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Safety Recommendation Details

Safety Recommendation R-87-067
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 NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): REVIEW AND AMEND OR RENEGOTIATE ITS CONTRACTS TO INCLUDE THE RIGHT TO CONDUCT AUDITS OR REVIEW ALL PRACTICES AND OPERATIONS OF ITS CONTRACT RAILROADS, NOT JUST CREW PERFORMANCE, WITH THE GOAL OF ELIMINATING UNSAFE PRACTICES. (R-83-061 TO AMTRAK WAS SUPERSEDED BY R-87-067 AND R-88-003)
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: 4/10/1992
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 4/10/1992
Response: Thank you for your December 27, 1991, response to Safety Recommendation R-87-67. This recommendation urged Amtrak to review and amend or renegotiate its contracts to include the right to conduct audits or review all practices and operations of its contract railroads, not just crew performance, with the goal of eliminating unsafe practices. The National Transportation Safety Board notes that Amtrak-employed crews now operate all Amtrak trains nationally, with the exception of portions of the triweekly service from Washington, D.C., to Indianapolis, Indiana. As a result, Amtrak supervisors have safety and operating rule oversight of Amtrak employees at all crew bases. In addition, mandatory efficiency tests are now in place to monitor rule compliance. With regard to the Washington to Indianapolis route, we appreciate Mr. Sullivan's letter of March 12, 1992, that specified CSX Transportation Company's (CSXT) oversight of its crews which operate over that route. The Safety Board notes your confidence in the CSXT's oversight of its crews. Since these actions meet the intent of this recommendation, the Safety Board has classified Safety Recommendation R-87-67 as "Closed--Acceptable Alternate Action."

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 12/27/1991
Response: AMTRAK STATED THAT ALL CREWS ARE NOW EMPLOYEES, WITH THE EXCEPTION OF THE TRI-WEEKLY SERVICE FROM WASHINGTON, D.C. TO INDIANAPOLIS, INDIANA. AMTRAK SUPERVISORS ARE NOW RESPONSIBLE FOR SAFETY AND OPERATING RULE COMPLIANCE. MANDATORY EFFICIENCY TESTING AND MONITORING OF RULES COMPLIANCE MEET THE SAME STANDARDS AS THE NORTHEAST CORRIDOR.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 1/31/1990
Response: This responds to your further correspondence to the National Transportation Safety Board's Safety Recommendation R-87-67 concerning field audits of all Amtrak contract carrier operations. The Safety Board notes that Amtrak conducted audits of its Midwest and Western Divisions during July and November 1989, respectively, and intends to conduct a second series of audits of its Northeast Corridor operating divisions in early 1990. We appreciate your summarizing the results of these audits as they occur, and look forward to receiving similar periodic reports in the future in order to judge the merits of this program over a suitable period of time. In the meantime, we will continue to hold this safety recommendation in an "Open --Acceptable Alternate Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 11/21/1989
Response: AN AUDIT OF OUR MIDWEST DIVISION WAS CONDUCTED BETWEEN JULY 24, AND JULY 30, 1989. THIS REVIEW FOCUSED ON AMTRAK'S CHICAGO TERMINAL OPERATION, AND ALSO INVOLVED MONITORING AMTRAK TRAINS OVER PORTIONS OF THE SOO LINE AND ILLINOIS CENTRAL RAILROADS. THE INITAIL AUDIT OF OUR WESTERN DIVISION WAS CONDUCTED BETWEEN NOVEMBER 4 AND NOVEMBER 11, 1989, FOCUSING ON AMTRAK'S LOS ANGELES TERMINAL OPERATION AND MONITORING THE OPERATION OF AMTRAK TRAINS OVER PORTIONS OF THE SANTE FE AND SOUTHERN PACIFIC. WE PLAN TO CONDUCT A SECOND SERIES OF AUDITS OF NORTHEAST CORRIDOR OPERATING DIVISIONS BEGINNING IN EARLY 1990. IN SUMMARY, THE RESULTS OF THE AUDITS CONDUCTED TO DATE INDICATE THAT COMPLIANCE WITH OPERATING PROCEDURES BY OPERATING PERSONNEL, AND SUPERVISORY OVERSIGHT IS AT A CONSISTENTLY HIGH LEVEL. WHERE EXCEPTIONS WERE NOTED ON AMTRAK OPERATING DIVISION, IMMEDIATE CORRECTIVE ACTION WAS INSTITUTED. AS A RESULT OF THE AUDITS OF THE WASHINGTON AND MIDWEST DIVISION, QUESTIONS AROSE REQUIRING CLARIFICATION OF CERTAIN CSX AND SOO LINE OPERATING PROCEDURES. THOSE AREAS HAVE BEEN ADDRESSED WITH RESPONSIBLE CSX AND SOO LINE OPERATING OFFICERS AND SATISFACTORILY RESOLVED.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 10/11/1989
Response: Thank you for your letter in further response to the National Transportation Safety Board's Safety Recommendation R-87-67 concerning field audits of all Amtrak contract carrier operations. The Safety Board acknowledges the initial efforts of Amtrak in conducting rules compliance and supervisory oversight audits on its Boston, New York, Philadelphia, and Washington Divisions (Northeast Corridor), and that these audits were directed at CSX Transportation as well as Amtrak operations. We are pleased that Amtrak was planning to conduct initial audits of its Midwest Division in July and of its Western Division in August 1989. The Safety Board may accept this initiative as an acceptable alternative to the requirements of this safety recommendation, depending on the success of the audit program. We would, therefore, appreciate receiving periodic reports summarizing the results of these audits, including the review of all practices and operations of its contract railroads, not just Amtrak crew performance. This information should enable the Safety Board to make a more informed judgment on the merits of this program. In the meantime, Safety Recommendation R-87-67 will continue to be held in an "Open--Acceptable Alternate Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/12/1989
Response: THE INITIAL EFFORTS OF THE TWO RECENTLY APPOINTED RULES SPECIALISTS HAVE BEEN DIRECTED AT REVIEWING THE LEVEL OF RULES COMPLIANCE AND SUPERVISORY OVERSIGHT OF THE NORHEAST CORRIDOR DIVISIONS. TO DATE, TWO-WEEK AUDITS AND SUBSEQUENT TWO-DAY FOLLOW-UP AUDITS HAVE BEEN CONDUCTED ON THE BOSTON, NEW YORK, PHILADELPHIA, AND WASHINGTON DIVISIONS. DURING THIS INITIAL REVIEW, OUR EFFORTS ARE DIRECTED PRIMARILY AT OUR OWN OPERATIONS AND THAT OF CSX TRANSPORTATION. ALTHOUGH SPECIFIC DATES AND LOCATIONS HAVE NOT YET BEEN FINALIZED, WE ARE PLANNING TO CONDUCT INITIAL AUDITS OF OUR MIDWEST DIVISION IN JULY, FOLLOWED BY THE WESTERN DIVISION IN AUGUST. THE PRIMARY FUNCTION OF THE RULES SPECIALISTS, WHEN ON THE PROPERTY OF OUR CONTRACT CARRIERS, WILL BE TO MONITOR THE COMPLIANCE OF AMTRAK EMPLOYEES WITH THE OPERATING RULES OF THOSE CARRIERS. THEY WILL BE PREPARED TO ADDRESS OPERATING PRACTICES TO THE EXTENT THAT PROBLEMS HAVE BEEN REPORTED OR DETECTED THROUGH THEIR OWN OBSERVATIONS.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 5/8/1989
Response: We have reviewed your letter in further response to the National Transportation Safety Board's Safety Recommendation R-87-67 for Amtrak to review all practices and operations of its contract railroads. The Safety Board appreciates receiving the listing of the new transportation management positions which were established in 1988. We also assume from your response that a major function of the two rules specialist positions in Philadelphia is to conduct field audits of all Amtrak's operating divisions in order to monitor the level of compliance with operating rules. We are concerned, however, that this increase in the number of positions within Amtrak's work force may be insufficient for Amtrak to effectively monitor its contract railroads. In that regard, we would appreciate receiving additional information concerning your plans for implementing the field audits to cover all the contract carrier operations. We would also appreciate an update on the number of field audits that have been conducted to date and a timetable for completing the initial audit of all contract carriers. Pending further response, this recommendation will be held in an "Open--Acceptable Alternate Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 1/30/1989
Response: AMTRAK ESTABLISHED 18 NEW POSITIONS IN THE TRANSPORTATION DEPT. IN 1988 IN ORDER TO MORE EFFECTIVELY MONITOR THE OPERATIONS OF OUR TRAINS ON CONTRACT CARRIER OPERATIONS. THE ADDITION OF THESE STRATEGICALLY-LOCATED POSITIONS TO UR EXISTING TRANSPORTATION MANAGEMENT FORCE WILL SUBSTANTIALLY INCREASE OUR CAPABILITY TO MONITOR CONTRACT CARRIER OPERATING PRACTICES. A MAJOR FUNCTION OF THE NEW RULES SPECIALIST POSITIONS IS TO CONDUCT FIELD AUDITS OF OUR OPERATING DIVISIONS TO MONITOR THE LEVEL OF COMPLIANCE WITH OPERATING RULES.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 12/20/1988
Response: …the board is concerned, based on the information provided, that some positions such as dispatchers which have a significant role in operations would not be monitored by Amtrak's supervision. Pending a further response to the Safety Board's concerns, Safety Recommendation R-87-67 is being held in an "Open--Unacceptable Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/5/1988
Response: AMTRAK STILL BELIEVES THERE IS NO CLEAR PATTERN OF UNSAFE OPERATING PRACTICES EXISTING ON ANY OF OUR CONTRACT CARRIERS. AS STATED PREVIOUSLY, THE ADDITIONS TO OUR FIELD SUPERVISION AND THE INCREASED MONITORING OF TRAIN OPERATIONS, IN CONJUNCTION WITH THE ASSUMPTION OF VIRTUALLY ALL TRAIN AND ENGINE CREWS, AFFORDS AMTRAK SUFFICIENT OVERSIGHT OF CONTRACT CARRIER OPERATING PRACTICES. AMTRAK MANAGEMENT REACTS QUICKLY TO CORRECT ANY DEVIATIONS FROM NORMAL, SAFE OPERATING PRACTICES THAT ARE REPORTED BY OUR CREWS AND/OR FIELD SUPERVISION.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 7/25/1988
Response: The Safety Board is aware that since the accident at Fall River, Wisconsin, the Soo Line Railroad has clarified the procedures to be followed when handling switches for crossover movements. The Board points out, however, that the goal of the Board's recommendation is for unsafe practices to be detected and eliminated before accidents occur. While we note your statement that the addition of field supervision, in conjunction with the recent assumption of train and engine crews, permits an increased capability to monitor carriers' train operations, Amtrak appears reluctant to extend its review beyond that of the operating crew. The Board continues to believe that Amtrak must assume an oversight role in all practices and operations of their trains to detect dangerous procedures and correct them before accidents occur. The procedure employed by the Soo Line Railroad before the accident had also been used on the Northeast Corridor and addressed by the Federal Railroad Administration in its 1984 special study on the Northeast Corridor, but no action was taken by Amtrak to determine if this dangerous procedure was being performed elsewhere. Amtrak is urged to reconsider the full intent of Safety Recommendation R-87-67, which is being held in an "Open--Unacceptable Action" tatus.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 6/8/1988
Response: AMTRAK DOES NOT BELIEVE ANY CLEAR PATTERN OF UNSAFE OPERATING PRACTICES EXISTS ON AMTRAK CONTRACT CARRIERS. WE AGREE THE SPECIFIC PROCEDURE EMPLOYED AT FALL RIVER BY THE SOO LINE RAILROAD COMPANY WAS UNSAFE, AND SOO LINE HAS TAKEN STEPS TO CORRECT THAT PROCEDURE. FOLLOWING THE DERAILMENT OF NO. 8, SOO LINE CLARIFIED THE PROCEDURES TO BE FOLLOWED WHEN HANDLING SWITCHES FOR CROSSOVER MOVEMENTS. THESE PROCEDURES ARE INCORPORATED AS AN ADDITION TO RULE 104(A) AND ARE A PART OF THE SPECIAL INSTRUCTIONS OF THE SOO LINE SYSTEM TIMETABLE (SEE ATTACHMENT A). WE BELIEVE THE POSITION THAT INCENTIVE PAYMENTS MAY HAVE BEEN A FACTOR IN SOO LINE'S DECISION TO USE THE PROCEDURE IS NOT SUPPORTED BY THE FACTS. THE PROCEDURE EMPLOYED WAS THE STANDARD METHOD USED BY THE SOO LINE WHEN TRACKS WERE REMOVED FROM SERVICE FOR MAINTENANCE. THE OBVIOUS INTENTION WAS TO MINIMIZE TRAIN DELAYS FOR ALL TRAINS, NOT JUST AMTRAK. TO THE EXTENT THAT AUDITS AND REVIEWS OF THE OPERATING PRACTICES OF MOST OF THE NATION'S MAJOR CARRIERS ARE NEEDED, WE NOW HAVE IMPROVED OUR ABILITY TO CONDUCT OPERATIONAL AUDITS. THE ADDITION OF AMTRAK'S FIELD SUPERVISION, IN CONJUNCTION WITH THE RECENT ASSUMPTION OF TRAIN AND ENGINE CREWS, PERMITS AN INCREASED CAPABILITY TO MONITOR CARRIERS' TRAIN OPERATIONS. ROUTINE SUPERVISION OF TRAIN DISPATCHERS, OPERATORS, SWITCH TENDERS AND RELATED PERSONNEL, HOWEVER, IS THE CONTRACTUAL RESPONSIBILITY OF THE CONTRACT RAILROADS. TO GO BEYOND THAT TO THE EXTENT THAT YOU ARE SUGGESTING WOULD BE BEST CONDUCTED BY THE AGENCY CHARGED WITH SUCH ACTIVITY, THE FEDERAL RAILROAD ADMINISTRATION.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 6/2/1988
Response: On February 8, 1988, the National Transportation Safety Board issued Safety Recommendations R-87-67 through -70 to the National Railroad Passenger Corporation (Amtrak) as a result of the Board's investigation of the derailment of Amtrak passenger train 8 operating on the Soo Line Railroad at Fall River, Wisconsin, on October 9, 1986. The National Transportation Safety Board is an independent Federal agency with the statutory responsibility . ..to promote transportation safety by conducting independent accident investigations and by formulating safety improvement recommendations" (Public Law 93-633). The Safety Board is vitally interested in any actions taken as a result of its safety recommendations. Our records show, however, that we have not received a response from Amtrak regarding the recommended actions. We would appreciate being informed as to what efforts are being made to implement these recommendations. The Safety Board's letter transmitting these recommendations is enclosed for your information. Thank you for your cooperation in this matter. We look forward to hearing from you in the near future.