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Safety Recommendation Details

Safety Recommendation R-94-013
Details
Synopsis: ON NOVEMBER 11, 1993, ABOUT 12:24 A.M. PACIFIC STANDARD TIME, A BURLINGTON NORTHERN (BN) FREIGHT TRAIN COLLIDED HEAD ON WITH A UNION PACIFIC (UP) FREIGHT TRAIN AT BN MILEPOST 102.8 SOUTH OF THE LONGVIEW JUNCTION SOUTH INTERLOCKING NEAR KELSO, WASHINGTON. AS A RESULT OF THE ACCIDENT ALL FIVE CREWMEMBERS FROM BOTH TRAINS WERE KILLED.
Recommendation: THE NTSB RECOMMEND THAT THE FEDERAL RAILROAD ASSOCIATION: AS PART OF YOUR MONITORING AND OVERSIGHT ACTIVITIES ON THE BURLINGTON NORTHERN AND UNION PACIFIC RAILROAD'S TRAIN CONTROL DEMONSTRATION PROJECT, IDENTIFY AND EVALUATE ALL POTENTIAL SAFETY AND BUSINESS BENEFITS OF THE POSITIVE TRAIN CONTROL SYSTEM CURRENTLY PROPOSED FOR THE NORTHWEST REGION OF THE UNITED STATES. CONSIDER THE VALUE OF THESE BENEFITS IN YOUR OVERALL ASSESSMENT OF THE SYSTEM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: KELSO, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MR001
Accident Reports: Head-On Collision and Derailment of Burlington Northern Freight Train with Union Pacific Freight Train
Report #: RAR-94-02
Accident Date: 11/11/1993
Issue Date: 11/23/1994
Date Closed: 1/26/2001
Addressee(s) and Addressee Status: FRA (Closed - Acceptable Action)
Keyword(s): Positive Train Control

Safety Recommendation History
From: NTSB
To: FRA
Date: 1/26/2001
Response: THE SAFETY BOARD NOTES THAT THE FRA HAS INCLUDED THE COST-BENEFIT INFORMATION COMPLETED AS A RESULT OF THE SUSPENDED BURLINGTON NORTHERN (BNSF) AND UNION PACIFIC'S (UP) TRAIN CONTROL DEMONSTRATION PROJECT IN THE COST-BENEFIT ANALYSIS PROVIDED BY THE "REPORT OF THE RAILROAD SAFETY ADVISORY COMMITTEE TO THE FEDERAL RAILROAD ADMINISTRATOR: IMPLEMENTATION OF POSITIVE TRAIN CONTROL SYSTEMS" (PTC). BASED ON THE FRA'S CONSIDERATION OF THE INFORMATION PROVIDED BY THE BNSF AND UP PTC DEMONSTRATION PROJECT IN THE FRA'S OVERALL ASSESSMENT AND VALUE OF PTC SYSTEMS FOR THE NATION, R-94-13 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FRA
To: NTSB
Date: 10/13/2000
Response: Letter Mail Controlled 10/23/2000 4:40:38 PM MC# 2001568 SINCE OUR LAST EXCHANGE OF CORRESPONDENCE ON THIS SUBJECT, THERE HAVE BEEN SEVERAL DEVELOPMENTS WHICH RELATE TO R-94-13. ONE OF THESE HAS BEEN THE SUSPENSION OF THE UP/BN PILOT PROJECT IN THE PACIFIC NORTHWEST. DURING THIS PROJECT, A MERGER HAD OCCURRED BETWEEN GENERAL ELECTRIC AND HARRIS RAILWAY ELECTRONICS. THE FORMATION OF GENERAL ELECTRIC-HARRIS (GEM) DID NOT AFFECT THE PTS PROJECT. IN FACT, GEH SUBMITTED A PROPOSAL FOR RELEASES 5 AND 6 TO FURTHER DEVELOP PTS WHICH WAS ULTIMATELY DECLINED BY THE RAILROADS. THE PLANNED COMPUTER MODEL, WHICH HAD BEEN ANNOUNCED, WAS NEVER BEGUN DUE TO DECISIONS BY THE MANAGEMENTS OF NEWLY MERGED OR ACQUIRED RAILROADS, FIRST THE MERGER OF BURLINGTON NORTHERN WITH THE ATCHISON, TOPEKA, AND SANTA FE (ATSF) TO FORM THE BURLINGTON NORTHERN SANTA FE RAILWAY (BNSF), THEN THE ACQUISITION BY UNION PACIFIC OF SOUTHERN PACIFIC TRANSPORTATION COMPANY. UP ADVISED FRA IN SEPTEMBER 1997, THAT IT HAD SPENT $10.5 MILLION FOR JOINTLY DEVELOPING AND TESTING THE PTS PROJECT WITH BN SINCE 1994. WE WRE ADVISED THAT THE SECOND PHASE OF THE PTS TESTING WAS SUCCESSFULLY COMPLETED IN JUNE 1997. THE THIRD AND FOURTH PHASES OF TESTING WERE TO INVOLVE MOVEMENT AUTHORITIES IN THE CENTRALIZED TRAFFIC CONTROL TERRITORY AND COMPLEX INTER-OPERABILITY PROCESSES. THE TESTS WERE FORECASTED TO BE COMPLETED BY MARCH 1998, AND THE RESULTS MADE PUBLIC BY JULY 1998. UP ADVISED FURTHER THAT UNTIL THIS TESTING IS COMPLETE, UP COULD NOT BE SURE THAT PTS IS AS SAFE AS CURRENT SIGNALING SYSTEMS, AND WAS RELUCTANT TO MAKE A COMMITMENT TO PROCEED WITH SYSTEM-WIDE IMPLEMENTATION OF AN UNPROVEN SYSTEM. DURING 1998, THE INVOLVED RAILROADS AGREED TO TERMINATE THE PILOT PROJECT. THE BN/ATSF MERGER RESULTED IN THE PTS PROJECT BEING HEADED UP BY A FORMER ATSF GROUP THAT HAD MORE INTEREST IN "TRAINGUARD" THAN PTS. BNSF DID NOT CONSIDER PTS A PRIORITY BECAUSE OF ITS ASSOCIATED COSTS AND REQUIRED INFRASTRUCTURE. THE BNSF DECLINED TO PURSUE FURTHER DEVELOPMENT OF PTS AND INSTEAD CHOSE TO PURSUE LESS COSTLY ALTERNATIVE MEANS OF ACHIEVING PTS-LIKE BENEFITS. THE UP/SOUTHERN PACIFIC MERGER RESULTED IN A FINANCIAL STRAIN THAT TOOK PTS OFF THE TABLE AS A PRIORITY. UP IS NOW ENGAGED IN PARTICIPATING IN THE ILLINOIS DEPT. OF TRANSPORTATION POSITIVE TRAIN CONTROL PROJECT ON ITS THE BETWEEN ST. LOUIS, MISSOURI, AND CHICAGO, IL. UP INSTRUCTED THAT ALL TESTING EQUIPMENT USED IN THE PACIFIC NORTHWEST PTS TEST PROGRAM BE SHIPPED BACK TO GEH. THERE WERE FOUR SOFTWARE RELEASES. COSTS WERE APPROXIMATELY $36 MILLION, WITH $15 MILLION EACH FROM THE TWO RAILROADS, AND $6 MILLION FROM GEH. THERE WAS NO FEDERAL OR STATE FUNDING. IN DECEMBER 1998, FRA WROTE TO GEH TO REQUEST A REPORT ON THE PACIFIC NORTHWEST PTS TEST PROGRAM AND THE STATUS OF DEVELOPMENT EFFORTS FOR PTS AND PTC FOR USE IN OUR EFFORTS TO DEVELOP ADVANCED TRAIN CONTROL SYSTEMS. GEH SUBSEQUENTLY PROVIDED FRA WITH A REPORT OF THOSE TEST RESULTS. FRA WAS INFORMED THE INFORMATION WAS PROPRIETARY IN NATURE. HOWEVER, GEH SUBSEQUENTLY ALLOWED THE RELEASE OF THE CONTENTS OF THE REPORT. THIS REPORT WAS THEN PROVIDED TO THE RAILROAD SAFETY ADVISORY COMMITTEE (RSAC) PTC WORKING GROUP IN UNRESTRICTED FORM FOR THEIR USE IN DETERMING THE VALUE OF PTC BENEFITS IN OUR OVERALL ASSESSMENT FOR THE NATION. THE SUSPENSION OF THE PACIFIC NORTHWEST PILOT PROJECT HAS NOT DETERRED FRA'S DILIGENCE IN ATTEMPTING TO DETERMINE PTC SAFETY AND BUSINESS COSTS AND BENEFITS FOR THE NATION. IN RECOGNITION OF THE TECHNICAL COMPLEXITIES OF THIS ISSUE, ON 9/30/97, FRA REQUESTED RSAC TO ACCEPT TASKS INVOLVING DEFINING PTC FUNCTIONALITIES, DESCRIBING AVAILABLE TECHNOLOGIES, EVALUATING COSTS AND BENEFIT OF POTENTIAL SYSTEMS, AND CONSIDERING IMPLEMENTATION OPPORTUNITIES AND CHALLENGES, INCLUDING DEMONSTRATION AND DEPLOYMENT. FRA ALSO REQUESTED THE RSAC TO ACCEPT A THIRD TASK, WHICH WOULD REQUIRE REVISING VARIOUS REGULATIONS TO ADDRESS THE SAFETY IMPLICATIONS OF PROCESSOR-BASED SIGNAL AND TRAIN CONTROL TECHNOLOGIES, INCLUDING COMMUNICATIONS-BASED OPERATING SYSTEMS. THE RSAC ACCEPTED THESE TASKS AS TASK NOS. 97-4 AND 97-5 CONCERNING DATA, AND TASK NO. 97-6 CONCERNING THE DEVELOPMENT OF STANDARDS. THE RSAC ALSO ESTABLISHED A WORKING GROUP, CONSISTING OF REPRESENTATIVES OF PASSENGER AND FREIGHT RAILROADS, LABOR ORGANIZATIONS, SIGNAL AND TRAIN CONTROL SUPPLIERS, AND CERTAIN STATES. A WORKING GROUP WAS CONVENED TO ADDRESS THE TASKS AND TWO TASKS FORCES WERE ESTABLISHED, A STANDARDS TASK FORCE, AND A DATA AND IMPLEMENTATION TASK FORCE. THE DATA AND IMPLEMENTATION TASK FORCE HAD THE PRIMARY RESPONSIBILITY OF DRAFTING A FINAL REPORT, WHICH WOULD BE A PROGRESS REPORT, INTENDED TO SUPPLEMENT THE REPORT ENTITLED, "RAILROAD COMMUNICATION AND TRAIN CONTROL," WHICH WAS PROVIDED TO CONGRESS ON 7/8/94, PURSUANT TO SECTION 11 OF THE RAILROAD SAFETY ENFORCEMENT AND REVIEW ACT (PUB. L. NO. 102365). FRA REPRESENTATIVES BRIEFED THE RSAC'S PTC WORKING GROUP MEMBERS ON THE CONCLUSIONS THE AGENCY REACHED IN ITS 1994 REPORT TO CONGRESS, AND WHAT HAD TRANSPIRED TO DATE. FRA HAD DETERMINED AT THE TIME OF THE REPORT TO UNDERTAKE CERTAIN ACTIONS TO INVEST IN THE DEVELOPMENT OF PTC, INCLUDING TO "INITIATE DEVELOPMENT OF A RISK ANALYSIS MODEL TO GUIDE DETERMINATION OF PRIORITIES (AMONG MAJOR FREIGHT RAIL CORRIDORS) FOR APPLICATION OF PTC TECHNOLOGY." IN 1995, FRA REQUESTED THE U.S. DEPT. OF TRANSPORTATION'S VOLPE NATIONAL TRANSPORTATION SYSTEMS CENTER (VOLPE CENTER) TO DETERMINE THE FEASIBILITY OF DEVELOPING A CORRIDOR RISK ASSESSMENT TOOL FOR RAILROAD OPERATIONS BASED ON A GEOGRAPHICAL INFORMATION SYSTEM (GIS) PLATFORM. FRA WAS INTERESTED IN USING ANALYSIS TOOLS TO DETERMINE IF THE DEPLOYMENT OF PTC COULD HAVE A BENEFICIAL SAFETY IMPACT ON SPECIFIC FREIGHT AND/OR PASSENGER RAIL CORRIDORS. IN 1996, THE VOLPE CENTER BEGAN TO BUILD THE GIS DATABASE, AND RELATED ANALYSIS EFFORT. AN ANALYTICAL MODEL THAT DESCRIBED RISK OF PTC PREVENTABLE ACCIDENTS BASED UPON GEOGRAPHICAL CHARACTERISTICS WAS DEVELOPED. THE PRELIMINARY RESULTS AND CONCLUSIONS WERE PRESENTED TO FRA AND RSAC. THIS ANALYSIS EFFORT IS REFERRED TO AS THE CORRIDOR RISK ASSESSMENT MODEL (CRAM). THE CRAM ANALYTICAL MODEL HAS NOT YET BEEN CONCLUDED. HOWEVER, THROUGH THE WORK OF AN ACCIDENT REVIEW TEAM, THE WORKING GROUP WAS ABLE TO DESCRIBE CATEGORIES OF PTC - PREVENTABLE EVENTS AND TO NOTE THEIR HIGHLY DISPERSED GEOGRAPHIC CHARACTERISTICS. TO ADDRESS COSTS AND BENEFITS OF PTC SYSTEMS, AN ECONOMICS TEAM WAS ASSEMBLED, CONSISTING OF ONE MEMBER OF RAIL MANAGEMENT, RAIL LABOR, AND FRA. THIS TEAM ENDEAVORED TO PLACE A COST ON SAFETY BENEFITS, I.E., FATALITIES, INJURIES, EQUIPMENT DAMAGE, TRACK AND RIGHT-OF-WAY DAMAGE, DAMAGE OFF THE RIGHT-OF-WAY, HAZARDOUS MATERIALS CLEANUP, EVACUATIONS, LOSS OF LADING, WRECK CLEARING, AND DELAYS. THE TEAM ALSO ENDEAVORED TO DEVELOP SYSTEM UNIT COSTS FOR ON-BOARD PROCESSORS, DIFFERENTIAL GLOBAL POSITIONING SYSTEM (DGPS) RECEIVERS, WAYSIDE INTERFACE UNITS, SOFTWARE DEVELOPMENT COSTS, ETC. THE PTC WORKING GROUP ALSO CONSIDERED "OTHER THAN SAFETY BENEFITS," WHICH WERE IDENTIFIED AS IMPROVED EQUIPMENT UTILIZATION, AND FUEL SAVINGS. THE WORKING GROUP'S DRAFT REPORT WAS COMPLETED IN AUGUST 1999, AND ON 9/8/99, THE RSAC UNANIMOUSLY ADOPTED THIS REPORT ENTITLED, "REPORT OF THE RAILROAD SAFETY ADVISORY COMMITTEE TO THE FEDERAL RAILROAD ADMINISTRATOR-IMPLEMENTATION OF POSITIVE TRAIN CONTROL SYSTEMS." COPIES OF THIS REPORT WERE SENT TO CONGRESS ON 5/17/00. THE "PROGRESS REPORT" IS INTENDED TO SUPPLEMENT THE REPORT ENTITLED "RAILROAD COMMUNICATION AND TRAIN CONTROL," WHICH WAS PROVIDED TO CONGRESS ON 7/8/94. BEGINNING ON PAGE 71 AND CONTINUING THROUGH PAGE 89 OF THE REPORT, IS THE DISCUSSION CONCERNING "COST AND BENEFITS OF PTC SYSTEMS." ADDITIONALLY, APPENDIX D OF THE REPORT, CONTAINS "BENEFITS AND COSTS OF APPLYING PTC (TABLES)." ALTHOUGH FRA WAS UNABLE TO ACCOMPLISH THE EXPRESSED INTENT OF THE BOARD WITH RESPECT TO THIS RECOMMENDATION BECAUSE THE COMPUTER MODEL WAS NEVER COMPLETED, THE RSAC AND ECONOMIC ANALYSIS DID PROVIDE IMPORTANT INFORMATION EMPHASIZING THE NEED TO ACHIEVE THE BROADEST POSSIBLE RANGE OF BENEFITS IN ORDER TO SUPPORT PTC DEPLOYMENT. THIS WILL REQUIRE INTEGRATION OF PTC DEPLOYMENT STRATEGIES INTO THE RAILROADS' BUSINESS PLANS.

From: NTSB
To: FRA
Date: 11/8/1995
Response: IN MAKING THIS RECOMMENDATION, THE BOARD FELT THAT FRA'S OVERSIGHT OF THE PROJECT WOULD ALLOW THE FRA TO BEGIN ASSESSING THE TRUE IMPACT THAT POSITIVE TRAIN SEPARATION CONTROL SYSTEMS MAY HAVE ON THE RAILROAD INDUSTRY. THE BOARD REALIZES THAT THE BN/UP DEMONSTRATION PROJECT IS A PILOT PROJECT. HOWEVER, BY THE VIRTURE OF BEING AN ACTUAL FIELD DEMONSTRATION, IT AFFORDS THE OPPORTUNITY TO BEGIN DEVELOPING INFO ON "POTENTIAL" BUSINESS BENEFITS. AN ACCURATE ASSESSMENT OF THE TRUE IMPACT OF PTS TECHNOLOGY ON THE RAILROAD INDUSTRY WILL CERTAINLY BE NEEDED IF REGUALTIONS ARE EVER ISSUED. THE BOARD FEELS STRONGLY THAT NOW IS THE TIME TO BEGIN COLLECTING DATA FOR THIS ASSESSMENT. SINCE YOUR RESPONSE, THE BOARD HAS RECEIVED YOUR 8/21/95, NEWS RELEASE ANNOUNCING A FINANCIAL GRANT TO THE WASHINGTON STATE DOT TO HELP DEVELOP HIGH-SPEED TRAIN CONTROL TECHNOLOGY. WE ARE PLEASED TO LEARN THAT GENERAL ELECTRIC-HARRIS-RAILWAY ELECTRONICS IS DEVELOP A COMPUTER MODEL TO SIMULATE THE DENSE NORTHWEST UNITED STATES RAIL CORRIDOR, WHICH WILL BE USED AS AN ASSESSMENT TOOL TO DETERMINE POTENTIAL COSTS & BENEFITS OF USING PTS. THE COMPUTER MODEL SATISFIES THE BOARD THAT THE RECOMMENDED ACTION IN UNDERWAY. PLEASE KEEP US INFORMED OF THE PROGRESS ON THE COMPUTER MODEL. IN THE MEANTIME, THE BOARD HAS CLASSIFIED R-94-13 "OPEN--ACCEPTABLE RESPONSE."

From: FRA
To: NTSB
Date: 3/24/1995
Response: JOLEN MOLITORIS - ADMINISTRATOR STATED THAT FRA IS COMMITTED TO IDENTIFYING & EVALUATING THE FULL RANGE OF FULL SAFETY FUNCTIONS THAT MIGHT BE ACHIEVED THROUGH A COMMUNICATION-BASED TRAIN CONTROL SYSTEM. GIVEN THE STRUCTURE & PURPOSE OF THE PILOT: A DETERMINATION OF NONSAFETY BUSINESS BENEFITS DETERMINATION WILL NOT BE FEASIBLE GIVEN THE STRUCTURE & PURPOSE OF THE PILOT. DURING THE PERIOD OF THE PILOT, THE PTS SYSTEM UNDER DEVELOPMENT WILL NOT BE THE PRIMARY METHOD OF TRAIN OPERATIONS, & ONLY A FRACTION OF THE TRAINS WILL BE EQUIPPED WITH ON-BOARD EQUIPMENT RESPONSIVE TO THE PTS SYSTEM. THE PACIFIC NORTHWEST PILOT IS NOT INTENDED AS A FREE-STANDING TRAIN SYSTEM, BUT RATHER AS A DEMONSTRATION OF TECHNOLOGY FOR APPLICATION ON A MUCH LARGER SCALE. BN & UP ARE MAKING RELATED INVESTMENTS ON A SYSTEM BASIS; & , IN THIS PARTICULAR CASE, ANY EXTENSION OF THE TRAIN CONTROL TECHNOLOGY MAY REALIZE NECESSARY ECONOMICS OF SCALE ONLY AT THE RAILROAD SYSTEM LEVEL. MORE FUNDAMENTALLY, FRA IS CONCERNED THAT NOTHING WOULD CHILL DEVELOPMENT OF THE EFFORT MORE READILY THAN A DECLARATION BY THE FEDERAL GOVERNMENT THAT WE INTENDED TO CONDUCT A "BUSINESS CASE" REVIEW OF THIS VOLUNTARY UNDERTAKING. IN FACT ANY SUGGESTION THAT FRA INTENDED TO SECOND-GUESS THE BUSINESS DECISIONS OF THE UP & BN COULD VERY WELL LEAD TO TERMINATION OF THE PTC PILOT PROJECT ON BOTH RAILROADS. UP & BN ARE EXERCISING LEADERSHIP TO ESTABLISH INTEROPERABILITY WITHIN THE INDUSTRY & COOPERATING FULLY WITH FRA ON THE THE SAFETY-RELATED DIMENSION OF THE PROGRAM. WE NEED TO SUPPORT, NOT INTRODUCE ADDITIONAL UNCERTAINTY INTO THE DIFFICULT BUSINESS DECISIONS IT ENTAILS.