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Safety Recommendation Details

Safety Recommendation R-99-025
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 EASBOUND CONSOLIDATED RAIL CORPORATION (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, 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 THE CLASS I RAILROADS AND AMTRAK: IN COOPERATION WITH THE FEDERAL RAILROAD ADMINISTRATION, THE AMERICAN SHORT LINE AND REGIONAL RAILROAD ASSOCIATION, THE BROTHERHOOD OF LOCOMOTIVE ENGINEERS, AND THE UNITED TRANSPORTATION UNION, DEVELOP, FOR ALL TRAIN CREWMEMBERS, TRAIN 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 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: 6/2/2004
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Closed - Acceptable Action)
BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Closed - Acceptable Action)
CSX Transportation, Inc. (Closed - Acceptable Action)
Kansas City Southern Railway Company (Closed - Acceptable Action)
Union Pacific (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Training and Education

Safety Recommendation History
From: NTSB
To: CSX Transportation, Inc.
Date: 6/2/2004
Response: The Safety Board discussed this recommendation with CSXT through contact with Mr. Wayne Workman, General Manager, Train Accident Prevention, who provided us a copy of CSXT's CRM training program for all train and engine service employees. The Board believes that this training addresses the four elements of the recommendation; accordingly, Safety Recommendation R-99-25 is classified "Closed--Acceptable Action."

From: NTSB
To: CSX Transportation, Inc.
Date: 4/22/2004
Response: Pat Sullivan spoke with Wayne Workman (904-359-1256), General Manager Train Accident Prevention, who stated that he would submit a copy of CSXT's Crew Resource Management training manual and video tape. Staff will review and determine if the intent of Safety Recommendation R-99-25 has been met.

From: NTSB
To: CSX Transportation, Inc.
Date: 5/17/2002
Response: CSXT's plan to bring its entire organization under one operating rulebook by midyear 2002, to teach CRM to all of its locomotive engineer trainees and new-hire conductors in 2002, and to provide CRM training throughout the year to employees deemed to need additional training are commendable. Accordingly, pending notification that these planned actions have been taken, Safety Recommendation R-99-25 remains classified "Open--Acceptable Response."

From: CSX Transportation, Inc.
To: NTSB
Date: 11/16/2001
Response: Letter Mail Controlled 01/23/2002 8:27:14 PM MC# 2020074 CSX recognizes the benefits of training our T&E employees in Crew Resource Management (CRM). This past year we consolidated most of the former Conrail property operating rules and practices into CSX practices. Approximately 20% of the former Conrail property continues to operate under the NORAC rules. We plan to accelerate this process to bring all of CSX under one operating rulebook by mid year 2002. We have progressed to the point that CRM will be taught in 2002 to all of our locomotive engineer trainees at our locomotive engineer's school in Cumberland, MD. And we plan to also teach CRM at all of our new hire conductor classes in 2002. CSX also has many training programs during the year directed at employees deemed to need additional training. These employees will also be provided training in CRM.

From: NTSB
To: CSX Transportation, Inc.
Date: 10/23/2001
Response: To date, we have not received any response from CSX Transportation, Inc., regarding this recommendation. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all our recommendations. A copy of the recommendation letter is enclosed. Please address your response to Ms. Marion C. Blakey, Chairman, National Transportation Safety Board, and refer to the recommendation by number.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 2/9/2001
Response: Mr. Grundmann provided to the Safety Board at a November 13, 2000, meeting attended by Safety Board staff, BNSF's "Crewmember Resource Management" manual and videotape. The manual and videotape together address crewmember proficiency, situational awareness, effective communications and teamwork, and strategies for appropriately challenging and questioning authority. Accordingly, Safety Recommendation R-99-25 to the BNSF is classified "Closed-Acceptable Action."

From: NTSB
To: Kansas City Southern Railway Company
Date: 7/12/2004
Response: Safety Board staff discussed this recommendation with Mr. Dennis Marzec, General Director of Rules and Training, who provided the Board a copy of the CRM training program and video that KCS assisted in developing for all train engine service employees. The Board has determined that this course addresses the four elements of the recommendation; accordingly, Safety Recommendation R-99-25 is classified "Closed--Acceptable Action."

From: NTSB
To: Kansas City Southern Railway Company
Date: 4/23/2004
Response: I am aware that KCS participated with the AAR in this endeavor and implemented a modified version. I need some supporting documentation, including a copy of the CRM training program. If you need further information, you can contact me at the telephone numbers below.

From: NTSB
To: Kansas City Southern Railway Company
Date: 1/27/2003
Response: In consideration of the KSC's participation in the Association of American Railroads' (AAR's) project to develop a CRM training program, this recommendation was classified "Open--Acceptable Response" on May 14, 2002. Mr. Davies' December 20, 2001, letter also indicated that KCS would be implementing a CRM training program in 2002. The Safety Board is interested in learning what progress has been made, both in the development of the AAR's training program in which the KSC is involved, and in the implementation of the KSC's program. Pending such update, Safety Recommendation R-99-25 remains classified "Open--Acceptable Response."

From: NTSB
To: Kansas City Southern Railway Company
Date: 5/14/2002
Response: Mr. Davies' letter indicates that the KCS is participating in the Association of American Railroads' project to develop a CRM training program. The letter also indicates that CRM training will be implemented in 2002 and delivered as part of the railroad's normal crew re-certification process. Accordingly, Safety Recommendation R-99-25 is classified "Open-Acceptable Response," pending completion and implementation of a CRM training program that includes the elements listed above. We would appreciate being informed when the training has been implemented.

From: Kansas City Southern Railway Company
To: NTSB
Date: 12/20/2001
Response: Letter Mail Controlled 02/11/2002 9:45:42 AM MC# 2020132 In cooperation with the Federal Railroad Administration, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers, and the United Transportation Union, develop, for all train crewmembers, train crew resource management training that addresses, at a minimum: * crew member proficiency, * situational awareness, * effective communication and teamwork, and * strategies for appropriately challenging and questioning authority. KCS participated on an Association of American Railroads sponsored committee, which has developed a Crew Resource Management training program. KCS plans to implement a modified version of this program through our computer based training (CBT) process for all KCS train crewmembers. We anticipate developing the CBT based - Crew Resource Management program in year 2002 and delivering it as part of our normal crew re-certification process. We feel this approach provides ready access to all train crewmembers, allows easy tracking of performance and will help ensure successful transfer of knowledge to the participants. Please contact Mark Vaughn (General Director Rules and Operating Practices, tel. 318-676-6168), Thomas A. Leopold (General Director Safety & Rules, 816-983-1941) or contact me if you should have any questions on this matter.

From: NTSB
To: Kansas City Southern Railway Company
Date: 10/30/2001
Response: To date, we have not received any response from the Kansas City Southern Railway Company regarding this recommendation. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all our recommendations. A copy of the recommendation letter is enclosed. Please address your response to Ms. Marion C. Blakey, Chairman, National Transportation Safety Board, and refer to the recommendation by number.

From: NTSB
To: Union Pacific
Date: 3/22/2002
Response: Your letter indicates that UP has coordinated with the American Association of Railroads in updating and enhancing UP's CRM program, and outlines the elements of the new program. UP also indicates its support for the recommendation, its commitment to expanding the key elements of CRM, and its continued commitment to using CRM in training, job briefings, efficiency testing, quality safety meetings, and safety contacts. Accordingly, Safety Recommendation R-99-25 is classified "Closed--Acceptable Action."

From: Union Pacific
To: NTSB
Date: 11/26/2001
Response: Letter Mail Controlled 01/29/2002 3:49:52 PM MC# 2020089 Union Pacific continues to use its Crew Resource Management (CRM) program as a training and awareness tool. Our CRM program was updated and enhanced last year in a collaborative project with the AAR. During the past few years, Union Pacific has expanded on the key elements of CRM that we use in training, job briefings, efficiency testing, quality safety meetings, and safety contacts. Crew Member Proficiency: In addition to new hire training and bi-annual rules exams, UP developed and implemented the Engineers Quality Management System (EQMS) and the Conductors Quality Management System'(CQMS). These are quality and data-driven tracking systems that analyze test scores, event recorder evaluations, ride evaluations, availability, discipline, and incidents, We also use simulators extensively for training, territory familiarization, and proficiency assessments. Effective communication and teamwork: Our focus on situational awareness and effective communication and teamwork have been formalized in Union Pacific's Red Zone initiative and in the Switching Operations Fatality Analysis (SOFA) program developed by railroad labor, management, and the FRA. Briefly, the Red Zone is defined as "that area within an arm's length of railroad track, or any physical position which places the employee in a life-threatening situation." This includes going between cars as well as when a train crew is proceeding on restrictive signal indication. Red Zones have been identified by all crafts and in all work environments. Strategies for Appropriately Challenging and Questioning Authority: The Union Pacific Employee Empowerment Policy, established in 1997, states that: Ø"No employee shall be required to perform any unsafe acts including any violations of law or Union Pacific rules; ØNo employee shall be disciplined , discriminated against or harassed as the result of his/her decision to empower themselves regarding safety issues that directly compromise personal safety." In addition, this is covered in the CRM section on "Conflict," and in the Cab Communication Quality Safety Meeting (QSM) which covers both communication techniques as well as conflict and conflict resolution.

From: NTSB
To: Union Pacific
Date: 10/30/2001
Response: To date, we have not received any response from the Union Pacific Corporation regarding this recommendation. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all our recommendations. A copy of the recommendation letter is enclosed. Please address your response to Ms. Marion C. Blakey, Chairman, National Transportation Safety Board, and refer to the recommendation by number.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 2/21/2001
Response: The Safety Board is pleased to learn that Amtrak not only supports the improvement of crew coordination and communications using Crew Resource Management (CRM) techniques, but has worked in conjunction with other Class I carriers and the Association of American Railroads in the development of a training curriculum. The Board also notes that CRM training modules, with videos, have been implemented at Amtrak’s Wilmington training facility and that Amtrak has briefed the Boards’ technical staff on its CRM training. Consequently, the Board believes that the intent of the recommendation has been met; therefore, Safety Recommendation R-99-25 is classified "Closed--Acceptable Action."

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 11/15/2000
Response: THE SAFETY BOARD IS PLEASED TO LEARN THAT AMTRAK SUPPORTS THE IMPROVEMENT OF CREW COORDINATION AND COMMUNICATIONS THROUGH THE USE OF CREW RESOURCE MANAGEMENT (CRM). WE ALSO APPRECIATE AMTRAK'S INVITATION FOR OUR STAFF TO ATTEND AMTRAK'S CRM TRAINING TO EVALUATE THE PROGRAM'S CONTENT. PENDING AN OPPORTUNITY FOR NTSB'S TECHNICAL STAFF TO ATTEND AND FULLY EVALUATE AMTRAK'S TRAINING, R-98-60 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 8/14/2000
Response: Letter Mail Controlled 08/21/2000 4:10:50 PM MC# 2001114 AMTRAK RECOGNIZES THE ONE METHOD OF IMPROVING CREW COORDINATION AND COMMUNICATION IS THROUGH TRAINING AND USAGE OF CRM. WE RECOGNIZE THAT CRM PROMOTES SAFE OPERATIONS BY EMPHASIZING THE EFFICIENT USE OF ALL RESOURCES TO ACHIEVE AND MAINTAIN BETTER COORDINATION OF ACTIVITIES. IN ORDER TO FURTHER ENHANCE CRM AT AMTRAK, WE HAVE IMPLEMENTED COURSE MODULES AT OUR WILMINGTON TRAINING CENTER THAT INCLUDES CRM MATERIAL AND VIDEOS. OUR PROGRAM WILL HIGHLIGHT EFFECTIVE COMMUNICATION, TEAMWORK, AND STRATEGIES TO BE USED BY OUR PERSONNEL TO ENSURE SAFE AND EFFICIENT RAILROAD OPERATIONS. WE BELIEVE THAT CRM WILL INCREASE CREWMEMBER PROFICIENCY AND SITUATIONAL AWARENESS OF OUR PERSONNEL DURING THEIR TOURS OF DUTY. ALSO, IN CONJUNCTION WITH THE OTHER CLASS I RAIL CARRIERS AND THE ASSOCIATION OF AMERICAN RAILROADS, AMTRAK PARTICIPATED IN THE DEVELOPMENT OF CURRICULUM FOR THE RAILROAD INDUSTRY ON THIS MATTER. AMTRAK HAS INVITED MEMBERS OF THE NTSB STAFF TO ATTEND ONE OF OUR MODULES, AT THEIR CONVENIENCE, TO SEE OUR FINAL PRODUCT.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 4/25/2000
Response: THE SAFETY BOARD COMMENDS AMTRAK FOR ITS ENGINEER TRAINING PROGRAM AND OTHER EXISTING PROGRAMS AIMED AT IMPROVING CREW MEMBER PROFICIENCY. THESE ACTIONS ARE A FIRST STEP TOWARDS TRAIN CREW RESOURCE MANAGEMENT (CRM) TRAINING. WE APPRECIATE AMTRAK'S COMMITMENT TO DEVELOP ITS OWN CRM TRAINING, INCLUDING YOUR INITIATIVE TO EXPLORE CRM PRINCIPLES AND TRAINING WITH YOUR BUSINESS PARTNERS THROUGH THE ASSOCIATION OF AMERICAN RAILROADS IN ORDER TO INCREASE THE EFFECTIVENESS OF AMTRAK'S PROGRAM. PLEASE KEEP US INFORMED OF YOUR SUCCESS IN DEVELOPING AND IMPLEMENTING CRM. BASED ON YOUR RESPONSE, THE SAFETY BOARD HAS CLASSIFIED R-99-25 "OPEN--ACCEPTABLE RESPONSE."

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 4/5/2000
Response: A MEETING WAS HELD ON 4/5/00 BETWEEN NTSB AND AMTRAK TO A FOLLOW-UP OF 7 OPEN SAFETY RECOMMENDATIONS WHERE AMTRAK STATED WHAT ACTION HAS OCCURRED OR IS PLANNED. AMTRAK WILL PROVIDE A WRITTEN RESPONSE BASED ON THE OUTCOME OF THE MEETING.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/20/1999
Response: AMTRAK HAS AGREED TO PARTICIPATE THROUGH THE AAR IN A STRUCTURED INITIATIVE REGARDING TRAIN CREW RESOURCE MANAGEMENT TRAINING. THE IMPORTANCE OF DEVELOPING CREW RESOURCE MANAGEMENT SKILLS IS RECOGNIZED AND EMBRACED. AMTRAK IS COMMITTED TO FURTHER EXPLORE AND INITIATE TCRM PRINCIPALS AND TRAINING WITH ALL OUR BUSINESS PARTNERS TO INCREASE THE EFFECTIVENESS OF OUR PROGRAM AND SUPPLEMENT THE INDUSTRY IN A PARALLEL EFFORT. WE WILL PROVIDE PERIODIC REPORTS.