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Safety Recommendation Details

Safety Recommendation R-97-020
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 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.
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: A review of the final rule, specifically section 238.103, Fire Safety, shows that the FRA now has a requirement for railroads to perform the recommended inspection. Therefore, Safety Recommendation R-97-20 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 a Final Rule for 49 CFR Part 238, "Passenger Equipment Safety Standards," in the Federal Register dated May 12, 1999. The rule became effective on July 12, 1999. 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 238.103, "Fire Safety." Specific paragraphs (a), (d) and (e) that bear upon this recommendation are quoted below: "Section 238.103 Fire safety. (a) Materials. (1) Materials used in constructing a passenger car or a cab of a locomotive ordered on or after September 8, 2000, or placed in service for the first time on or after September 9, 2002, shall meet the test performance criteria for flammability and smoke emission characteristics as specified in Appendix B to this part, or alternative standards issued or recognized by an expert consensus organization after special approval of FRA under Sec. 238.21. (2) On or after November 8, 1999, materials introduced in a passenger car or a locomotive cab, as part of any kind of rebuild, refurbishment, or overhaul of the car or cab, shall meet the test performance criteria for flammability and smoke emission characteristics as specified in Appendix B to this part, or alternative standards issued or recognized by an expert consensus organization after special approval of FRA under Sec. 23 8.21. (d) Fire safety analysis for existing passenger equipment. (1) Not later than July 10, 2000, each passenger railroad shall complete a preliminary fire safety analysis for each category of existing rail equipment and current rail service. (2) Not later than July 10, 2001, each such railroad shall- (i) Complete a final fire safety analysis for any category of existing passenger equipment and service evaluated during the preliminary fire safety analysis as likely presenting an unacceptable risk of personal injury. In conducting the analysis, the railroad shall consider the extent to which materials comply with the test performance criteria for flammability and smoke emission characteristics as specified in Appendix B to this part or alternative standards approved by FRA under this part. (ii) Take remedial action to reduce the risk of personal injuries to an acceptable level in any such category, if the railroad finds the risk to be unacceptable. In considering remedial action, a railroad is not required to replace material found not to comply with the test performance criteria for flammability and smoke emission characteristics required by this part, if: (A) The risk of personal injuries from the material is negligible based on the railroad's operating environment and the material's size, or location, or both; or (B) The railroad takes alternative action which reduces the risk of personal injuries to an acceptable level. (3) Not later than July 10, 2003, each such railroad shall- (i) Complete a fire safety analysis for all categories of equipment and service. In completing this analysis, the railroad shall, as far as practicable, determine the extent to which remaining materials comply with the test performance criteria for flammability and smoke emission characteristics as specified in Appendix B to this part or alternative standards approved by FRA under this part. (ii) Take remedial action to reduce the risk of personal injuries to an acceptable level in any such category, if the railroad finds the risk to be unacceptable. In considering remedial action, a railroad is not required to replace material found not to comply with the test performance criteria for flammability and smoke emission characteristics required by this part, if: (A) The risk of personal injuries from the material is negligible based on the railroad's operating environment and the material's size, or location, or both; or (B) The railroad takes alternative action which reduces the risk of personal injuries to an acceptable level. (3) Not later than July 10, 2003, each such railroad shall- (i) Complete a fire safety analysis for all categories of equipment and service. In completing this analysis, the railroad shall, as far as practicable, determine the extent to which remaining materials comply with the test performance criteria for flammability and smoke emission characteristics as specified in Appendix B to this part or alternative standards approved by FRA under this part. (ii) Take remedial action to reduce the risk of personal injuries to an acceptable level in any such category, if the railroad finds the risk to be unacceptable. In considering remedial action, a railroad is not required to replace material found not to comply with the test performance criteria for flammability and smoke emission characteristics required by this part, if: (A) The risk of personal injuries from the material is negligible based on the railroad's operating environment and the material's size, or location, or both; or (B) The railroad takes alternative action which reduces the risk of personal injuries to an acceptable level. (4) Where possible prior to transferring existing equipment to a new category of service, but in no case more than 90 days following such a transfer, the passenger railroad shall complete a new fire safety analysis taking into consideration the change in railroad operations and shall effect prompt action to reduce any identified risk to an acceptable level. (5) As used in this paragraph, "category of rail equipment and current rail service" shall be determined by the railroad based on relevant fire safety risks, including available ignition sources, presence or absence of heat/smoke detection systems, known variations from the required material test performance criteria or alternative standards approved by FRA, and availability of rapid and safe egress to the exterior of the vehicle under conditions secure from fire, smoke, and other hazards. (e) Inspection, testing, and maintenance. Each railroad shall develop and adopt written procedures for the inspection, testing, and maintenance of all fire safety systems and fire safety equipment on the passenger equipment it operates. The railroad shall comply with those procedures that it designates as mandatory for the safety of the equipment and its occupants." As the provisions of the new rules state, FRA has now required railroads to perform a comprehensive inspection of all commuter passenger cars to verify that the interior materials of these cars meet the expected performance requirements for flammability and smoke emissions characteristics. Based upon the publication of these applicable provisions in our Final Rule, FRA respectfully requests that the Board consider classifying Safety Recommendation R-97-20 as "Closed--Acceptable Action."

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