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Safety Recommendation Details

Safety Recommendation R-98-008
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Railroad
Location: Kelso, CA, United States
Is Reiterated: No
Is Hazmat: No
Accident #: LAX97FR004
Accident Reports: Derailment of Union Pacific Railroad Unit Freight Train 6205 West
Report #: RAR-98-01
Accident Date: 1/12/1997
Issue Date: 2/25/1998
Date Closed: 4/14/2004
Addressee(s) and Addressee Status: Association of American Railroads (Closed - Reconsidered)

Safety Recommendation History
From: NTSB
To: Association of American Railroads
Date: 4/14/2004
Response: The Safety Board notes that on January 30, 1997, the Federal Railroad Administration (FRA) published Safety Bulletin 97-01 in the Federal Register addressing recommended safety practices for certain locomotives equipped with emergency fuel line cut-off devices inside locomotive control compartments at locations that enable the device to be activated unintentionally. The bulletin recommended that all railroads inspect locomotives to ensure that the cut-off switch is not located in such a position, and that if it is, it should be relocated or provided with a safeguarding device that would prevent unintentional activation. Also, until any improperly located device was relocated or protected, the locomotive was not to be used in the lead position. In retrospect, the Safety Board believes that this was a proactive effort on the part of the FRA and precluded the need for the issuance of R-98-1 to the FRA or R-98-8 to the AAR. Given that the safety bulletin was published in the Federal Register prior to the issuance of this recommendation, Safety Recommendation R-98-8 is classified "Closed--Reconsidered."

From: NTSB
To: Association of American Railroads
Date: 2/19/2004
Response: On 2/19/2004, Board staff met with representatives from the AAR regarding this recommendation. The discussion revolved around a similar Safety Recommendation, R-98-1, issued to the Federal Railroad Administration. On 1/30/97, FRA published a notice of Safety Bulletin 97-01 in the Federal Register addressing recommended safety practices for certain locomotives equipped with emergency fuel line cut-off devices located inside the locomotive control compartment at a location which enables the cut-off device to be activated unintentionally. The bulletin recommended that all railroads inspect locomotives to ensure that the cut-off switch is not located in such a position that it may be inadvertently activated and that if the device is so located, it should be relocated or provided with a safeguarding device that would prevent unintentional activation. Also, until any improperly located device was relocated or protected, the locomotive was not to be used in the lead position. The recommendation to the FRA was closed on 08/06/02 as reconsidered.

From: NTSB
To: Association of American Railroads
Date: 12/6/2000
Response: The Safety Board notes that the AAR requests that these recommendations remain in an "open" posture as the association’s committees consider action. As these recommendations were issued between 2 and 9 years ago, the Safety Board would appreciate receiving a substantive response to all of them within 60 days as to contemplated actions and a schedule to complete such actions. Pending receipt of the requested information within 60 days, the above-listed Safety Recommendations are classified "Open--Acceptable Response." In your reply, please refer to the Safety Recommendations by number.

From: Association of American Railroads
Date: 8/21/2000
Response: Letter Mail Controlled 08/22/2000 3:21:24 PM MC# 2001122 The rail industry, through its appropriate committees, is carefully considering the above-referenced recommendation. When that review is completed, I will notify you of the resolution.

From: NTSB
To: Association of American Railroads
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.