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Safety Recommendation Details

Safety Recommendation R-95-021
Details
Synopsis: AT 4:36 A.M. ON 5/16/94, THE SOUTHBOUND NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK) TRAIN 87, SILVER METEOR, COLLIDED WITH AN INTERMODAL TRAILER THAT HAD EITHER FALLEN OR WAS FALLING FROM A FLAT CAR ON THE PASSING NORTHBOUND CSX TRANSPORTATION INC. FREIGHT TRAIN R176-15 (CSXT 176) AT SELMA, NORTH CAROLINA. AMTRAK TRAIN 87 CONSISTED OF A TWO-UNIT LOCOMOTIVE & 18 CARS; CSXT 176 CONSISTED OF A THREE-UNIT LOCOMOTIVE & 52 CARS. ALL BUT THE LAST CAR OF AMTRAK TRAIN 87 DERAILED, & THE NEXT TO THE LAST CAR ON CSXT 176 ALSO DERAILED. ON AMTRAK TRAIN 87, THE ASSISTANT ENGINEER WAS KILLED, THE ENGINEER SUSTAINED SERIOUS INJURIES, & 1 ON-BOARD SERVICE CREWMEMBER & 119 PASSENGERS RECEIVED MINOR INJURIES. THE OPERATING CREW ON CSXT 176 SUSTAINED NO INJURIES. THE NTSB DETERMINED THAT THE PROBABLE CAUSE OF THE DERAILMENT OF AMTRAK TRAIN 87 WAS THE FAILURE OF THE CSX INTERMODAL CORPORATION (CSXI) LOADING CREW TO PROPERLY SECURE THE INTERMODAL TRAILER TO THE FLAT CAR ON CSXT 176 & THE FAILURE OF CSXI TO HAVE IN PLACE A COMPREHENSIVE INSPECTION PROGRAM.
Recommendation: THE NTSB RECOMMENDS THAT THE FRA: ADVISE THE NTSB WITHIN 90 DAYS OF ITS PROGRESS WITH THE RAILROAD INDUSTRY IN ITS ACTIONS TOWARD THE SEVEN PROBLEM AREAS IDENTIFIED IN ITS TRAILER-ON-FLAT CAR (TOFC) & CONTAINER-ON-FLAT CAR (COFC) LOADING & SECUREMENT SAFETY REPORT. ALSO, ENSURE THAT THE RAILROAD INDUSTRY HAS IMPLEMENTED THE SEVEN POLICIES BY 12/31/95.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: SELMA, NC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MR004
Accident Reports: Amtrak Train 87 Derailment after Colliding with Intermodal Trailer from CSXT Train 176
Report #: RAR-95-02
Accident Date: 5/16/1994
Issue Date: 3/29/1995
Date Closed: 5/17/2005
Addressee(s) and Addressee Status: FRA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 5/17/2005
Response: When the Safety Board issued this recommendation in 1995, we were interested in learning of the actions being taken to address the seven issue areas identified in a report the FRA's Administrator submitted to the Secretary of Transportation on September 12, 1994, entitled Trailer-on-Flat Car and Container-on-Flat Car Loading and Securement Report (listed below). 1. Uniform minimum set of training requirements 2. Written standard operating procedures 3. Post-load, Pre-departure inspections 4. Effective TOFC/COFC securement system preventative maintenance 5. Practice of loading containers over defective trailer hitches 6. Design standards for trailers and containers 7. Best practices for intermodal facilities In the report, FRA stated that if voluntary industry actions were not sufficient, additional measures to reduce the potential for intermodal securement accident/incidents would be necessary. We appreciate receiving a copy of FRA's latest study entitled Intermodal Securement Safety Nationwide Audit 1999-2002; Final Report and Data Analysis - July 2004. While this report does not elaborate on the seven issue areas, the Safety Board is aware through correspondence with the FRA and Association of American Railroads (AAR), numerous staff discussions with both the AAR and FRA, and a review of industry documents developed related to intermodal loading and securement that these seven issue areas have been addressed, specifically through revisions to the AAR Manual of Standards and Recommended Practices, Intermodal Equipment Manual, and the development of Standard Operating Procedures for Intermodal Securement, including an Intermodal Securement Safety Audit Form. While we had hoped, at the time we issued this recommendation, that more timely action would have occurred, we believe that ultimately a comprehensive effort was made to improve the loading and securement of TOFC/COFC operations. In view of this effort, Safety Recommendation R-95-21 is classified "Closed--Acceptable Action."

From: FRA
To: NTSB
Date: 11/5/2004
Response: Letter Mail Controlled 11/16/2004 11:06:41 AM MC# 2040679 The FRA initiated a comprehensive audit of Trailer-on-Flat Car, and Container-on-Flat Car (TOFC/COFC) loading and securement in August 1999. This audit encompassed 18-months of inspections between 1999 and 2003, and covered the entire country. Each major railroad and almost every Class II railroad that handles TOFC/COFC traffic was visited, and facilities handling volumes ranging from several trailers per week, to hundreds of thousands of containers or trailers per year, were audited. At the beginning of the audit, FRA considered the option of either revising 49 Code of Federal Regulations Part 215, or taking another appropriate course of action. During the audit period the Association of American Railroads (AAR) instituted a Standard Operating Procedure (SOP) for intermodal pre-departure inspection, which addressed the concerns of the NTSB. Based upon FRA's inspection of over 18,600 platforms (combined trailer & container loading positions), the overall equipment deficiency ratio was only 5.75%. This included many "minor" types of deficiencies, which, in themselves, would not lead to the loss of a trailer or container from a moving train. Regarding the issue of improperly stored Inter-Box Connectors (IBCs). 281 occurrences were observed, including those found on walkways, car decks, or next to but outside of their storage boxes. The most dangerous condition considered in the study was a trailer hitch jaw or rotor not locked. This deficiency led to the shifting of a loaded trailer, which struck an Amtrak train at Smithfield, North Carolina, on May 15. 1994, and that warranted the intermodal audit program. Only six occurrences of unlocked trailer hitches were observed and they were early in the audit. After the implementation of the AAR's Intermodal SOP, no further instances of unlocked hitches were identified. In summary, the data collected during this audit did not indicate a clear and compelling need for FRA to initiate a regulatory proceeding to correct the loading deficiencies identified. The SOP action taken by the railroad industry to minimize loading deficiencies appears to be appropriate, and the rate of securement failures is decreasing. A Safety With a Team meeting was held on March 17, 2004, at the NTSB's Headquarters in Washington, DC. At this meeting the status of Safety Recommendations R-95-21 and R-00-10 were discussed. The NTSB representatives indicated that pending receipt and review of the final report, they would propose that Safety Recommendations R-95-21 and R-00-10 be classified as "Closed--Acceptable Action." Although Safety Recommendation R-00.11 was not discussed at this meeting, the NTSB staff indicated that the same discussion for Safety Recommendations R-95-21 and R-00- 10 would alternatively satisfy the requirements of Safety Recommendation R-00-11. The FRA has now published the "Intermodal Securement Safety Nationwide Audit 1999-2002 Final Report and Data Analysis, July 2004, "and is providing ten copies to the NTSB as enclosures to this letter. As a result of FRA's safety inspections associated with the eighteen-month nationwide audit, resulting in the AAR's development of an SOP for intermodal securement, FRA respectfully requests the NTSB classify Safety Recommendations R-95-21, R-00-10, and R-00-11 as "Closed--Acceptable Action."

From: NTSB
To: FRA
Date: 3/17/2004
Response: On 3/17/2004, Board staff met with FRA staff to discuss this recommendation. The FRA provided the AAR Manual for the Standard Operating Procedures for Intermodal Securement, revised 2004, and Power Point slides for review. The AAR has also provided a video titled Trailer and Container Securement. FRA conducted three comprehensive audits of 18,600 platforms and found 3,954 defects. Defects were either operator error or equipment failures. A final report is expected to be completed in May 2004.

From: NTSB
To: FRA
Date: 1/5/2001
Response: THE SAFETY BOARD NOTES THAT ON 5/4/95, THE FRA PROVIDED INFORMATION TO THE BOARD ON ITS PLANS TO ADDRESS THE SEVEN PROBLEM AREAS RAISED IN THE FRA'S 1994 REPORT ON TOFC/COFC LOADING AND SECUREMENT. THE FRA HAS ALSO CONDUCTED AUDITS OF ACTIONS TAKEN BY THE RAILROAD INDUSTRY TO IMPROVE TOFC/COFC SAFETY IN THE INTERIM 5 YEARS. THE SAFETY BOARD UNDERSTANDS THAT THE DATA ACQUISITION PORTION OF THE STUDY WILL BE COMPLETED BY APRIL 2001, AND THAT YOUR FINAL REPORT IS EXPECTED TO BE COMPLETED IN JULY 2001. THE SAFETY BOARD ORIGINALLY ASKED FOR IMPLEMENTATION OF THE REFERENCED POLICIES BY 12/31/95, AND IS DISAPPOINTED THAT ALTHOUGH 5 YEARS HAVE PASSED, THE POLICIES RECOMMENDED IN THE FRA REPORT HAVE YET TO BE IMPLEMENTED. THEREFORE, R-95-21 IS CLASSIFIED "OPEN--UNACCEPTABLE ACTION," PENDING IMPLEMENTATION. THE SAFETY BOARD APPRECIATES YOUR OFFER TO BE BRIEFED ON THE FINDINGS TO DATE OF YOUR INTERNAL PROGRESS REVIEW. PLEASE CONTACT ELAINE WEINSTEIN, ACTING DIRECTOR, OFFICE OF SAFETY RECOMMENDATIONS AND ACCOMPLISHMENTS, AT 202-314-6170 TO ARRANGE THIS MEETING.

From: FRA
To: NTSB
Date: 7/7/2000
Response: Letter Mail Controlled 07/12/2000 9:40:36 AM MC# 2000875 FRA PROVIDED THE SAFETY BOARD AN INITIAL RESPONSE ON 5/4/95, THAT OUTLINED OUR PLAN TO ADDRESS EACH OF THE SEVEN CONCERNS. WE THEN ASSESSED THE VOLUNTARY ACTIONS TAKEN BY THE RAILROAD INDUSTRY REGARDING INTERMODAL SECUREMENT SINCE 1995, AND CONDUCTED TWO INTERIM AUDITS TO DETERMINE THE PROGRESS TO DATE. A THIRD COMPREHENSIVE AUDIT WAS STARTED IN OCTOBER 1999, AND WILL CONTINUE FOR APPROXIMATELY 18 MONTHS. THROUGHOUT, FRA HAS BEEN WORKING WITH THE ASSOCIATION OF AMERICAN RAILROADS, TTX COMPANY, AND THE CLASS I RAILROADS TO DEVELOP A LONG-TERM STRATEGY FOR INTERMODAL SAFETY. CURRENTLY, WE ARE COMPILING THE DATA FROM THE NATIONWIDE AUDIT, AND WE ANTICIPATE THAT THE DATA ACQUISITION PORTION OF THE STUDY WILL BE COMPLETED BY APRIL 2001. A FINAL REPORT SHOULD BE AVAILABLE BY THE FOLLOWING JULY. FRA HAS RECENTLY PROVIDED THE BOARD STAFF WITH MATERIALS RELATED TO OUR INTERNAL PROGRESS REVEIW FOR THIS ACTIVITY, AND WE WOULD WELCOME THE OPPORTUNITY TO PROVIDE A FULL BRIEFING REGARDING THE INSPECTIONS CONDUCTED AND FINDINGS TO DATE. WE WILL PRESENT THE SAFETY BOARD WITH A FULL REPORT ONCE THE AUDIT IS FINISHED. FRA APPRECIATES THE SAFETY BOARD'S RECOMMENDATION AND THE OPPORTUNITY TO ADDRESS IMPORTANT SAFETY ISSUES.

From: NTSB
To: FRA
Date: 6/29/2000
Response: THE SAFETY BOARD WOULD APPRECIATE LEARNING WHETHER THE FRA HAS COMPLETED THIS EVALUATION. THE FRA'S RESPONSE TO THIS RECOMMENDATION MAY BE DISCUSSED AT A BOARD MEETING ON 7/11/00, RELATING TO AN ACCIDENT THAT OCCURRED IN CRISFIELD, KANSAS.

From: NTSB
To: FRA
Date: 8/1/1995
Response: THE BOARD IS PLEASED THAT THE FRA HAS PROMPTLY PROVIDED THE REQUESTED INFO. THE BOARD ALSO NOTES THAT THE FRA INTENDS TO ASSESS VOLUNTARY ACTIONS TAKEN BY THE RAILROAD INDUSTRY DURING THE LAST QUARTER OF THIS CALENDAR YEAR. PENDING THE RESULT OF THAT FOLLOW-UP SURVEY, THE BOARD HAS CLASSIFIED R-95-21 "OPEN--ACCEPTABLE RESPONSE."

From: FRA
To: NTSB
Date: 5/4/1995
Response: JOLENE MOLITORIS - ADMINISTRATOR STATED THAT FRA SHARES THE NTSB'S CONCERN REGARDING THE ADEQUACY OF CURRENT PRACTICES WITH RESPECT TO TOFC/COFC LOADING & SECUREMENT OPERATIONS. FRA HAS TAKEN STEPS TO ENSURE THAT THE RAILROAD INDUSTRY IS ADDRESING THE SEVEN AREAS OF SAFETY CONCERN IDENTIFIED IN THE SEPTEMBER FRA REPORT. AS PART OF THE COOPERATIVE PARTNERSHIP WITH THE RAILROAD INDUSTRY PROPOSED BY FRA, FRA HOSTED A MEETING ON FEBRUARY 22 THAT PROVIDED A FORUM FOR VARIOUS INDUSTRY REPRESENTATIVES TO ADDRESS THE STATUS & PROGRESS MADE TO DATE WITH RESPECT TO THE IDENTIFIED AREAS OF SAFETY CONCERN. THE MINUTES OF THE MEETING ARE ENCLOSED. THE AAR IS DEVELOPING AN INTERMODAL EQUIPMENT TASK FORCE THAT IS IN THE PROCESS OF DEVELOPING NUMBEROUS TRAINING AIDS FOR INDUSTRY-WIDE USE. FRA IS SCHEDULED TO MEET WITH AAR IN MAY TO REVIEW THESE TRAINING AIDES. FRA HAS DEVELOPED A TOFC/COFC INSPECTION & OBSERVATION REPORT TO BE COMPLETED BY FRA FIELD INSPECTORS AS PART OF THEIR ROUTINE INSPECTIONS. FRA IS ALSO PLANNING TO CONDUCT A FOLLOW-UP TOFC/TOFC LOADING SITE SURVEY DURING THE LAST QUARTER OF THIS CALENDER YEAR. THE APPROACH DETAILED ABOVE WILL EFFECTIVELY REMEDIATE THE SEVEN IDENTIFIED AREAS & FRA DOES NOT PLAN TO INITIATE FORMAL REGULATORY ACTIONS REGARDING LOADING OPERATIONS AT THIS TIME. HOWEVER,IF THE VOLUNTARY ACTIONS TAKEN BY THE RAILROAD INDUSTRY DO NOT SUFFICIENTLY ADDRESS THE AREAS TO CONCERN IDENTIFIED BY FRA, ADDITIONAL MEASURES WILL BE TAKEN TO REDUCE THE POTENTIAL FOR SIMILAR ACCIDENTS. FRA WILL KEEP THE NTSB INFORMED.