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Safety Recommendation Details

Safety Recommendation R-99-016
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 PROCEDURES THAT ACTIVELY ENGAGE CREWMEMBERS IN OBSERVING AND CONFIRMING ALL SIGNAL ASPECTS.
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): Crew Resource Management

Safety Recommendation History
From: NTSB
To: Norfolk Southern Corporation
Date: 8/9/2001
Response: The Safety Board notes that NS Operating Rule 34 was revised effective January 21, 2000, and now requires a designated employee to communicate by radio the name and location of each signal affecting movement. The Board also notes that the NS efficiency check system includes a provision for reviewing voice tape recordings to monitor recorded crew radio announcements. Based on your response, Safety Recommendation R-99-16 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: NS Operating Rule 34 was revised effective January 21, 2000 by Operations Division Bulletin. The fifth paragraph of Operating Rule 34 now reads as follows: "The conductor, or a conductor trainee or trainman in the absence of the conductor, when riding on the controlling locomotive will communicate by radio the name and location of each signal affecting his movement as soon as the signal becomes visible. When there is no conductor, conductor trainee, or trainman, the engineer or engineer trainee will communicate the signal information." The Rules Committee did review the proposed recommendation that train crews be required to maintain written record of all signal aspects governing their movement. However, the committee felt that the revision to Operating Rule 34 effectively accomplished the objective of crew members' alertness with respect to observing and confirming all signal aspects. Note also that radio broadcasts of signal aspects occur at the actual time signals are seen, and written records could be postponed until later. As outlined in NS' original response to R-99-16, our efficiency check system already includes a provision for reviewing voice tape recordings. Compliance with Operating Rule 34 can be checked as our radio base stations are both monitored and recorded. Thus, a record of crew radio announcements (such as calling signals) is available. All of our dispatching offices are equipped with reel-to-reel tape machines or digital recorders. The reel-to-reel machines record constantly while the digital machines record only when transmissions are detected. The reel-to-reel tapes are rotated between 7 to 30 days, depending on the office. The digital recorders usually have two tapes per recording territory. The tapes are maintained until they become full and are then rotated. With the revision of Operating Rule 34 and implementation of the NTSB recommended crew resource management training, NS believes that it has fully addressed NTSB recommendation R-99- 16, bringing closure to this recommendation.

From: NTSB
To: Norfolk Southern Corporation
Date: 6/27/2000
Response: THE SAFETY BOARD COMMENDS THE NS FOR AGREEING TO REVISE RULE 34 AND FOR CONSIDERING THE USE OF A WRITTEN RECORD OF SIGNAL ASPECTS. WE ALSO APPRECIATE THE NS'S INTENTION TO AMEND ITS RULES TO MAKE CONDUCTORS RESPONSIBLE FOR CALLING THE ASPECT OF ALL SIGNALS VIA RADIO. PENDING COMPLETION OF THESE ACTIONS THE SAFETY BOARD HAS CLASSIFIED R-99-16 "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 CURRENTLY, NS OPERATING RULE 34 DOES NOT DEFINE WHICH MEMBER OF THE CREW IS REQUIRED TO ANNOUNCE A SIGNAL VIA RADIO. THE NS RULES COMMITTEE WILL AMEND THE RULES TO REQUIRE A CONDUCTOR ON THE CONTROLLING UNIT TO BE RESPONSIBLE FOR CALLING THE ASPECT OF ALL SIGNALS VIA RADIO. NS RULES DO NOT REQUIRE THAT A WRITTEN RECORD BE KEPT OF THE SIGNAL ASPECTS THAT A TRAIN AND ENGINE CREW ENCOUNTER EN ROUTE. NS HAS RECEIVED COPIES OF THE INSTRUCTIONS USED BY OTHER RAILROADS OUTLINING THE REQUIREMENTS FOR REPORTING RESTRICTIVE SIGNALS. NS IS CONSIDERING THESE INSTRUCTIONS FOR USE IN NS OPERATIONS. NS BELIEVES THAT PORTIONS OF THESE INSTRUCTIONS MAY HAVE APPLICABILITY AND WILL BE IMPLEMENTED IF NO OTHER RULES ARE ADVERSELY AFFECTED.