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Safety Recommendation Details

Safety Recommendation R-97-018
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: Provide promptly a prescribed inspection & maintenance test cylce to ensure the proper operation of all emergency exit windows as well as provide that the 180-day inspection & maintenance test cycle is prescribed in the final rule.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 7/27/2001
Addressee(s) and Addressee Status: FRA (Closed - Acceptable Alternate Action)
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: NTSB
To: FRA
Date: 7/27/2001
Response: For the Tier 1 passenger equipment, FRA's final rule addresses periodic mechanical inspection to include minimum requirements for the interior and exterior mechanical components, which shall be inspected not less frequently than every 184 days, for seats, luggage racks, beds/bunks, safety latches and straps, and couplers. The final rule, however, requires inspection of a representative sample of emergency windows, instead of all emergency windows. Although the final rule does not incorporate a similar requirement for Tier II passenger equipment, the FRA states that it will not allow Tier II equipment to be used prior to FRA approval of an inspection, testing, and maintenance program. With respect to the proper operation of emergency exit windows in Tier II equipment, the FRA states that it would generally apply, at a minimum, the Tier I inspection requirements when granting approval of a railroad's program. The FRA's approach to this recommendation for Tier II equipment is considered an acceptable alternative approach to the intent of the Board's recommendation. Therefore, based on the sampling methods outlined in the May 4, 1998, final rule, both of which must meet a 95-percent confidence level, Safety Recommendation R-97-18 is classified "Closed--Acceptable Alternate Action."

From: FRA
To: NTSB
Date: 5/20/2001
Response: Letter Mail Controlled 05/25/2001 7:18:45 PM MC# 2010437: FRA provided an initial response for thls safety recommendation to the NTSB in our letter dated February 25, 1998. FRA advised that: “Passenger railroads completed emergency window inspections under E.O. 20 by April 20, 1996. Most railroads have continued to include these inspections in periodic inspections of the equipment. FRA is preparing final rules based on proposals for regular inspection at a 180-day cycle. FRA may take interim action pending the effective date of the final rule, if necessary by amending the emergency order. As further information, we are advised that commuter railroads are voluntarily including checks of emergency windows in their periodic maintenance programs.” In its letter of September 30, 1999, the Board stated, in part, “We delayed responding because the FRA was developing rulemakings addressing several of these safety recommendations. Rather than delay our response any longer, the Safety Board has decided to reply to Safety Recommendations R-97-9 through -13 and -21 . Once we have carefully evaluated the new regulations, we will reply to Safety Recommendations R-97-14 through -20.” After FRA’s initial response, and before the Board’s September 30, 1999 reply, FRA published a Final Rule for 49 CFR Part 238, “Passenger Eqiiipinent Safety Standards,” in the Federal Register dated May 12, 1999. The rule became effective July 12, 1999. As you are aware, the construction of the Final Rule separated specific requirements into two separate “tiers.” Tier I was defined as “operating at speeds not exceeding 125 mph.” Tier 11 was defined as “operating at speeds exceeding 125 mph but not exceeding 150 mph.” Subpart D of the Final Rule contains “Inspection, Testing, and Maintenunce Requirements for Tier I Passenger Equipment,” and Subpart F contains “Inspection, Testing, and Maintenance Requirements for Tier 11 Passenger Equipment.” For Tier 1 passenger equipment, within Subpart D of the Final Rule, new 0 238.307 “Periodic mechanical inspection of passenger cars and unpowered vehicles used in passenger trains,” is in relation to this recommendation. Specifically, this is addressed in paragraph (d) of 4 238.307, at subparagraph (4), as quoted below: ‘‘5 238.307 (d) The periodic mechanical inspection shall specifically include the following interior and exterior mechanical components, which shall be inspected not less frequently than every 184 days. At a minimum, this inspection shall determine that: Seats and seat attachments are not broken or loose. Luggage racks are not broken or loose. All beds and bunks are not broken or loose, and a11 restraints or safety latches and straps are in place and function as intended. A representative sample of emergency window exits on the railroad’s passenger ears properly operate, in accordance with the requirements of Sec. 239.107 of this chapter. Each coupler is in the following condition: (i) ( 5 ) The distance between the guard arm and the knuckle nose is not more than 51/2 inches on standard type couplers (MCB contour 1904), or not more than 55/16 inches on D&E couplers; The free slack in the coupler or drawbar not absorbed by friction devices or draft gears is not more than !4 inch; and The draft gear is not broken.” For Tier I1 passenger equipment, FRA did not incorporate a similar requirement in the Final Rule for reason that FRA is requiring more extensive safety planning requirements for Tier TI railroad operations. Provisions for Tier I1 passenger equipment are found in Subpart F, “Inspection, Testing, and Maintenance Requirements f o r Tier I1 Passenger Equipment,” of 49 CFR Part 238. As discussed in the 1997 NPRM, there is currently no operating history with regard to Tier II equipment, and thus there are no regulations or industry standards establishing detailed testing, inspection, or maintenance procedures, criteria, and intervals for the equipment. FRA believes that the introduction of a new type of passenger equipment offers the opportunity for a fresh start. The final rule takes the approach to set general guidelines on the process to be used by the operating railroad, together with the system developer, to develop an inspection, testing, and maintenance program. The operating railroad and the system developer together have the best information, expertise, and resources necessary to develop the details of an effective inspection, testing, and maintenance program. The operating railroad is thereby granted some latitude to develop the operational details of the program, using the system safety process to justify the safety decisions that are made. However, FRA intends to exercise final approval of the inspection, testing, and maintenance program posed by the operating railroads; rail labor organizations will be given an opportunity to discuss their concerns with FRA during the approval process set forth in 5 238.505. Tier JJ equipment may not be used prior to FRA approval of an inspection, testing, and maintenance program. Section 238.503 of the Final Rule provides for each railroad shall obtain FRA approval of a written inspection, testing, and maintenance program for Tier II passenger equipment prior to implementation of that program and prior to commencing passenger operations using that equipment. Section 238.505 provides for the Program approval procedure. Paragraph (c) of Sec. 238.505, is quoted below: “(c) Approval. (1) Within 60 days of receipt of each initial inspection, testing, and maintenance program, FRA will conduct a formal review of the program. FRA will then notify the primary railroad contact person and the designated employee representatives in writing whether the inspection, testing, and maintenance program is approved and, if not approved, the specific points in which the program is deficient. If a program is not approved by FRA, the railroad shall amend its program to correct all deficiencies and resubmit its program with the required revisions not later than 45 days prior to commencing passenger operations. (2) FRA will review each proposed amendment to the program within 45 days of receipt. FRA will then notify the primary railroad contact person and the designated employee representatives in writing whether the proposed amendment has been approved by FRA and, if not approved, the specific points in which the proposed amendment is deficient. The railroad shall correct any deficiencies and file the corrected amendment prior to implementing the amendment. (3) Following initial approval of a program or amendment, FRA may reopen consideration of the program or amendment for cause stated. With respect to the proper operation of emergency exit windows in Tier II equipment, FRA as a general rule would apply, as a minimum, the Tier I inspection requirements when granting approval of a railroad’s program. Based upon the provisions contained in the Final Rule for inspection of emergency exit window inspection requirements, it is believed that FRA has accomplished the full intent of this recommendation by the Board. We, therefore, request the Board to consider classifyng Safety Recommendation R-97-18 as “Closed-Acceptable Action.”

From: FRA
To: NTSB
Date: 3/12/2001
Response: Letter Mail Controlled 03/19/2001 10:42:56 AM MC# 2010231 After FRA's initial response, and before the Board's September 30, 1999 reply, FRA published a Final Rule for 49 CFR Part 238, "Passenger Equipment Safety Standards," in the Federal Register dated May 12, 1999. The rule became effective July 12, 1999. As you are aware, the construction of the Final Rule separated specific requirements into two separate "tiers." Tier I was defined as "operating at speeds not exceeding 125 mph." Tier II was defined as "operating at speeds exceeding 125 mph but not exceeding 150 mph." Subpart D of the Final Rule contains "Inspection, Testing, and Maintenance Requirements for Tier II Passenger Equipment," and Subpart F contains "'Inspection, Testing, and Maintenance Requirements for Tier II Passenger Equipment." For Tier 1 passenger equipment, within Subpart D of the Final Rule, new section 238.307 "Periodic mechanical inspection of passenger cars and unpowered vehicles used in passenger trains," is in relation to this recommendation. Specifically, this is addressed in paragraph (d) of section 238.307, at subparagraph (4), as quoted below: Section 238.307 (d) The periodic mechanical inspection shall specifically include the following interior and exterior mechanical components, which shall be inspected not less frequently than every 184 days. At a minimum, this inspection shall determine that: (1) Seats and seat attachments are not broken or loose. (2) Luggage racks are not broken or loose. (3) All beds and bunks are not broken or loose, and all restraints or safety latches and straps are in place and function as intended. (4) A representative sample of emergency window exits on the railroad's passenger cars properly operate, in accordance with the requirements of Sec. 239.107 of this chapter. (5) Each coupler is in the following condition: (i) The distance between the guard arm and the knuckle nose is not more than 5 l/2 inches on standard type couplers (MCB contour 1904), or not more than 5 5/16 inches on D&E couplers; (ii) The free slack in the coupler or drawbar not absorbed by friction devices or draft gears is not more than % inch; and (iii) The draft gear is not broken." For Tier II passenger equipment, FRA did not incorporate a similar requirement in the Final Rule for reason that FRA is requiring more extensive safety planning requirements for Tier II railroad operations. Provisions for Tier II passenger equipment are found in Subpart F, "Inspection Testing, and Maintenance Requirements for Tier II Passenger Equipment," of 49 CFR Part 238. As discussed in the 1997 NPRM, there is currently no operating history with regard to Tier II equipment, and thus there are no regulations or industry standards establishing detailed testing, inspection, or maintenance procedures, criteria, and intervals for the equipment. FRA believes that the introduction of a new type of passenger equipment offers the opportunity for a fresh start. The final rule takes the approach to set general guidelines on the process to be used by the operating railroad, together with the system developer, to develop an inspection, testing, and maintenance program. The operating railroad and the system developer together have the best information, expertise, and resources necessary to develop the details of an effective inspection, testing, and maintenance program. The operating railroad is thereby granted some latitude to develop the operational details of the program, using the system safety process to justify the safety decisions that are made. However, FRA intends to exercise final approval of the inspection, testing, and maintenance program posed by the operating railroads; rail labor organizations will be given an opportunity to discuss their concerns with FRA during the approval process set forth in Section 238.505. Tier II equipment may not be used prior to FRA approval of an inspection, testing, and maintenance program. Section 238.503 of the Final Rule provides for each railroad shall obtain FRA approval of a written inspection, testing, and maintenance program for Tier II passenger equipment prior to implementation of that program and prior to commencing passenger operations using that equipment. Section 238.505 provides for the Program approval procedure. Paragraph (c) of Sec. 238.505, is quoted below: (c) Approval. (1) Within 60 days of receipt of each initial inspection, testing, and maintenance program, FRA will conduct a formal review of the program. FRA will then notify the primary railroad contact person and the designated employee representatives in writing whether the inspection, testing, and maintenance program is approved and, if not approved, the specific points in which the program is deficient. If a program is not approved by FRA, the railroad shall amend its program to correct all deficiencies and resubmit its program with the required revisions not later than 45 days prior to commencing passenger operations. (2) FRA will review each proposed amendment to the program within 45 days of receipt. FRA will then notify the primary railroad contact person and the designated employee representatives in writing whether the proposed amendment has been approved by FRA and, if not approved, the specific points in which the proposed amendment is deficient. The railroad shall correct any deficiencies and file the corrected amendment prior to implementing the amendment. (3) Following initial approval of a program or amendment, FRA may reopen consideration of the program or amendment for cause stated. With respect to the proper operation of emergency exit windows in Tier II equipment, FRA as a general rule would apply, as a minimum, the Tier I inspection requirements when granting approval of a railroad's program. Based upon the provisions contained in the Final Rule for inspection of emergency exit window inspection requirements, it is believed that FRA has accomplished the full intent of this recommendation by the Board. We, therefore, request the Board to consider classifying Safety Recommendation R-97-18 as "Closed-Acceptable Action."

From: NTSB
To: FRA
Date: 9/30/1999
Response: Thank you for your February 25, 1998, letter concerning Safety Recommendations R-97-9 through -2 1, which were issued to the Federal Railroad Administration (FRA) following the National Transportation Safety Board’s investigation of the February 16, 1996, collision between two passenger trains at Silver Spring, Maryland. We delayed responding because the FRA was developing rulemakings addressing several of these safety recommendations. Rather than delay our response any longer, the Safety Board has decided to reply to Safety Recommendations R-97-9 through -13 and -21. Once we have carefully evaluated the new regulations, we will reply to Safety Recommendations R-97-14 through -20. Please accept our apology for taking so long to reply to your letter.

From: FRA
To: NTSB
Date: 2/25/1998
Response: Passenger railroads completed emergency window inspections under E.O. 20 by April 20, 1996. Railroads have continued to include these inspections in periodic inspections of the equipment. Under the Passenger Train Emergency Preparedness docket, FRA has prepared a final rule based on proposals for regular inspection at a 180-day cycle. Should the need arise, FRA will take interim action pending the effective date of the final rule by amending the emergency order.