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Safety Recommendation Details

Safety Recommendation R-97-019
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 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 & marked for easy identification in emergencies & derailments, & that these requirements be incorporated into minimum passenger car safety standards.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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 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: The final rule for 49 CFR Part 239 provides a requirement for the emergency door release mechanism placement to be in a readily accessible position and for marking it for easy identification in emergencies and derailments. That final rule also promotes scheduled inspection, maintenance, and repair of emergency window and door exits. The rule specifically calls for the repair of all imperative window and door exits before returning the car to service. Therefore, Safety Recommendation R-97-19 is classified "Closed--Acceptable Action."

From: FRA
To: NTSB
Date: 5/21/2001
Response: Letter Mail Controlled 05/25/2001 7:18:45 PM MC# 2010437

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 two separate Final Rules that bear upon Safety Recommendation R-97-19. The first was the publication of the Final Rule for 49 CFR Part 239, "Passenger Train Emergency Preparedness," in the Federal Register dated May 4, 1998. This rule became effective July 6, 1998. The second was FRA's Final Rule for 49 CFR Part 238, "Passenger Equipment Safety Standards," as published in the Federal Register dated May 12, 1999. The rule became effective July 12, 1999. Within 49 CFR Part 239, Section 239.107, Emergency exits, relates to the "marking" requirement of Safety Recommendation R-97-l9. This requirement is specifically found in paragraph (a) of Section 239.107, as quoted below: "Section 239.107 Emergency exits. For additional requirements related to emergency window exits, see part 223 of this chapter. (a) Marking. Each railroad operating passenger train service shall determine for each passenger car that is in service, except for self-propelled cars designed to carry baggage, mail, or express: (1) That all door exits intended for emergency egress are either lighted or conspicuously and legibly marked with luminescent material on the inside of the car and that clear and understandable instructions are posted at or near such exits. (2) That all door exits intended for emergency access by emergency responders for extrication of passengers are marked with retroreflective material and that clear and understandable instructions are posted at each such door." Within 49 CFR Part 238, Subpart B-"Safety Planning and General Requirements," contains provisions relating to this safety recommendation, for all Tier I and Tier II passenger equipment, specifically at Section 238.111, "Pre-revenue service acceptance testing plan." This rule is divided into two separate parts, namely: paragraph (a) for "Passenger equipment that has previously been used in revenue service in the United States," and paragraph (b) for "Passenger equipment that has not been used in revenue service in the United States." Paragraph (a) of Section 238.111 applies not only to the actual equipment which has previously been used in revenue service in the United States or to equipment which is manufactured identically thereto. Paragraph (a) also applies to equipment which is similarly manufactured to that equipment and has no material differences in safety-critical components or systems. Paragraph (b) of Section 238.111 contains the requirements for a railroad placing passenger equipment in service for the first time on its system when the equipment has not previously been used in revenue service in the United States - in other words, when the equipment is not covered by paragraph (a). Each railroad must develop a pre-revenue service acceptance testing plan and submit the plan to FRA at least 30 days prior to beginning testing. Each railroad is also under an independent duty to comply with the other requirements of Part 238 and 239. As you are aware, the construction of the Final Rule for 49 CFR Part 238 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 C of the Final Rule contains "Specific Requirements for Tier I Passenger Equipment," and Subpart E contains "Specific Requirements for Tier II Passenger Equipment." For Tier I passenger equipment, the Final Rule contains section 238.235 Doors, within Subpart C, which is quoted below: "Section 238.235 Doors. (a) By December 31, 1999, each powered, exterior side door in a vestibule that is partitioned from the passenger compartment of a passenger car shall have a manual override device that is: (1) Capable of releasing the door to permit it to be opened without power from inside the car; (2) Located adjacent to the door which it controls; and (3) Designed and maintained so that a person may readily access and operate the override device from inside the car without requiring the use of a tool or other implement. (b) Each passenger car ordered on or after September 8, 2000, or placed in service for the first time on or after September 9, 2002 shall have a minimum of two exterior side doors, each door providing a minimum clear opening with dimensions of 30 inches horizontally by 74 inches vertically. Note: The Americans with Disabilities Act (ADA) Accessibility specifications for Transportation Vehicles also contain requirements for doorway clearance (See 49 CFR part 38). Each powered, exterior side door on each such passenger car shall have a manual override device that is: (1) Capable of releasing the door to permit it to be opened without power from both inside and outside the car; (2) Located adjacent to the door which it controls; and (3) Designed and maintained so that a person may access the override device from both inside and outside the car without requiring the use of a tool or other implement. (c) A railroad may protect a manual override device used to open a powered, exterior door with a cover or a screen capable of removal without requiring the use of a tool or other implement. (d) Marking and instructions. [Reserved]" For Tier II passenger equipment, the Final Rule contains Section 238.439 Doors, within Subpart E, which is quoted below: "Section 238.439 Doors. (a) Each passenger car shall have a minimum of two exterior side doors, each door providing a minimum clear opening with dimensions of 30 inches horizontally by 74 inches vertically. Note: The Americans with Disabilities Act (ADA) Accessibility Specifications for Transportation Vehicles also contain requirements for doorway clearance (See 49 CFR part 38). (b) Each passenger car shall be equipped with a manual override feature for each powered, exterior side door. Each manual override must be: (1) Capable of releasing the door to permit it to be opened, without power, from both inside and outside the car; (2) Located adjacent to the door which it controls; and (3) Designed and maintained so that a person may readily access and operate the override device from both inside and outside the car without the use of any tool or other implement. (c) The status of each powered, exterior side door in a passenger car shall be displayed to the crew in the operating cab. If door interlocks are used, the sensors used to detect train motion shall be nominally set to operate at 3 mph. (d) Each powered, exterior side door in a passenger car shall be connected to an emergency back-up power system. (e) A railroad may protect a manual override device used to open a powered, exterior door with a cover or a screen capable of removal without requiring the use of a tool or other implement. (f) A passenger compartment end door (other than a door providing access to the exterior of the trainset) shall be equipped with a kick-out panel, pop-out window, or other similar means of egress in the event the door will not open, or shall be so designed as to pose a negligible probability of becoming inoperable in the event of car body distortion following a collision or derailment. (g) Marking and instructions. [Reserved]" As the provisions of the new rules state, FRA has now required railroads to have functional exterior emergency door release mechanisms on passenger cars before they are placed into revenue service, that the emergency release mechanism is placed in a readily accessible position, and is marked for easy identification in emergencies and derailments. Based upon the publication of these applicable provisions in our Final Rules, FRA respectfully requests that the Board consider classifying Safety Recommendation R-97-19 as "Closed--Acceptable Action."

From: FRA
To: NTSB
Date: 2/25/1998
Response:

From: FRA
To: NTSB
Date: 10/6/1997
Response: THIS IS AN INCORRECT ENTRY PER J. REMINES ON 3/16/98.