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Safety Recommendation Details

Safety Recommendation R-97-009
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, and Washington, DC.; it consisted of a locomotive and three commuter cars. The Amtrak train, operating in revenue service between Washington DC., and Chicago, Illinois, consisted of 2 locomotives and 15 cars.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Amend 49 Code of Federal Regulations Part 229 to require the recording of train crewmembers' voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Silver Spring, MD, United States
Is Reiterated: Yes
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: 8/28/1997
Date Closed: 8/6/2004
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s): Recorders

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/16/2019
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Railroad Administration’s (FRA) notice of proposed rulemaking (NPRM) titled “Locomotive Image and Audio Recording Devices for Passenger Trains,” which was published at 84 Federal Register 35712 on July 24, 2019. The NTSB notes the FRA is (1) proposing to require the installation of inward- and outward-facing locomotive image recording devices on all lead locomotives in passenger trains and (2) addressing the use of the recordings to conduct operational tests. To the extent applicable, the NTSB is pleased that the NPRM is partially responsive to our recommendations. However, for the reasons provided in this response, we are disappointed that these long awaited proposed requirements do not include audio recordings and do not apply to freight railroads—two critical factors identified in numerous accident investigations that have prompted our existing safety recommendations. The NTSB provides comments on the following: whether to require both passenger and freight railroads to install image recording devices and whether audio recording should be included, the extent to which the proposed requirements should apply to recording devices that are voluntarily installed, whether a specific run-time or shutoff requirement should be included for recording devices, whether additional equipment is needed to address high levels of background noise inside locomotive cabs, recorder technical and crashworthiness issues, whether the recorders should only operate when a train is in motion, the appropriateness of proposed implementation dates, and whether the final rule should include a prohibition on public disclosure of any audio or video recording. The NTSB has determined that dozens of previous railroad accident investigations would have benefitted from inward- and outward-facing audio and image recorders. In a number of those accidents, the operator died, was seriously injured, or could not recall details from moments before the accident. However, even in the accidents in which the operator was not injured, audio and image recorders could have verified what the operator saw and heard, as well as what actions the operator took during the accident sequence. Such recorded information allows the NTSB to identify critical safety improvements and issue recommendations to prevent similar accident circumstances from reoccurring. Recorders also definitively document relevant information that regulatory agencies, such as the FRA, often state they require to help justify the costs of implementing safety improvements. This NPRM was prompted in part by NTSB Safety Recommendations R-97-9, R-07-3, R 10-1 and -2, and reiterations of these recommendations following several other investigations involving both passenger and freight railroads. The currently applicable recommendations issued to the FRA are R-10-1 and R-10-2.

From: NTSB
To: FRA
Date: 11/10/2004
Response: As part of its November 10, 2004 meeting addressing the Safety Board's Most Wanted List of safety improvements, the Board voted to: Remove Cab Voice Recorders as an issue area in Railroad. Safety Recommendation R-97-9 was classified "Closed-Unacceptable Action" during the last year (see attachment 1) and was the only recommendation in this issue area.

From: NTSB
To: FRA
Date: 8/6/2004
Response: In the SWAT meeting, the FRA indicated that no action would be taken in response to this recommendation, noting that the process of implementing any requirement for voice recording would be difficult and would divert attention from other safety priorities. The FRA also indicated that it has been engaged in other matters that it believed necessarily claimed higher priority, including revision of regulations for steam locomotive inspections, track safety standards, and locomotive engineer certification as well as the issuance of the first rules for passenger train emergency preparedness and passenger equipment safety standards. In addition, significant efforts have been expended to address implementation of positive train control systems, including issuance of a final rule to facilitate introduction of innovative and more cost-effective systems. The Safety Board acknowledges the FRA's workload and commends the FRA for its initiatives in these areas. However, given that the FRA has determined it will not take action to implement this recommendation, and given that the Board continues to believe in the recommendation's merit, we have no choice but to classify Safety Recommendation R-97-9 "Closed--Unacceptable Action."

From: NTSB
To: FRA
Date: 9/30/2003
Response: I appreciate your detailed discussion and update on these important safety issues, which currently remain on the Safety Board's Most Wanted List of safety improvements. Because these are important safety issues and because your letter raises interesting questions that I believe merit further discussion, I accept your offer to brief the Board members on the safety recommendations. Ms. Stephanie Perkins from my office will contact your office to arrange a briefing time that is mutually acceptable to our Board Members, you, and your senior staff.

From: FRA
To: NTSB
Date: 5/5/2003
Response: Letter Mail Controlled 5/5/2003 2:24:31 PM MC# 2030229 FRA has previously communicated our concerns with respect to this recommendation and, after review, has reluctantly come to the conclusion that this recommendation should not be implemented at the present time. In brief, the Board asks that FRA mandate creation of a capability to capture, retain, protect and preserve voice recordings on well over 20,000 locomotives with the hope that, at some future time, the information captured on the recording will prove instrumental in assisting the Board in determining probable cause in a railroad accident investigation. Although we recognize that there have been occasions when the Board’s staff has felt it may have been helpful to probe further the actions of operating crews in order to conduct analysis bearing on probable cause, the occasions to date have been quite limited. In none of these cases has the Board been unable to make a statutory finding of probable cause. Indeed, information available to the Board following major train accidents is increasingly rich and diverse, including sources such as the following: . Locomotive event recorders, which are increasingly capable of capturing and preserving a wide range of data; . Dispatch center-to-train radio communication recordings, which are likely to contain the most safety-critical communications, i.c., those between the dispatcher and crew; and . Electronic data logs in devices such as signal controllers, highway-rail crossing controllers, and defect detectors. As before, the Board is also able to draw on traditional sources such as records of employee training and hours of service and testimony of surviving crew members and other railroad personnel and members of the public who may have interacted with fatally injured personnel in the hours preceding the event. FRA understands the human factor issues that the Board has called attention to in the wake of these accidents and has not hesitated to initiate responsive action to Board recommendations based on the absence of voice recorder data. Thus, while we recognize that such information might be helpful at the margin of some investigations, we cannot perceive a strong public need to take the requested action at this time. Implementation of cab voice recorders would involve a significant expense for installation, maintenance and verification that units are in compliance with Federal requirements. The Surface Transportation Board has found that the railroad industry is not earning its cost of capital, and we are seeing indications of deferred maintenance in some sectors. While deferred maintenance is not itself a safety problem, in the past it has led to management challenges that have potentiated safety problems. Particularly under these circumstances, other safety initiatives that FRA is undertaking, including many undertaken at the Board’s suggestion or with the Board’s strong support, should not have to compete with actions that are not supported by a clear showing that safety benefits will outweigh the costs. FRA appreciates that, as time passes and other uses are found for recording media that may create synergies with other public and private purposes, the Board’s recommendation may warrant re-examination. However, for the present FRA requests that the Board accept FRA’s judgment with respect to overall railroad safety priorities and place this recommendation in the status of "Closed--Reconsidered."

From: NTSB
To: FRA
Date: 4/17/2003
Response: At the June 7, 2002, meeting, the FRA indicated it was unlikely that any action would be taken in response to this recommendation. The FRA noted that the process of implementing any requirement for voice recording would be difficult and would divert attention from other safety priorities. Nevertheless, the FRA requested that the Safety Board again highlight the benefits of recording train crewmembers' voice communications. The FRA also requested that the Board address the noise factor issue, ways that security would be enhanced, and the Board's position regarding the FRA's handling of information after accidents to which the Board does not respond. Safety Recommendation R-97-9 remains classified "Open--Unacceptable Response." In the Bryan, Ohio, accident report, the Safety Board outlined in detail the benefits of a locomotive cab audio recorder. In that accident, audio recordings would have captured the voices of the crewmembers if and when they called out the signal indications to one another, as required by operating rules. If the crew had been calling restrictive signals by name or color, an audio recorder in the locomotive cab would have confirmed that information. The absence of a callout would have meant either (1) that the crewmembers had perceived the indication to be clear or (2) that they had failed to see the signal because of the denseness of the fog or because they had been distracted. We continue to believe that recorded crew communications may have provided valuable clues in reconstructing the accident, which, in turn, could have enabled the carrier, the railroad unions, and the FRA to make systemic changes to prevent similar accidents from occurring. With respect to the noise issue, while the environment in the locomotive cab can be extremely noisy, current recording technology is capable of capturing a broad range of acoustic information even in noisy environments. Audio analysis, filtering, and playback technology permit the extraction of voice and other audio information from even degraded recordings. As we mentioned in the Bryan, Ohio, accident report, an audio recorder might have captured other sounds within the locomotive cab that would have been important in reconstructing the accident. With respect to the security of audio recordings, it is important to note that 49 United States Code 1154, which addresses discovery and use of cockpit and surface vehicle recordings and transcripts, defines explicit limits and restrictions to discovery in a judicial proceeding of transcripts or recordings and prohibits the dissemination of those parts of transcripts or recordings that are subject to discovery. Further, the Federal Aviation Administration (FAA) has established regulatory protection to prevent the FAA from using any part of voice recorder transcripts or recordings for enforcement or certificate actions. Similar statutory and regulatory protections could be implemented by the FRA. Recorders (of all types) that are installed in a commercial vehicle are the property of the carrier that operates that vehicle. That carrier would have access to these recorders and any data that they contain in circumstances (accident or non-accident) that do not involve a Safety Board accident investigation. In aviation, the use of cockpit voice recorders by carriers is often addressed in collective bargaining agreements between the carriers and their unions, rather than through regulations promulgated by the FAA. A similar solution could be anticipated between the railroads and their unions.

From: NTSB
To: FRA
Date: 9/19/2001
Response: The FRA has requested that the Safety Board clarify its intent with respect to what type of train operations would be covered by voice recorders, the amount of time captured by voice recorders, and whether radio communications should be covered. With respect to FAA's question as to whether freight trains would be covered by this recommendation, the Safety Board points out that this recommendation was reiterated in its report on the investigation of the accident in Bryan, Ohio, on January 17, 1999, involving Conrail freight trains. With respect to the intercity operations, radio communications issue, and the length of recording time, the Board's position is that as much data as possible on as many train operations as possible be included. Having said that, the Board believes that these issues are precisely the type of issues that would be addressed during the rulemaking process. Consequently, the Safety Board urges the FRA to initiate rulemaking and solicit comments on the questions that you have posed. The use of automatic information recording devices is one of the Board’s "Most Wanted" safety issues. The Board is disappointed with the FRA’s position and its lack of progress on this issue, and we believe there is more than enough experience in the other modes of transportation for the FRA to begin the process leading to the use of voice recorders. Accordingly, Safety Recommendation R-97-9 remains classified "Open--Unacceptable Response" pending implementation of the recommendation.

From: FRA
To: NTSB
Date: 5/21/2001
Response: Letter Mail Controlled 05/25/2001 7:18:45 PM MC# 2010437: FRA notes that prior Board correspondence has not responded to four out of the five questions that FRA respectfully addressed to the Board in our initial response to this recommendation. FRA still desires clarification as to whether it is intended by the recommendation that all locomotives, including freight locomotives, be included. Is it intended that intercity passenger locomotives, which often have a single crew member in the cab, be equipped, even if the cab is inaccessible to other crewmembers? Is it the Board’s intent to capture all voice communication for the trip (e.g., up to 12 hours) or just the period immediately approaching the accident (as suggested by the narrative in the Silver Spring accident report)? To what extent should radio communications be captured by the recording system? Responses to these requests for clarification of the recommendation would be appreciated. FRA does appreciate being advised of the enactment of legislation that safeguards use of voice recordings by the Board in events involving surface modes. Since our initial response, FRA has raised this issue on the agenda of the Railroad Safety Advisory Committee, which declined to consider the matter. FRA nevertheless met with representatives of affected employees and railroads to discuss this recommendation and receive their individual views. Those representatives expressed uniform and apparently firm opposition to any requirement for recording any conversations in the cab. Accordingly, the Board and FRA must be mindful that the process of implementing any requirement for voice recording would be difficult and would involve some distraction from attention to other safety priorities. Unlike event recorders, which can appropriately be used by railroads to evaluate performance of personnel and equipment prior to an accident, the case for voice recorders rests exclusively on their utility in the context of accident investigation. To date, FRA has not been persuaded that the additional information that would be yielded by this technique would be sufficient to offset the cost of installing the technology, maintaining it, and conducting sufficient compliance oversight to reasonably assure its proper functioning. However, we appreciate that this is a matter to which the Board attaches great importance. Accordingly, when a new Federal Railroad Administrator is confirmed, FRA will further review this issue based on the Board’s response to the questions we have posed and provide a further response. Until FRA is able to achieve the intent of the Board’s recommendation, we request that Safety Recommendation R-97-9 be retained in "Open-Acceptable Action."

From: NTSB
To: FRA
Date: 5/9/2001
Response: From the accident report of the collision involving three Consolidated Rail Corporation freight trains operating in fog on a double main track near Byran, Ohio on January 17, 1999 (report adopted 5/9/2001): In its investigation of the February 16, 1996, accident in Silver Spring, Maryland, involving the collision of a MARC train with an Amtrak passenger train, the Safety Board identified the need for train operating cabs to have voice recording devices, similar to the type installed in the cockpit of aircraft. In its report of the Silver Spring accident, the Safety Board observed that in aviation, for more than 35 years, the cockpit voice recorder (CVR) has been a key tool in documenting the circumstances leading up to an accident and has proven to be invaluable in determining the cause of aviation accidents and in enhancing aviation safety. The Board noted that, although current locomotive event recorders had great utility in providing mechanical response data, they could not answer some human performance questions about the crewmembers’ actions. In the case of the Silver Spring accident, the Safety Board concluded that if the MARC locomotive had been equipped with an LCAR, investigators could have determined from the communications before the collision the factors that may have affected the MARC train operator’s actions. The Safety Board therefore made the following recommendation to the FRA: R-97-9 Amend 49 Code of Federal Regulations Part 229, to require the recording of train crewmembers’ voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings. The FRA responded on February 25, 1998, stating, in part, Unlike event recorders, which have value in determining rules compliance prior to an accident, use of voice recorder information would, as suggested by the recommendation, be limited exclusively to use in an accident investigation. Other uses would be viewed as inappropriate electronic monitoring of employees’ conversations in the workplace, whether or not work related. Capturing voice recordings in a locomotive cab may present practical issues not encountered in aviation. Headsets with intercom capability are the exception, rather than the rule, in locomotive cabs. Significant interrelationships exist between efforts to limit occupational noise exposure in cabs and the effective recording of conversations. Issues of comfort have also been raised by employees and their representatives when use of headsets has been proposed for reduction of occupational noise exposure. Employee representatives cite 8-12-hour shifts and varying environmental conditions in locomotive cabs. The potential release of voice recordings subsequent to an accident presents additional issues. A special statutory exception has been required in the aviation context to prevent inappropriate use of voice recordings following events drawing significant notoriety. Enacting full effective regulations in the absence of special purpose legislation would appear to present a difficult conflict in public policy...Since the Board would be the primary user of voice data, does the Board intend to utilize the power conferred under its charter statute to recommend legislation affording appropriate controls on release of voice recordings in the rail mode? On September 30, 1999, the Safety Board responded, in part, The issues you raise, while new to the railroad industry, have been resolved concerning the use of voice recordings in aviation. You may wish to discuss the issues with [the] Federal Aviation Administrator…to obtain an understanding of how these issues were satisfactorily resolved allowing the use of this important technology to improve aviation safety. This understanding would be useful in helping to overcome the obstacles to the use of cab voice recorders to improve railroad safety. We also suggest that the FRA contact the Coast Guard to review the pending requirements for the use of voice recordings on the bridges of vessels. The International Maritime Organization, a United Nations’ specialized agency responsible for improving maritime safety and preventing pollution from ships, is developing requirements that certain ships have voice recorders by 2002. You may also be aware that legislation to address voice recording privacy in all the modes of transportation is included in the Board reauthorization bill pending before Congress. However, while we are ready to work with you to resolve this matter, we believe there is more than enough experience in the other modes of transportation for the FRA to begin the process leading to the use of cab voice recorders. Since your reply indicates a lack of positive action, the Board classifies R-97-9 “Open—Unacceptable Response.” In answer to the FRA’s concern about the release of information, the Safety Board notes that Public Law 106-424, signed on November 1, 2000, includes provisions for withholding from public disclosure voice and video recorder information for all modes of transportation. Section 5 (d)(1), “Confidentiality of Recordings,” stipulates, in part: The [Safety] Board may not disclose publicly any part of a surface vehicle voice or video recorder recording or transcript of oral communications by or among drivers, train employees, or other operating employees responsible for the movement and direction of the vehicle or vessel, or between such operating employees and company communication centers, related to an accident investigated by the Board. However, the Board shall make public any part of a transcript or any written depiction of visual information that the Board decides is relevant to the accident. With the passage of this legislation, the Safety Board is now able to protect the data obtained from an LCAR in the same manner the Board has always protected data obtained from a CVR. The Safety Board is convinced that, for the safety of train operating crews, the conversations and voice communications of those in the locomotive cab must be recorded to help identify the causes of accidents. With the additional evidence provided by the Bryan, Ohio, accident, the Safety Board reiterates Safety Recommendation R-97-9 to the FRA.

From: NTSB
To: FRA
Date: 2/26/2001
Response: The last official correspondence from the FRA on this recommendation was dated February 25, 1998. The Board subsequently classified Safety Recommendation R-97-9 "Open--Unacceptable Response" on September 30, 1999, because the FRA’s reply had indicated a lack of positive action. The Safety Board would appreciate learning of any actions the FRA has taken since the last correspondence to address Safety Recommendations R-87-16, R-93-12, R-97-9, and R-97-13. Enclosed are copies of the original recommendation letters for your convenience. In addition to R-97-9 and R-97-13, several other recommendations were issued to the FRA in connection with the Silver Spring, Maryland, accident (R-97-10 through -12 and -14 through -21), and there has been no response from the FRA to any of these recommendations since the Safety Board’s letter dated September 30, 1999. Because we are interested in obtaining an expedited update on the four recommendations addressed in this letter, we would appreciate an update on the other recommendations (R-97-10 through -12 and -14 through -21) under separate cover.

From: NTSB
To: FRA
Date: 9/30/1999
Response: THE ISSUES YOU RAISE, WHILE NEW TO THE RAILROAD INDUSTRY, HAVE BEEN RESOLVED CONCERNING THE USE OF VOICE RECORDINGS IN AVIATION. YOU MAY WISH TO DISCUSS THE ISSUES WITH FEDERAL AVIATION ADMINISTRATOR JANE F. GARVEY, TO OBTAIN AN UNDERSTANDING OF HOW THESE ISSUES WERE SATISFACTORILY RESOLVED ALLOWING THE USE OF THIS IMPORTANT TECHNOLOGY TO IMPROVE AVIATION SAFETY. THIS UNDERSTANDING SHOULD BE USEFUL IN HELPING TO OVERCOME THE OBSTACLES TO THE USE OF CAB VOICE RECORDERS TO IMPROVE RAILROAD SAFETY. I ALSO SUGGEST THAT THE FRA CONTACT THE COAST GUARD TO REVIEW THE PENDING REQUIREMENTS FOR THE USE OF VOICE RECORDINGS ON THE BRIDGES OF VESSELS. THE INTERNATIONAL MARITIME ORGANIZATION, A UNITED NATIONS' SPECIALIZED AGENCY RESPONSIBLE FOR IMPROVING MARITIME SAFETY AND PREVENTING POLLUTION FROM SHIPS, IS DEVELOPING REQUIREMENTS THAT CERTAIN SHIPS HAVE VOICE RECORDERS BY 2002. YOU MAY ALSO BE AWARE THAT LEGISLATION TO ADDRESS VOICE RECORDING PRIVACY ISSUES IN ALL THE MODES OF TRANSPORTATION IS INCLUDED IN THE BOARD'S REAUTHORIZATION BILL PENDING BEFORE CONGRESS. HOWEVER, WHILE WE ARE READY TO WORK WITH YOU TO RESOLVE THIS MATTER, WE BELIEVE THERE IS MORE THAN ENOUGH EXPERIENCE IN THE OTHER MODES OF TRANSPORTATION FOR THE FRA TO BEGIN THE PROCESS LEADING TO THE USE OF CAB VOICE RECORDERS. SINCE YOUR REPLY INDICATES A LACK OF POSITIVE ACTION, THE BOARD CLASSIFIES R-97-9 "OPEN--UNACCEPTABLE RESPONSE."

From: FRA
To: NTSB
Date: 2/25/1998
Response: THIS IS A NEW RECOMMENDATION IN THE RAIL MODE AND APPEARS TO STEM FROM A SINGLE ACCIDENT. ALTHOUGH THE DISCUSSION IN THE SILVER SPRING ACCIDENT REPORT POINTS TO THE UNAVAILABILITY OF INFORMATION CONCERNING THE CONVERSATIONS IN THE CONTROL COMPARTMENT PRIOR TO THE ACCIDENT, IT IS NOT CLEAR FROM THE REPORT WHAT SPECIFICALLY--APART FROM CONFIRMING THE CLEAR IMPLICATIONS OF THE REPORT NARRATIVE--WOULD HAVE BEEN GAINED FROM DOCUMENTING THOSE CONVERSATIONS. UNLIKE EVENT RECORDERS, WHICH HAVE VALUE IN DETERMINING RULES COMPLIANCE PRIOR TO AN ACCIDENT, USE OF VOICE RECORDER INFORMATION WOULD, AS SUGGESTED BY THE RECOMMENDATION, BE LIMITED EXCLUSIVELY TO USE IN AN ACCIDENT INVESTIGATION. OTHER USES WOULD BE VIEWED AS INAPPROPRIATE ELECTRONIC MONITORING OF EMPLOYEES' CONVERSATIONS IN THE WORKPLACE, WHETHER OR NOT WORK RELATED. CAPTURING VOICE RECORDINGS IN A LOCOMOTIVE CAB MAY PRESENT PRACTICAL ISSUES NOT ENCOUNTERED IN AVIATION. HEADSETS WITH INTERCOM CAPABILITY ARE THE EXCEPTION, RATHER THAN THE RULE, IN LOCOMOTIVE CABS. SIGNIFICANT INTER-RELATIONSHIPS EXIST BETWEEN EFFORTS TO LIMIT OCCUPATIONAL NOISE EXPOSURE IN CABS AND THE EFFECTIVE RECORDING OF CONVERSATIONS. ISSUES OF COMFORT HAVE ALSO BEEN RAISED BY EMPLOYEES AND THEIR REPRESENTATIVES WHEN USE OF HEADSETS HAS BEEN PROPOSED FOR REDUCTION OF OCCUPATIONAL NOISE EXPOSURE. EMPLOYEE REPRESENTATIVES CITE 8-12 HOUR SHIFTS AND VARYING ENVIRONMENTAL CONDITIONS IN LOCOMOTIVE CABS. THE POTENTIAL RELEASE OF VOICE RECORDINGS SUBSEQUENT TO AN ACCIDENT PRESENTS ADDITIONAL ISSUES. A SPECIAL STATUTORY EXCEPTION HAS BEEN REQUIRED IN THE AVIATION CONTEXT TO PREVENT INAPPROPRIATE USE OF VOICE RECORDINGS FOLLOWING EVENTS DRAWING SIGNIFICANT NOTORIETY. ENACTING FULLY EFFECTIVE REGULATIONS IN THE ABSENCE OF SPECIAL-PURPOSE LEGISLATION WOULD APPEAR TO PRESENT A DIFFICULT CONFLICT IN PUBLIC POLICY. IS IT DESIRED THAT ALL LOCOMOTIVES, INCLUDING FREIGHT LOCOMOTIVES, BE EQUIPPED WITH VOICE RECORDERS? IT IS INTENDED THAT PASSENGER LOCOMOTIVES TYPICALLY OPERATED BY A SINGLE EMPLOYEE BE INCLUDED, EVEN IF THE LOCOMOTIVE CAB IS INACCESSIBLE TO OTHER CREW MEMBERS REQUIRED TO BE STATIONED IN THE OCCUPIED PASSENGER COACHES (AS IF OFTEN THE CASE IN INTERCITY SERVICE)? FROM THE POINT OF VIEW OF THE BOARD'S OBJECTIVES FOR ACCIDENT INVESTIGATION, WOULD A RECORDING OF 2 HOURS DURATION BE SUFFICIENT, AS APPARENTLY SUGGESTED BY THE REPORT NARRATIVE AT PAGE 51-52? TO WHAT EXTENT SHOULD RADIO COMMUNICATIONS BE CAPTURED BY THE RECORDING SYSTEM? SINCE THE BOARD WOULD BE THE PRIMARY USER OF VOICE DATA, DOES THE BOARD INTEND TO UTILIZE THE POWER CONFERRED UNDER ITS CHARTER STATUTE TO RECOMMEND LEGISLATION AFFORDING APPROPRIATE CONTROLS ON RELEASE OF VOICE RECORDINGS IN THE RAIL MODE?

From: NTSB
To: FRA
Date: 11/24/1997
Response: Notation 6938: The National Transportation Safety Board is pleased to respond to the Notice of Proposed Rulemaking (NPRM), "Passenger Equipment Safety Standards" (49 Code of Federal Regulations [CFR], Part 216, et at.), published in the Federal Register on September 23, 1997. "The Safety of Passengers in Railroad Passenger Cars" is on the Safety Board's "Most Wanted" list. The inclusion of Part 238 to 49 CFR and the amendments to other applicable parts of the Federal regulation is a necessary addition of new regulations. In 1968, the Safety Board recommended that the Secretary of Transportation sought legislation to authorize the Federal Railroad Administration (FRA) to prescribe basic passenger car safety standards, and since 1969, the Safety Board has urged the FRA to address passenger equipment safety standards. In the Safety Board's continuing efforts to address passenger equipment safety standards, the Board has issued safety recommendations and offered comments as a result of its accident investigations to reflect changes necessary to improve the effectiveness of passenger transportation. The Safety Board has reviewed the NPRM and offers comments on Part 229 and' the following sections of Part 238: • Section 238. 15 • Section 238.103 • Section 238.2231 • Section 238.231 • Section 238.235 • Section 238.237 • Section 238.401 • Section 238.423 • Section 238.431 • Section 238.437 • Section 238.439 • Section 238.441 The Safety Board is concerned that some of the proposed regulations do not comprehensively address areas critical to ensure passenger equipment safety. The proposed regulations do not address "Operator's Controls and Cab Layout" and "Emergency Communications" in Tier I operations. Therefore, the Safety Board urges the FRA to include these two safety areas in the NPRM on "Passenger Equipment Safety Standards" for Tier I operations. The FRA should re-examine and drop all references in the regulations that state "ordered on or before" and "ordered on or after." The phrases may allow some railroads an opportunity to take advantage of potential loopholes in this process and circumvent the intent of the regulation. For example, a railroad would be in technical compliance with the proposed regulation if it was to formally "place an order" for equipment before the regulated "order date," and then introduce a "change order" for a design that predates the regulation or if the railroad placed an order before the regulated "order date" when the equipment would have an inordinately long delivery lead time; both examples would have the effect of grandfathering in a preregulation design. Further, reference to and reliance on an "ordered date" would be difficult to administer and enforce. A fixed time period from the introduction of the regulation, such as 2 years, should be more than adequate for railroads to be in compliance. Alternately, reliance on the "date of manufacture," rather than the "ordered date," would be far easier to administer and regulate. The waiver process is also available to railroads if an equipment supply problem occurs. The following comment~ address specific items in the NPRM: Part 229, Railroad Locomotive Safety Voice Recording Current locomotive event recorders have great utility but only provide mechanical response data. They cannot answer some questions raised in an accident investigation about the train crewmember's knowledge and actions. The FRA could have included train crewmember voice recording requirements in the 1993 regulations for locomotive event recorders as part of the minimum parameters to be recorded. They contemplated issuing a rule requiring voice recorders in locomotive compartments but rejected the idea because it did not consider them a necessary safety measure. The Safety Board believes that required recording of the train crewmembers' voice communications is a valuable investigation tool and is essential for ascertaining details about the circumstances of an accident. As a result of the Safety Board's investigation of the Silver Spring, Maryland accident, I the Safety Board issued the following recommendation to the FRA: R-97-9 Amend 49 Code of Federal Regulations Part 229 to require the recording of train crewmembers' voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings. The Safety Board urges the FRA to implement this recommendation through the rulemaking process. Part 238, Passenger Equipment Safety Standards Subpart A - General Section 238.15, Movement of Passenger Equipment with Defective Power Brakes The FRA proposes allowing movement of passenger cars with varying degrees of power brake defects. A cut-out power brake is an inoperative power brake, but the failure or cutting out of a secondary brake system (as defined in section 238.5) does not result in inoperative brakes. For example, failure of dynamic brakes does not render a power brake inoperative unless the dynamic brakes are primary brakes. The Safety Board agrees with the FRA that passenger operations need flexibility to move passengers safely to their destination or, at minimum, to a location where passengers can safely disembark. However, because the braking systems of passenger locomotives are generally different from those of freight locomotives, the Safety Board believes that this section of the regulation should also include dynamic brakes on passenger locomotives as part of the primary braking system. The dynamic braking system of passenger locomotives is usually integrated with the pneumatic braking system in a blended braking system or it is automatically activated when the locomotive is placed into emergency, as in the case of the MARC locomotive in the Silver Spring accident and most new Amtrak locomotives. In any event, the dynamic braking systems on passenger locomotives are designed to supplement the pneumatic system and provide the smoothest and shortest braking possible. The Safety Board therefore believes that tile dynamic braking of passenger locomotives are a part of the primary braking system and that dynamic brake failure should prevent a locomotive from further use until repair can be made. The Safety Board has most recently supported this position when it issued a safety recommendation as a result of the Kelso, California accident: R-98-5 Separate the dynamic brake requirements from the Power Brake La\\ rulemaking and immediately conclude rulemaking to require that railroads verify that dynamic braking systems on all locomotives equipped with dynamic brakes are functioning properly before trains are dispatched. (Also, see the Safety Board's comments on Sections 238.231 and 238.421. Brake Systems) Subpart B - System Safety and General Requirements Section 238.103, General System Safety Requirements The FRA delineated minimum criteria to be included in a railroad's principal safety document. The Safety Board supports the FRA mandating the contents of the system safety plan for minimal consistency and oversight within the industry. The Safety Board's experience has been that when railroads are allowed to regulate themselves, incorporating safety elements into the document becomes a matter of convenience and not a necessity. The Safety Board believes that the system safety plans should be comprehensive and address the entire railroad system in which the passenger equipment operates. If industry does not have a comprehensive system safety plan, it may not be able to identify, track, monitor, or rectify situations that can lead to unsafe conditions. System safety should be a continuous, iterative process that has a built-in feedback mechanism and should be used throughout the program's life cycle to arrive at the best plan possible. The Safety Board has made safety recommendations urging the FRA to include specific safety regulations in a system safety plan. The following safety recommendations address some of the elements of system safety plans that should also be included in the General System Safety Requirements: R-76-29: Require carriers to train employees in emergency procedures to be used after an accident, to establish priorities for emergency action, and to conduct accident simulation to test the effectiveness of the program inviting civic emergency personnel participation. R•80•6: Develop and validate through simulated disaster exercises a model emergency response plan for the guidance of the railroad industry in formulating individual plans to be utilized by their train crewmembers in the event of emergency and its decision to rely on voluntary cooperation of the railroad industry. Based on the FRA's inaction to timely develop appropriate emergency response guidelines its employees in implementing an emergency response plan, these safety recommendations were classified "Closed-Unacceptable Action" (R-76-29 on June 26, 1986, and R-80-6 on December 18, 1987). Therefore, the Safety Board urges the FRA to revise section 238.103 to comply with the intent of the two recommendations. Subpart C - Specific Requirements for Tier I Passenger Equipment Sections 238.223, Fuel Tanks The Safety Board agrees with the FRA that external fuel tanks on Tier I operations should incorporate, at a minimum, on an interim basis, the Association of American Railroads (AAR) Manual of Standards and Recommended Practices. Performance Requirements for Diesel Electric Locomotive Fuel Tanks. Recommended Practice 506.4 Although the recommended practice is an adequate safety standard for Tier I operations, the Safety Board proposes that more demanding safety standards for passenger locomotives be included in the permanent Tier I fuel tank regulations. The permanent safety standards for fuel tank regulations should provide a higher ground clearance, compartmentalization, and a bottom skid plate. The Safety Board issued Safety Recommendation R-92-10 to the FRA and similar recommendations to the AAR, to the Electro-Motive Division of General Motors, and General Electric Company addressing fuel tank design and identifying concerns about safety problems caused by diesel fuel spills from fuel tanks being ruptured or punctured: R-92-10 Conduct, in conjunction with the Association of American Railroads, General Electric, and the Electro-Motive division of General Motors, research to determine if the locomotive fuel tank can be improved to withstand forces encountered in the more severe locomotive derailment accidents or if fuel containment can be improved to reduce the rate of fuel leakage and fuel ignition. Consideration should be given to crash or simulated testing and evaluation of recent and proposed design modifications to the locomotive fuel tank, including increasing the structural strength of end and side wall plates, raising the tank higher above the rail, and using internal tank bladders and foam inserts. As a result of the investigation of the Silver Spring accident, the Safety Board also reiterated Safety Recommendations R-92-IO,-16, and -17 respectively, to the FRA, the General Electric Company, and the Electro-Motive Division of General Motors. These safety recommendations have been classified "Open-Acceptable Response" because some railroads have begun to use locomotives that have fuel tanks with thicker skins, bottom skid plates, and to locate fuel tanks higher off the rails. Requirements for fuel tank height and skid plates for external fuel tanks are addressed in section 238.423 for Tier 11 operations. Previous Safety Board's accident investigations involving fuel tank integrity were conducted on Tier I operations and therefore these requirements should be also included in Tier I operations. The advantages of having higher ground clearance was shown during two recent Amtrak derailments that the Safety Board is investigating (Kingman, Arizona and Garden City, Georgia). Investigation of both accidents revealed that essentially no fuel loss occurred in the involved locomotive units (GE models P40 and P42). Fuel tank integrity was maintained despite a substantial accumulation of debris beneath the fuel tanks that may have otherwise damaged current, conventional frame-suspended fuel tanks. The maintenance of fuel tank integrity can be attributed to higher than typical fuel tank ground clearance. which is not found in current, conventionally designed frame- suspended fuel tanks. The Safety Board believes that fuel tank regulations should require higher ground clearance for both Tier I and Tier II operations. Fuel tank compartmentalization, as suggested in Safety Recommendation R-92-2 is not addressed in the requirements for either external or internal fuel tanks in Tier I or Tier II operations. The Safety Board supports continued research tor fuel tank compartmentalization to remedy fuel loss during derailments which could result in spillage of enough fuel to constitute a fire or environmental hazard fuel tank compartmentalization is required in aviation applications, where fuel tanks within the fuselage contour must be able to resist rupture and retain fuel under inertia forces prescribed for emergency landing conditions Therefore, research should be conducted to determine if similar successes can be attained in railroad applications. Section 238.231, Brake System Railroads have consistently held that dynamic brakes are not safety-critical devices because the friction brake alone is capable of safely stopping a train if dynamic brakes are not available. The Safety Board believes that dynamic brakes are a component of the train's primary braking system and should not be construed as a secondary braking system, because operating train crewmembers depend upon them as an integral part of the entire braking system. Dynamic brakes are necessary to control the speed of the train during normal operations and help stop the train in emergency. However, paragraph (j) contains proposed provisions that only define dynamic brakes as part of the secondary braking systems, not as safety-critical devices, because their failure may not result in unacceptable thermal inputs into friction brake components. The proposed rule would afford railroads more flexibility in dealing with defective secondary braking systems by allowing locomotives to be dispatched with inoperative dynamic brakes. Because dynamic brakes are relied upon by train crew members to slow the speed of a train to a controllable speed and to reduce the stopping distance during an emergency brake application, they perform it safety-critical function. The Safety Board has most recently supported this position when it issued two safety recommendations as a result of the January 12, 1997, Kelso, California, accident: R-98-5 Separate the dynamic brake requirements from the Power Brake Law rulemaking and immediately conclude rulemaking to require that railroads verify that dynamic braking systems on all locomotives equipped with dynamic brakes are functioning properly before trains are dispatched. R-98-6 Require railroads to ensure that all locomotives with dynamic braking be equipped with a device in the cab of the controlling locomotive unit to indicate to the operating engineer the real-time condition of the dynamic brakes on each trailing unit. During the investigation of the February 16, 1996, Silver Spring collision the Safety Board determined that the stopping distance was increased when the dynamic brake became disabled after the engineer placed the reverser6 in the opposite direction of movement as he tried to stop the train before to impact. The Safety Board issued Safety Recommendations R-97-42 to the AAR and -45 to the American Short Line Railroad Association, the Brotherhood of Locomotive Engineers, the United Transportation Union, the International Brotherhood of Teamsters and the American Public Transit Association: R-97-42 and -45 Inform your membership of the circumstances of this accident and caution them not to use the reverser during emergency brake applications for those trains on which the use of the reverser will eliminate the dynamic braking thus increasing the stopping distance. The Safety Board has classified Safety Recommendations R-97-42 and -45 "Open-Initial Response" and "Open-Await Response." respectively. Section 238.235, Emergency Window Exits This section should address the size, location, and number of emergency window exits installed in passenger cars. The FRA is proposing that the emergency window exit in Tier I passenger cars have a minimum unobstructed opening with dimensions of 24 inches horizontally and 18 inches vertically. The FRA also proposes that emergency exit window openings on Tier II operations have a minimum unobstructed opening with dimensions of 30 inches horizontally and 30 inches vertically. Emergency exit window size should not be a function of the train's operating speed. but rather a function of emergency response, evacuation, and anthropometric requirements. Backboards used by emergency responders to evacuate injured people vary in size. Adult backboards typically measure either 24 inches horizontally by 72 inches long, 16 inches horizontally by 72 inches vertically, or 12 inches horizontally by 84 inches. Also, a typical steel basket stretcher measures about 23 inches horizontally by 8 inches deep by about 81 inches vertically. In the case of a 24-inch backboard, the proposed emergency window opening would be equal in size and. thus, may not afford a sufficient opening. In addition, if the derailed vehicle is at such an angle that the vertical dimension is now the horizontal dimension, the evacuation equipment may not tit the window size without precariously tilting the evacuee. Also, an emergency responder with a self- contained breathing apparatus (SCBA) may have a difficult time entering an 18-inch vertical opening. Therefore, the Safety Board believes that the horizontal and vertical openings of emergency window exits for both Tier I and Tier II operations should be the same in size. Furthermore, the emergency window exit minimum dimensions should be dictated by the size dimensions needed to extricate an injured person from the passenger car and to allow ingress of an emergency responder fitted with a SCBA into the passenger car. The Safety Board believes that the quantity of required emergency windows exits should be predicated on the capacity of the passenger car, the number of door exits. And the scientifically determined time needed to completely evacuate a fully loaded passenger car. This evacuation requirement should be performance-based and similar in content to that of the airworthiness standards. The Safety Board believes that a minimum quantity requirement of emergency window exits alone is not sufficient. The proposed regulation should include a quantity of emergency window exits that are determined by performance-based guidelines conducive to a complete and timely evacuation. Although the prescribed emergency exit windows should be staggered rather than opposite each other, they must be distributed as uniformly as practical, allowing for passenger distribution. Sections 238.237 & 238.441, Doors Safety Recommendation R-97-l4, issued as a result of the Safety Board's investigation of the Silver Spring accident, urged that passenger cars be required to have easily accessible interior emergency quick-release mechanisms adjacent to exterior passageway doors. The proposed rule providing a 2-year period after the effective date of the final rule in which passenger cars will be equipped with manual overrides of emergency exit doors is unacceptable. This recommendation should be implemented on an accelerated schedule. The Safety Board requests that the FRA take appropriate emergency measures to ensure that remedial action is taken until new requirements can be incorporated in the passenger equipment safety standards. Operator's Controls and Cab Layout In Tier I operations, the "Operator's Controls and Cab Layout" section is not addressed in the proposed rule, as addressed in Tier II operations, section 238.447. The Safety Board believes that the FRA should also require minimum operator controls and cab layout for both locomotive units and cab control cars for Tier I operations. As a result of the Kelso, California, accident, the Safety Board made Safety Recommendations R-98-8 and -10, respectively to the FRA and the AAR: R-98-8 Alert locomotive manufacturers and railroad operators about the dangers posed by improperly located safety-significant controls and switches in locomotives. The Safety Board also issued Safety Recommendation R-98-10 to the Union Pacific Railroad Company: R-98-10 Relocate and/or protect all safety-significant controls and switches in your locomotives so they cannot be inadvertently activated or deactivated. The Safety Board believes that the minimum elements proposed in section 238.447 for Tier II operations are sufficient and should also be included in Tier I operations for the operator's control and cab layout to be ergonomically designed and to minimize the chance of human error in both types of operations. Emergency Communications The FRA has not proposed regulations for emergency communications in ,Tier I operations. The Safety Board believes that emergency communications are necessary for Tier I operations because the majority of passenger train accidents have occurred in those operations. Emergency communication regulations should include not only intratrain communications but also emergency radio communication requirements from the train to outside sources. As a result of the Safety Board's investigation of the October 17, 1975, Wilmington, Delaware, accident, Safety Recommendation R-76-28 was issued to the FRA: R-76-28 Require carriers to provide emergency lighting and communication systems on passenger cars and to provide for predeparture inspection to assure their operability. The Safety Board classified this recommendation "Closed-Unacceptable Action" on June 26, 1986. The FRA believes that the extant lighting communication systems provide adequate service under emergency conditions and that requiring the installation of additional emergency stand-by power sources for emergency lighting and communication facilities is economically unjustifiable. Additionally, as a result of the Safety Board's investigation of an Amtrak accident in Washington, D.C.,s Safety Recommendation R-88-77 was issued to the FRA because train crewmembers could not establish communication with railroad dispatchers when the train was stopped in a tunnel: R-88-77 Undertake a system review of existing tunnels used in passenger operations to determine needed changes in ventilation, lighting, communications, and other safety features, and establish priorities for corrective action. Safety Recommendation R-88-77 was classified "Closed-Acceptable Alternate Action" as result of Amtrak's efforts to conduct a survey on all tunnels in excess of a 1,000 feet through which its trains operate; to develop cost estimates to make changes in ventilation, lighting, and communications; and to provide these costs estimates to the railroads that own the property at which time these railroads did not want to assume the costs to make the required tunnel changes. Amtrak also developed and provided emergency response training to the emergency responders responsible for these tunnels in excess of 1,000 feet. Subpart E - Specific Requirements for Tier II Passenger Equipment Section 238.401, Scope The FRA has added a new class of operations (Tier II) for railroad passenger equipment operating at speeds between 125 and 150 mph. The designated requirements in this subsection are recommendations provided by a panel of experts, based on a consensus of the Passenger Equipment Safety Standards Working Group and the Railroad Safety Advisory Committee. The subject matter is relatively new and the Safety Board has no open safety recommendations in this area. However, the Safety Board reiterates its previous comments and safety recommendations that are reflected in Tier I operation designations. Section 238.423, Fuel Tanks See the Safety Board's comments on section 238.223, stating that external fuel tank compartmentalization should be required. Section 238,431, Brake System See the Safety Board's comments on section 238.231, urging that dynamic brakes be included in primary braking systems. Section 238.437, Emergency Communications The proposed regulation on emergency communication regulations should not only include intratrain communications, but should also include emergency radio communication requirements from the train to outside sources. Safety Recommendations R-76-28 and R-88-77 were designated for Tier I operations and should also be included in the regulations for Tier II operations. Basic emergency communications should not be a function of speed as defined in section 238.5, but a function of the design and configuration of the train and the terrain in which it operates. See the Safety Board's comments on the need for regulations relating to Tier I operations. Section 238.439, Emergency Window Exits and Roof Hatches See the Safety Board's comments on section 238.235 concerning the quantity, size, and location of emergency window exits. Section 238.441, Doors See the Safety Board's comments on section 238.237 addressing the need to relocate emergency door release mechanisms in a more timely manner. The Safety Board appreciates the opportunity to present its views on the proposed rulemaking.

From: NTSB
To: FRA
Date:
Response: At the November 8, 2007 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations R-06-14 and R-06-15 on the Federal MWL under the issue category “Reduce Accidents and Incidents Caused by Human Fatigue.” This issue was removed from the MWL in 2008.

From: NTSB
To: FRA
Date:
Response: At the 1997 Most Wanted List of Transportation Safety Improvements Board Meeting, the Board voted to add Safety Recommendations H-97-18, M-95-6, and R-97-9 to the MWL in the issue area "Automatic Information Recording Devices." Safety Recommendations A-98-54, A-99-16, A-99-17, A-99-18, A-99-28, A-99-29, A-99-59, A-99-60, A-00-030, H-99-53, H-99-54, and R-98-30 were added at a later date.