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Safety Recommendation Details

Safety Recommendation R-96-072
Details
Synopsis: ABOUT 4:10 A.M. ON 2/1/96, ATCHISON, TOPEKA AND SANTA FE RAILWAY COMPANY (ATSF) FREIGHT TRAIN H-BALT1-31, EN ROUTE FROM BARSTOW, CALIFORNIA, TO LOS ANGELES, WAS TRAVELING WESTBOUND ON THE ATSF SOUTH MAIN TRACK WHEN IT DERAILED AT MILEPOST 60.4 NEAR CAJON JUNCTION, CALIFORNIA. AFTER THE DERAILMENT AND THE SUBSEQUENT RAIL CAR PILEUP, WHICH INVOLVED FIVE CARS CONTAINING HAZARDOUS MATERIALS, A FIRE IGNITED THAT ENGULFED THE TRAIN AND THE SURROUNDING AREA. THE CONDUCTOR AND THE BRAKEMAN SUSTAINED FATAL INJURIES; THE ENGINEER SUFFERED SERIOUS INJURIES.
Recommendation: THE NTSB RECOMMENDS THAT THE FRA: REVISE YOUR FORM F6180-49A TO INCLUDE EVENT RECORDERS IN THE OTHER ITEMS TO BE INSPECTED SECTION ON THE FORM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: Cajon, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MR002
Accident Reports: Derailment of Freight Train H-BALTI-31 Atchison, Topeka and Santa Fe Railway Company
Report #: RAR-96-05
Accident Date: 2/1/1996
Issue Date: 3/5/1997
Date Closed: 10/26/2005
Addressee(s) and Addressee Status: FRA (Closed - Acceptable Alternate Action)
Keyword(s): Recorders

Safety Recommendation History
From: NTSB
To: FRA
Date: 10/26/2005
Response: The Safety Board notes that the final rule now requires the presence of the event recorder to be noted on Form FRA F6180-49A (the locomotive's "Blue Card") with the make and model of the event recorder noted under the "Remarks" section. When a locomotive event recorder has been successfully inspected, tested, and maintained, it should also be noted on the card. Because the intent of the recommendation has been met without the FRA's having to revise the form, Safety Recommendation R-96-72 is classified "Closed--Acceptable Alternate Action."

From: NTSB
To: FRA
Date: 8/30/2004
Response: Notation 7657: The National Transportation Safety Board has reviewed the Federal Railroad Administration (FRA) notice of proposed rulemaking (NPRM), “Locomotive Event Recorders,” Docket No. FRA-2003-16357, Notice No. 1 (RIN-2130-AB34), published in the Federal Register on June 30, 2004. The Safety Board has long supported the installation and use of event recorders on trains, and since 1993, when the FRA required the use of locomotive event recorders, has advocated the development of standards for the survivability of these devices in accidents. Since then, the Board has continued to investigate accidents in which critical event recorder data are lost because the event recorders are compromised due to impact forces, fire exposure, and in some cases, water. The issue of “Locomotive Event Recorder Crashworthiness Standards” is on the Safety Board’s Most Wanted List of Transportation Safety Improvements. This NPRM represents a positive response from the FRA to a number of the Safety Board’s locomotive event recorder-related recommendations regarding testing and maintenance, documentation of the recorder, and crashworthiness standards. The Board offers the following comments on the proposed locomotive event recorder rules. Section 229.5, Definitions As a result of its investigation of the railroad accident near Secaucus, New Jersey, on November 23, 1996 [SIR-97-01], the Safety Board issued the following recommendation. Inform the railroad industry that traction motor current is not a valid indicator of throttle position, and the requirement to record throttle position contained in 49 Code of Federal Regulations [CFR] 229.5(g) cannot be met by recording traction motor current. Ensure that all operators currently using traction motor current as a substitute for throttle position modify their event recording systems to monitor and record throttle position directly. (R-97-55) “Throttle position” is a new definition in the proposed rule. The proposed definition calls for measuring the power requested by the engineer/operator at any and all of the discrete output positions of the throttle and states further that, “If the throttle quadrant on a locomotive has continuously variable segments, the recorder would be required to capture the exact level of speed/tractive effort requested on a scale of 0 to 100 percent of the output variable.” It is the Safety Board’s understanding that if the throttle has no discrete notches or positions, the recorder would be required to capture the continuously variable output at a resolution of no less than 1/256 of the full-scale output (fractional conversion to an 8-bit digital system). The Board believes this proposed definition is necessary and the specific methods to record the power requested by the engineer/operator should be included in the final rule. Section 229.25, Tests: Every Periodic Inspection, and Section 229.27, Annual Tests As a result of its investigations of accidents in Cajon Junction, California, on February 1, 1996 [RAR-96-05], and near Secaucus, New Jersey, on November 23, 1996 [SIR-97-01], the Safety Board issued R-96-70 and R-97-56, respectively. Revise 49 CFR 229.25(e)(2) to require that event recorders, including microprocessor-based event recorders that are equipped with a self-test function, be tested during the quarterly inspections of the locomotive in such a manner that the entire event recording system, including sensors, transducers, and wiring, is evaluated. Such testing should include, at a minimum, a review of the data recorded during actual operation of the locomotive to verify parameter functionality as well as cycling all required recording parameters and determining the full range of each parameter by reading out recorded data. (R-96-70) Pending the result of your railroad safety advisory committee event recorder working group and your implementation of suitable requirements concerning event recorder system maintenance, require that microprocessor-based event recorders equipped to perform self-tests be subject to the testing inspection procedures currently applicable to all other types of event recorders. (R-97-56) The proposed rule does not change the current regulations for non-microprocessor recorders, which must still be inspected on a quarterly basis. However, the proposed rule allows microprocessor recorders with self-monitoring features to be inspected on an annual basis by determining if the event recorder has displayed an indication of a failure and by analyzing a download of the locomotive’s operational data. Although the Safety Board believes the proposed revisions to this section are an improvement from the current sole reliance on a fault indicator incorporated into many of the current microprocessor-based event recorder systems, the Board urges the FRA to further specify required maintenance inspections, at appropriate intervals, to ensure that data element sensors that are not currently monitored under other scheduled inspections are operating within their specified limits and that the data are being supplied to the recorder. The Board agrees that an annual test that includes a download and readout of recorded data by qualified personnel could determine any sensor, transducer, or wiring failures. However, the Board must also point out the necessity of testing the full range of all parameters recorded. Because certain types of failures rarely occur during normal operation of the locomotive, the Board would prefer that the NPRM contain a provision for the testing of the sensors, transducers, or wiring for data elements that are not cycled during the normal operation of the locomotive more often than on an annual basis. Section 229.135, Event Recorders (a) Duty to Equip and Record In the Cajon Junction, California, accident report, the Safety Board also issued the following recommendation. Revise your form F6180-49A to include event recorders in the “other items to be inspected” section of the form. (R-96-72) The intent of this recommendation was to ensure that inspections of event recorders were recorded. The Safety Board notes that the proposed rule will require that form FRA F6180-49A be used to document the dates when all required tests and inspections are performed on the event recorder. The proposed rule also amends Parts 229.25 and 229.27 to specify the scheduled testing requirements according to the type of recorder installed. The Board further notes that the requirements of this section apply to lead locomotives, controlling remote distributed-power locomotives, and multiple-unit (MU) locomotives. The Board is unsure, however, about the applicability of these rules to manned helper locomotives placed within a train consist. The Board therefore urges the FRA to clarify this section and include the applicability of the proposed standards to manned helper locomotives placed within a train consist or at the rear of a train consist. (b) Equipment Requirements The Safety Board is encouraged by several provisions in this section of the proposed rule. The proposed regulation includes requirements for equipping new or remanufactured locomotives with certified crashworthy memory modules and the required data elements that must be captured by these event recorders. The Board is encouraged by the provisions included in the proposed regulations to expand the list of required data elements that must be recorded. The Board notes that the new MU locomotives addressed in subparagraph b(4) will be required to record “wheel slip/slide alarm activation”; however, this data element will not be required for new freight locomotives. A wheel slip/slide alarm is found on locomotives currently in service. This data element is also captured on some recorders of locomotives equipped with wheel slip/slide alarms, so the omission of this data element from the list of required data elements for new freight locomotives is confusing. The Board urges FRA to include this data element in subparagraph b(3) for freight locomotives. The Safety Board also supports recording or providing a means of determining if a brake application or release results from the manipulation of brake controls by the locomotive engineer or from a command originating from or executed by an on-board computer. This information would include safety-critical train control data routed to the locomotive engineer’s display and commands sent and received by the lead locomotive to distributed power locomotives. The Board notes the introduction of new technologies and the growing reliance for safety critical operations on these systems. Therefore, any on-board computer inputs that affect train operation/handling should be considered essential and should be recorded. The Safety Board agrees with the provisions in the proposed rule to eliminate the use of event recorders using magnetic tape. It is the hope of the Board that this regulation, and the principal manufacturer’s discontinuance of replacement tapes, will expedite the migration from magnetic tapes to hardened memory modules. The Board urges FRA to set an ambitious “sunset date” for current recorders using magnetic tape. Appendix D – Criteria for Certification of Crashworthy Event Recorder Memory Module The following Safety Board recommendation on event recorder crashworthiness was issued in conjunction with the Board’s investigation of the collision and derailment of two Union Pacific freight trains in Devine, Texas, on June 27, 1997 [RAR-98-02]. Working with the railroad industry, develop and implement event recorder crashworthiness standards for all new or rebuilt locomotives by January 1, 2000. (R-98-30) The NPRM proposes to change the current regulations by including Appendix D to Part 229, which delineates criteria for the certification of crashworthy event recorder memory modules. The Safety Board is a proponent for the adaptation of elements in the European Organization for Civil Aviation Equipment (EUROCAE) standards for flight data and cockpit voice recorders because of their proven performance in regard to crashworthiness. The Board recognizes that these standards were developed for aviation, but believes that their merits argue persuasively for their applicability to locomotive event recorders. Nonetheless, the standards proposed in the NPRM, Tables 1 and 2, are less stringent than those specified by EUROCAE, although those listed in Table 2 are more rigorous than those listed in Table 1. The NPRM also proposes that manufacturers be allowed to choose which of the tables to follow. The Safety Board does acknowledge the work accomplished by event recorder manufacturers who have moved forward on their own to establish performance criteria for survivability. However, the Board urges the FRA to adopt the more rigorous performance criteria described in Table 2 of Appendix D as a minimum and to provide a time period within which manufacturers who are currently using the testing criteria in Table 1 must adopt and implement the Table 2 performance criteria to certify their crashworthy event recorder memory modules. In the Board’s continuing efforts to address the survivability of event recorders, it will monitor and offer recommendations as a result of its accident investigations to reflect changes necessary to improve the effectiveness of the crashworthiness standards. The Safety Board believes the proposed regulation on locomotive event recorders will enhance the safety of rail transportation and therefore supports the rulemaking except as noted. The Board appreciates the opportunity to comment on this proposed rulemaking.

From: NTSB
To: FRA
Date: 3/17/2004
Response: On 3/17/2004, Board staff met with FRA staff regarding this recommendation. According to revisions proposed by FRA, paragraph (a) of §229.135 is essentially unchanged, except as necessary to accommodate the proposed changes or additions to subsequent paragraphs in §229.135 and to support the intention of the Safety Board's recommendation. Proposed Rule- Section 229.135(a). Duty to equip and record. Except as provided in paragraphs (c) and (d) of this section, a train operated faster than 30 miles per hour shall have an in-service event recorder, of the type described in paragraph (b) of this section, in the lead locomotive. The presence of the event recorder shall be noted on Form FRA F6180-49A (by writing the make and model of event recorder with which the locomotive is equipped) under the REMARKS section...

From: NTSB
To: FRA
Date: 8/6/2002
Response: As discussed at the June 7 meeting, crashworthy locomotive event recorders is one issue that we all hope can be brought to closure in the next 2 years; we anticipate reviewing the notice of proposed rulemaking when it is issued. The Safety Board will assist the FRA any way possible to finalize this rule, as that action will bring to closure Safety Recommendations R-96-70, -71, -72, and -73; R-97-56; and R-98-30 and -57, which, pending final rulemaking on this issue, remain classified "Open--Unacceptable Response."

From: NTSB
To: FRA
Date: 9/30/1997
Response: AGAIN, THE BOARD IS DISAPPOINTED WITH THE FRA'S DECISION TO REFER THE RECOMMENDATION TO WORKING GROUP. BECAUSE RECORDER INSPECTIONS ARE NOW REQUIRED, IT SEEMS LOGICAL TO LIST RECORDER ON THE FORM AS AN ITEM TO BE INSPECTED. THE FORM WAS LAST REVISED IN 1985, & THE REQUIREMENT THAT EVENT RECORDING BE INSPECTED DURING A LOCOMOTIVE'S QUARTERLY INSPECTION WENT IN EFFECT IN 1995. UNTIL THE FRA HAS TAKEN THE RECOMMEND ACTION, R-96-72 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: FRA
To: NTSB
Date: 8/15/1997
Response: JOLENE MOLITORIS, ADMINISTRATOR RESPPONDED THAT THE FRA HAS REFERRED THE EVENT RECORDED ISSUE RECOMMENDATIONS R-96-70 THROUGH -73) TO THE RAIL SAFETY ADVISORY COMMITTEE FOR HANDLING. THE RSAC PROCESS WILL LEAD TO EXPEDITED ACTION ON THESE RECOMMENDATIONS.