and training. The Safety Board has long been concerned about uniformity of interpretation and understanding of operating rules. This concern was recently highlighted in the Board's report of the head-on collision of two Burlington Northern (BN) freight trains at Wiggins, Colorado, on April 13, 1984, and the rear-end collision of two BN freight trains near Newcastle, Wyoming, on April 22, 1984. In this regard, the Board is pleased to note that items 2 and 3 of the guidelines address this concern. The Board has been equally concerned over the years with the quality of instruction on some major railroads, particularly those that have no rules department or full-time rules examiners. In such cases, training has been entrusted to unqualified line supervisors and the training does little to enhance employees' knowledge. As a result, the Board is again pleased to note that items 4, 5, and 7 address the need to have an effective and competent rules instructor in charge of training and rules classes. In this area, we note further that item 8 addresses the need for sufficient discussion time, and we believe this to be an important minimum standard. However, while we note that instruction is alluded to in a number of the standards, there is no specific standard requiring that adequate instruction time be provided for, and we would encourage the AAR to address further this particular aspect of training. We further note that, while testing is mentioned in items 4 and 13, there is no detailed discussion of testing procedures. As these minimal guidelines are further refined, the Safety Board encourages you to provide more specifics on testing procedures that will provide a thorough demonstration that each participant has an understanding of the information given during the training. The Safety Board believes that AAR's effort to develop minimal guidelines for rules classes and testing procedures is an acceptable alternative to the intent of Safety Recommendation R-85-84, which, consequently, has been placed in an "Open--Acceptable Alternate Action" status. The Board, through its accident investigations, will monitor the actions taken by industry to determine if they are adequate and in line with the minimal guidelines. The Board encourages the AAR to conduct an in-depth followup with industry to determine also if the minimal guidelines are being met.

From: Association of American Railroads
To: NTSB
Date: 12/23/1986
Response: YOU MAY RECALL IN MY LETTER OF MAY 21, 1986, I SUGGESTED THAT A MEMBER OR MEMBERS OF YOUR STAFF ATTEND THE NEXT AAR OPERATING RULES COMMITTEE SCHEDULED TO MEET IN OCTOBER AND REVIEW THE NATIONAL TRANSPORTATION SAFETY BOARD'S RECOMMEN DATION (R-85-84) WITH THAT GROUP. I AM PLEASED TO ADVISE THAT MESSRS. JOHN A. REHOR AND EDWIN R. BUTLER OF THE NTSB ATTENDED THE OCTOBER MEETING AND, AS A RESULT OF THEIR INPUT THE RULES COMMITTEE ADOPTED AND APPROVED "MINIMAL GUIDELINES FOR RULES CLASSES AND TESTING PROCEDURES."

From: NTSB
To: Association of American Railroads
Date: 7/9/1986
Response: The Safety Board notes that in response to our letter of May 12, 1986, in which we urged the Association of American Railroads (AAR) to reconsider the full intent of Safety Recommendation R-85-84, the AAR Rules Committee will address this issue at its next meeting in October. The Safety Board would be ipleased to have a representative from our staff attend the meeting and, in this regard, please contact Mr. John Rehor of the Railroad Accident Division at (202) 382-6844 as to the exact time and location of the meeting. Safety Recommendation R-85-84 will remain in its current status of "Open--Unacceptable Action" pending the outcome of that meeting. Your cooperation in this matter is appreciated.

From: Association of American Railroads
To: NTSB
Date: 5/21/1986
Response: IN MY LETTER OF OCTOBER 2, 1985, I MENTIONED THAT THE AAR OPERATING RULES COMMITTEE HAD REVIEWED RECOMMENDATION R-85-84, AND THE GENERAL CONSENSUS WAS THAT IT WOULD NOT BE APPROPRIATE TO ADOPT A MODEL PROGRAM FOR THE INDUSTRY. HOWEVER, IN VIEW OF YOUR CONTINUING INTEREST IN THIS SUBJECT, I HAVE REQUESTED THE RULES COMMITTEE TO AGAIN ADDRESS THE ISSUE. THE NEXT MEETING OF THE RULES COMMITTEE WILL BE IN OCTOBER, AND IT WOULD BE MOST BENEFICIAL IF A REPRESENTATIVE FROM YOUR STAFF COULD ATTEND AND BE AVAILABLE TO ANSWER ANY QUESTIONS THAT MAY ARISE.

From: NTSB
To: Association of American Railroads
Date: 5/12/1986
Response: The Safety Board notes with concern the Association of American Railroads (AAR) statement regarding the fact that the probable cause of the accident could not be determined. The AAR should be well aware that the Safety Board often addresses through safety recommendations issues which have been developed as a result of accident investigations but which are not necessarily mentioned in or a part of the probable cause of an accident. The AAR's statement that instruction and testing procedures need to be brought out of the "theoretical" and applied to the "actual" both in normal and emergency conditions in effect summarizes the intent of the Board's recommendation. In this regard, the Board believes that the AAR may have placed too much emphasis on or misunderstood the use of the word "model" in the Board's recommendation. As we indicated in our previous letter of January 24, 1986, the recommendation addresses a methodology of rules instruction which would be applicable throughout the industry but which at the same time could be tailored to the operating rules and characteristics of the individual railroads. For example, if the AAR were to use a set of operating rules from a given railroad and develop instruction and testing techniques that would require employees to demonstrate that they understand how those rules are applied, the AAR would have in effect developed a model program which the individual railroads could then tailor to their specific rules and operating characteristics. The Board again urges the AAR to reconsider the full intent of Safety Recommendation R-85-84 which will remain in its current status of "Open--Unacceptable Action."

From: Association of American Railroads
To: NTSB
Date: 2/24/1986
Response: WE REGRET THAT THE BOARD CONTINUES TO ASSUME THAT THE DEVELOPMENT OF MODEL INSTRUCTION AND TESTING PROCEDURES FOR OPERATING RULES ARE NECESSARY TO PREVENT A REOCCURRENCE OF THE CIRCUMSTANCES LEADING TO THE AMTRAK COLLISION. AS STATED IN THE BOARD'S OWN REPORT, THE PROBABLE CAUSE OF THE ACCIDENT COULD NOT BE DETERMINED. WE AGREE WITH THE BASIC PREMISE THAT INSTRUCTION AND TESTING PROCEDURES NEED TO BE BROUGHT OUT OF THE "THEORETICAL" AND APPLIED TO THE "ACTUAL" BOTH IN NORMAL AND EMERGENCY CONDITIONS; HOWEVER, WE ALSO BELIEVE THIS IS BEST ACCOMPLISHED BY CONCENTRATING ON THE SPECIFIC OPERATING AREAS RATHER THAN TRYING TO COVER AN ENTIRE INDUSTRY WITH ONE UNIVERSAL PROGRAM. THE WIDE RANGE OF TRAINING PROGRAMS IN EFFECT AMONG OUR MEMBER RAILROADS IS CONSTANTLY BEING REVIEWED AND EVALUATED BY THE AAR OPERATING RULES COMMITTEE AND THE OPERATING RULES ASSOCIATION. THIS PROCESS HAS PROVED TO BE EXTREMELY BENEFICIAL TO ALL PARTICIPATING RAILROADS INCLUDING THE SHORT LINES. THERE EXISTS A FREE-FLOW OF TRAINING PHILOSOPHY, CONCEPTS AND TECHNIQUES BETWEEN OUR MEMBERS AND WE FEEL THAT THIS ACTIVITY IS SUPERIOR TO DEVELOPING AN INDUSTRY "MODEL" THAT WOULD BE SUITABLE FOR ALL OPERATING CHARACTERISTICS.

From: NTSB
To: Association of American Railroads
Date: 1/24/1986
Response: The Safety Board is disappointed in the Association of American Railroads' (AAR) response to this recommendation. The Board points out that the goal of this recommendation is for employees to demonstrate that they not only know the wording of the operating rules but that they understand how the rules are to be applied both in normal and emergency operating conditions. The Board believes that rules classes and examinations, as currently structured in the industry, are not accomplishing this goal. The Board's investigation of the Astoria, Queens, accident, as well as the other accidents discussed in the Board's August 5, 1985, recommendation letter, support this belief. The Board does not agree with the AAR's assessment that the different physical characteristics of each property and the various types of operations preclude the development of model instruction and .testing procedures. The recommendation addresses a methodology of rules instruction which would be applicable throughout the industry, regardless of the physical characteristics of the individual railroads. The Board urges the AAR to reconsider the full intent of Safety Recommendation R-85-84, which will be held in an "Open-- Unacceptable Action" status, pending further response.

From: Association of American Railroads
To: NTSB
Date: 10/2/1985
Response: THE AAR OPERATING RULES COMMITTEE HAS REVIEWED NTSB'S RECOMMENDATION R-85-84 AND AGREE THAT A MODEL PROGRAM WOULD BE DESIRABLE. HOWEVER, DUE TO THE DIFFERENT PHYSICAL CHARACTERISTICS OF EACH PROPERTY COUPLED WITH THE VARIOUS TYPES OF OPERATIONS, IT WOULD NOT BE FEASIBLE TO ADOPT A MODEL PROGRAM FOR THE INDUSTRY. EACH CARRIER HAS ITS OWN FORMAT FOR CONDUCTING RULES CLASSES AND TESTING PROCEDURES. THE RULES OF EACH CARRIER ARE DESIGNED TO COVER THEIR RESPECTIVE REQUIREMENTS UNDER VARIOUS OPERATING CONDITIONS AND ARE IN PLACE AS A RESULT OF THEIR SPECIFIC OPERATING EXPERIENCES OVER THE YEARS.