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Safety Recommendation Details

Safety Recommendation R-87-061
Details
Synopsis: ON OCTOBER 9, 1986, EASTBOUND NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK) PASSENGER TRAIN 8 DERAILED IN FALL RIVER, WISCONSIN. EACH OF THE FREIGHT TRAINS PRECEDING TRAIN 8 RECEIVED INFORMATION THAT PREPARED THEM EITHER TO CROSS OVER FROM ONE TRACK TO ANOTHER AT FALL RIVER BECAUSE OF TRACK WORK IN THE AREA OR TO STOP AT FALL RIVER FOR IN STRUCTIONS. HOWEVER, THE ENGINEER OF TRAIN 8 DID NOT HAVE ANY ADVANCE NOTIFICATION OR TRAIN ORDER TO INDICATE THAT HIS TRAIN WAS TO CROSS OVER FROM THE EASTWARD TO THE WESTWARD TRACK IN FALL RIVER. AS A RESULT, TRAIN 8 ENTERED THE CROSSOVER AT 70 MPH AND THE LOCOMOTIVE UNITS OVERTURNED. THE AUTHORIZED SPEED FOR THE CROSSOVER WAS 10 MPH. TWO LOCOMOTIVE UNITS AND 10 PASSENGER CARS DERAILED; THE FIREMAN WAS KILLED, TWO CREWMEMBERS WERE INJURED SERIOUSLY, AND TWO RECEIVED MODERATE INJURIES. OF THE 215 PASSENGERS ON BOARD, 26 WERE INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE SOO LINE RAILROAD: ESTABLISH AT EACH CREW CHANGE POINT A REQUIREMENT FOR THE TESTING OF THE RADIO BY CREWMEMBERS TO A PREDETERMINED POINT THAT WOULD BE EQUAL TO THE FARTHEST POINT THE RADIO WOULD BE REQUIRED TO TRANSMIT AND RECEIVE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: FALL RIVER, WI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA87MR001
Accident Reports: Derailment of Amtrak Passenger Train 8 Operating on the Soo Line Railroad
Report #: RAR-87-05
Accident Date: 10/9/1986
Issue Date: 2/8/1988
Date Closed: 7/12/1989
Addressee(s) and Addressee Status: Canadian Pacific Railway (Soo Line Railway Company) (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Canadian Pacific Railway (Soo Line Railway Company)
Date: 7/12/1989
Response:

From: Canadian Pacific Railway (Soo Line Railway Company)
To: NTSB
Date: 2/16/1989
Response: IN LINE WITH RECOMMENDATION R-87-61, THE SOO LINE HAS INSTRUCTIONS WHICH READ AS FOLLOWS: "IN THE APPLICATION OF RULE 515, TEST MUST BE MADE WITH A RADIO BASE STATION." WITH THE INSTALLATION OF ADDITIONAL RADIO BASE STATIONS TO IMPROVE THE SAFETY AND EFFICIENCY OF THE OPERATION, THE SOO LINE IS CONFIDENT THAT OUR RADIO COVERAGE AND PROCEDURES HAVE BEEN IMPROVED RESULTING IN IMPROVED SAFETY IN THE USE OF RADIOS FOR RAILROAD OPERATIONS.

From: NTSB
To: Canadian Pacific Railway (Soo Line Railway Company)
Date: 12/20/1988
Response:

From: Canadian Pacific Railway (Soo Line Railway Company)
To: NTSB
Date: 8/30/1988
Response: IN ADDITION TO THE RULES ENUMERATED IN OUR MAY 9, 1988 LETTER AS TO THE TESTING OF LOCOMOTIVE RADIOS FOR QUALITY, DEPENDABILITY AND READABILITY OF TRANSMISSIONS, THE SOO HAS ESTABLISHED PROCEDURES THAT REQUIRE THE TESTING OF LOCOMO TIVE RADIOS WITH AREA BASE STATIONS AT ALL CREW CHANGE POINTS. THE TESTING OF LOCOMOTIVE RADIOS WITH RAILROAD PERSONNEL USING A PORTABLE RADIO WITHIN THE IMMEDIATE VICINITY OF THE ENGINE IS UNACCEPTABLE FOR AN ENGINE/RADIO TEST. IN ORDER TO PREVENT AN INCIDENT SIMILAR TO THE FALL RIVER DERAILMENT FROM OCCURRING, THE SOO LINE HAS ADOPTED AND IMPLEMENTED PROCEDURES PROVIDING FOR THE ISSUANCE OF TRAIN ORDERS REQUIRING A TRAIN TO STOP UNLESS VERBAL AUTHORITY TO PROCEED IS RECEIVED FROM A SWITCH TENDER AT A SITE WHERE THE TRAIN WILL TRANSFER FROM ONE TRACK TO ANOTHER. THEREFORE, IN THE EVENT THAT RADIO COMMUNICATIONS FAIL ENROUTE AFTER THE INITIAL LOCOMOTIVE RADIO TEST, THE MOVEMENT IS STILL PROTECTED AS THE TRAIN MUST STOP AND NOT PROCEED UNTIL VERBAL CONTACT IS MADE WITH THE SWITCH TENDER FOR INSTRUCTIONS.

From: NTSB
To: Canadian Pacific Railway (Soo Line Railway Company)
Date: 7/25/1988
Response:

From: NTSB
To: Canadian Pacific Railway (Soo Line Railway Company)
Date: 6/2/1988
Response:

From: Canadian Pacific Railway (Soo Line Railway Company)
To: NTSB
Date: 5/9/1988
Response: THE GENERAL CODE OF OPERATING RULES HAS CONTAINED IN IT APPROXIMATELY 28 RULES THAT ENCOMPASS THE PROPER USE OF RADIOS FOR BOTH PORTABLE AND BASE STATIONS. THE RULES ARE VERY SPECIFIC ANND COVER A VERY WIDE RANGE OF THEIR USAGE. RULE 515 PERTAINS TO THE TESTING OF RADIOS USED IN TRAIN OPERATIONS OUTSIDE OF YARD LIMITS. RULE 516 IS VERY SPECIFIC IN STATING THE MINIMUM NUMBER OF TIMES RADIOS MUST BE TESTED BY BOTH THE CONDUCTOR AND ENGINEER DURING THEIR TOUR OF DUTY TO ENSURE THE RADIOS ARE WORKING PROPERLY. RULE 517 ADDRESSES THE EXCHANGE OF VOICE TRANSMISSIONS AND QUALITY AND READABILITY OF THE TRANSMISSIONS. THE ABOVE MENTIONED RADIO RULES DO NO SPECIFY A MINIMUM DISTANCE TO BE OBSERVED WHEN CHECKING AND/OR TESTING A RADIO FOR QUALITY AND RELIABILITY. HOWEVER, WHEN EXCHANGING VOICE TRANSMIS SIONS, BOTH PARTICIPANTS ARE USUALLY A DISTANCE THAT EQUALS THE LENGTH OF THEIR TRAIN. WHEN LOCATIONS AND CONDITIONS PERMIT, A MUCH GREATER DISTANCE IS UTILIZED IN THE TEST. WE HAVE BEEN SATISFIED THAT THIS TYPE OF RADIO TEST IS IN COMPLIANCE WITH THE RULES GOVERNING SAME AND PROVIDES THE USERS THE INSURANCE THE RADIOS ASSIGNED FOR THEIR USAGE ARE IN GOOD, OPERATING CONDITION.