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Safety Recommendation Details

Safety Recommendation R-99-015
Details
Synopsis: ON 3/25/98, ABOUT 4:48 A.M. EASTERN STANDARD TIME, SOUTHBOUND NORFOLK SOUTHERN CORPORATION (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 HUNTING DISTRICT AND THE CONRAIL CHICAGO MAIN LINES CROSS AT GRADE AT THE EAST END OF THE TOWN OF BUTLER, IN. 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 NORFOLK SOUTHERN CORPORATION: DEVELOP AND IMPLEMENT METHODS TO IMPROVE EMPLOYEE COMPLIANCE WITH COMPANY RULES AND INSTRUCTIONS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 8/9/2001
Addressee(s) and Addressee Status: Norfolk Southern Corporation (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Norfolk Southern Corporation
Date: 8/9/2001
Response: In previous correspondence dated June 27, 2000, the Safety Board noted the efforts of NS to improve employee compliance with company rules and instructions through efficiency testing knowledge of field supervisors; this was accomplished by developing and issuing to all field supervisors the Supervisors Guidelines for Conducting Efficiency Checks and Instructions for Accessing the Rules Program. Because a student engineer was on board one of the trains involved in the Butler, Indiana, collision, the Safety Board also commended the NS for its intentions to hold student engineers to the same safety standards and responsibilities that engineers must meet; this was accomplished by revising NS Operating Rule 106, which addresses crewmember responsibilities when rules infractions by other crewmembers are observed. Safety Recommendation R-99-15 was classified "Open--Acceptable Response," pending notification that Rule 106 had been revised. The NS has informed the Safety Board that the Rules Committee has reviewed Rule 106 and has determined that the rule, as written, would be applicable to student engineers and that, consequently, no changes are deemed necessary. The Safety Board agrees with this interpretation. Consequently, based on NS's previous efforts to improve the effectiveness of field supervisors as they monitor employee compliance with company rules and instructions, Safety Recommendation R-99-15 is classified "Closed--Acceptable Action."

From: Norfolk Southern Corporation
To: NTSB
Date: 12/27/2000
Response: Letter Mail Controlled 01/03/2001 5:15:39 PM MC# 2010002: As stated in our letter of October 26, 1999, NS Operating Rules Committee undertook an in-depth review of Operating Rule 106. The Rules Committee, which is comprised of representatives from Transportation, Safety, Engineering, Mechanical, Operating Rules, Law, Human Resources and Transportation Planning, is charged with the responsibility of evaluating and formulating constructive recommendations to enhance Operating Rules and procedures. After due consideration of the proposed rule revision, the committee concluded that Rule 106, as written, addresses the responsibilities of the student engineer. The second paragraph of Operating Rule 106 states: "Other members of the crew must call attention of conductor or engineer immediately to any apparent failure to observe requirements of rules, timetable, train orders, messages or other instructions." The rule continues: "When conditions require stopping the train or reducing speed and the engineer or conductor fails to take proper action to do so, or should the engineer become incapacitated, other crew members must take necessary action to stop the train." Since student engineers are considered as an "Other Crew" member under Rule 106, they are held to the same safety standards and accountabilities as any other member of the crew. NS considers that Rule 106, as written, and the other procedures implemented as outlined in this letter and our letter of October 26, 1999, adequately address the required actions necessary to bring closure to R-99-15.

From: NTSB
To: Norfolk Southern Corporation
Date: 6/27/2000
Response: THE SAFETY BOARD WAS PLEASED TO LEARN THAT THE NS HAS DEVELOPED AND ISSUED NEW WRITTEN GUIDELINES TO IMPROVE THE EFFECTIVENESS OF FIELD SUPERVISORS AS THEY MONITOR EMPLOYEE COMPLIANCE WITH COMPANY RULES AND INSTRUCTIONS. WE ALSO COMMEND THE NS'S INTENTION TO HOLD STUDENT ENGINEERS TO THE SAME SAFETY STANDARDS AND RESPONSIBILITIES THAT ENGINEERS MUST MEET. PENDING NOTIFICATION THAT OPERATING RULE 106 HAS BEEN REVISED, THE SAFETY BOARD HAS CLASSIFIED H-99-15 "OPEN--ACCEPTABLE RESPONSE."

From: Norfolk Southern Corporation
To: NTSB
Date: 10/26/1999
Response: Letter Mail Controlled 10/28/1999 4:23:24 PM MC# 991193 WHILE INSTRUCTIONS FOR USING THE SYSTEM HAVE PREVIOUSLY BEEN ISSUED BY LETTER TO DIVISION SUPERINTENDENTS, IT WAS FOUND THAT NOT ALL SUPERVISORS HAD READY ACCESS TO THE INSTRUCTIONS. IN ORDER TO IMPROVE EFFICIENCY TESTING KNOWLEDGE OF FIELD SUPERVISORS, THE SUPERVISOR'S GUIDELINES FOR CONDUCTING EFFICIENCY CHECKS AND INSTRUCTIONS FOR ACCESSING THE RULES PROGRAM (RULES PROGRAM MANUAL) WAS DEVELOPED AND ISSUED TO ALL FIELD SUPERVISORS ON 11/1/98. IN ADDITION TO THE RULES PROGRAM MANUAL, THE NS COMPUTERIZED SYSTEM INCLUDES MANY HELP SCREENS AND ON-LINE HELP IS AVAILABLE TO USERS OF THE SYSTEM. THE RULES PROGRAM MANUAL REQUIRES THAT SUPERVISORS CONDUCT EFFICIENCY CHECKS ON LOCOMOTIVE ENGINEER TRAINEES, AS WELL AS COACH-TRAINED LOCOMOTIVE ENGINEERS, TO INSURE THAT THE REQUIREMENTS OF CATEGORIES 1, 2, AND 3 ARE COMPLIED WITH IN ALL ASPECTS. THE SPECIFIC INSTRUCTIONS TO SUPERVISORS COVERED IN CATEGORIES 1 THROUGH 3 ARE AS FOLLOWS: CATEGORY 1 - SIGNALS INDICATING STOPS (NS RULE 240, NORAC RULE 241); CATEGORY 2 - MOVEMENTS AT RESTRICTED SPEED (NS RULES 11, 93, 105, 180, 239, 245, 290, 309, 402, 423, 425, 431, 461, 462 AND NORAC RULES 80, 96, 97, 98, 241, 290, 291, 402, 501, 502, 550, AND 562); CATEGORY 3 - SPEED RESTRICTIONS (NS RULE 109 AND NORAC RULE 124). IN ADDITION TO THE TYPES OF TESTS LISTED ABOVE, THE RULES PROGRAM MANUAL ALSO PLACES INCREASED EMPHASIS ON THE FOLLOWING EMPLOYEE EFFICIENCY TESTS, AND DEFINES THE MINIMUM NUMBER OF CHECKS EACH SUPERVISOR IS TO PERFORM: YARD LIMITS; SWITCHING, HANDBRAKES, SHOVING, SWITCHES AND DERAILS; BLUE SIGNALS; RULES FOR EQUIPMENT OPERATION AND HANDLING; HAZARDOUS MATERIALS; RULE G-DRUG AND ALCOHOL PROHIBITIONS; TRACK WARRANT CONTROL; ROADWAY WORKER PROTECTION; AND ON-TRACK EQUIPMENT. IN ORDER TO FURTHER ENSURE THAT RULES AND INSTRUCTIONS ARE FOLLOWED ON BOARD A LOCOMOTIVE, NS IS IN THE PROCESS OF REVISING OPERATING RULE 106 IN ORDER TO HOLD THE STUDENT ENGINEER TO THE SAME SAFETY STANDARDS AND OPERATING RESPONSIBILITIES OF PROMOTED ENGINEERS. AS REVISED, RULE 106 IS EXPECTED TO READ AS FOLLOWS: "IN THE APPLICATION OF THIS RULE, A STUDENT ENGINEER OPERATING A TRAIN UNDER THE SUPERVISION OF A COACH-TRAINED ENGINEER IS CONSIDERED TO HAVE THE SAME OPERATING RESPONSIBILITIES AS THE ENGINEER OF THE TRAIN." ON 4/28/98 NS ISSUED ANOTHER BULLETIN (ATTACHED AS APPENDIX 3) TO CLARIFY OPERATING RULE 34. THE THIRD PARAGRAPH OF OPERATING RULE 34 STATES THAT: "WHEN CALLING A SIGNAL, YOU MUST COMMUNICATE ITS ASPECT WITH OTHER CREW MEMBERS WHEN THE SIGNAL FIRST COMES INTO VIEW AND AGAIN BEFORE THE SIGNAL IS PASSED. IN ADDITION, THE SIGNAL MUST BE CALLED ON THE RADIO. THIS INCLUDES SIGNALS DISPLAYING A 'CLEAR' ASPECT."