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Safety Recommendation Details

Safety Recommendation R-96-007
Details
Synopsis: ABOUT 5:38 P.M. ON 2/16/96, EASTBOUND MARYLAND RAIL COMMUTER (MARC) TRAIN 286 COLLIDED WITH WESTBOUND NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK) TRAIN 29, THE CAPITOL LIMITED, AT MILEPOST 8.55 ON CSX MAIN TRACK NEAR SILVER SPRING, MARYLAND. THE MARC TRAIN WAS OPERATING IN THE PUSH MODE IN REVENUE SERVICE BETWEEN BRUNSWICK , MARYLAND, & WASHINGTON, D.C.; IT CONSISTED OF A LOCOMOTIVE & THREE COMMUTER CARS. THE AMTRAK TRAIN, OPERATING IN REVENUE SERVICE BETWEEN WASHINGTON D.C., & CHICAGO, ILLINOIS, CONSISTED OF 2 LOCOMOTIVES & 15 CARS.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Inspect all commuter rail equipment to determine whether it has: (1) easily accessible interior emergency quick-release mechanisms adjacent to exterior passageway doors; (2) removabale windows or kick panel in interior and exterior passageway doors; and (3) prominently displayed retroreflective signage marking all interior and exterior emergency exits. If any commuter equipment lacks one or more of these features, take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (Superseded by R-97-14 through R-97-16) (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Railroad
Location: Silver Spring, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MR004
Accident Reports: Collision and Derailment of Maryland Rail Commuter MARC Train 286 and National Railroad Passenger Corporation AMTRAK Train 29
Report #: RAR-97-02
Accident Date: 2/16/1996
Issue Date: 3/12/1996
Date Closed: 8/28/1997
Addressee(s) and Addressee Status: FRA (Closed - Superseded)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 3/23/2012
Response: Notation 8393: The National Transportation Safety Board (NTSB) has reviewed the Federal Railroad Administration (FRA) Notice of Proposed Rulemaking (NPRM) entitled, "Passenger Train Emergency Systems II," which was published in 77 Federal Register 154 on January 3, 2012. The NPRM aims to improve the safety of passenger trains through the development and enhancement of requirements for passenger car emergency systems. Specifically, in the NPRM, the FRA proposes new requirements for interior vestibule doors and low-location emergency exit path markings, along with new requirements for emergency lighting in all passenger cars. Also, the FRA proposes to enhance the requirements for survivability of emergency lighting systems in new passenger cars and for emergency egress and rescue access signage. Finally, the FRA seeks to clarify existing requirements for participation in debriefing and critique sessions following emergency situations and full-scale simulations. The NPRM addresses safety recommendations issued by the NTSB from its investigation of the Maryland Rail Commuter (MARC) train collision with a National Railroad Passenger Corporation (Amtrak) train near Silver Spring, Maryland, on February 16, 1996.1 Eight passengers and three crewmembers died, while 26 others were injured in the accident. The NTSB investigation uncovered several safety problems; for example, some passengers could not egress the MARC train. The NTSB expressed concern regarding passengers' ability to exit through interior and exterior passageway doors. Additionally, two passengers on the MARC train reported that emergency lighting was not available following the accident, which made it more difficult to move in the darkness. The NTSB investigation revealed that the main car battery powering the emergency lighting had been damaged as a result of the derailment. The NTSB expressed concern regarding emergency lighting survivability because the location of the battery supplying power to the emergency lighting system below the car made it susceptible to damage from the rail, the car's trucks, and the ground surface in the event of a derailment. Among the recommendations that NTSB issued as a result of the Silver Spring accident investigation, the FRA was provided with an urgent recommendation to: Inspect all commuter rail equipment to determine whether it has: (1) easily accessible interior emergency quick-release mechanisms adjacent to exterior passageway doors; (2) removable windows or kick panel in interior and exterior passageway doors; and (3) prominently displayed retroreflective signage marking all interior and exterior emergency exits. If any commuter equipment lacks one or more of these features, take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. Urgent (R-96-7) The Urgent Safety Recommendation R-96-7 was classified "Closed-Superseded" on August 28, 1997, by Safety Recommendations R-97-14 through -16 for long term action. Require all passenger cars to have easily accessible interior emergency quick-release mechanism adjacent to exterior passageway doors and take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (R-97-14) Safety Recommendation R-97-14 was classified as "Closed-Acceptable Action" on July 27, 2001, after the FRA published a Final Rule titled, "Passenger Equipment Safety Standards," at 64 Federal Register 25540-25705 on May 12, 1999 (codified at 49 Code of Federal Regulations(CFR) 238.235, "Doors"). The rule became effective December 31, 1999. Require all passenger cars to have either removable windows, kick panels, other suitable means for emergency exiting through the interior and exterior passageway doors where the door could impede passengers exiting in an emergency and take appropriate emergency measures to ensure corrective action until these measures are incorporated into minimum passenger car safety standards. (R-97-15) Safety Recommendation R-97-15 currently IS classified as "Open-Unacceptable Response." Issue interim standards for the use of luminescent or retroreflective material or both to mark all interior and exterior emergency exits in all passenger cars as soon as possible and incorporate the interim standards into minimum passenger car safety standards. (R-97-16) Safety Recommendation R-97-16 was classified "Closed-Acceptable Action" on February 3, 2000, after the FRA published a Final Rule titled, "Passenger Train Emergency Preparedness" at 63 Federal Register 24629-24683 on May 4, 1998 (codified at 49 CFR 239.l07(a)(l), "Emergency exits"). Require all passenger cars to contain reliable emergency lighting fixtures that are each fitted with a self-contained independent power source and incorporate the requirements into minimum passenger car safety standards. (R-97-17) Safety Recommendation R-97-17 currently is classified as "Open-Unacceptable Response." Provide promptly a prescribed inspection and maintenance test cycle to ensure the proper operation of all emergency exit windows as well as provide that the 180-day inspection and maintenance test cycle is prescribed in the final rule. (R-97-18) Safety Recommendation R-97-18 was classified "Closed-Acceptable Alternate Action" on July 27, 2001, after the FRA published a Final Rule at 64 Federal Register 25540-25705 (codified at 49 CFR 238.307(d)(4), "Periodic mechanical inspection of passenger cars and unpowered vehicles used in passenger trains"). Require that all exterior emergency door release mechanisms on passenger cars be functional before a passenger car is placed in revenue service, that the emergency door release mechanism be placed in a readily accessible position and marked for easy identification in emergencies and derailments, and that these requirements be incorporated into minimum passenger car safety standards. (R-97-19) Safety Recommendation R-97-19 was classified "Closed-Acceptable Action" on July 27, 2001, after the FRA published a Final Rule at 64 Federal Register 25540-25705 (codified at 49 CFR 238.111, "Pre-revenue service acceptance testing plan" and 238.235, "Doors"). Require that a comprehensive inspection of all commuter passenger cars be performed to independently verify that the interior materials in these cars meet the expected performance requirements for flammability & smoke emissions characteristics. (R-97-20) Safety Recommendation R-97-20 was classified "Closed-Acceptable Action" on July 27, 2001, after the FRA published a Final Rule at 64 Federal Register 25540-25705 (codified at 49 CFR 238.103, "Fire safety"). The Safety Board notes that there are no current regulations addressing a "suitable means for emergency exiting through the interior and exterior passageway doors where the door could impede passengers exiting in an emergency." The Safety Board notes that the NPRM's proposed new section 238.112, "Doors," contains explicit requirements for each vestibule door and any other interior door intended for passage through a passenger car in the event the door will not open in an emergency, or the car is on its side and the door is difficult to open. Therefore, the Safety Board considers the proposed requirements in the NPRM to be consistent with the intent of Safety Recommendation R-97-l5. The Safety Board notes that although current regulations2 address emergency lighting with a back-up power system for each passenger car, the regulations do not provide for emergency lighting fixtures that are each fitted with a self-contained independent power source. The Safety Board notes that proposed new section 238.115, "Emergency lighting," will contain explicit requirements that emergency lighting shall be provided in each passenger car in accordance with the minimum requirements specified in American Public Transportation Association Standard SS-E-013-99, Rev. 1, "Standard for Emergency Lighting System Design for Passenger Cars," October 2007, or an alternative standard providing at least an equivalent level of safety if approved by the FRA pursuant to section 238.21. Therefore, the Safety Board considers the proposed requirements in the NPRM to be consistent with the intent of Safety Recommendation R-97-l7. The NTSB is encouraged that the various actions indicated in the NPRM are under consideration. In addition, the NTSB notes that the FRA anticipates each passenger car to be equipped with a removable panel or removable window in the vestibule door and any other interior door intended for passage through a passenger car during an emergency within 4 years of the rulemaking. However, it is unfortunate that more than 17 years after the Silver Spring accident, no design changes have yet been required for passenger car doors or emergency lighting. The NTSB is encouraged that industry and the FRA are exploring options to address passenger car door kick panels and emergency lighting. Thus, the NTSB supports the intent of the NPRM. The NTSB remains concerned, however, about the significant length of time it is taking to make a modification available to operators. The NTSB appreciates the opportunity to comment on this NPRM.

From: FRA
To: NTSB
Date: 8/5/1999
Response: Letter Mail Controlled 8/9/99 4:42:05 PM MC# 990871:

From: NTSB
To: FRA
Date: 8/28/1997
Response: During the investigation of the Silver Spring accident, the Safety Board identified problems with the inspection of commuter rail emergency egress from the passenger cars that contributed to the number of fatalities and therefore issued Urgent Safety Recommendation R-96-7 on March 12, 1996. After reviewing the FRA response of June 6, 1996, the Safety Board classified Safety Recommendation R-96-7 Open-Acceptable Action to the first two parts and Open-Acceptable Alternate Action to the third part on March 21, 1997. The FRA had stated in that response that it had inspected 1,250 pieces of railroad equipment on 16 commuter organizations, that any variation in the inspection results was indicative of equipment age and of difference by commuter agencies, and that emergency quick-release mechanisms were typically accessible to passengers; although, many were not adjacent to exterior passageway doors. In addition, the FRA had stated that marking emergency exits inside cars with luminescent rather than retroreflective materials may be better. The FRA, however, has taken no immediate action to make corrections. The Safety Board acknowledges the FRA efforts concerning its urgent safety recommendation and recognizes the complexities of developing practical solutions within the requested 1-year period; therefore, the Safety Board classifies Safety Recommendation R-96-7 Closed--Superseded and is substituting it with Safety Recommendations R-97-14 through -16 for longer-term action.

From: NTSB
To: FRA
Date: 3/12/1997
Response: THE BOARD ALSO NEEDS TO KNOW IF THE 16 COMMUTER SYSTEMS ARE ALL O F THE COMMUTER ORGANIZATIONS THAT THE FRA REGULATES & HOW THE RESULTS OF THE INSPECTION BREAK DOWN BY COMMUTER ORGANIZATION. IN SHORT, WITHOUT MORE INFO, THE BOARD CANNOT ADEQUATELY EVALUATE THE SCOPE OF THE INSPECTION PROGRAM.SPECTION. THE FIRST PART OF THE RECOMMENDATION ADDRESSES THE NEED FOR QUICK-RELEASE MECHANISMS FOR DOORS. THE BOARD IS PARTICULARLY INTERESTED IN KNOWING HOW MANY CARS REQUIRE 'SHORT-TERM" ACTION & HOW THE FRA PLANS TO DEAL WITH THOSE CARS. WE ALSO NEED TO KNOW THE PERCENTAGE OF CARS REQUIRING "MID-TERM" OR "LONG-TERM" ACTION THAT BELONG TO EACH OF THE COMMUTER ORGANIZATIONS REGULATED BY THE FRA. CONSEQUENTLY, THE BOARD HAS CLASSIFIED THE FIRST PART OF R-96-7 "OPEN--ACCEPTABLE RESPONSE" & ASKS THE FRA TO PROVIDE MORE SPECIFIC INFO. THE SECOND PART OF THE RECOMMENDATION ADDRESSES THE NEED FOR REMOVABLE WINDOWS OR KICK PANELS. THE FRA HAS DEMONSTRATED THAT, GIVEN THE WIDE VARIETY IN COMMUTER EQUIPMENT, THE INDUSTRY NEED TO DO MORE ANALYSIS. THE BOARD HAS CLASSIFIED THE SECOND PART OF R-96-7 "OPEN--ACCEPTABLE RESPONSE" & ASKS THAT THE FRA KEEP THE BOARD INFORMED OF PROGRESS IN THIS AREA. THE THIRD PART OF THE RECOMMENDATION ADDRESSES THE NEED FOR RETROREFLECTIVE MARKING. THE BOARD AGREES WITH THE FRA THAT IT MIGHT BE BETTER TO MARK EMERGENCY EXITS INSIDE CARS WITH LUMINESCENT, RATHER THAN RETROREFLECTIVE, MATERIAL. CONSEQUENTLY, THE BAORD HAS CLASSIFIED THE PART OF R-96-7 "OPEN--ACCEPTABLE ALTERNATE RESPONSE." THE BOARD BELIEVES THAT THE FRA SHOULD DEVELOP & ISSUE INTERIM STANDARDS TO THE COMMUTER RAIL INDUSTRY AS QUICKLY AS POSSIBLE. IN CLOSING, THE BOARD WOULD LIKE TO ACKNOWLEDGE THAT THE FRA IS RESPONDING TO THE CONCERNS OF THE RECOMMENDATION & THAT THE APPRECIATES THE COMPLEXITIES THE FRA IS CONFRONTING IN DEVELOPING PRACTICAL SOLUTIONS. THE BOARD LOOKS FORWARD TO WORKING WITH THE FRA & THE INDUSTRY IN IMPROVING EMERGENCY EGRESS FROM COMMUTER RAIL EQUIPMENT.

From: FRA
To: NTSB
Date: 6/6/1996
Response: HONORABLE JOLEN M. MOLITORIS, ADMINISTRATOR, FRA , RESPONDED ON 6/6/96, THAT THE FRA HAS INSPECTED A TOTAL OF 1,250 PIECES OF EQUIPMENT IN USE ON 16 COMMUTER ORGANIZATIONS. THE VARIATION IN THE INSPECTION RESULTS IS INDICATIVE OF THE AGE & VARIETY OF EQUIPMENT OPERATED BY THE DIFFERENT COMMUTER AGENCIES. THOSE INSPECTIONS INDICATED THAT MANY EMERGENCY QUICK-RELEASE MECHANISMS WERE NOT LOCATED ADJACENT TO EXTERIOR PASSAGEWAY DOORS, BUT WERE ACCESSIBLE TO PASSENGERS. EQUPMENT WITH MANUALLY OPERATED DOORS WAS NOT EQUIPPED WITH EMERGENCY QUICK-RELEASE MECHANISMS, NOR ARE THEY REQUIRE FOR EMERGENCY OPERATION. ACCORDING TO THE FRA INSPECTORS, SIGNAGE MARKING THE INTERIOR & EXTERIOR EMERGENCY EXITS VARIED CONSIDERABLY FROM ONE PROPERTY TO THE NEXT & BETWEEN DIFFERENT TYPES OF EQUIPMENT OWNED & OPERATED BY THE SAME PROPERTY. IN CONDUCTING THE EVALUATION, FRA HAS ENDEAVORED TO CONSIDER THE BOARD'S RECOMMENDATION WITHIN THE OVERALL CONTEXT OF PASSENGER EGRESS RESCUE ACCESS, AS WELL AS PASSENGER SAFETY GENERALLY. ON MARCH 26, FRA MET WITH THE PASSENGER EQUIPMENT SAFETY STANDARDS WORKING GROUP & THE PASSENGER EMERGENCY PREPAREDNESS WORKING GROUP TO CONSIDER NTSB RECOMMENDATION. THE FOLLOWING CONSENSUS WAS REACHED BY THE WORKING GROUPS REGARDING EMERGENCY DOOR OPERATION (SHORT, MID, & LONG TERM). EMERGENCY DOOR OPERATION - SHORT TERM. THE MINORITY OF PASSENGER CARS WITH EMERGENCY RELEASE MECHANISMS THAT CAN BE ACCESSED ONLY THROUGH USE OF HAND TOOLS (COIN, PENS, ETC.) WILL BE RETROFITTED IMMEDIATELY SO THAT ACCESS TO THE EXISTING EMERGENCY RELEASE WILL BE ENHANCED. FRA WILL WORK WITH RAILROADS THROUGH REVIEW OF THE INTERIM SYSTEM SAFETY PLANS TO ENSURE COMMUTERS ARE PROVIDED MEANINGFUL INFO REGARDING THE LOCATION & FUNCTION OF THE QUICK-RELEASE FEATURES. EMERGENCY DOOR OPERATION - MID-TERM. THE COMMUTER RAILROADS, THROUGH AMERICAN PUBLIC TRANSIT ASSOCIATION (APTA), WILL REPORT TO THE FRA THE REQUIREMENTS NECESSARY TO THE FRA THE REQUIREMENTS NECESSARY TO RELOCATE QUICK-RELEASE MECHANISMS ADJACENT TO EXTERIOR DOORS & REPORT TO FRA HOW QUICKLY THIS CAN BE ACCOMPLISHED. AT LEAST ONE RAILROAD IS INITIATING SUCH A PROGRAM FOR COMPLETION BY JULY 31. EMERGENCY DOOR OPERATION - LONG-TERM. THE PASSENGER EQUIPMENT SAFETY STANDARDS WORKING GROUP IS CONSIDERING A SIGNIFICANT RANGE OF OPTIONS FOR ENHANCING EMERGENCY EGRESS. THE SUGGESTION OF REMOVABLE WINDOWS IN DOORS HAS NOT BEEN THE SUBJECT OF RESEARCH OR TECHNICAL DESIGN WORK. THE EFFECTIVENESS OF SUCH AN APPROACH IS UNKNOWN GIVEN THEY VARYING HEIGHT & DIMENSIONS OF CURRENT DOOR WINDOWS. APTA WILL REPORT TO THE WORKING GROUP, THEIR FINDINGS ON HOW TO IMPLEMENT THIS CONCEPT & WILL ADDRESS IT IN THE NPRM FOR PASSENGER EQUIPMENT SAFETY. DOOR WINDOOWS THAT CAN BE EASILY REMOVED IN AN EMERGENCY ARE BEING EQUIPPED WITH APPROPRIATE SIGNAGE & INSTRUCTIONS. ACCORDING TO FRA, THE CONCEPT OF KICK PANELS HAS NOT BEEN UTILIZED IN NORTH AMERICAN RAIL EQUIPMENT. THE FRA ALONG WITH CONCURRENCE FROM THE JOINT WORKING GROUPS REGARDING THE INSTALLATION OF KICK PANELS BELOW THE WINDOW LEVELS IN EXTERIORS DOORS WAS EVALUATED AS UNACCEPTABLE FOR SAFETY REASONS. INTRODUCTION OF KICK PANELS IN EXTERIOR DOORS WOULD APPARENTLY CREATE AN UNACCEPTABLE RISK OF A INADVERTENT USE, PARTICULARLY BY CHILDREN. IN ADDITION, PENETRATION OF OCCUPIED AREAS BY OBJECTS FROM THE OUTSIDE IS ALSO A POTENTIAL CONCERN. APTA IS CURRENTLY EVALUATING THE KICK PANEL & DOOR WINDOW ISSUES, & APTA'S REPORT WILL BE TAKEN UP BY THE PASSENGER EQUIPMENT SAFETY STANDARDS WORKING GROUP IN JULY FOR POSSIBLE INCLUSION IN THE NPRM. APTA IS WORKING CLOSELY WITH THE FRA TO HELP IDENTIFY APPROPRIATE INSTRUCTIONS AT VARIOUS DOOR LOCATIONS OR AT EACH DESIGNATED WINDOW. THE WORKING GROUPS ASSESSSMENT OF THE USE OF RETROREFLECTIVE MATERIALS AT EMERGENCY EXIT LOCATIONS INSIDE THE VEHICLE HAS BEEN EVALUATE AS INEFFECTIVE. HOWEVER, THE WORKING GROUPS DID ENDORSE EXPLORATION OF LUMINESCENT MATERIALS TO MARK & PROVIDE INSTRUCTION FOR EMERGENCY EXIT USE. IN CONCLUSION, FRA IS WORKING TO ENSURE READY PASSENGER EGRESS & RESCUE ACCESS CONSISTENT WITH HE INTENT OF THE BOARD'S RECOMMENDATION. INSPECTION OF EMERGENCY WINDOW EXITS FOR PROPER OPERATION, MARKING & INSTRUCTIONS HAVE BEEN REQUIRED. AN NPRM ON PASSENGER EMERGENCY PREPAREDNESS THAT WILL ADDRESS PERMANENT SYSTEMS OF MARKING & INSTRUCTION USING RETROREFLECTIVE MATERIALS FOR RESCUE ACCESS LOCATIONS & LUMINESCENT MATERIALS FOR EXIT LOCATIONS AS WELL AS MAKE PERMANENT THE REQUIREMENT FOR PERIODIC VERIFICATION OF WINDOW EXIT EASE OF OPERATION, IS EXPECTED TO BE ISSUED WITHIN THE NEXT FEW WEEKS. THE NPRM FOR PASSENGER EQUIPMENT SAFETY STANDARDS WILL ADDRESS ISSUES INTEGRAL TO CAR CONSTRUCTION, SUCH AS POSITIONING OF QUICK-RELEASE MECHANISMS, EGRESS THROUGH DOORS THAT MAY BE JAMMED DUE TO ACCIDENT DAMAGE, & DESIGN OF WINDOWS TO FACILITATE RESCUE ACCESS. FRA INDENDS TO WORK WITH INDIVIDUAL RAILROADS, BETWEEN NOW & ISSUANCE OF FINAL RULES IN THESE PROCEEDINGS, TO EXPLOIT OPPORTUNITEIS FOR EARLY IMPLEMENTATION OF MEASURES RESPONSIVE TO THE CONCERNS INPLICIT IN THE BOARD'S RECOMMENDATION.