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Update on Rail Safety Issues, Brotherhood of Locomotive Engineers and Trainmen, National Association of State Legislative Board Chairmen Annual Meeting, New Orleans, Louisiana
Deborah A. P. Hersman
Update on Rail Safety Issues, Brotherhood of Locomotive Engineers and Trainmen, National Association of State Legislative Board Chairmen Annual Meeting, New Orleans, Louisiana

Thank you, John (Tolman) for that introduction and for inviting me to join you today. It's great to be here in the "City of New Orleans." And, it's great to be back with railroaders - people who love trains - leaders who do so much to make railroads safe and successful.

I want to thank BLET for all the good work you do with our investigators and for your strong support of the NTSB. We have an important relationship. Your members and your safety teams have been routinely involved in our investigations and provide Safety Board investigators with invaluable information and insight on the unique operational aspects of an accident. This "added value" allows our investigators to ask more focused questions to obtain all information related to the accident. The safety team also helps the investigative process by helping to facilitate interviews with injured employees and the family members of employees.

Most recently, you have been involved in investigations in Westville, Indiana; and Cherry Valley, Illinois; and accidents in Kansas City, Missouri; and Bedford Park, Illinois, where employees involved in remote-control locomotive operation (RCO) were fatally injured.

Last month, we held our Board meeting on the June 2009 train derailment in Cherry Valley. An eastbound CN freight train, which consisted of two locomotives and 114 cars carrying ethanol, derailed at a highway/rail grade crossing. The ethanol release and resulting fire killed one person in a car waiting at the crossing and injured seven more. It also led to the mandatory evacuation of about 600 homes and caused nearly $8 million in damages.

This accident could serve as a case study for all modes of transportation about why safety management systems are so important. You can have safety procedures - and you can have employees designated to perform safety functions - but, unless you ensure those procedures are followed and employees are communicating effectively, they will not prevent accidents.

Since I joined the NTSB in 2004, we have investigated dozens of rail accidents. Today, I want to share with you some of the key lessons learned. I will touch briefly on four areas: Positive Train Control, restricted speed, distraction, and fatigue. Then, I'll be delighted to hear your comments and answer your questions - always the most valuable part of a gathering like this.

Positive Train Control

In our investigations, the NTSB always looks at the human, the machine, and the environment. What we are finding is that while the machines that railroads use are built to be more reliable and the environment that railroaders work in is designed with more redundancies, the railroader is still a human. Humans are fallible and make mistakes, yet operational accidents - whether on the mainline or in yards or at grade crossings - can be prevented with technology, notably Positive Train Control (PTC).

Steve Klejst, our director of the Office of Railroad, Pipeline, and Hazardous Materials Investigations, was just at PTC World Congress in Orlando where he made a presentation on PTC's safety benefits.

We are disappointed about possible delay of PTC. As you may know, there are proposals in Congress being considered to extend the current PTC implementation deadline of December 31, 2015. No action has yet been taken.

As good and as experienced and as well trained as the locomotive engineer and trainmen are, the fact is that the human is the weak link and it's important to have a system designed to be fail safe. PTS will do that.

Restricted Speed

Yes, there's technology, like PTC, but the engineer has ultimate responsibility for the operation of the train. It's important to operate at a speed that assures you have the ability to control the train.

You all know this. Yet, our investigations of six rear-end collisions in the past twelve months raised a flag about safe train operations relying on crewmember compliance with the railroad's restricted speech requirements. Two of these six collisions resulted in fatalities.

Red Oak, Iowa, April 17, 2011

Low Moor, Virginia, May 21, 2011

Mineral Springs, North Carolina, May 24, 2011

DeWitt, NY, July 6, 2011

DeKalb, Indiana, August 19, 2011

Westville, IL, January 6, 2012

This is why in January we urged both BLET and the United Transportation Union to work collaboratively with members, carriers, and the Federal Railroad Administration to ensure compliance of train and engine crews with speed restrictions.

It's essential that you educate your membership about the importance of operating their trains in accordance with restricted speed operating rules. You should also work with your railroads to identify the potential for similar occurrences and take appropriate mitigating actions.


This is an issue of growing concern. We have seen it in all modes of transportation. In rail, the NTSB identified distraction due to text messaging as the cause of a commuter train engineer's running a red signal in suburban Los Angeles in September 2008. The result: a head-on collision with a freight train, killing 25 and injuring dozens. The engineer, who had a history of using his cell phone for personal communications while on duty, sent and received 250 text messages during the three days leading up to the accident.

This past December, we issued our boldest recommendation yet: We called for a nationwide ban on the use of portable electronic devices while driving. It's time to change the conversation about distraction. We need to begin a new chapter and figure out how to change attitudes and change behavior. We must focus on getting attention back into the driver's seat.

This is why the NTSB is holding a forum next week on Attentive Driving: Countermeasures for Distraction. We are bringing in experts from academia, government, and industry to share the current state of knowledge about human behavior, technology, and safety.

This is a topic that affects everyone. This forum will be streamed live via the NTSB website. I hope you can join us.


Fatigue is a serious safety issue. Over the years, the NTSB has investigated numerous accidents across all modes of transportation in which fatigue was cited as the probable cause or a contributing factor. Last year, the NTSB once again placed fatigue on its Most Wanted List of transportation safety improvements.

Tired operators pose a safety risk because fatigue can degrade every aspect of human performance. It slows reaction time, impairs judgment, and degrades memory. Fatigue is complex, multifaceted, and we all have a role to play in eliminating fatigue in transportation.

Addressing fatigue is a three-legged stool - individuals, regulators, and employers. It's up to the individual employee to make sure that he or she is not fatigued or drowsy at work by reporting for duty well rested and prepared to assume their duties. Regulators have a role to play in establishing hours-of-service regulations that provide a safety net for workers as well as by setting standards that will help to identify and mitigate fatigue.

I commend FRA on the new hours-of-service rule it issued in October. The new rule improves the work-rest issues of train and engine-service employees. While there is still a significant issue with the lengthy time it sometimes takes for an employee to travel from home to work, the new rule does improve the work-rest issues of train and engine service employees. It also limits the total time on duty for both freight and passenger service employees. Further, it addresses the differences between freight and passenger operations, e.g., unpredictable reporting times for freight vs. predictable reporting times and rest days for passenger rail. The new rule also requires employees in passenger service to receive periodic fatigue training.

Yes, addressing fatigue is complicated. It's good that the new rule requires employees in passenger service to receive fatigue training. In addition, fatigue management plans are required, and passenger carriers would benefit from a plan that addresses unscheduled work. In addition, employers should develop guidance and rules for proper screening, detection, and treatment for sleep disorders, like obstructive sleep apnea, as well as address the scheduling challenges of a 24/7 workplace.

In closing, in his book Death Rode the Rails, Mark Aldrich wrote that early in the last century, railroads annually killed or maimed tens of thousands of workers, passengers and trespassers. From 1882 to 1912, nearly half of all U.S. deaths were from railroad accidents. Typhoid fever, a distant second, accounted for just 7 percent. Mark Twain mocked the public worries. He said that rail travel was not as dangerous as sleeping - since many more people died in bed.

There is no mocking now. As an industry, look at how far you have come. From thousands killed on the job a century ago to an annual average of 20 over the past ten years.

Things have changed. Rail travel is safer. And much credit for the improvement should go to the Brotherhood of Locomotive Engineers and Trainmen (BLET) and its members.

Thank you for all that you do. Now, I'm delighted to hear your comments and take your questions.