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Safety Recommendation Details

Safety Recommendation R-91-029
Details
Synopsis: ABOUT 3:13 A.M. EASTERN DAYLIGHT TIME, ON 8/9/90, NORTH BOUND NORFOLK SOUTHERN (NS) FREIGHT TRAIN 188 COLLIDED WITH SOUTHBOUND NS LOCAL FREIGHT TRAIN G-38 AT CONTROL POINT DAVIS NEAR SUGAR VALLEY, GEORGIA. THE CONDUCTOR ON TRAIN 188 & THE CONDUCTOR & ENGINEER ON TRAIN G-38 WERE FATALLY INJURED. THE TRAINMEN ON BOTH TRAINS & THE ENGINEER ON TRAIN 188 RECEIVED MINOR INJURIES. DAMAGE WAS ESTIMATED AT $1,268,680.
Recommendation: THE NTSB RECOMMENDS THAT THE NORFOLK SOUTHERN CORPORATION: CHECK THE LOCOMOTIVE DIAGNOSTIC COMPUTER "LOG" AT AWAY FROM-HOME TERMINALS TO DETERMINE & PROMPTLY CORRECT FAULTS THAT OCCURRED DURING A TRIP.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: SUGAR VALLEY, GA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA90MR008
Accident Reports: Collision and Derailment of Norfolk Southern Train 188 with Norfolk Southern Train G-38
Report #: RAR-91-02
Accident Date: 8/9/1990
Issue Date: 9/16/1991
Date Closed: 2/1/1993
Addressee(s) and Addressee Status: Norfolk Southern Corporation (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Norfolk Southern Corporation
Date: 2/1/1993
Response: THE BOARD IS PLEASED TO NOTE THAT THE NS HAS REVISED RULE L-240 WITH THE INTENT OF ENSURING THAT DAILY INSPECTION REPORTS REFLECT RESETTING OF SYSTEM DISABLING FAULTS. THIS REVISION SHOULD ENSURE THAT THE FAULTS REPORTED BY THE LOCOMOTIVE DIAGNOSTIC COMPUTER WILL RECEIVE ATTENTION BY THE MECHANICAL DEPARTMENT. THE BOARD HAS CLASSIFIED RECOMMENDATION R-91-29 "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: Norfolk Southern Corporation
To: NTSB
Date: 12/11/1992
Response: NSR REVISED RULE L-240 TO ADDRESS DIAGNOSITC COMPUTER DEFECT MESSAGES . . TO REQUIRE REPORTING OF DEFECT MASSAGES WHETHER RESET OR NOT.

From: NTSB
To: Norfolk Southern Corporation
Date: 10/20/1992
Response: THE BOARD DOES NOT BELIEVE THAT VISUALLY EXAMINING THE LOG WILL REVEAL SYSTEM DISABLING FAULTS THAT OCCURRED DURING OPERATION BUT THAT WERE RESET ON THE COMPUTER BY CREWMEMBERS & NOT REPORTED ON THE DAILY INSPECTION REPORT (AS OCCURRED IN THE SUGAR VALLEY ACCIDENT). THE BOARD WOULD LIKE TO KNOW WHETHER SPECIFIC INSTRUCTIONS HAVE BEEN ISSUED TO EMPLOYEES ABOUT REPORTING ON THE DAILY INSPECTION REPORT THE RESETTING OF ANY SYSTEM DISABLING FAULT THAT OCCURS ON A LOCOMOTIVE DURING OPERATION. THE BOARD SUGGESTS THAT THE NS TAKE STEPS TO ENSURE THAT DAILY INSPECTION REPORTS REFLECT RESETTING OF SYSTEM DISABLING FAULTS. PENDING THE NS PRESENTING A VIABLE ALTERNATIVE SOLUTION TO THIS PROBLEM, RECOMMENDATION R-91-29 WILL REMAIN "OPEN--UNACCEPTABLE RESPONSE."

From: Norfolk Southern Corporation
To: NTSB
Date: 6/15/1992
Response: NSR DOES NOT CONCUR THAT THE COMPUTER "LOG" SHOULD BE CHECKED AT AWAY-FROM-HOME TERMINALS, SINCE IT DOES NOT HAVE QUALIFIED PERSONNEL AT ALL TERMINALS TO INTERPRET PROPERLY THE FAULT HISTORY OR TO MAKE NECESSARY REPAIRS. NSR'S CURRNET DAILY INSPECTION FORM PROVIDES FOR REPORTING OF ANY TROUBLE EXPERIENCE DURING A TRIP.

From: NTSB
To: Norfolk Southern Corporation
Date: 5/8/1992
Response: Safety Recommendation R-91-29 asked the NS to check the locomotive diagnostic computer "LOG" at away-from-home terminals to determine and promptly correct faults that occurred during a trip. The Safety Board notes that the NS does not believe that the computer "LOG" should be checked at away from home terminals because qualified personnel are not available at all such terminals to interpret the data. The NS further believes that its daily inspection form meets the need expressed in the recommendation. In its investigation, the Safety Board found that the dynamic braking problems experienced by train No. 188's second unit had not been reported on the daily inspection form and that the computer "LOG" had not been checked for some time. A review of this unit's computer-stored information following the accident revealed the dynamic brakes were malfunctioning on the previous trip. A prompt review of the computer information would have ensured the correction of the dynamic brake problems without delay. The Safety Board realizes that some away-from-home terminals might not have facilities available. However, the act of delaying the "LOG" review until the 92-day inspection permits problems promptly. to persist that could have been repaired The Safety Board believes that new technology in this area could be used effectively to improve safety and asks that you reconsider your position. We have classified Safety Recommendation R-91-29 as "Open--Unacceptable Response" pending further response.

From: Norfolk Southern Corporation
To: NTSB
Date: 1/8/1992
Response: NSR DOES NOT CONCUR THAT THE COMPUTER "LOG" SHOULD BE CHECKED AT AWAY-FROM-HOME TERMINALS, SINCE IT DOES NOT HAVE QUALIFIED PERSONNEL AT ALL TERMINALS TO INTERPRET PROPERLY THE FAULT HISTORY OR TO MAKE NECESSARY REPAIRS. NS'S CURRENT DAILY INSPECTION FORM PROVIDES FOR REPORTING OF ANY TROUBLE EXPERIENCED DURING A TRIP.