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Safety Recommendation Details

Safety Recommendation R-12-017
Details
Synopsis: On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway (BNSF) coal train C-BTMCNMO-26, BNSF 9159 East, travelling about 23 mph, collided with the rear end of standing BNSF maintenance-of-way (MOW) equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost (MP) 448.3 on main track number two on the Creston Subdivision of the BNSF Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Red Oak, IA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA11FR002
Accident Reports: Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train
Report #: RAR-12-02
Accident Date: 4/17/2011
Issue Date: 5/10/2012
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 12/1/2015
Response: We are encouraged that the FRA is developing a rule requiring each covered railroad to include a fatigue management plan in its RRP and to review and revise, as necessary, this fatigue management plan at least every 2 years. We are also encouraged that you intend to review railroads’ RRPs to ensure compliance, in accordance with the RSIA. We support your research and employment of biomathematical models to examine the schedules of employees involved in human performance?related accidents and your use of railroad data to validate and calibrate the two models currently in use. Further, we are pleased that you have developed a protocol for validating and calibrating any models that might be developed in the future and that you intend to continue learning from the practical application of biomathematical models to railroads’ fatigue management plans. Accordingly, pending the timely issuance of a final rule that satisfies Safety Recommendation R-12-17, it is classified OPEN—ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 2/11/2015
Response: -From Sarah Feinberg, Acting Administrator: Section 20156(d)(2) mandates that FRA issue regulations requiring each covered railroad to include a Fatigue Management Plan in its RRP that meets the requirements of Section 20156(±). In particular, the regulations must require covered railroads to review and revise their Fatigue Management Plans at least once every 2 years. Section 20156(f)(1 ). RSIA also requires FRA to review RRP plans to ensure the railroads are complying with their plans. Section 20156(a)(3). Based on input from an RSAC working group, FRA is working on a third regulation to meet the fatigue management provisions in Section 20156. Additionally, once the final rule is issued, FRA anticipates that it will also publish a guidance document on fatigue risk management programs (FRMP) for covered railroads that outlines, for example, the components of an FRMP and the steps to establish an FRMP. FRA believes some railroads will elect to model the fatigue effects of their schedules using biomathematical models. The reliability, validity, and practical limitations of such models are, therefore, of critical importance to the effectiveness of fatigue management. As part of its longterm research emphasis into fatigue in the railroad industry, FRA has employed biomathematical models to examine the schedules of railroad employees involved in human factor-related accidents. In addition, FRA has used railroad data to validate two models in current use and to calibrate the models with one another. The report discussing validation and calibration can be found at http://www.fra.dot.govIeLib/details/L04301#p1_z5_gDkbiomathematical. Finally, FRA has developed a protocol that can be used to validate and calibrate any models that might be developed in the future, available at http://www.fra.dot.gov/eLib/details/L04703#p1_z5__gD_kbiomathematical. Going forward, FRA will continue to learn from the practical application of biomathematical models as they are used as part of railroads' Fatigue Management Plans.

From: NTSB
To: FRA
Date: 9/23/2013
Response: The NTSB is satisfied with the FRA’s efforts to establish management controls to abate human fatigue throughout the railroad industry, and we encourage the FRA to continue its work to mitigate human fatigue. However, we issued Safety Recommendation R-12-17 with a particular purpose in mind: for the FRA to monitor and assess the real-world utility and limitations of biomathemathical models of human fatigue. The reliability, validity, and practical limitations of these models need to be clarified through disciplined application and evaluation in railroad fatigue management systems. Pending the enhanced utility of such systems through a structured assessment of biomathemathical models, Safety Recommendation R-12-17 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 6/13/2013
Response: -From Joseph C. Szabo, Administrator: Thank you for your March 8, 2013, letter to the Federal Railroad Administration (FRA) concerning the National Transportation Safety Board (NTSB) Safety Recommendations R-13-05 through R-13-08, R-06-10, R-12-17, R-10-01, and R-10-02. These recommendations were issued (or, in the case of previously issued recommendations, reiterated) as a result ofthe report on the September 30,2010, accident, in which two Canadian National Railway (CN) freight trains collided near Two Harbors, Minnesota. The enclosure outlines FRA's response to each recommendation (except R-10-01 and R-1 0-02, which NTSB reclassified in its March 8, 2013, letter) and the safety systems and regulations in place to address them. Based upon the information provided below, FRA respectfully requests that NTSB classify Safety Recommendations R-13-05, R-13-06, and R-06-10 as "Closed-Reconsidered" and R-13-07 as "Closed-Acceptable Alternate Action." Additionally, FRA requests that NTSB classify Safety Recommendation R-13-08 as "OpenAcceptable Response" and R-12-17 remain "Open-Acceptable Response." We look forward to continuing to work with you to address these important rail safety matters. Section 103 of the RSIA (Section 1 03) requires that certain railroads develop RRPs. 49 U.S.C. § 20156. Section 103 requires a railroad to include a fatigue management plan in its RRP that meets certain requirements. 49 U.S.C. § 20156(d)(2). As part of the development of fatigue management plans, the RSIA requires railroads to consider the need to include in their fatigue management plans a number of elements, including providing opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders; and providing employee education and training on the physiological and human factors that affect fatigue. Section 1 03 further requires that the Secretary of Transportation conduct an annual review of a railroad's RRP to ensure that the railroad is complying with its plan, and railroads are required to review and revise their fatigue management plans at least once every 2 years. Currently, FRA, in conjunction with a Railroad Safety Advisory Committee working group is developing a fatigue management regulation that will be responsive to the RSIA requirements. Additionally, FRA has developed a Fatigue Risk Management Systems (FRMS) guidance document for railroads, outlining the components of an FRMS, the steps to establishing an FRMS, and evaluation requirements. Under this regulatory structure, railroads may use biomathematical models to assist them in understanding the effects on fatigue presented by various schedules, but the use of such models will not be explicitly . required. Additionally, Section 103 requires that a railroad developing an RRP conduct a risk analysis, which must include fatigue-related risks. It must "identifY and analyze the aspects of its railroad, including operating rules and practices, infrastructure, equipment, employee levels and schedules, safety culture, management structure, employee training, and other matters, including those not covered by railroad safety regulations or other Federal regulations, that impact railroad safety." 49 U.S.C. § 20156(c). Finally, FRA is also actively seeking railroads to participate in pilot projects that will examine the effects of scheduling pools, advance call times, and decreased time at the awayfrom home terminal on the fatigue experienced by train crews.

From: NTSB
To: FRA
Date: 3/8/2013
Response: From the report Collision of Two Canadian National Railway Freight Trains near Two Harbors, Minnesota, September 30, 2010, adopted Feb. 12, 2013, issued on March 8, 2013: The circumstances of this accident suggest that fatigue played a role in the events leading up to the accident. The conductor elected to remove himself from the lead locomotive and remain on the second locomotive unit for much of the trip, thereby physically isolating himself from the engineer and student engineer. Being located in the second unit by himself would have provided him an opportunity to nap or sleep. When the final track authority before the accident was issued by the RTC, the conductor incorrectly repeated the engine number of the northbound train his train was scheduled to meet, an error that was detected by the RTC. Such an error could be attributed to reduced cognitive functioning associated with fatigue. Furthermore, he did not walk to the first locomotive unit and discuss the contents of the track authority with the engineer and student engineer, as was required by CN rules and FRA regulations. The willful lack of effective communications and coordination among the crewmembers most likely was due to their fatigue. Therefore, the NTSB concludes that fatigue-induced performance errors contributed to the accident. The NTSB has identified fatigue as a factor in numerous transportation accidents, the most recent railroad accident investigation involving fatigue was a rear-end collision that occurred near Red Oak, Iowa, on April 17, 2011, that resulted in fatalities to both crewmembers on the striking train and over $8.7 million in damage. The NTSB’s investigation determined that both crewmembers on the striking train had fallen asleep due to fatigue. The NTSB noted that the Rail Safety Improvement Act (RSIA) passed by Congress in 2008 mandated that railroads develop fatigue management plans. The Red Oak, Iowa, accident report described the RSIA requirements and FRA’s implementation as follows: The RSIA gives railroads 4 years after enactment of the law in which to develop these plans, which must include methods to manage and reduce fatigue experienced by railroad employees in safety-related positions and to reduce the likelihood of accidents, incidents, injuries, and fatalities caused by fatigue. There are several elements to the RSIA‘s fatigue management plan requirements, many of which are relevant to this accident. Three of these elements are listed here and discussed below: Employee education and training on the physiological and human factors that affect fatigue, as well as strategies to reduce or mitigate the effects of fatigue, based on the most current scientific and medical research and literature. Opportunities for identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. Scheduling practices for employees, including innovative scheduling practices, on-duty call practices, work and rest cycles, increased consecutive days off for employees, changes in shift patterns, appropriate scheduling practices for varying types of work, and other aspects of employee scheduling that would reduce employee fatigue and cumulative sleep loss. In a December 19, 2011, letter, the FRA advised the NTSB that it is currently in the process of drafting guidance for railroads to develop fatigue management plans as part of a larger railroad risk-reduction program. The guidance is expected to be issued in early 2013. The FRA also has recently formed a Railroad Safety Advisory Committee (RSAC) working group to provide advice on developing fatigue management plans. On June 11, 2012, in coordination with the Volpe Center; Harvard Medical School, Division of Sleep Medicine; and the WGBH Educational Foundation; the FRA launched a Railroader Guide to Health Sleep website (http://www.railroadersleep.org). The website provides information to train crewmembers about fatigue and its countermeasures. This is an initial step by the FRA and other stakeholders to implement a fatigue guidance resource. Discussions with the FRA disclosed that the FRA is drafting rule text, which it will present to the RSAC in April 2013. Task teams from the RSAC are working on additional fatigue guidance information. The development and implementation of fatigue management plans will be an important step in improving railroad safety. In the Red Oak, Iowa, investigation, the NTSB recommended that the FRA: Establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue. (R-12-17) The FRA responded in a letter dated July 31, 2012, stating that it was working with an RSAC working group to develop a regulation document responsive to RSIA requirements. The letter also advised NTSB that FRA had developed a fatigue risk management systems guidance document. Safety Recommendation R-12-17 is classified “Open?Acceptable Response.” The NTSB appreciates that FRA is taking these steps and takes this opportunity to reiterate Safety Recommendation R-12-17 to the FRA.

From: NTSB
To: FRA
Date: 10/16/2012
Response: The NTSB is aware that section 103 of the RSIA requires the Secretary of Transportation to conduct an annual review of a railroad’s risk reduction plan to ensure the railroad is complying with its plan and that railroads will be required to review and revise their Fatigue Management Plans at least once every 2 years. Because the FRA is working with the RSAC to address Safety Recommendations R-12-17 and -18 as well as the RSIA requirements, these recommendations are classified OPEN—ACCEPTABLE RESPONSE pending completion of these efforts.

From: FRA
To: NTSB
Date: 7/31/2012
Response: -From Joseph C. Szabo, Administrator: Thank you for your May 10, 2012, letter to the Federal Railroad Administration (FRA) concerning National Transportation Safety Board (NTSB) Safety Recommendations R-12-16 through -22, R-02-24 through -26, and R-10-01 and -02. These recommendations were issued as a result the April17, 2011, rear-end collision of eastbound BNSF Railway (BNSF) coal train C-BTMCNM0-26, BNSF 9159 East, into standing BNSF maintenance-of-way equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. FRA has enclosed its responses to the above-mentioned recommendations. The FRA respectfully requests that NTSB classify Safety Recommendations R -12-16 through -20 and -22 as "Open-Acceptable Response." Additionally, we request that NTSB classify Safety Recommendations R-12-21 as "Closed-Reconsidered," and R-02-24 as "Closed-Acceptable Alternative Action." Lastly, FRA requests Safety Recommendations R-02-25 and -26, and R-10-01 and -02, remain "Open-Acceptable Response." I appreciate your interest in this important transportation matter. We look forward to working with you. The RSIA further requires under Section 103 that the Secretary conduct an annual review of a railroad’s risk reduction plan to ensure the railroad is complying with its plan. Under the RSIA, railroads will be required to review and revise their Fatigue Management Plans at least once every 2 years. Currently, FRA, in conjunction with an RSAC working group, is working on a regulation document that is responsive to the requirements outlined in RSIA. Additionally, FRA has developed a Fatigue Risk Management Systems (FRMS) guidance document for the railroads that outlines the components of an FRMS, the steps to establishing an FRMS, and evaluation requirements. Additionally, the RSIA requires under Section 103(c) that a railroad developing an RRP must conduct a risk analysis. The risk analysis will include fatigue-related risks. This risk analysis must “identify and analyze the aspects of its railroad, including operating rules and practices, infrastructure, equipment, employee levels and schedules, safety culture, management structure, employee training, and other matters, including those not covered by railroad safety regulations or other Federal regulations, that impact railroad safety.” FRA is also actively seeking railroads to participate in pilot projects that will examine the effects of scheduling pools, advanced call times, and decreased time at the away-from-home terminal on the fatigue experienced by train crews.