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Safety Recommendation Details

Safety Recommendation R-87-066
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: TO THE FEDERAL RAILROAD ADMINISTRATION: Conduct a thorough study of the selection process, training, duties, and responsibilities of train dispatchers to determine if the workload is beyond the normal job stress level and determine what selection and training standards are used for train dispatchers. Establish selection and training standards and limits of workload for dispatchers. (Superseded by R-98-28)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action/Superseded
Mode: Railroad
Location: FALL RIVER, WI, United States
Is Reiterated: Yes
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: 6/25/1998
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action/Superseded)
Keyword(s): Dispatch, Training and Education

Safety Recommendation History
From: NTSB
To: FRA
Date: 6/25/1998
Response: THE BOARD ADVISED THE FRA THAT IT WAS DISAPPOINTED THAT MANY OF THE STUDY'S FINDINGS & CONCERNS WERE NOT ADEQUATELY ADDRESSED IN THE PUBLISHED RECOMMENDATIONS FOR ACTION. FOR EXAMPLE, THE STUDY IDENTIFED SEVERAL MAJOR SAFETY-RELATED PROBLEMS IN THE OCCUPATIONAL STRESS, WORKLOAD, ENVIRONMENTAL POLICIES AFFECTING DISPATCHERS, BUT THE FRA STILL HAS NOT COMPLETED SATISFACTORY REGULATORY ACTIVITY TO ESTABLISH DISPATCHER STANDARDS. THEREFORE, THE BOARD CONCLUDED THAT FRA HAS FAILED TO DEVELOP DISPATCHER STANDARDS & NEEDS TO ACCELERATE THE ESTABLISHMENT OR REGULATORY STANDARDS FOR TRAIN DISPATCHERS. BECAUSE THE FRA HAS ONLY PARTIALLY MET THE INTENT OF R-87-66 CONDUCTING A STUDY OF THE SELECTION PROCESS, TRAINING, DUTIES, & RESPONSIBILITIES OF TRAIN DISPATCHERS, THE BOARD IS CLASSIFYING R-87-66 "CLOSED--UNACCEPTABLE ACTION/SUPERSEDED" BY R-98-28. THE BOARD BELIEVES THATTHE FRA SHOULD DEVELOP & ESTABLISH DISPATCHER SELECTION & TRAINING STANDARDS, DISPATCHER TRAINER STANDARDS, & WORKLOAD LIMITS FOR DISPATCHERS BY JANUARY 2000.

From: NTSB
To: FRA
Date: 12/15/1995
Response: THE BOARD IS PLEASED TO LEARN THAT THE FRA HAS COMPLETED THE REQUESTED STUDY. THE BOARD IS DISAPPOINTED, HOWEVER, THAT MANY OF THE STUDY'S FINDINGS & CONCERNS WERE NOT SPECIFICALLY ADDRESSED BY THE FRA IN ITS RECOMMENDATIONS FOR ACTION. FOR EXAMPLE, THE STUDY IDENTIFIED SEVERAL MAJOR SAFETY -RELATED SHORTCOMINGS IN CURRENT OCCUPATIONAL STRESS, WORK LOAD, & ENVIRONMENTAL POLICIES AFFECTING DISPATCHERS, BUT THE FRA'S RECOMMENDATIONS TO ADDRESS THESE CONCERNS FELL SHORT OF RESOLVING THE PROBLEMS. WE WOULD BE REASSURED IF THE FRA'S RECOMMENDATIONS DEALT MORE PRECISELY WITH THE SHORTCOMINGS & CONCERNS CITED IN THE STUDY. THE BOARD HAS LINKED SEVERAL OF THESE SHORTCOMINGS DIRECTLY TO PAST ACCIDENTS. THE BOARD, HOWEVER, CAUTIONS THE FRA AGAINST EMPHASIZING THE VALUE OF TECHNOLOGICAL ADVANCES OR INCREASED TRAINING THAT MUST BE OPERATIONALLY VALIDATED TO DETERMINE THEIR CONTRIBUTION TO DISPATCHING SAFETY. PLEASE KEEP US INFORMED OF YOUR ACTIVITIES IN RESPONSE TO THIS RECOMMENDATION. UNTIL THE FRA COMPLETES SATISFACTORY REGULATORY ACTIVITY IN THIS AREA, THE BOARD HAS CLASSIFIED R-87-66 "OPEN--ACCEPTABLE RESPONSE."

From: FRA
To: NTSB
Date: 8/11/1995
Response: JOLENE M. MOLITORIS - ADMINSTRATOR FRA, STATED THE RAIL SAFETY ENFORCEMENT & REVIEW ACT REQUIRED THE FRA TO REVIEW THE TRAIN DISPATCHER WORK ENVIRONMENT & REPORT THE RESULTS TO THE CONGRESS. IN RESPONSE, THE FRA CONDUCTED A THOROUGH REVIEW OF TRAIN DISPATCHER OPERATIONS THROUGHOUT THE COUNTRY. A REPORT TO CONGRESS WAS PRODUCED BY FRA & IS ATTACHED. FRA IS NOW WORKING WITH THE INDUSTRY TO DEVELOP REGULATIONS FOR DISPATCHERS TRAINING. THE GOAL IS THREE YEARS.

From: NTSB
To: FRA
Date: 2/10/1992
Response:

From: FRA
To: NTSB
Date: 9/26/1991
Response: THE FRA ADMINISTRATOR CITED THE JULY 1990 DISPATCHER ASSESSMENT AND SUBSEQUENT REPORT TO CONGRESS AS EVIDENCE THAT TECHNICAL TRAINING APPEARS ADEQUATE. HE THEN CITED A UPCOMING STUDY PROJECT WHICH WILL COVER TRAINING, WORKLOAD, OCCUPATIONAL STRESS, AND FATIGUE ALL RELATED TO THE RAILROAD DISPATCHER. IN CLOSING HE APPEALED FOR CLOSURE OF THE RECOMMENDATION.

From: NTSB
To: FRA
Date: 5/7/1991
Response:

From: FRA
To: NTSB
Date: 9/21/1990
Response: FRA, IN ITS REPORT TO CONGRESS, TRAIN DISPATCHER TRAINING INQUIRY, MOST OF THESE ISSUES ARE ADDRESSED (COPY ENCLOSED, ALONG WITH A COPY OF THE NATIONAL TRAIN DISPATCHER ASSESS MENT 1987-1988). WITH RESPECT TO THE PROCESS USED TO SELECT CANDIDATES FOR TRAIN DISPATCHING ASSIGNMENT, FRA DID NOT DEVELOP EVIDENCE TO SUPPORT A PREMISE THAT TRAIN DISPATCHER PERSONNEL WERE BEING INAPPROPRIATELY SELECTED. FURTHER, FRA ACCIDENT DATABASE DOES NOT DISCLOSED A STATISTICALLY SIGNIFICANT PATTERN OF ACCIDENTS CAUSED BY INADEQUATELY TRAINED OR INEXPERIENCED DISPATCHERS. THEREFORE FRA WILL NOT PURSUE THE PROMULATION OF STANDARDS ON THESE MATTERS OR ESTABLISH PERSONNEL SELECTION CRITERIA. FRA WILL CONTINUE TO MONITOR CHANGING SYSTEMS AS AN ONGOING FUNCTION. WITH THE TRAINING INQUIRY AND AND ASSESSMENT COMPLETED, THE RECOMMENDATION IS FULFILLED AND SHOULD BE RECONSIDERED AND CLOSED.

From: FRA
To: NTSB
Date: 10/30/1989
Response:

From: NTSB
To: FRA
Date: 4/27/1989
Response:

From: FRA
To: NTSB
Date: 3/10/1989
Response: WE ARE IN COMPLETE AGREEMENT WITH THE NEED FOR THIS ANALYSIS AND COMMENCED THE PROJECT MORE THAN 20 MONTHS AGO. THIS ASSESSMENT REPRESENTS THE MOST EXTENSIVE DATA GATHERING PRO JECT IN THE AGENCY'S HISTORY, AND WE BELIEVE IT WILL PLUG A MAJOR GAP IN OUR EXISTING DATA. THE FIELD WORK IS NOW COMPLETE AND WE ARE IN THE FINAL STAGES OF PREPARING THE DRAFT REPORT. IT IS INTENDED THAT THE REPORT BE PUBLISHED AND A PUBLIC HEARING BE HELD. WE WILL PROVIDE THE NTSB WITH AN ADVANCE COPY. WE DO NOT AT THIS POINT REQUEST THAT THE RECOMMENDATION BE CLOSED, BUT WILL DO SO UPON COMPLETION OF THE ASSESSMENT PROCESS.

From: NTSB
To: FRA
Date: 2/14/1989
Response: From the accident report of the head-end collision of Consolidated Rail Corporation freight trains UBT-506 and TV-61 near Thompsontown, Pennsylvania on January 14, 1988. The Board adopted this report on 2/14/1989. Also, the Safety Board reiterated the following safety recommendation to the Federal Railroad Administration: R-87-65 and R-87-66.

From: NTSB
To: FRA
Date: 6/15/1988
Response: