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Safety Recommendation Details

Safety Recommendation R-87-068
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): IN COOPERATION WITH THE RAILROADS THAT OPERATE AMTRAK PASSENGER TRAINS, INSTALL ELECTRICALLY LOCKED SWITCHES ON THE MAIN LINE TRACKS THAT WOULD PROHIBIT THE OPERATION OF THE SWITCH AFTER A TRAIN HAS PASSED THE LAST SIGNAL BEFORE THE SWITCH.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 12/20/1988
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 12/20/1988
Response: The Safety Board had hoped that Amtrak would pursue a cooperative approach with the railroads to install electrically locked switches on main line tracks, as suggested in Safety Recommendation R-87-68. Amtrak, however, appears reluctant to implement this recommendation. Since the Board believes that further dialogue on this issue would prove futile, Safety Recommendation R-87-68 has been placed in a "Closed--Unacceptable Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/5/1988
Response: AMTRAK IS NOT QUESTIONING THE SAFETY REDUNDANCY OF ELECTRICALLY LOCKED MAIN LINE SWITCHES. WE BELIEVE, HOWEVER, THAT OUR COST ESTIMATE IS CORRECT, AND THE POSSIBILITY OF PROVIDING SUCH SWITCHES IS SIMPLY NOT POSSIBLE UNDER PRESENT BUDGET CONSTRAINTS.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 7/25/1988
Response: The Board questions the high cost cited by Amtrak for installing electrically locked switches, but, more importantly, the Board sees no evidence in your response which supports your contention that from an operating standpoint, circuited electric locks prohibiting operation of a switch after a train has passed the last signal in approach to such switch is unacceptable. The Board agrees with your statement that in many cases where crossover movements are made at hand-operated switches, the train to be crossed over must be held to await the passage of an opposing train operating on the adjacent track. We further agree that where non-shunting track equipment is occupying the track beyond the crossover, or where an opposing movement is being made on the same track as the train to be diverted, normal alignment of a switch can be just as critical. The Board points out, however, and as Amtrak should be well aware, the dispatcher has the option of giving the switch to the switchtender once it has been determined that the block in question is not occupied. The safety redundancy in electrically locked switches is obvious. The Board finds your comment regarding written notification interesting, particularly in view of the fact that Amtrak does not provide written notification on the Northeast Corridor, as was evidenced by the accident at Chester, Pennsylvania, on January 29, 1988. Further, the tendency in industry today is to provide notification by radio. Written notification, as you outline, already, would only add an extra burden to dispatchers and operators, who in many cases, have a heavy workload. In short, the Board believes that Amtrak has provided no justification for not implementing this recommendation, and Amtrak is urged to reconsider its position. In the meantime, Safety Recommendation R-87-68 will be held in an "Open--Unacceptable Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 6/8/1988
Response: THE BOARD'S RECOMMENDATION TO INSTALL CIRCUITED ELECTRIC LOCKS ON ALL MAIN LINE CROSSOVERS IS FINANCIALLY UNREALISTIC. SUCH INSTALLATIONS WOULD COST APPROXIMATELY $25,000 PER LOCATION. EVEN WITHOUT AN ACCURATE LISTING OF THE TOTAL NUMBER OF INSTALLATIONS INVOLVED OVER 23,000 ROUTE MILES, A MULTIMILLION DOLLAR INVESTMENT WOULD BE NEEDED. FURTHER, FROM AN OPERATING STANDPOINT, CIRCUITED ELECTRIC LOCKS PROHIBITING OPERATION OF A SWITCH AFTER A TRAIN HAS PASSED THE LAST SIGNAL IN APPROACH TO SUCH SWITCH IS UNACCEPTABLE. IN MANY CASES WHERE CROSSOVER MOVEMENTS ARE MADE AT HAND-OPERATED SWITCHES, THE TRAIN TO BE CROSSED OVER MUST BE HELD TO AWAIT THE PASSAGE OF AN OPPOSING TRAIN OPERATING ON THE ADJACENT TRACK. WHERE NON- SHUNTING TRACK EQUIPMENT IS OCCUPYING THE TRACK BEYOND THE CROSSOVER, OR WHERE AN OPPOSING MOVEMENT IS BEING MADE ON THE SAME TRACK AS THE TRAIN TO BE DIVERTED, NORMAL ALIGNMENT OF A SWITCH CAN BE JUST AS CRITICAL. THE FALL RIVER ACCIDENT, HOWEVER, DEMONSTRATED THAT WHAT IS MORE ESSENTIAL THAN SWITCH POSITION IN SUCH OPERATIONS IS PRIOR WRITTEN NOTIFICATION TO ALL TRAINS APPROACHING SUCH LOCATIONS, INCLUDING A CLEARANCE PROVISION FOR A TRAIN TO PASS THE LOCATION. AS THE BOARD'S REPORT NOTED, THE SPEED AT WHICH NO. 8 WAS OPERATING AS IT APPROACHED FALL RIVER RESULTED NOT ONLY FROM SIGNAL ASPECTS BUT ALSO, AND MORE IMPORTANTLY, FROM FAILURE TO PROVIDE WRITTEN NOTIFICATION THAT A SWITCHTENDER WAS ON DUTY OR THAT THE TRAIN WOULD BE DIVERTED. IN SUCH CIRCUMSTANCES, IF THE TRACK BEYOND FALL RIVER WERE OCCUPIED BY TRACK EQUIPMENT OR AN OPPOSING TRAIN AND THE CROSSOVER WAS IN NORMAL POSITION, ABSENCE OF NOTIFICATION COULD RESULT IN JUST AS SERIOUS A POTENTIAL FOR AN ACCIDENT. THE NTSB MENTIONS THE FRA SPECIAL STUDY OF THE NORTHEAST CORRIDOR, SUGGESTING SOO LINE PROCEDURES ARE IN EFFECT ON THE NEC. AMTRAK'S PROCEDURE, HOWEVER, IN A SITUATION SUCH AS OCCURRED AT FALL RIVER, IS TO ESTABLISH A TEMPORARY BLOCK STATION MANNED BY AN OPERATOR, AND TO REQUIRE TRAINS TO OBTAIN A BULLETIN ORDER AND A TRAIN ORDER BEFORE PASSING THE BLOCK STATION. WE BELIEVE THE PROCEDURE, IF USED BY THE SOO LINE, WOULD HAVE AVOIDED THE DERAILMENT OF NO. 8.

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 Saf$y 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.