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Safety Recommendation Details

Safety Recommendation R-12-022
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: Revise Title 49 Code of Federal Regulations Part 229 to require crashworthiness performance validation for all new locomotive designs under conditions expected in a collision.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Red Oak, IA, United States
Is Reiterated: No
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 - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: FRA
To: NTSB
Date: 5/23/2018
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA) response to twelve National Transportation Safety Board (NTSB) Safety Recommendations (see list below). Over half of these recommendations are currently classified as "Open - Acceptable Response," and because the FRA has addressed the intent of the recommendations, no further action is necessary. FRA therefore requests that these be classified as "Closed- Acceptable Action." For the remaining five, FRA has evaluated each recommendation relative to current and potential new regulations, including requirements for conducting cost-benefit analysis of each potential measure to address each recommendation, and has concluded FRA cannot reasonably take further action on them. Thus, FRA respectfully asks the NTSB to classify each of them as "Closed." Overall, the twelve Safety Recommendations in question are: • R-01-02 • R-12-21 • R-13-22 • R-14-17 • R-01-17 • R-12-22 • R-13-38 • R-14-44 • R-08-06 • R-12-41 • R-14-16 • R-14-48 In the enclosure, FRA discusses the challenges to implement these recommendations, describes what actions the agency has performed, and explains why FRA cannot proceed further, other than to audit compliance as appropriate. Each recommendation is addressed in the enclosure in the following manner: • NTSB Safety Recommendation Number; • Text of the Safety Recommendation as issued by the NTSB; • Status (e.g., "Open-Acceptable Response"); • FRA's position on the Safety Recommendation (see bolded text in shaded boxes); • A summary of the accident that led the NTSB to issue the recommendation; • A summary of the NTSB and FRA correspondence regarding each recommendation; and • FRA's explanation for why we cannot pursue any further action on the recommendation. To facilitate closure of these recommendations, FRA met with the NTSB on March 1, 2018, to expound on our reasoning and answer questions. This enclosure only includes those recommendations for which we believe we came to an understanding. If FRA can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer. Please note that Federal agencies like FRA are required to follow the direction of Executive Orders 12866 and 13563 for rulemaking, which require quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 specifically states that: Each agency shall assess both the costs and the benefits of the intended regulation and, recognizing that some costs and benefits are difficult to quantify, propose or adopt a regulation only upon a reasoned determination that the benefits of the intended regulation justify its costs. To meet the requirements of these Executive Orders, for each proposed and final regulation issued, FRA performs a regulatory analysis to: 1. Establish whether Federal regulation is necessary and justified to achieve a social goal; and 2. Clarify how to design regulations in the most efficient, least burdensome, and most cost effective manner. While issuing regulations to implement many of these NTSB recommendations could improve railroad safety in the specific railroad accident or incident from which each arose, regulatory action to implement these recommendations would result in financial and safety costs that far exceed the societal benefits of improved safety or accident avoidance. Based on the associated cost-benefit analysis, implementing regulations that are required by some of these recommendations would not meet the intent of the Executive Orders listed above, which is inconsistent with the Administration's regulatory policy. Where applicable, FRA has calculated the anticipated costs and benefits of each recommendation and included that information with each detailed response. Please also note, in the 2016 Federal Railroad Administration Report to Congress on Actions Taken to Implement Unmet Statutory Mandates and Address Open Recommendations by the National Transportation Safety Board and the Department of Transportation's Inspector General Regarding Railroad Safety, FRA informed Congress that the agency would be taking no further action on these twelve recommendations. Current Status: Open-Unacceptable Response FRA has published a final rule that fulfills the intent of the recommendation. FRA intends to take no further action on the recommendation, and respectfully requests that the NTSB close it. The NTSB issued Safety Recommendation R-12-22 in response to the previously-mentioned accident on April 17, 2011, near Red Oak, IA. (See Safety Recommendation R-12-21, above). In its February 12, 2015, correspondence to the NTSB, FRA stated that it was not feasible to develop regulation based on an exhaustive catalog of conditions expected in a collision, and that these varied and rare conditions are not a good basis for establishing broadly applicable performance standards. If regulations were developed to cover extremely unusual accident scenarios, such as what occurred at Red Oak, the resulting requirements would be marginally effective, cost-inefficient, and not properly address most accident scenarios. Under 49 CFR § 229 .209, FRA may consider proposals for the development and use of alternative crash worthy designs, including those based on performance standards. In its reply dated August 11, 2016, the NTSB stated: We are aware of the provisions of 49 CFR section 229.209, which is why we ask that you determine the metrics of crashworthiness of new locomotive designs with railroad equipment expected in the operating environment, such as maintenance-of-way equipment, locomotives, hi-rail vehicles, freight cars, and passenger cars. We have not asked you to create a complete catalog of conditions expected in a collision; however, we do ask that you evaluate other crash-involved equipment in addition to freight cars and locomotives. Pending such action and the completion of rulemaking as recommended, Safety Recommendation R-12-22 is classified OPEN--UNACCEPTABLE RESPONSE. FRA's actions to address R-12-22: FRA's Crashworthiness Design Requirements (49 CFR part 229, subpart D) sets forth standards for the design of crashworthy locomotives. While these standards will not protect all occupants in all collision situations, they will have the greatest effect on the reduction of cab crew injuries and fatalities associated with the most prevalent types of locomotive collisions, including several inline and oblique collision scenarios. The term "design standard" means a specification for the crashworthiness design of locomotives-a set of design requirements which specify ultimate performance, yet are not so specific in nature that they leave little flexibility to the designer. The overall design of the locomotive is allowed to vary so long as the specified crashworthiness design requirements are met. FRA does not want to inhibit innovation of equipment designs and will consider alternative crashworthy designs pursuant to the requirements of 49 CFR § 229 .209. FRA believes that its Crash worthiness Design Requirements address the most prevalent types of locomotive collisions. Additionally, the estimated cost to the industry to comply with potential regulations created to address this specific recommendation is estimated to be $2.3 billion. Benefits for such a rulemaking would come from a reduction in injuries or fatalities once an accident occurred, but improving the crash worthiness of the locomotive does not prevent the accident from occurring. FRA and railroads are investing resources in crash prevention, which overall has a significantly larger benefit than improved crashworthiness. As new technologies are more broadly implemented like positive train control (PTC) which NTSB agrees will greatly improve crash prevention, potential benefits will be further reduced. FRA has addressed the recommendation, and respectfully requests that NTSB reclassify this recommendation as, "Closed--Acceptable Action."

From: NTSB
To: FRA
Date: 8/11/2016
Response: We are aware of the provisions of 49 CFR section 229.209, which is why we ask that you determine the metrics of crashworthiness of new locomotive designs with railroad equipment expected in the operating environment, such as maintenance-of-way equipment, locomotives, hi-rail vehicles, freight cars, and passenger cars. We have not asked you to create a complete catalog of conditions expected in a collision; however, we do ask that you evaluate other crash-involved equipment in addition to freight cars and locomotives. Pending such action and the completion of rulemaking as recommended, Safety Recommendation R-12-22 is 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. It is not feasible to create a complete catalog of "conditions expected in a collision," and FRA disagrees with using such an approach to develop safety regulations. Certain conditions that can be expected based on experience are rare and are not a good basis for establishing broadly applicable performance standards. Locomotive crashworthiness scenarios include collisions with expected types of railroad equipment, such as freight cars and locomotives. To FRA's knowledge, a collision of this nature has never occurred before. If regulations are reactively developed to cover extremely unusual accident scenarios, such as what occurred at Red Oak, Iowa (a rear-end collision with specialized maintenance-of-way cars that fold in half when impacted), the resulting requirements will not properly address most accidents and will be only marginally effective and cost inefficient. FRA also notes that existing crashworthiness regulations do not prohibit or discourage performance-based methods of compliance. Under Title 49 Code of Federal Regulations Section 229.209, FRA may consider proposals for the development and use of alternative crashworthy designs, including those based on performance standards.

From: NTSB
To: FRA
Date: 7/2/2013
Response: We are disappointed in the FRA’s response to this recommendation and do not agree that the requirements specified in 49 CFR Part 229 address the concern that prompted us to issue Safety Recommendation R 12 22. Current crashworthiness requirements are design standards, which fix requirements under prescribed conditions. Performance standards, rather, attempt to define equipment performance requirements; for example, maintaining survivable space in a control compartment following a collision. Although the current locomotive crashworthiness standards include a procedure for validating alternative locomotive designs that are not consistent with any FRA-approved locomotive crashworthiness design standard, this requirement was not effective in identifying and ensuring the crashworthiness of the modular operating cab as an alternate design. Although we appreciate that this is a difficult issue to resolve, the FRA has failed to address the intent of Safety Recommendation R-12-22 in its response. Consequently, this recommendation is classified OPEN—UNACCEPTABLE RESPONSE pending the FRA’s consideration of our comments above. We urge the FRA to reconsider its position. I believe that the FRA would benefit from a meeting at the staff level to discuss the intent of this recommendation; accordingly, Mr. Patrick Sullivan of my staff will contact the FRA’s NTSB liaison to set up a meeting.

From: FRA
To: NTSB
Date: 4/8/2013
Response: -From Joseph C. Szabo, Administrator: This letter is to update you on the status ofNational Transportation Safety Board (NTSB) Safety Recommendations R-12-04, and R-12-20 and -22, issued to the Federal Railroad Administration (FRA) on March 2, 2012, and May 10, 2012, respectively. Safety Recommendation R-12-04 was issued as a result ofthe June 19, 2009, derailment of eastbound Canadian National Railway (CN) Freight Train U70691-18 in Cherry Valley, Illinois. Safety Recommendations R-12-20 and -22 were issued as a result of 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. The enclosure outlines FRA's response to each recommendation and the safety systems and regulations in place to address them. Therefore, FRA respectfully requests that NTSB classify Safety Recommendations R-12-04 as "Closed-Acceptable Action" and Safety Recommendations R-12-20 and -22 as "Closed-Reconsidered." We look forward to continuing to work with you on important safety issues. The Locomotive Crashworthiness Design Requirements encompass considerably more than the two sections cited by NTSB in their clarification ofR-12-22. For example, Title 49 Code of Federal Regulations (CFR) Sections 229.205 and 229.206 incorporate the crashworthiness design requirements of Association of American Railroads Standard S-580 by reference. Title 49 CFR Part 229, Appendix E, gives collision scenarios on which crashworthy designs may be based.• Title 49 CFR §§ 229.207 and 229.209 give alternatives that locomotive designers or manufacturers may pursue and 49 CFR § 229.211 discusses the processing of petitions for FRA approval of alternate designs. These requirements were based on years of FRA-sponsored crash testing and simulations, which, in tum, were based on a variety of conditions expected in a collision. The criteria for these conditions was based on the most common and recurring types of collisions. Due to the infrequency of certain types of events, not all collision scenarios can be expected. Such is the case with the rear-end collision in Red Oak, Iowa. Based on both historical and recent data collection, the probability of an event happening similar to the one that occurred in Red Oak, Iowa, is remote. Though a variety of collision scenarios was considered, it is virtually impossible to account for every individual and remote occurrence within the economic requirement for FRA regulations. FRA believes the objectives of R-12-22 have largely been met in the regulations already in place.

From: NTSB
To: FRA
Date: 10/16/2012
Response: The following is provided in response to FRA’s request for clarification of the terms “crashworthiness performance validation” and “conditions expected in a collision,” as used in this safety recommendation. • Crashworthiness performance validation: We are recommending that the FRA ensure that all new locomotive designs comply with the design requirements specified in 49 CFR 229.141 or the alternate requirements specified in 49 CFR 229.209. • Conditions expected in a collision: We are recommending that the FRA require this validation for all accidents of the types identified in 49 CFR 229, as well as those of the types identified in the recent accident data collected by the FRA. Pending a detailed response from the FRA explaining how it plans to implement Safety Recommendation R-12-22, the recommendation is classified OPEN—AWAIT RESPONSE.

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. FRA seeks clarification of what is meant by the phrases “crashworthiness performance validation” and “conditions expected in a collision.” FRA has sponsored various collision tests, the results of which are available for use by locomotive designers; however, none exactly duplicate any new locomotive design. Similarly, various collision scenarios have been used in these tests, but as demonstrated by the way in which the clip car folded nearly in half at Red Oak, not all possible conditions can be “expected.”