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Safety Recommendation Details

Safety Recommendation R-99-013
Details
Synopsis: ON 3/25/98, ABOUT 4:48 A.M. EASTERN STANDARD TIME, SOUTHBOUND NORFOLK SOUTHERN CORP. (NORFOLK SOUTHERN) TRAIN 255L5, WHICH WAS EN ROUTE TO FORT WAYNE, INDIANA, STRUCK EASTBOUND CONSOLIDATED RAIL CORP. (CONRAIL) TRAIN TV 220, WHICH WAS EN ROUTE TO COLUMBUS, OHIO. THE COLLISION OCCURRED WHERE THE NORFOLK SOUTHERN HUNTINGTON DISTRICT AND THE CONRAIL CHICAGO MAIN LINES CROSS AT GRADE AT THE EAST END OF THE TOWN OF BUTLER, INDIANA. BOTH LOCOMOTIVES AND FIVE CARS FROM THE NORFOLK SOUTHERN TRAIN DERAILED, AND THREE CARS FROM THE CONRAIL TRAIN, TWO WITH MULTIPLE STACKED PLATFORMS, DERAILED. THE NORFOLK SOUTHERN CONDUCTOR WAS KILLED; THE ENGINEER AND STUDENT ENGINEER SUSTAINED MINOR INJURIES. THE TWO CONRAIL CREWMEMBERS WERE NOT INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL RAILROAD ADMINISTRATION: IN COOPERATION WITH CLASS I RAILROADS, THE AMERICAN SHORT LINE AND REGIONAL RAILROAD ASSOCIATION, THE BROTHERHOOD OF LOCOMOTIVE ENGINEERS, AND THE UNITED TRANSPORTATION UNION, DEVELOP AND REQUIRE, FOR ALL CREWMEMBERS, CREW RESOURCE MANAGEMENT TRAINING THAT ADDRESSES, AT A MINIMUM: CREWMEMBER PROFICIENCY, SITUATIONAL AWARENESS, EFFECTIVE COMMUNICATION AND TEAMWORK, AND STRATEGIES FOR APPROPRIATELY CHALLENGING AND QUESTIONING AUTHORITY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: Butler, IN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CHI98FR009
Accident Reports: Collision of Norfolk Southern Corporation Train 255L5 with Consolidated Rail Corporation Train TV 220
Report #: RAR-99-02
Accident Date: 3/25/1998
Issue Date: 7/29/1999
Date Closed: 5/6/2003
Addressee(s) and Addressee Status: FRA (Closed - Acceptable Alternate Action)
Keyword(s): Crew Resource Management

Safety Recommendation History
From: NTSB
To: FRA
Date: 5/6/2003
Response: The Safety Board appreciates the FRA's comprehensive update of efforts to implement CRM training in the railroad industry. From the information the FRA has provided and through direct communication with the Association of American Railroads and many of the Class I railroads, we are aware of the video training program, workbook, and training modules addressing CRM training that have been developed and distributed to the Class I and regional railroads. The Board believes that since the Butler, Indiana, accident, the railroad industry has made great strides to embrace the concept of CRM training. We are also pleased to note that further refinements to current CRM training will be realized based on the ENSCO, Inc., Crew Resource Management Training Project, which will be conducted by the Texas Transportation Institute. We would appreciate receiving updates as progress is made on that project. The industry's voluntary development and implementation of CRM training is an acceptable alternate approach to the requirement for the training called for in the Board's recommendation. Consequently, Safety Recommendation R-99-13 is classified "Closed--Acceptable Alternate Action."

From: FRA
To: NTSB
Date: 2/13/2003
Response: Letter Mail Controlled 4/21/2003 11:51:58 AM MC# 2030125 Following our receipt of Safety Recommendation R-99-13, and after giving consideration as to what would be the best approach to implement crew resource management (CRM) training in the railroad industry, it was FRA's original intent to make a CRM presentation to the members of the Railroad Safety Advisory Committee (RSAC), to be held in Washington, D.C., on January 28, 2000. Following that presentation, FRA then intended to formally ask the RSAC Planning Group to consider the task of evaluating this safety recommendation to determine the best method of developing and implementing CRM training in the rail industry. FRA advised the Safety Board of this intent on January 12, 2000, in advance of the RSAC meeting held on January 28, 2000. The Board then advised FRA, in its letter dated August 17, 2000, that it was pleased to learn that FRA had agreed to begin the dialogue necessary for the development of CRM training. While the Board noted that use of the RSAC would be a suitable method to begin the dialogue, the Board was concerned that resources needed for the development of CRM may be diverted to other worthwhile projects. The Board requested that FRA keep them informed of the project's progress. At that time, the Safety Board classified Safety Recommendation R-99-l 3 as "Open--Acceptable Response." During a meeting held on June 7, 2002, FRA representatives provided verbal updates to Safety Board representatives concerning all safety recommendations issued to FRA that remain in "open" status. During the discussion of Safety Recommendation R-99-13, FRA representatives verbally brought the Safety Board members up to date on the status of our efforts concerning the implementation of CRM training in the rail industry. In a letter to FRA, dated August 6, 2002, former Safety Board Chairman Marion C. Blakey acknowledged that as a result of the above mentioned meeting, there were several recommendations that could be brought to closure as soon as the Safety Board received some additional information from FRA. A list, provided as an enclosure to that letter, listed Safety Recommendation R-99-13 as one of the recommendations that could be closed. Therefore, below is a general update to the progress we have made concerning Safety Recommendation R-99-l3. At the full RSAC meeting held on January 28, 2000, a formal joint presentation concerning CRM was made by the Safety Board's Dr. Stephen Jenner, and FRA's Mr. Terry Doyle. Following that presentation, there was a general discussion about this subject among the RSAC members that caused FRA to depart from its original intent to request the RSAC to accept the development of CRM training as an RSAC task. The basic reason for this change from FRA's original intent was an announcement made by Mr. Charles Dettmann of the Association of American Railroads (AAR). Mr. Dettmann announced that the AAR, NS, Union Pacific Railroad, and the Canadian Pacific Railway, were in the process of developing a generic CRM training program and that the program would be available within the next 60 days. Mr. Dettmann stated that the program would allow customization by each individual railroad. The AAR had created a CRM task force to address the subject of a CRM training program. The minutes of the AAR's Safety and Operations Management Committee (SOMC) teleconference held on February 18,2000, reflect that agreement was reached on a recommendation by the AAR's Risk Management Working Committee's CRM Task Force to approve an industry approach to CRM training, in answer to the Safety Board's recommendation. NS completed the production of this generic video program, together with a workbook for use by an instructor or for use by an individual student or group of students. AAR's SOMC endorsed tailoring this program with the FRA, the Brotherhood of Locomotive Engineers (BLE), and the United Transportation Union (UTU), in a manner consistent with the recommendations from the Safety Board. FRA was provided with a preliminary copy of both the video and workbook for our review. FRA found the video and workbook to be excellent in its content and treatment of the subject, and so advised those responsible for producing this material. The video and the workbook were structured in modules to cover the four specific issues that were contained in Safety Recommendation R-99-13, as follows: 1. Crewmember Proficiency (Module 1); 2. Situational Awareness (Module 2); 3. Effective Communication and Teamwork (Module 3); and 4. Strategies for appropriately challenging and questioning authority, entitled "Conflict Resolution Techniques" (Module 4). The video and workbook also contain appropriate introductory material to acquaint railroad employees with the history and background of CRM. The estimated time for an individual employee or group of employees to complete the entire CRM training program is approximately 2 ½ to 3 hours. After final editing, on November 20,2000, the AAR informed its member railroads, and the American Short Line and Regional Railroad Association (ASLRRA), of the availability of this material which NS agreed to distribute to all railroads desiring copies of this program. Enclosed is a packet of copies of letters issued by AAR during June and July 2000, to the ASLRRA and Class I railroads, enclosing a copy of this CRM training program. We believe that the Safety Board has already received a copy of the final generic CRM training video, and the workbook from NS, and therefore we are not including another copy with this letter. While FRA believes that the cooperative effort within the railroad industry to develop the CRM training program is an excellent start toward achieving the intent of Safety Recommendation R-99-13, we have also embarked upon a more in-depth and longer term approach to this subject. FRA has contracted with ENSCO, Inc., who, in turn, has entered into a contract with the Texas Transportation Institute (TTI) to conduct the ENSCO, Inc., Crew Resource Management Project. The objective of this project is to examine the crew interactions that exist in current railroad operations which affect safety and to develop strategies to enhance safety through more effective "teaming." This project is currently in progress and is expected to continue through fiscal year 2004. There are eight tasks designed to be carried out to achieve the objective of this project: · Task 1 - Literature Review; · Task 2 - Survey of Railroad Operational Teams; · Task 3 - Survey of Existing Railroad CRM Programs and Training Methods; · Task 4 - Team Mapping to Training Methods; · Task 5 - Final Report; · Task 6 - Development of a Pilot Railroad CRM Training Program; · Task 7 - Phased Implementation of Pilot Railroad CRM Training Program; and · Task 8 - Report on Tasks 6 & 7. Enclosed is a copy of the ENSCO, Inc., Crew Resource Management Project Update, prepared in December 2002, which elaborates on the individual tasks indicated above and mentioning progress made to date. FRA believes that this longer-term contract with TTI will provide us with a better understanding of how CRM training in the rail industry should be modified in the future. Based upon the actions that FRA has taken, and the cooperative actions taken by the AAR, several Class 1 railroads, the ASLRRA, the BLE, and the UTU, we respectfully request that the Safety Board consider classifying Safety Recommendation R-99-13 as "Closed-Acceptable Action."

From: NTSB
To: FRA
Date: 8/17/2000
Response: The Safety Board is pleased to learn that FRA has agreed to begin the dialogue necessary for the development of crew resource management training (CRM). While the Board notes that use of the Railroad Safety Advisory Committee would be a suitable method to begin dialogue, we are concerned that resources needed for the development of CRM may be diverted to other worthwhile projects. Please keep us informed of the project's progress. Based on your response, Safety Recommendation R-99-13 is classified "Open-Acceptable Response."

From: FRA
To: NTSB
Date: 1/12/2000
Response: Letter Mail Controlled 01/19/2000 2:39:50 PM MC# 2000091 THE RECOMMENDATION RELATING TO CREW RESOURCE MANAGEMENT, R-99-13, IS ONE THAT WILL REQUIRE A CONSIDERABLE AMOUNT OF DIALOGUE WITH THE RELEVANT INTERESTED PARTIES. FRA WILL FORMALLY ASK THE RAILROAD SAFETY ADVISORY COMMITTEE PLANNING GROUP AT ITS NEXT MEETING SCHEDULED FOR 1/28/00, TO CONSIDER THE TASK OF EVALUATING THIS RECOMMENDATION. REPRESENTATIVES OF THE CLASS I RAILROADS, THE AMERICAN SHORT LINE AND REGIONAL RAILROAD ASSOCIATION, THE BROTHERHOOD OF LOCOMOTIVE ENGINEERS, AND THE UNITED TRANSPORTATION UNION WILL BE INVITED TO PARTICIPATE IN THE EVALUATION OF THAT RECOMMENDATION.