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Safety Recommendation Details

Safety Recommendation R-99-029
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, IN, STRUCK EASTBOUND CONSOLIDATED RAIL CORPORATION (CONRAIL) TRAIN TV 220, WHICH WAS EN ROUTE TO COLUMBUS, OH. 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 HARMON INDUSTRIES: IDENTIFY AND CONTACT ALL CUSTOMERS WHO PURCHASED ELECTRO CODE 4 UNITS MANUFACTURED FROM 1987 TO 1988, AND INSTITUTE A SYSTEMATIC CORRECTIVE PROGRAM FOR THE REPAIR OR REPLACEMENT OF FAULTY ELECTROLYTIC CAPACITORS.
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: 2/25/2003
Addressee(s) and Addressee Status: Harmon Industries, Inc. (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Harmon Industries, Inc.
Date: 2/25/2003
Response: In previous correspondence from Harmon Industries, dated August 11, 1999, the Safety Board was informed that a program had been initiated with the Federal Railroad Administration (FRA) and the railroads to replace the affected units. Although the Board has not received any further information directly from GE Transportation Systems-Global Signaling, we have received an update from the FRA regarding its follow-up process to ensure that the affected capacitors have been identified and are being replaced. In this regard, we note that since the FRA's Notice of Safety Advisory No. 2000-2 was published in June 2000, advising the rail industry of the need to immediately identify and replace or upgrade the capacitors in question, the FRA has worked closely with the railroads and GE Transportation Systems-Global Signaling to ensure that this replacement program is completed. As these actions are fully responsive to the intent of the Board's recommendation, Safety Recommendation R-99-29 is classified "Closed--Acceptable Action."

From: Harmon Industries, Inc.
To: NTSB
Date: 8/11/1999
Response: Letter Mail Controlled 8/12/99 12:52:50 PM MC# 990881 I am supplementing my letter to you dated August 3, 1999 with additional information concerning the Electro Code 4 issues addressed in our Product Improvement Announcement 98-101 ("PIA 98-101"). PIA 98-101 applies to modules 211S,211SRP, and 212A. PIA 98-101 states that the dates of manufacture at issue for modules 211S and 211SRP are between March 1994 and March 1998. PIA 98-101 did not state the manufacturing dates for module 212A. We hereby advise you that the manufacturing dates at issue for module 212A are approximately from 1984 through April 1998. We modified module 212A for all units sold after April 1998. We issued PIA 98-101 in May of 1998. We determined that it would not be useful to specify a manufacturing date range in PIA 98-101 for module 212A because the PIA applies to all 212A modules manufactured from Electro Code 4's introduction to the date we modified the module. We therefore recommended that the railroads upgrade all 212A modules. Our investigations after the Butler, Indiana accident identified multiple factors that, when combined, could have resulted in short periods of a dark signal. One of the factors was abnormal energy supplied to the Electro Code unit. Another factor was a failed capacitor on the 211 module. The final factor involved multiple capacitor failures on the 212A module. Failed capacitors on only one module did not cause a dark system in our tests. Nevertheless, we advised our customers in PIA 98-101 to upgrade all three of the modules in question. Electro Code is designed to provide the safest possible signal display even when operating with numerous failed components. In certain circumstances, a dark display is the safest display possible because it signals the train crew to stop the train. Our tests have shown that a failure combination involving all of the above-identified factors could result in an intermittently dark signal. Although there may be evidence of each of these factors at the Butler, Indiana site, the presence of the factors does not mean that the signal was dark at the actual time of the accident.