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Safety Recommendation Details

Safety Recommendation R-97-010
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: Require comprehensive failure mode & effects analyses, including a human factors analysis, for all signal system modifications.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
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: 8/28/1997
Date Closed: 9/30/1999
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: FRA
To: NTSB
Date: 5/21/2001
Response: Letter Mail Controlled 05/25/2001 7:18:45 PM MC# 2010437- Recommendation not addressed: R-97- 10 Closed-Unacceptable Action. None Required as Closed.

From: NTSB
To: FRA
Date: 9/30/1999
Response: THE SAFETY BOARD FOUND IN ITS INVESTIGATION OF THE SILVER SPRING ACCIDENT THAT IMPROVEMENTS TO THE SIGNAL SYSTEM WOULD HAVE REQUIRED ONLY A ROUTINE INSPECTION BY THE FRA TO DETERMINE WHETHER THE MODIFICATIONS MET APPLICABLE STANDARDS. THE BOARD APPRICIATES THE FRA'S DISCUSSION OF THE MERITS OF THIS RECOMMENDATION BUT IS DISAPPOINTED THAT THE FRA HAS CONCLUDED THAT FAILURE MODES ANALYSES WOULD BE BURDENSOME IF APPLIED TO ALL CASES. BECAUSE THE FRA HAS REJECTED THIS RECOMMENDATION, THE BOARD HAS CLASSIFIED R-97-10 "CLOSED--UNACCEPTABLE ACTION."

From: FRA
To: NTSB
Date: 2/25/1998
Response: FRA AND THE FEDERAL TRANSIT ADMINISTRATION HAVE PREVIOUSLY NOTED THEIR COMMITMENT TO EXAMINATION OF SAFETY ISSUES RELATED TO TRANSIT GRANT PROPOSALS AFFECTING COMMUTER RAIL SERVICE. THIS FOCUS WILL BE USEFUL OVER THE COMING YEARS TO PROMOTE A MIGRATION TO MORE SECURE TRAIN CONTROL SYSTEMS. AGAIN, THE OBJECTIVE SHOULD BE INITIATIVES OF SIGNIFICANT SCOPE THAT HAVE THE POTENTIAL TO ADDRESS SAFETY RISKS THAT ARE COMMON TO A VARIETY OF PHYSICAL LOCATIONS. FRA AGREES THAT FMEA AND OTHER ANALYTICAL TECHNIQUES ARE USEFUL MEANS OF STRUCTURING THE DEBATE OVER APPROPRIATE SIGNAL AND TRAIN CONTROL TECHNOLOGY FOR VARIOUS TYPES OF OPERATIONS. THIS TYPE OF ANALYSIS IS PARTICULARLY APPROPRIATE FOR USE IN DEVELOPMENT OF A NEW TYPE OF TRAIN CONTROL SYSTEM. HOWEVER, FRA BELIEVES THAT APPLICATION OF FMEA ON A CASE-BY-CASE BASIS TO EVERY SITUATION WHERE SIGNALS MAY BE ALTERED OR RELOCATED WOULD, IN PRACTICE, BECOME A HIGHLY BURDENSOME AND SUBJECTIVE EXERCISE DEPENDENT ON THE JUDGMENT OF THE INDIVIDUAL ANALYST. THE BEHAVIOR OF HUMAN OPERATORS IS POWERFULLY INFLUENCED BY THE OPERATING ENVIRONMENT (VEHICLES, CONTROL SYSTEMS, GRADES AND CURVATURES, SIGHT DISTANCES, WEATHER) 'HUMAN INTERACTIONS (CREW RESOURCE MANAGEMENT, PUBLIC INTERFACE), AND CHARACTERISTICS OF THE INDIVIDUAL OPERATOR (AGE, EXPERIENCE, TRAINING, HEALTH, ALERTNESS, ETC.). SERIAL, MICROSCOPIC FOCUS ON ONE ELEMENT OF THIS COMPLEX AT A SINGLE LOCATION IS UNLIKELY TO PRODUCE A BALANCED ALLOCATION OF RESOURCES FOR SAFETY OPTIMIZATION. DECISIONS CONCERNING SIGNAL ARRANGEMENTS AND RAILROAD OPERATING RULES SHOULD BE BASED ON THE BEST DATA AVAILABLE AND SHOULD PROVIDE GUIDANCE THAT IS USEFUL ACROSS ONE OR MORE CLASSES OF COMMON SITUATIONS, RECOGNIZING OPPORTUNITIES FOR BROADER IMPROVEMENTS THAN WOULD BE POSSIBLE WITH A HIGHLY SITUATIONAL ORIENTATION. AS NOTED ABOVE, THE DELAYED IN BLOCK PROVISION OF E.O.20 ADDRESSES THE PARTICULAR ISSUE PLACED IN SHARP FOCUS BY THE SILVER SPRING ACCIDENT. THE BROADER ISSUE OF ENGINEERS FAILING TO HEED APPROACH SIGNALS IN A WIDE VARIETY OF CIRCUMSTANCES IS ADDRESSED DAILY THROUGH OPERATIONAL TESTS, CERTIFICATE ACTIONS UNDER THE LOCOMOTIVE ENGINEER CERTIFICATION RULES, AND A VARIETY OF OTHER WAYS, INCLUDING A RECENT SAFETY DIRECTIVE THAT ADDRESSES THESE ISSUES ACROSS A BROAD FRONT (62 FR 35330; JUNE 30, 1997). HOWEVER, ULTIMATELY POSITIVE TRAIN CONTROL (PTC) SYSTEMS CAPABLE OF MAINTAINING TRAIN SEPARATION AND ENFORCING OTHER MOVEMENT RESTRICTIONS SHOULD BE OUR OBJECTIVE. THROUGH THE RAILROAD SAFETY ADVISORY COMMITTEE (RSAC), FRA HAS INITIATED A REVIEW OF PTC TECHNOLOGY THAT WILL INCLUDE DEVELOPMENT OF PERFORMANCE STANDARDS FOR SUCH SYSTEMS. SAFETY BOARD STAFF MEMBERS ARE SERVING AS ADVISORS TO THE RSAC WORKING GROUP. THIS EFFORT WILL INCLUDE A STRONG EMPHASIS ON INTEGRATION OF RAILROAD OPERATING RULES AND THE TRAIN CONTROL APPARATUS INTO A SECURE METHOD OF OPERATION. IN RESPONSE TO THE BOARD'S RECOMMENDATIONS, FRA WILL URGE INCLUSION OF FMEA TECHNIQUES AS PART OF THE SAFETY ACCEPTANCE PROCEDURE FOR NEW METHODS OF OPERATION. FRA AGREES WITH THE NEED TO CONDUCT SOUND ANALYSIS IN THE DESIGN OF ANY METHOD OF OPERATION. (IN RAIL PARLANCE, A "METHOD OF OPERATION" INCLUDES BOTH THE PHYSICAL INFRASTRUCTURE OF THE SIGNAL AND/OR TRAIN CONTROL SYSTEM AND THE PERTINENT RULES THAT GOVERN TRAIN MOVEMENTS). WE BELIEVE THAT SUCH ANALYSIS SHOULD BE CONDUCTED AT THE SYSTEM LEVEL, CONSIDERING THE ATTRIBUTES OF THE SIGNAL OR TRAIN CONTROL SYSTEM, THE ASSOCIATED OPERATING RULES, AND THE KNOWN DATA CONCERNING HUMAN PERFORMANCE UNDER SIMILAR CONDITIONS. THIS SHOULD BE CONTRASTED WITH POTENTIALLY AD HOC ANALYSIS CONDUCTED IN AN ATTEMPT TO ANALYZE THE VARIABLE EFFECTS OF MINOR CHANGES IN A METHOD OF OPERATION AT A PARTICULAR LOCATION. FRA DOUBTS THAT SUCH METHODS COULD SUCCEED DUE TO THE ABSENCE OF MEANINGFUL INPUT DATA BEARING ON THE DEGREE OF RISK POSED BY POTENTIAL FAILURE MODES. NTSB'S DISCUSSION OF THIS ISSUE IN THE SILVER SPRING REPORT SUGGESTS THAT, HAD THE RECOMMENDED ANALYSES BEEN CONDUCTED WHEN THE SUBJECT TRAFFIC CONTROL SYSTEM WAS INSTALLED ON THE LINE IN QUESTION, THE ACCIDENT MAY HAVE BEEN PREVENTED BY ONE OF SEVERAL MEANS. NTSB REFERENCES ADOPTION OF A DELAYED-IN-BLOCK RULE CHANGE AS ONE OF THE ALTERNATIVE STEPS THAT MIGHT HAVE BEEN TAKEN (REPORT AT 53), ALONG WITH PLACEMENT OF AN EXIT SIGNAL AT THE STATION, IMPLEMENTATION OF A CAB SIGNAL SYSTEM, OR IMPLEMENTATION OF A NEW POSITIVE TRAIN SEPARATION SYSTEM. AMONG THESE OPTIONS, ONLY THE PLACEMENT OF THE EXIT SIGNAL WOULD HAVE CONSTITUTED A SITE-SPECIFIC RESPONSE, AND EVEN IN THAT CASE THERE WOULD HAVE BEEN IMPLICATIONS FOR OTHER LOCATIONS (SEE DISCUSSION BELOW). FOR INSTANCE, INSTALLATION OF A CAB SIGNAL SYSTEM WOULD HARDLY BE A PROPORTIONAL RESPONSE TO THE POSSIBILITY OF AN ENGINEER FORGETTING AN APPROACH SIGNAL BECAUSE OF AN UNSCHEDULED STOP AT A PARTICULAR PASSENGER STATION. TAKEN AS A PROBLEM OCCURRING IN A SINGLE LOCATION, NO ACTION AT ALL WOULD LIKELY HAVE BEEN SUPPORTED BY AN ANALYSIS CONDUCTED PRIOR TO THIS ACCIDENT. THE DIFFICULTY OF PROCEEDING IN THIS MANNER IS ILLUSTRATED BY THE COLLISION THAT GAVE RISE TO THE RECOMMENDATION. IT IS DOUBTFUL THAT SUCH ANALYSIS COULD HAVE RELIABLY PREDICTED THAT THE FOLLOWING FACTORS WOULD CORRESPOND IN TIME AT THAT LOCATION WITHIN THE USEFUL LIFE OF THE SIGNAL SYSTEM: >LIGHT PASSENGER LOAD PERMITTING THE TRAIN CREW TO GATHER IN THE CONTROL COMPARTMENT. >- CHALLENGING ENVIRONMENTAL CONDITIONS (E.G., HEAVY SNOW). >- THE REQUIREMENT TO STOP FOR PASSENGERS WHO HAD BOARDED THE WRONG TRAIN. >- THE RECENT DOVETAILING OF SENIORITY ROSTERS, LEADING TO POSSIBLE PREOCCUPATION BY AT LEAST ONE CREWMEMBER WITH MATTERS OTHER THAN SAFE OPERATIONS. >- DISTRACTION ASSOCIATED WITH BROKEN COMMUNICATIONS AS TWO TRAINS PASSED AT THE LOCATION WHERE DEFECT DETECTORS WERE POSITIONED. IT IS CLEAR THAT ISSUES BROADER THAN MODIFICATION OF THE SIGNAL SYSTEM IN THE VICINITY OF THE KENSINGTON STATION ON THE BRUNSWICK LINE ARE IMPLICATED IN NTSB'S CONCERNS. BROAD, RATHER THAN NARROW ACTIONS ARE INDICATED BY THOSE CONCERNS. TO THAT END, FRA HAS TAKEN EMERGENCY ACTION TO ADDRESS THE WEAKNESS IN THE METHOD OF OPERATION WHICH LED TO THE SILVER SPRING ACCIDENT. THAT IMPROVEMENT IS IN EFFECT ACROSS THE RAIL SYSTEM--NOT JUST AT A FEW LOCATIONS WHERE SIGNALS ARE RELOCATED OR OTHER MODIFICATIONS ARE MADE DURING ANY CALENDAR PERIOD. FRA CONDUCTED A SAMPLING OF COMMUTER, INTERCITY, AND AMTRAK PASSENGER LINES, NOT EQUIPPED WITH CAB SIGNALS, TO ESTABLISH A CROSS SECTION FOR THE NATION OF PASSENGER STATIONS WHICH HAVE EXIT SIGNALS. FRA DETERMINED THAT ONLY A SMALL NUMBER OF PASSENGER STATIONS ARE EQUIPPED WITH EXIT SIGNALS. MANY OF THE SIGNALS THAT ARE VISIBLE UPON THE EXIT OF A STATION ARE LOCATED THERE SOLELY DUE TO THE BREAKING DISTANCE AND SPACING REQUIREMENTS OF 49 CFR 236.24. THIS REGULATION REQUIRES EACH ROADWAY SIGNAL TO BE LOCATED WITH RESPECT TO THE NEXT SIGNAL OR SIGNALS WHICH GOVERN TRAIN MOVEMENTS IN THE SAME DIRECTION TO PROVIDE PROPER DISTANCES FOR REDUCING SPEEDS OR STOPPING BY MEANS OF A BRAKE APPLICATION, OTHER THAN AN EMERGENCY APPLICATION, BEFORE REACHING THE POINT WHERE REDUCED SPEED OR STOPPING IS REQUIRED. A REDUCED SPEED ASPECT REQUIRES SPACING ADEQUATE TO SLOW TO PRESCRIBED SPEED BEFORE REACHING THE NEXT SIGNAL. AN ASPECT REQUIRING A STOP AT THE NEXT SIGNAL REQUIRES SPACING ADEQUATE TO STOP WITHOUT AN EMERGENCY BRAKE APPLICATION BEFORE REACHING THE NEXT SIGNAL. THE FOLLOWING EXAMPLES ARE REPRESENTATIVE OF THE DATA THAT WAS GATHERED BY FRA FIELD PERSONNEL: THE NORFOLK SOUTHERN PIEDMONT DIVISION IS A TWO-TRACK MAIN LINE SIGNALED FOR TRAFFIC IN BOTH DIRECTIONS (TCS). AMTRAK RUNS ON THIS LINE FROM LYNCHBURG, VIRGINIA, MILEPOST 172.5 TO MILEPOST 15.0 NEAR SPRINGFIELD, VIRGINIA. VIRGINIA RAILWAY EXPRESS ALSO RUNS ON THIS LINE FROM MILEPOST 35.9 TO MILEPOST 15.0. THERE ARE 17 PASSENGER STATIONS USED BY AMTRAK AND VRE ON THIS LINE. ALL SIGNALS ARE SPACED FOR BRAKING DISTANCE WITH ONLY THE LYNCHBURG AND THE BRU-VRE-YARD STATIONS LOCATED WHERE THE SIGNALS ARE USED FOR STATION EXIT. TRAINS OPERATING ON THE "SAMTRANS" PENINSULA LINE ARE GOVERNED BY SIGNAL INDICATIONS DISPLAYED BY WAYSIDE SIGNALS THAT ARE SPACED BASED ON REQUIRED BRAKING DISTANCES. THERE ARE 46 PASSENGER STATIONS ON THIS LINE BETWEEN SAN FRANCISCO AND SAN JOSE, CA. NONE OF THE STATIONS HAVE PASSENGER STATION SIDINGS OR USE EXIT SIGNALS. THESE AND OTHER FINDINGS CONFIRM THAT THERE IS NO ESTABLISHED PRACTICE IN THE INDUSTRY TO PLACE DISTANT SIGNALS FOR INTERLOCKINGS AND CONTROL POINTS AT LOCATIONS' EXITING STATIONS. OBVIOUSLY, MANY LOCATIONS EXIST WHERE DISTANT SIGNALS ARE PLACED BETWEEN STATIONS AND THE NEXT HOME SIGNAL OR CONTROL POINT; HOWEVER, THIS PLACEMENT IS GOVERNED BY REQUIRED STOPPING DISTANCES, NOT THE OBJECTIVE OF REMINDING THE ENGINEER OF THE SIGNAL INDICATION FOLLOWING THE STATION STOP. ISSUANCE OF EMERGENCY ORDER (E.O.) NO. 20 HAS ADDRESSED A COMMON HAZARD AT EACH OF THESE LOCATIONS WHERE A DELAYED IN BLOCK RULE WAS NOT ALREADY APPLICABLE.