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Safety Recommendation Details

Safety Recommendation R-12-024
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 ASSOCIATION OF AMERICAN RAILROADS: Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of on-board video and audio recorders. The memory modules should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable 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: Association of American Railroads (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Association of American Railroads
Date: 5/1/2019
Response: Mr. Hamberger’s letter addressed the Rail Safety Advisory Committee’s inability to reach a consensus regarding parameters for the use of recording devices in controlling locomotive cabs; however, it did not mention the crash-protected memory modules we recommended. We continue to see accidents in which crash-protected memory modules would have aided our investigation, and we believe it is essential that you develop a standard requiring their use. For example, in our investigation of a June 24, 2012, Goodwell, Oklahoma, freight railroad accident, we could not review any video recordings because the locomotives were completely destroyed by a postcrash fire. It is possible that our investigation would have revealed more factual information—and thereby resulted in greater safety benefit—if the lead locomotive had been equipped with a crash protected memory module. Until your membership or operations department establishes a standard for crash-protected memory modules for all new and existing installations of on-board video and audio recorders, Safety Recommendation R-12-24 is classified OPEN--UNACCEPTABLE RESPONSE.

From: Association of American Railroads
To: NTSB
Date: 10/24/2016
Response: -From Edward R. Hamberger, President and CEO: NTSB Safety Recommendation R-12-24 recommends that the Association of American Railroads (AAR) develop an industry standard specifying the use of crash-protected memory modules for locomotive audio and videorecorders. Subsequent to the issuance of this recommendation, the Federal Railroad Administration (FRA) initiated a Rail Safety Advisory Committee (RSAC) Working Group in 2014. The purpose of this group as outlined in the Task Statement was: "To develop regulatory recommendations addressing the installation and use of recording devices in controlling locomotive cabs. The recommendations should address installation requirements and timelines, technical controls, recording retention periods, retrieval of recordings, controlled custody of recordings, crashworthiness standards, use of recordings for accident investigation and railroad safety study purposes, and the use of recordings in conducting operational tests." The RSAC Working Group embarked on nearly a year of concentrated work providing FRA useful information on all of the items listed in the Task Statement. AAR members noted that a significant number of outward-facing cameras has been voluntarily deployed for over 20 years and that many railroads were beginning the deployment of inward-facing cameras on locomotives. In most cases, the railroads have not installed cost-prohibitive crash-hardened memory modules, which are not necessary for small-capacity modules used by event recorders. The railroads are aware of only one instance in the past 20 years of deployment where an outward facing camera's non-crash-hardened module was lost due to accident damage. In March, 2015, FRA concluded that the RSAC Working Group would not promptly reach consensus and advised that the agency would proceed to rulemaking using input from the Working Group. Additionally, the Fixing America's Surface Transportation Act mandates the use of cameras on passenger trains, adding further impetus to the initiation of a rulemaking proceeding. With FRA expected to initiate formal rulemaking on cameras in the near future, it would be inappropriate for the industry to develop its own standard. Accordingly, the status of Safety Recommendation R-12-24 should be changed to "Closed-Reconsidered."

From: NTSB
To: Association of American Railroads
Date: 6/17/2014
Response: On July 29, 2014, my staff met with yours to discuss the design criteria you have proposed in the revised AAR S-580, section 6.10, Cab Attachment for Modular Cab Locomotives. In that meeting, we explained our belief that these criteria will result in designs having far less structural strength than that of the existing EMD SD70ACe locomotive. Our position is based on our analysis of the performance of such a locomotive that was involved in the Red Oak collision (Railroad Accident Report NTSB/RAR-12/02, http://www.ntsb.gov/doclib/reports/2012/RAR1202.pdf). Our staffs agreed to further technical discussion to resolve NTSB concerns. Pending the outcome of these discussions, Safety Recommendations R-12-23 is classified “Open—Acceptable Response.” Safety Recommendation R-12-24 remains classified OPEN—ACCEPTABLE RESPONSE, pending our receipt of additional information.

From: Association of American Railroads
To: NTSB
Date: 5/14/2014
Response: -From Edward R. Hamberger, President and Chief Executive Officer: In its May 10, 2012 letter advising AAR of this recommendation, the Safety Board also issued Safety Recommendation R-12-24 concerning standards for crash-protected memory modules. As information, AAR indicated agreement with this Recommendation for new and replacement devices in a September 23, 2013 letter to the Safety Board.

From: NTSB
To: Association of American Railroads
Date: 12/27/2013
Response: We are encouraged that the AAR Locomotive Committee will develop a standard for crash protected memory modules of onboard video and audio recorders. We encourage the AAR to research and, if necessary, exceed the survivability criteria specified in 49 CFR 229.135, Appendix D, Table 2. Although Appendix D retains the proposed criteria for certification of an event recorder memory module as crashworthy, we believe there may be superior alternative performance?based criteria that would survive more extreme conditions, particularly for fire and heat, than those built to the criteria given in Table 2. In addition, we urge you to reconsider your position on requiring crash-protected memory modules for all existing installations. Pending the development of a standard for crash-protected memory modules for onboard video and audio recorders, Safety Recommendation R-12-24 is classified OPEN—ACCEPTABLE RESPONSE.

From: Association of American Railroads
To: NTSB
Date: 9/3/2013
Response: Edward R. Hamberger, President and Chief Executive Officer: I am writing in response to your letter of August 14, 2013, referring to the reiteration of the National Transportation Safety Board's (NTSB) Safety Recommendation R-12-24 made to the Association of American Railroads (AAR). This recommendation was a result of your investigation of the April 17, 2011, collision of two BNSF Railway trains near Red Oak, Iowa. The NTSB investigation found that the on-board memory module for the video camera on the lead locomotive of the striking unit was destroyed in the collision sequence. Resulting from the investigation the NTSB made the following safety recommendations to AAR: Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of on-board video and audio recorders. The memory modules should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations229. 135 Appendix D, Table 2. (R-12-24) When we received notification of the issuance of Safety Recommendation 12-24, we directed the AAR Locomotive Committee to look into the survivability of memory modules for video and audio recorder. Subsequently we responded in our letter dated January 11, 2013, agreeing with the need for a standard on the crashworthy-protection of memory modules of on-board video and audio recorders. We further noted that the AAR will set about the development of memory modules to meet or exceed survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2. Additionally, AAR representatives met with NTSB staff on April 30, 2013, to review this recommendation. We would like to further note that the AAR does not agree that all existing installations should be required to be retrofitted according to such a standard. Instead, when completed the standard will be required for all new and replacement installations from a set date. AAR will continue to keep NTSB staff informed of any further actions on the development of the standard for the hardening of memory modules for all new video and audio recorders. In the interim if you have any questions regarding actions to this recommendation, please contact my office or Michael Martino (202-639-2212) a member of my staff. Again, I want to thank you and the NTSB for your untiring diligence in working for a safer railroad environment.

From: NTSB
To: Association of American Railroads
Date: 8/14/2013
Response: From the report of the Head-On Collision of Two Union Pacific Freight Trains Near Goodwell, Oklahoma, June 24, 2012, adopted June 18, 2013, RAR-13-02, issued August 14, 2013: The video recorders on the locomotives in the Goodwell accident were not required by regulation and were not protected from impact or fire. The video recorders from the trailing locomotives of both trains were undamaged and downloaded normally but provided limited information. The video recorder from the lead locomotive on the eastbound train was not recovered. The video recorder from the lead locomotive of the westbound train was severely damaged by fire. The enclosure was opened and inside were unrecognizable burned and broken small pieces of debris, dust, and ash. (See figure 7.) Outward-facing video cameras are not required by regulation. However, some railroads are installing them to record conditions related to accidents involving pedestrians and highway-rail grade crossings. Both locomotives in the Goodwell, Oklahoma, accident and the lead locomotive in the April 17, 2011, Red Oak, Iowa, accident (NTSB 2012) had outward-facing video cameras. However, in both accidents, the video data were not available because the recorded data were not stored in crashworthy memory modules and were lost to collision and fire damage. The NTSB believes that it would be a good safety practice for railroads to ensure that data from these cameras are safeguarded. The NTSB concludes that because data from locomotive video cameras are typically not stored in crashworthy memory modules, important operational and safety data are at risk of being lost after an accident. Addressing this risk provides an opportunity for the industry to revisit the best methods to preserve electronic data. In the Red Oak, Iowa, report, the NTSB made the following recommendation to the AAR: Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of onboard video and audio recorders. The memory modules should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations Section 229.135, Appendix D, Table 2. (R-12-24) (NTSB 2012) Because valuable information contained in the recorders was destroyed by the collision and subsequent fire in the Goodwell, Oklahoma, accident, the NTSB reiterates Safety Recommendation R-12-24 to the AAR and appreciates the work being done to develop the standard.

From: Association of American Railroads
To: NTSB
Date: 1/11/2013
Response: -From Edward R. Hamberger, President and Chief Executive Officer: Please refer to my letter of July 30, 2012, pertaining to the BNSF Railway collision near Red Oak, Iowa, wherein we promised a response following our AAR Locomotive Committee meeting in late August. Please accept our apologies for the length of time it has taken to follow up on that promise. There were two recommendations made by the Board following its investigation. These are shown below. Revise Association of American Railroads Standard S-580 to provide protection for the occupants of isolated cabs in the event of a collision, and make the revision applicable to all locomotives, including those newly constructed, rebuilt, refurbished and overhauled. (R-12-23) Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of on-board video and audio recorders. The memory modules should meet or exceed survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2. (R-12-24) In regard to recommendation R -12-23, the AAR does not agree that a revision is required to Standard S-580 specifically for isolated cabs. This standard details crashworthiness requirements for locomotive collision posts and short hood structure regardless of design. In this report, NTSB incorrectly states that the isolated or modular cab has no standard for collision protection. In fact, locomotives with isolated or modular cabs, such as the SD70ACe models, are governed by the same requirements as all other locomotives manufactured in conformance with S-580 as revised in 2008. In the subject collision, an object penetrated the short hood in an area between the collision posts, striking the isolated cab module and causing it to separate from its securement to the structural underframe. The cab module was then rotated more than 90 degrees and crushed against the electrical compartment structure. In this case, the collision posts and short hood structure were destroyed owing to forces generated in this collision which substantially exceeded the design requirements of Standard S-580. AAR and its Locomotive Committee consider this collision to have been a unique occurrence owing to the work equipment involved, and the set of circumstances that led to the penetration of the locomotive cab by the load presented by the so called scorpion car. Numerous locomotives manufactured according to the same AAR standard have provided sufficient protection in other collisions. This was indeed a rare event; there are no records indicating any failures of the modular cab involved in other collisions. Thus, we seek to have Safety Recommendation R-12-23 listed as Closed Acceptable Alternate Action. In regard to recommendation R-12-24, AAR agrees with NTSB regarding the need for standards for crash-protected memory modules for installations of on-board video and audio recorders. AAR will set about development for memory modules to meet or exceed survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2. However, AAR does not agree that all existing installations should be required to be retrofitted according to such a standard. Instead, when completed the standard will be required for all new and replacement installations from a set date forward. For Safety Recommendation R-12-24, we ask that the status be considered as Closed Acceptable Alternate Action. Thank you for the opportunity to review and comment on this report.

From: Association of American Railroads
To: NTSB
Date: 7/30/2012
Response: -From Robert C. VanderClute, Senior Vice President, Safety and Operations: I am writing to you in response to the National Transportation Safety Board's (NTSB) letter issuing Recommendation R -12-09 to the Association of American Railroads (AAR). This recommendation was a product of the NTSB's investigation of the June 19,2009, derailment of eastbound Canadian National Railway Company (CN) freight train U70691-18 at a highway/rail grade crossing in Cherry Valley, Illinois. AAR is in the process of arranging a meeting with NTSB staff to review the circumstances present during the derailment sequence at the Cherry Valley accident. The purpose of this meeting is to glean more information about the factors which led to the development of Safety Recommendation R-12-09. I have asked Michael Martino, a member of my staff, to coordinate the meeting between our two organizations. -From Edward R. Hamberger, President and Chief Executive Officer: I am writing to follow-up on my March 19,2012, letter regarding the National Transportation Safety Board's (NTSB) Safety Recommendations R -11-08 and R -11-09. These two Safety Recommendations were made to the Association of American Railroads (AAR) as a result of five railroad collisions that occurred in 2011. While Safety Recommendation R-11-08 has been closed, R-11-09 remains open. Safety Recommendation R-11-09 recommends to the AAR: "Examine the effectiveness of your member railroads' restricted speed and compliance programs. " On May 8, 20] 2, AAR and NSTB staff, along with representatives from all Class I railroads met and discussed the use of "restricted proceed." Following the meeting, the railroads had internal discussions on "restricted proceed" operations. Relevant is the Federal Railroad Administration's Safety Advisory 2012-02, issued on April 25, 2012. The Safety Advisory stated: "(to) remind railroads and their employees of the importance of compliance with relevant railroad operating rules when trains and locomotives are to be operated at restricted speed. This safety advisory contains a preliminary discussion of recent train accidents involving a failure to operate at restricted speed and makes recommendations to railroads to ensure employee compliance with the requirements of restricted speed operating rules." Attached are some examples of how carriers responded to this Safety Advisory. I believe the AAR and its members have fulfilled the NTSB objective in issuing R-11-09. Thus, we request that the NTSB close Safety Recommendation R-11-09 as "Closed –Acceptable Alternative Action." -From Edward R. Hamberger, President and Chief Executive Officer: I am writing to you in response to National Transportation Safety Board's (NTSB) letter issuing Recommendations R-12-23 & R-12-24 to the Association of American Railroads (AAR). These recommendations were issued from your investigation of the April 17, 2011, collision of the eastbound BNSF Railway coal train C-BTMCNMO-26, with the rear end of a standing BNSF Railway maintenance of way equipment train U-BRGCRI-15, near Red Oak, Iowa. The NTSB investigation of the BNSF Railway collision at Red Oak, Iowa, found that the isolated locomotive cab module on the lead locomotive unit on BNSF train C-BTMCNMO-26, detached from the deck of the locomotive and was subsequently rotated and crushed resulting in no survivable space for the crewmembers. Resulting from the investigation, the NTSB made the following safety recommendations to the AAR: Revise Association of American Railroads Standard S-580 to provide protection for the occupants of isolated operating cabs in the event of a collision, and make the revision applicable to all locomotives, including those newly constructed, rebuilt, refurbished, and overhauled. (R-12-23) Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of on-board video and audio recorders. The memory modules should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2. (R-12-24) Since receiving your letter regarding these two recommendations, the AAR initiated discussions pertaining to the standards of the crew compartment modules. We plan to further discuss the facts promulgated from the Red Oak investigation with the AAR Locomotive Committee at their next meeting scheduled in the latter part of August 2012. After that meeting, we hope to have our response to Safety Recommendations R-12-23 and R-12-24 to the NTSB. On another item, I would first like to thank the NTSB for noting in the Red Oak report that Safety Recommendation R-11-08 issued to the AAR was classified "Closed – Acceptable Action." Thank you again for the closing of Safety Recommendation R-II-08, and we will respond to you regarding our actions to close Safety Recommendations R-12-23 and R-12-24 as soon as possible.