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Safety Recommendation Details

Safety Recommendation R-93-028
Details
Synopsis: AT 9:34 A.M. ON JANUARY 18, 1993, NORTHERN INDIANA COMMUTER TRANSPORTATION DISTRICT (NICTD) EASTBOUND COMMUTER TRAIN 7, TRAVELING FROM CHICAGO ILLINOIS, TO SOUTH BEND, INDIANA, AND NICTD WESTBOUND COMMUTER TRAIN 12, TRAVELING FROM SOUTH BEND TO CHICAGO, COLLIDED AT MILE POST (MP) 61.1 IN GARY, INDIANA. TRAIN 7 AND TRAIN 12 CONSISTED OF TWO AND OF THREE PASSENGER CARS, RESPECTIVELY. TRAIN 7 PASSED A STOP SIGNAL AT MP 61.2, AND ITS LEAD CAR 27 BLOCKED WESTBOUND TRAFFIC WHERE THE TRACKS INTERSECT. AFTER TRAIN 12 CROSSED THE GARY GAUNTLET BRIDGE, THE LEFT FRONT CORNER OF ITS LEAD CAR 36 STRUCK THE LEFT FRONT CORNER OF THE TRAIN 7 LEAD CAR 27. AS A RESULT OF THE COLLISION, 7 PASSENGERS DIED AND 95 PEOPLE SUSTAINED INJUREIS. THE ESTIMATED DAMAGE FOR BOTH TRAIN WAS $854,000.
Recommendation: THE NTSB RECOMMENDS THAT THE ASSOCIATION OF AMERICAN RAILROADS: DEVELOP IMPROVED PROCEDURE FOR DETERMINING FITNESS FOR DUTY FOR RAILROAD PERSONNEL IN SAFETY-SENSITIVE POSITIONS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: GARY, IN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA93MR002
Accident Reports: Collision between Northern Indiana Commuter Transportation District Eastbound Train 7 and Westbound Train 12
Report #: RAR-93-03
Accident Date: 1/18/1993
Issue Date: 1/7/1994
Date Closed: 2/25/1999
Addressee(s) and Addressee Status: Association of American Railroads (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Association of American Railroads
Date: 2/25/1999
Response: THE SAFETY BOARD APPRECIATES BEING KEPT INFORMED ABOUT CURRENT RAILROAD INDUSTRY ACTIVITIES IN RESPONSE TO THIS IMPORTANT RECOMMENDATION. WE NOTE THE INDUSTRY'S INABILITY TO DEVELOP PRACTICAL PROCEDURES FOR EVALUATING AN INDIVIDUAL'S FITNESS FOR DUTY (OTHER THAN ALCOHOL AND DRUG TESTING), AND WE UNDERSTAND THAT, IN LIEU OF EFFECTIVE FATIGUE MEASURING METHODS, THE INDUSTRY IS COMBATTING FATIGUE BY EXPLORING MODIFICATIONS TO THE WORK ENVIRONMENT AND BY PROVIDING EDUCATIONAL TOOLS TO IMPROVE THE QUALITY OF EMPLOYEE REST WHILE OFF DUTY. THE BOARD ALSO NOTES THE ONGOING EFFORT IN THIS AREA UNDER THE AUSPICES OF THE WORK/REST TASK FORCE AND THE NORTH AMERICAN RAIL ALERTNESS PARTNERSHIP. THE BOARD IS DISAPPOINTED THAT THE AAR HAS BEEN UNABLE TO IDENTIFY A FEASIBLE METHOD FOR DETERMINING FITNESS FOR DUTY OF RAILROAD EMPLOYEES. WE UNDERSTAND THAT NOW AAR DOES NOT HAVE THE HUMAN FACTORS RESEARCH CAPABILITY NEEDED TO DEVELOP IMPROVED TESTING PROCEDURES DUE TO THE REORGANIZATION AND SUBSEQUENT DOWNSIZING OF THE AAR. HOWEVER, THIS RECOMMENDATION WAS MADE MORE THAN 5 YEARS AGO, AND WE HAVE BEEN UNABLE TO DOCUMENT ANY EFFORT BY AAR TO TAKE A LEADERSHIP ROLE IN DEVELOPMENT OF THE RECOMMENDED PROCEDURES. CONSEQUENTLY, THE BOARD HAS CLASSIFIED R-93-28 "CLOSED--UNACCEPTABLE ACTION."

From: Association of American Railroads
To: NTSB
Date: 2/23/1998
Response: Letter Mail Controlled 2/26/98 2:29:08 PM MC# 980257 AAR IS STILL UNAWARE OF TESTING MEASURES (OTHER THAN ALCOHOL AND DRUG TESTING) THAT HAVE DEMONSTRATED EFFECTIVENESS IN MEASURING AN INDIVIDUAL'S FITNESS FOR DUTY IN THE RAILROAD ENVIRONMENT. HOWEVER, SIGNIFICANT WORK IS UNDERWAY TO COUNTER EMPLOYEE FATIGUE IN THE RAILROAD INDUSTRY. THE ENCLOSED COMPENDIUM DISCUSSES THESE EFFORTS, WHICH INCLUDE SCHEDULED STARTING TIMES, ASSIGNED REST DAYS, ADDITIONAL TIME OFF BETWEEN TRIPS, EVALUATION OF TECHNOLOGY, REST POLICIES, EDUCATIONAL PROGRAMS AND PHYSIOLOGICAL SCREENING. THE COMPENDIUM SHOWS THAT THE INDUSTRY IS COMBATING FATIGUE BY EXPLORING MODIFICATIONS TO THE WORK ENVIRONMENT AND BY GIVING EMPLOYEES EDUCATIONAL TOOLS TO IMPROVE THE QUALITY OF THEIR REST WHILE THEY ARE OFF DUTY. HOWEVER, RESEARCH TO DATE HAS NOT IDENTIFIED A PRACTICAL PROCEDURE TO EVALUATE AN INDIVIDUAL'S FITNESS FOR DUTY. THROUGH THE EFFORTS OF THE WORK/REST TASK FORCE AND THE NORTH AMERICAN RAIL ALERTNESS PARTNERSHIP, THE RAILROADS AND THEIR LABOR ORGANIZATIONS CONTINUE TO RESEARCH THIS COMPLEX AREA.

From: NTSB
To: Association of American Railroads
Date: 6/15/1994
Response: THE BOARD IS PLEASED THAT THE AAR SUPPORTS THE INTENT OF THIS RECOMMENDATION, & WE ARE INTERESTED IN LEARNING MORE ABOUT THE APPLICATION OF FITNESS EVALUATION STRATEGIES IN THE REAILROAD ENVIRONMENT. WE COMMEND THE AAR FOR DEDICATING RESOURCES TO THE WORK/REST REVIEW TASK FORCE & LOOK FORWARD TO THE RESULTS OF ITS EFFORTS. THE BOARD'S HUMAN PERFORMANCE STAFF WOULD WELCOME THE OPPORTUNITY TO DISCUSS WITH YOUR STAFF THE APPLICABILITY OF THESE STUDIES TO THE RAILROAD ENVIRONMENT. BASED ON THE INFO PROVIDED IN YOUR LETTER, THE BOARD HAS CLASSIFIED R-93-28 "OPEN--ACCEPTABLE RESPONSE."

From: Association of American Railroads
To: NTSB
Date: 3/15/1994
Response: EDWIN L. HARPER, PRESIDENT & CEO, STATED THAT THE WORK/REST REVIEW TASK FORCE, IS ACTIVE IN DEVELOPING SPECIFIC CAUSES OF IMPAIRMENT CAUSED BY FATIGUE. IT IS CURRENTLY ANALYZING WORK SCHEDULES TO DETERMINE IF EMPLOYEES WHO EXHIBITED IMPAIRED PERFORMANCE (HAVE BEEN INVOLVED IN AN ACCIDENT, INJURY OR RULE VIOLATION) HAVE DIFFERENT WORK SCHEDULE CHARACTERISTICS THAN THE NORM. BY IDENTIFYING SUCH DIFFERENCES IT MAY BE POSSIBLE TO DEVELOP ACTIONS TO IMPROVE SAFETY. IN ADDITION TO WORK THE SCHEDULE ANALYSIS, THE TASKFORCE IS ALSO CONSIDERING STRATEGIES THAT MAY BE USEFUL TO ALL EMPLOYEES. OTHER THAN ALCOHOL & DRUG TESTING, IS NOT AWARE OF OTHER TESTING PROGRAMS ON THE MARKET WHICH HAVE DEMONSTRATED EFFECTIVENESS IN MEASURING AN INDIVIDUALS FITNESS FOR DUTY. AAR WOULD BE ERY INTERESTED IN LEARNING WHAT PARTICULAR TESTS NTSB HAD IN MIND IN MAKING ITS RECOMMENDATION.