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Safety Recommendation Details

Safety Recommendation R-99-023
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: DESIGNATE DEDICATED PERSONNEL TO RECORD AND TRACK ALL SIGNAL MALFUNCTIONS AND REPAIRS IN ORDER TO IDENTIFY RECURRING, UNRESOLVED FAILURES.
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: The Safety Board notes that NS has revised its signal failure reporting process with designated Communications and Signal (C&S) personnel at its Atlanta Trouble Desk to record and track all significant signal malfunctions and repairs. The Board further notes that NS now has a conference call each weekday with the Chief Engineer, Regional Chief Engineers, and each of their C&S Division heads to discuss troubles in individual divisions. The Board appreciates your assurance that every signal trouble report on NS is tracked each day by division, region, and system personnel to ensure proper handling and closure. Accordingly, Safety Recommendation R-99-23 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 has enhanced its process to review and identify systemic Signal and Electric (S&E) failures. Dedicated personnel at the Atlanta C&S (Communication and Signal) Trouble Desk, staffed 24 hours a day, 7 days a week, record and track all significant signal malfunctions and repairs. The policy for reporting is outlined in NS' Standard Operations Procedures, C&S Department Procedure, Signal Failure Reporting, revised November 5, 1998, copy attached. Under the revised NS policy, trouble calls during normal duty will be called in at the end of or during the work period. When on overtime, the call is to made immediately upon completion of trouble call. The criteria for reporting an S&E Trouble Report is: 1. At the completion of any trouble call that involves (or possibly involves) a train delay (whether during normal duty or on overtime). 2. All broken rails and slide fence activation, even if no train delays. 3. All major occurrences, even if there are no train delays, such as code line outages, TSA outages, power outages, etc. Each report is entered in a database with an assigned condition code to identify the type of trouble. The database allows NS to institute a monthly review of all trouble categories to identify systemic problems that occur across the system. At the end of each month, a report of the previous month's occurrences, sorted by category, is provided to the five Chief Engineers for review. A review is conducted by the five Chief Engineers (the Regional Chief Engineers C&S, the Chief Engineers Signal Construction and Chief Engineer C&S Engineering). In addition, the database is reviewed by the AVP C&S and is available to the 12 C&S Division General Supervisors. The S&E Trouble Report was previously distributed in hard copy only. Now, it is posted on the C&S LAN for review by a greater number of personnel. The database of signal trouble reports for each month can be sorted and reviewed by trouble type, division, territory, location, etc. This enhances our ability to identify problem locations and systemic operational problems. NS has taken additional action to identify and correct C&S problems. A conference call held each weekday with the Chief Engineer, Regional Chief Engineers, and each or their C&S Division heads provides a forum for discussion of troubles on the individual divisions. As an additional means of communication, a signal trouble clearance form has been established on our electronic C&S bulletin board that allows maintainers to more easily report trouble closures. Every signal trouble report is tracked each day by division, region, and system personnel to insure proper handling and closure. Under our previous system of reviewing C&S troubles, NS was able to recognize and identify the light out problem with certain Harmon Electrocode equipment. In addition, we implemented a remediation program to correct the problem and bring it to the attention of other railroads. Unfortunately, the Butler incident occurred before the component replacement was implemented on the Lake Division. NS believes that its enhanced and revised process of S&E trouble reporting, the various system, regional and division reviews each month of the trouble call database, as well as improved electronic bulletin board forms and communication now fully addresses the Safety Board's concerns in Recommendation R-99-23. We believe this brings closure to this recommendation.

From: NTSB
To: Norfolk Southern Corporation
Date: 6/27/2000
Response: THE SAFETY BOARD IS AWARE THAT NS HAS PERSONNEL IN ATLANTA TO RECORD AND TRACK ALL REPORTED SIGNAL MALFUNCTIONS AND REPAIRS. HOWEVER, BOARD INVESTIGATORS FOUND DURING THIS INVESTIGATION THAT THE ATLANTA SIGNAL DESK DID NOT HAVE ANY RECORDS ABOUT SIGNAL PROBLEMS IN BUTLER BECAUSE THE PROBLEMS WERE CALLED IN ONLY IF THE SIGNAL PROBLEM HAD TAKEN AN EXTENDED TIME TO REPAIR. THE RECOMMENDATION WAS INTENDED TO ENSURE THAT TECHNICALLY QUALIFIED PERSONNEL ARE IN PLACE TO RECORD AND HANDLE SIGNAL TROUBLE REPORTS AS SOON AS THEY ARE REPORTED BY A TRAIN CREW TO ELIMINATE THE POSSIBILITY OF REPEATED TROUBLE REPORTS. THE SAFETY BOARD ASKS THAT THE NS DESIGNATE DEDICATED PERSONNEL AS REQUESTED IN THIS RECOMMENDATION. PENDING ADDITIONAL INFORMATION, THE SAFETY BOARD HAS CLASSIFIED R-99-23 "OPEN--UNACCEPTABLE RESPONSE."

From: Norfolk Southern Corporation
To: NTSB
Date: 10/26/1999
Response: Letter Mail Controlled 10/28/1999 4:23:24 PM MC# 991193 NS HAS PERSONNEL STATIONED IN ATLANTA, GA WHO RECORD AND TRACK ALL REPORTED SIGNAL MALFUNCTIONS AND REPAIRS. THESE PERSONNEL ARE QUALIFIED C&S COORDINATORS WHO MAN A 24-HOUR DESK. ANY VERIFIED OCCURRENCE OF SIGNAL FAILURE IS COMMUNICATED BY AT LEAST ONE OF THREE MEANS. THEY ARE: (1) DAILY TROUBLE REPORTS FROM THE SYSTEMS OPERATIONS CONTROL CENTER, (2) SIGNAL MAINTAINER OVERTIME REPORTS AND (3) WORK DAY CONFERENCE CALLS BETWEEN EACH LEVEL OF SUPERVISION AND THEIR REPORTS FOCUS HAS BEEN PLACED ON A HIGH LEVEL OF COMMUNICATION. THE COMMUNICATION IS A 360' LOOP. LISTED BELOW ARE THE POSITIONS INVOLVED IN THE COMMUNICATIONS LOOP: TRAIN CREWS REPORT SIGNAL TROUBLE TO DISPATCHER; DISPATCHER REPORTS TROUBLE TO MAINTAINER; MAINTAINER CORRECTS PROBLEM AND REPORTS TO COORDINATOR. IF UNABLE TO REPAIR PROBLEM, CONTACTS SUPERVISOR; COORDINATOR REPORTS ALL TROUBLES DAILY VIA MORNING REPORT; SUPERVISOR CHECKS ON TROUBLE REPORT AND METHODS OF REPAIR VIA MORNING REPORT; CHIEF ENGINEER SCRUTINIZES ENTIRE PROCESS FOR CORRECTIVE HANDLING TO PREVENT RECURRING SIGNAL TROUBLES.