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Safety Recommendation Details

Safety Recommendation R-09-003
Details
Synopsis: On Friday, November 30, 2007, about 11:23 a.m., Amtrak (National Railroad Passenger Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck the rear of standing Norfolk Southern Railway Company freight train 23M near Chicago, Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and five crewmembers were transported to hospitals; two passengers and one crewmember were subsequently admitted. The weather was clear, and the temperature was 30º F. Estimated damage was $1,299,000.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require that emergency exits on new and remanufactured locomotive cabs provide for rapid egress by cab occupants and rapid entry by emergency responders.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Chicago, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA-08-MR-003
Accident Reports:
Report #: RAR-09-01
Accident Date: 11/30/2007
Issue Date: 4/2/2009
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: FRA
To: NTSB
Date: 3/22/2019
Response: -From Ronald L. Batory, Administrator: As noted in previous FRA correspondence in response to NTSB Safety Recommendation R-09-03 , since NTSB's issuance of the Recommendation, FRA has actively analyzed, researched, and acted to address the issue of locomotive egress and crew rescue. FRA has collaborated on the issue with the railroad industry through the Railroad Safety Advisory Committee, the American Public Transportation Association, and the Association of American Railroads (AAR). As also noted in previous FRA correspondence, informed by this industry collaboration, AAR revised the industry standard for locomotive crashworthiness-AAR Standard S-580-to increase the required strength of the cab's structure, which greatly increases survivable cab volume for locomotive occupants during a collision. Therefore, the revised standard increases the likelihood that locomotive cab exits will be accessible after a collision, improving egress for cab occupants and entry by emergency responders. The standard applies to both new and rebuilt locomotives and has been incorporated into FRA's locomotive safety standards regulations (49 Code of Federal Regulations Part 229). FRA believes that the updated AAR Standard will allow sufficient access to exits in locomotive cabs after a collision, ensuring cab occupants have a way to rapidly exit the cab, and emergency responders a way to rapidly enter the cab. During the collaboration noted above, FRA also discussed with industry the possibility of adding egress and access points to locomotive cabs (e.g., roof hatches or removable windows) to address NTSB' s recommendation. While industry opted not to pursue developing a standard addressing access points on a locomotives cab now, FRA understands that several locomotive builders are building new locomotives with additional egress and access points, and several railroads have acquired new locomotives with roof hatches. At least one railroad has acquired new locomotives with removable side windows. FRA also notes (as it did in its February 12, 2015 response) that in over 15 years, FRA data indicates that only one injury occurred attributable to "opening" or "getting out" of a locomotive cab after an accident. Imposing a regulatory requirement to address one injury in over 15 years cannot be justified from a cost benefit perspective, particularly when the industry has voluntarily taken action to address the concern by updating AAR Standard S-580 and FRA has taken additional action in the form of training for emergency responders in the rescue of locomotive occupants (discussed further in FRA's February 12, 2015, letter). For the reasons discussed above, FRA will take no further action on Safety Recommendation R- 09-03, and respectfully requests the NTSB close the Recommendation. I appreciate your interest in these important safety issues. If FRA can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer.

From: NTSB
To: FRA
Date: 8/11/2016
Response: We acknowledge the progress you have made with respect to developing and distributing the training video for emergency responders addressing the best methods for entering a locomotive cab that is not in an upright position. However, we do not agree with your position that the recently implemented Association of American Railroads Standard S-580 will adequately address the problem of rapid egress from, or entry to, locomotive cabs, because the standard does not define modular cab or subfloor, which we consider essential. Further, it specifies that requirements for the 400,000-pound vertical load for modular cabs apply only to locomotives built after July 1, 2017, and not to all locomotives, as we recommend. We point out that we have not suggested that escape hatches be integrated into the locomotive roof area or that that any modification be made that might interfere with locomotive securement, and accordingly urge you to reconsider your position. In the meantime, Safety Recommendation R-09-03 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 2/12/2015
Response: -From Sarah Feinberg, Acting Administrator: This letter is to update you on the status of the National Transportation Safety Board's (NTSB) Safety Recommendations R-09-03, R-12-21 and R-1 2-22, R-12-39 through R-12-41 , and R-13-05, issued to the Federal Railroad Administration (FRA). These recommendations were assigned to our Motive Power and Equipment Division for issues pertaining to rapid egress of occupants and entry of emergency responders, crashworthiness standards, and detection of signal-emitting portable electronic devices. In the enclosure, FRA responds to the safety recommendations and explains the actions FRA has taken in response to the recommendations. Therefore, FRA respectfully requests that the NTSB classify Safety Recommendations R-09-03 and R-1 3-05 as "Closed- Acceptable Alternate Action," and Safety Recommendations R-12-22 and R-12-41 as "Closed Reconsidered." Additionally, FRA respectfully requests that Safety Recommendations R-12-21, R -12-3 9, and R -12-40 remain as "Open-Acceptable Response." I look forward to continuing to work with you on important safety issues. The Federal Railroad Administration's (FRA) review of reported accident data for the last 15 years revealed one injury attributed to "opening" (FRA accident code 49), or "getting out" (FRA accident code A6), of a locomotive cab after an accident. Although during this same time period a railroad also reported one fatality as attributable to getting out of or opening a locomotive cab, FRA believes that the railroad misapplied the accident code. According to the narrative included in the railroad's report, the individual was crushed under the rolled locomotive. This indicates that he exited or was ejected from the cab during the accident, rather than being prevented from making rapid egress, as the accident codes suggest. Thus, based on the safety data, it would be an imprudent use of FRA resources to establish regulatory requirements to address a potential safety hazard that resulted in only one injury in the last 15 years. Moreover, the new rail-industry crashworthiness standard will increasingly reduce the number of potential injuries and fatalities related to the rapid egress by cab occupants and rapid entry by emergency responders, as compliant locomotives become a larger portion of the industry fleet. The recent implementation of the new Association of American Railroads Standard S-580, applicable to all new or rebuilt locomotives, increased the strength of the cab's structure, which greatly increased the survivable volume for occupants. The greater survivable volume increases the likelihood that the exits will be accessible. The increased accessibility of the existing exits improves egress by cab occupants and entry by emergency responders. In addition, FRA believes that the National Transportation Safety Board (NTSB) has not fully considered the positive effects of the emergency responder training that FRA developed and distributed after this safety recommendation was originally made. FRA gave the video to emergency responders nationwide. The video depicts possible rescue procedures, including the best methods for entering a locomotive cab that is not in an upright position. This education increases the likelihood that emergency responders will be able to rapidly enter the locomotive cab after an accident. Finally, further action in this area would conflict with FRA implementation of its responses to other related NTSB recommendations. For example, implementation of Positive Train Control (PTC) requires railroads to install additional antennas on the cab roof limiting space available for potential escape/rescue hatches that could provide for rapid access and egress. Also, FRA rulemakings directed at securing the cab against intruder entry would be compromised by changes such as additional emergency access instruction labels on cab exterior access points. An intruder equipped with common tools could use the emergency entry instructions to force his way into the cab.

From: NTSB
To: FRA
Date: 1/15/2014
Response: Our last letter from the FRA regarding this recommendation was dated May 20, 2009. Based on information contained in that letter, on December 17, 2009, we classified Safety Recommendation R-09-3 “Open—Acceptable Response.” We continue to believe that the circumstances of the Chicago, Illinois, accident provide added impetus for the FRA to reconsider the issue of rapid egress from, and ingress to, locomotive cabs. Accordingly, pending our receipt of an update from the FRA regarding action to satisfy Safety Recommendation R 09-3, the recommendation is classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FRA
Date: 12/1/2011
Response: CC# 201100449 was closed administratively; no response was written or mailed.

From: FRA
To: NTSB
Date: 4/12/2011
Response: -From Ray LaHood, Secretary of the United States Department of Transportation: NTSB Classification and Actions Taken by FRA: Open – Acceptable Response. FRA shares the NTSB’s concern that means of rapid egress and rescue access be provided for locomotive cabs. FRA regulations require that locomotives manufactured on or after January 1, 2009, provide for emergency egress. See 49 CFR § 229.206. FRA has also funded research into locomotive egress and crew rescue. Moreover, FRA has developed and disseminated a training video titled, “Locomotive Emergency Response Operations,” to local emergency responders throughout the country and is exploring additional educational opportunities. FRA will present this recommendation and its actions to RSAC’s Locomotive Standards Working Group for further consideration. NTSB has advised that pending FRA’s implementation of a requirement that emergency exits provide for rapid exit by crewmembers and rapid entry by emergency responders, this safety recommendation is classified “Open-Acceptable Response.” Actions Needed to Be Taken by FRA: Continue educational efforts. Consult with RSAC.

From: NTSB
To: FRA
Date: 12/17/2009
Response: The FRA indicates that it shares the NTSB’s concern about rapid egress and rescue access for locomotive cabs. This concern was addressed in part by a design requirement codified in a final rule on June 28, 2006, in 49 Code of Federal Regulations (CFR) 229.206. The FRA’s design requirements have been included in the Association of American Railroad Locomotive Crashworthiness Requirement’s Standard S-580 and incorporated by reference. Section 6.3.1 of S-580, which applies to locomotives manufactured after December 31, 2008, states, “The locomotive cab must allow for exit through at least one opening (e.g. engineer’s side door, nose door, windows) in any locomotive orientation.” However, one opening may not be adequate or may not always function as intended, which was the case in this accident. Recognizing this, the FRA funded research into locomotive egress and crew rescue. A roof-mounted escape hatch concept was developed. In addition, a windshield system that could be removed from inside or outside the locomotive cab and a rear door hinge system that could be removed from inside or outside the locomotive cab were examined. The NTSB notes that the FRA took the initiative a step further, acknowledging that it might not be possible to modify existing locomotives or that train crewmembers might not be able to exit the locomotive on their own. The FRA developed a training video, titled “Locomotive Emergency Response Operations,” and provided 15,000 copies to local fire departments, police departments, and other emergency responders throughout the country to inform them of how best to respond to railroad accidents. In conjunction with the National Fire Administration, the FRA is looking into developing course material based on the video to provide to various state fire academies to be used in their syllabi, and the FRA also has locomotive cab mock-ups, used in the filming of the video, that it may provide to firefighter training centers. The NTSB believes that the circumstances of the Chicago, Illinois, accident have provided added impetus for the FRA to reconsider the issue of rapid egress from and ingress for locomotive cabs. The NTSB notes that the FRA will present this recommendation to the Railroad Safety Advisory Committee’s Locomotive Standards Working Group for further consideration. Pending the FRA’s implementing a requirement that emergency exits provide for rapid exit by crewmembers and rapid entry by emergency responders, Safety Recommendation R-09-3 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 5/20/2009
Response: Letter Mail Controlled 6/2/2009 4:37:02 PM MC# 2090347: - From Joseph C. Szabo, Administrator: The Federal Railroad Administration (FRA) shares the Board’s concern that means of rapid egress and rescue access be provided for locomotive cabs. The applicable language of the final rule on Locomotive Crashworthiness, codified at Title 49 Code of Federal Regulations Section 229.206, requires locomotives manufactured on or after January 1, 2009, to have a provision for emergency access as required in Association of American Railroads Standard S-580. Section 6.3.1 of S-580, which was revised in parallel with the FRA rulemaking, provides as follows: The locomotive cab must allow for exit through at least one opening (e.g. engineer’s side door, nose door, windows) in any locomotive orientation. Recognizing that means of egress may not always function as intended after a severe accident, FRA funded research into locomotive egress and crew rescue. After analysis of feedback from locomotive cab crews and rescue personnel, a roof-mounted escape hatch concept was developed. In addition, secondary emergency egress concepts were developed utilizing a windshield system that could be removed from inside or outside the locomotive cab, and a rear door hinge system that can be removed from inside or outside the locomotive cab. Recognizing that it may not be possible to modify existing locomotives and that crew members are not always ambulatory following a severe accident, FRA developed a 28-niinute training video titled Locomotive Emergency Response Operations and provided 1 5,000 copies to local fire departments, police departments, and other emergency responders throughout the country to educate and make them aware of how to best respond to railroad accidents. The video explains the best approach for the emergency responders to utilize when approaching an accident, how to ensure their own safety, and the inherent dangers of the railroad equipment and the tracks. Along with the video, emergency responders are provided with a list that contains the telephone numbers for the major railroads and FRA regional offices, a checklist they should use when approaching the accident site, instructions on entering the locomotive, and a checklist on how to provide flagging for oncoming trains. I am enclosing a copy of these materials for your information. The FRA is presently looking at the possibility of developing course material based on the video in conjunction with the National Fire Administration, and providing the course material to various State fire academies to be used as part of their curricula. FRA also has drawings of locomotive cab mock-ups used in the filming of the video and is looking into providing them to firefighter training centers for trainees to utilize. The Board’s presentation of this recommendation and the circumstances of the Chicago accident provide additional impetus for consideration of these issues. Accordingly, as soon as practicable, FRA will present this recommendation and its actions to date, to the Railroad Safety Advisory Committee’s Locomotive Standards Working Group for further consideration. FRA will report to you the results of those discussions when complete. As always, participation of Board staff will be appreciated. Based upon this response, FRA respectfully requests that NTSB classify Safety Recommendation R-09-03 as Open-Acceptable Action.