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Safety Recommendation Details

Safety Recommendation R-87-070
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): ESTABLISH SAFEGUARDS TO PREVENT CONTRACT RAILROADS FROM USING UNSAFE PRACTICES TO QUALIFY FOR ON-TIME INCENTIVE PAYMENT FOR ON-TIME PERFORMANCE OF AMTRAK PASSENGER TRAINS.
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 Board continues to question Amtrak's position that unsafe practices are not being employed to qualify for on-time incentive payments. In previous correspondence, we have highlighted indications that carriers have employed unsafe procedures, and while perhaps not aware of the consequences, management has understood that these procedures were being employed and that they expedited the movement of trains. The Board fails to understand why Amtrak has not acted to establish safeguards as outlined in Safety Recommendation R-87-70. In view of Amtrak's decision not to address this issue, Safety Recommendation R-87-70 has been placed in a "Closed--Unacceptable Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/5/1988
Response: AMTRAK REITERATES THAT THERE IS NO INFORMATION OR EVIDENCE TO SHOW THAT ANY CONTRACT CARRIER ENCOURAGES OR CONDONES UNSAFE OPERATING PRACTICES IN ORDER TO QUALIFY FOR ON-TIME INCENTIVE PAYMENTS. AS STATED IN OUR COMMENTS FOR R-87-67, AMTRAK'S OPERATING CREWS AND FIELD SUPERVISORY PERSONNEL REPORT UNSAFE OPERATING PRACTICES AS THEY OCCUR, AND EXPEDIENT CORRECTIVE ACTION IS THEN TAKEN WITH THE CARRIER RAILROAD INVOLVED.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 7/25/1988
Response: As a result of the Board's investigation of an Amtrak passenger train collision and derailment on the Illinois Central Gulf (ICG) at Wilmington, Illinois, on July 28, 1983, the Board documented speed violations on the ICG which may have occurred as a result of the carrier's desire to enhance its on-time performance. Amtrak, however, violations continued to occur. took no action to determine why speed In the Fall River accident, the fact remains that a dangerous procedure, which expedited the movement of trains, was in effect and understood by Soo Line management which took no action to prohibit its use. In view of Amtrak's apparent reluctance to conduct reviews or audits of all practices and operations of its contract railroads, the Board questions Amtrak's confidence that unsafe practices are not being employed to qualify for on-time incentive payments. It is possible that the implied emphasis by Soo Line management to keep train 8 on schedule affected the performance of the individuals involved in the movement of the train, and this impression led them to believe that on-time performance was the most important factor. The Board is aware that a carrier's right to earn incentives is provided in section 402(a) of the Rail Passenger Service Act. The Board believes, however, that Amtrak has an obligation to assure that railroads are not circumventing safe operating practices to earn these incentives. Amtrak is urged to reconsider the full intent of Safety Recommendation R-87-70, which is being held in an "Open--Unacceptable Action" status.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 6/8/1988
Response: AS STATED IN OUR RESPONSE TO R-87-67, WE DO NOT BELIEVE THE FACTS DEMONSTRATE ANY AMTRAK CONTRACT CARRIER DOES OR WOULD CONSIDER EMPLOYING UNSAFE OPERATING PRACTICES TO QUALIFY FOR INCENTIVE PAYMENTS. IF THE SAFETY BOARD HAS SUCH INFORMATION AND CAN IDENTIFY THE PRACTICES AND RAILROADS INVOLVED, WE WILL, OF COURSE, TAKE IMMEDITE ACTION TO HAVE THEM CORRECTED, INCLUDING REQUESTING THE ASSISTANCE OF THE FEDERAL RAILROAD ADMINISTRATION. IN THE ABSENCE OF SPECIFIC INFORMATION, WE WILL CONTINUE TO WORK TO ESTABLISH CLOSER COOPERATION WITH ALL OUR CONTRACT CARRIERS AND TO STRENGTHEN OUR MONITORING PROCEDURES BOTH ON BOARD OUR TRAINS AND IN THE GENERAL OPERATING ENVIRONMENT OF EACH CONTRACT CARRIER. IT SHOULD BE NOTED, HOWEVER, THAT A CARRIER'S RIGHT TO EARN INCENTIVES IS PROVIDED IN SECTION 402(A) OF THE RAIL PASSENGER SERVICE ACT.

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.