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Safety Recommendation Details

Safety Recommendation R-12-041
Details
Synopsis: On Friday, June 24, 2011, about 11:19 a.m. Pacific daylight time, a 2008 Peterbilt truck-tractor occupied by a 43-year-old driver was traveling north on US Highway 95 near Miriam, Nevada. The truck-tractor was pulling two empty 2007 side-dump trailers. As it approached an active highway–railroad grade crossing consisting of two cantilever signal masts with flashing lights and two crossing gate arms in the descended position, it failed to stop and struck the left side of Amtrak train no. 5, which was passing through the grade crossing from the northeast. The collision destroyed the truck-tractor and two passenger railcars. The train came to a stop without derailing; however, a fire ensued, engulfing two railcars and damaging a third railcar. The accident killed the truck driver, the train conductor, and four train passengers; 15 train passengers and one crewmember were injured. The National Transportation Safety Board (NTSB) determines that the probable cause of the Miriam, Nevada, accident was the truck driver’s delayed braking and the failure of John Davis Trucking to adequately maintain the brakes on the accident truck. Contributing to the number of fatalities and the severity of injuries was insufficient passenger railcar side impact strength.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require that passenger railcar doors be designed to prevent fire and smoke from traveling between railcars.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Miriam, NV, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY11MH012
Accident Reports: Highway-Railroad Grade Crossing Collision US Highway 95
Report #: HAR-12-03
Accident Date: 6/24/2011
Issue Date: 1/28/2013
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 believes implementation of this recommendation would result in an overall decrease in the safety of passengers and crew members as explained below. FRA intends to take no further action, and respectfully requests that the NTSB close this recommendation. The NTSB issued Safety Recommendation R-12-41 in response to a June 24, 2011, accident near . Miriam, NV, where a truck-tractor failed to stop at a highway grade crossing and struck the side of an Amtrak train that was passing through the grade crossing. The collision and resulting fire destroyed the truck-tractor and two passenger railcars. The train came to a stop without derailing, but the accident killed the truck driver, the train conductor, and four train passengers; 15 train passengers and one crewmember were injured. In its February 12, 2015, correspondence to the NTSB, FRA stated that it is not feasible to design doors that would meet the requirements of this recommendation. The NTSB stated in its August 11, 2016, reply: In your letter, you state that, during an emergency, additional time and effort is needed to operate a fire door, delaying egress and access through such a door. Although we agree that egress and access through end doors is paramount, the recommended fire-rated door would delay the spread of heat, flame, and smoke and would thus help to prevent serious or fatal injury. A formal evaluation of both (1) the technology of fire-rated doors for rail passenger cars and (2) the benefits of reducing the risks of smoke and fire spreading compared to risks posed by impediments to egress is needed before concluding, as you have, that competing safety objectives preclude benefits from the action we recommend. We acknowledge that the issues you raise in your letter are important, but until they are formally evaluated, they should not be considered a basis for concluding that the recommended action is not warranted. Accordingly, pending your taking the recommended action or conducting a formal evaluation that determines the recommended action is not justified, Safety Recommendation R-12-41 requires that remains classified OPEN-UNACCEPTABLE RESPONSE. FRA's actions to address R-12-41: Safety Recommendation R-12-41 calls for requiring doors in passenger railcars be designed to prevent fire and smoke from moving between railcars. FRA recognizes the door at the end of the car as a path of emergency egress and access. In a collision or derailment, minor distortions of the door structure, or a change in the orientation of the door due to a car being displaced from its upright position, could cause the door to fail to operate as intended. As such, FRA has required emergency door releases and removable windows or panels be installed in these doors to enable emergency egress without the use of a tool. In an emergency, FRA believes that, if the door functioned, it would be left open by exiting passengers during an evacuation. If the removable window or panel were used, it would emulate an open door. In either case, any enhancements made to the door to stop fire and smoke from traveling between railcars would be defeated. FRA respectfully asks that the NTSB reclassify Safety Recommendation R-12-41 as, "Closed Reconsidered."

From: NTSB
To: FRA
Date: 2/3/2017
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Railroad Administration’s (FRA) notice of proposed rulemaking (NPRM), Passenger Equipment Safety Standards; Standards for Alternative Compliance and High-Speed Trainsets, published on December 6, 2016. The NTSB appreciates the FRA’s efforts to update the Passenger Equipment Safety Standards, 49 Code of Federal Regulations (CFR) Part 238 but wants to ensure that the FRA addresses key safety issues previously identified in the following accidents: Miriam, Nevada R-12-41 (Status: Open-Unacceptable Response) Require that passenger railcar doors be designed to prevent fire and smoke from traveling between railcars. Background On June 24, 2011, about 11:19 a.m. Pacific daylight time, a 2008 Peterbilt trucktractor occupied by a 43-year-old driver was traveling north on US Highway 95 near Miriam, Nevada. The truck-tractor was pulling two empty 2007 side-dump trailers. As it approached an active highway–railroad grade crossing consisting of two cantilever signal masts with flashing lights and two crossing gate arms in the descended position, it failed to stop and struck the left side of Amtrak train no. 5, which was passing through the grade crossing from the northeast. The collision destroyed the truck-tractor and two passenger railcars. The train came to a stop without derailing; however, a fire ensued, engulfing two railcars and damaging a third railcar. The accident killed the truck driver, the train conductor, and four train passengers; 15 train passengers and one crewmember were injured. The National Transportation Safety Board determined that the probable cause of the Miriam, Nevada, accident was the truck driver’s delayed braking and the failure of John Davis Trucking to adequately maintain the brakes on the accident truck. Contributing to the number of fatalities and severity of injuries was insufficient passenger railcar side impact strength.

From: NTSB
To: FRA
Date: 8/11/2016
Response: In your letter, you state that, during an emergency, additional time and effort is needed to operate a fire door, delaying egress and access through such a door. Although we agree that egress and access through end doors is paramount, the recommended fire-rated door would delay the spread of heat, flame, and smoke and would thus help to prevent serious or fatal injury. A formal evaluation of both (1) the technology of fire-rated doors for rail passenger cars and (2) the benefits of reducing the risks of smoke and fire spreading compared to risks posed by impediments to egress is needed before concluding, as you have, that competing safety objectives preclude benefits from the action we recommend. We acknowledge that the issues you raise in your letter are important, but until they are formally evaluated, they should not be considered a basis for concluding that the recommended action is not warranted. Accordingly, pending your taking the recommended action or conducting a formal evaluation that determines the recommended action is not justified, Safety Recommendation R-12-41 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 NTSB' s focus on the safety hazards caused by leaving the railcar end doors open during an evacuation overlooks the greater hazards that would be created if the doors had to be reopened for each instance of occupant egress or emergency responder access during an emergency. Both sliding and swinging doors interact closely with the surrounding car body structure, at the hinge, track, jamb, pocket, and/or latch. Even minor distortion of that structure due to the forces of collision or derailment, or simply a change in the orientation of the door due to a car being significantly displaced from its upright position, could cause the door to fail to operate as intended. Thus, during an emergency, additional time and effort would be needed to operate the door, delaying egress and access through those doors. Adding weight or tighter seals to make the doors smoke and fire resistant would create a similar distortion and could cost lives in such an emergency. Also, it is not clear how the proposed fire and smoke resistant doors would affect the removable panels contained in existing emergency exit doors. If the panels were also modified to be self-closing to prevent the intrusion of fire and smoke, it would further delay passenger egress and emergency responder access during an emergency. The NTSB recommendation overlooks the need for a design balancing these competing safety objectives. FRA has no reported injuries from fire or smoke damage. FRA cannot cost justify the expense of installing fire doors on passenger cars without a safety justification. Based on the safety data, evacuating passengers quickly is a higher priority than reducing property damage from fire and smoke after all persons have left the car.

From: NTSB
To: FRA
Date: 7/29/2013
Response: We note that the FRA considers its actions complete in regard to Safety Recommendation R-12-41; however, because the regulations cited in Part 238 do not address the NTSB’s intent in issuing the recommendation, we suspect that the FRA may not have fully understood our objective. Some of the railcar end doors appear to have been left open during the evacuation in Miriam, Nevada, and we believe that the fire may have propagated to adjacent railcars though these openings. Current rail passenger equipment safety standards (as found in 49 CFR Part 238) do not require passenger railcar end doors to be fire doors, which delay the spread of heat, flame, and smoke and can thus help to prevent serious or fatal injury without impeding passengers in an emergency situation. We are concerned that the FRA disagrees with our analysis on the issue of railcar fire doors, and we urge the FRA to reconsider its position not to require the recommended enhancement. Pending the FRA’s reconsideration of its position, Safety Recommendation R-12-41 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 5/1/2013
Response: -From Joseph C. Szabo, Administrator: Thank you for your January 28, 2013, letter to the Federal Railroad Administration (FRA) concerning the National Transportation Safety Board (NTSB) Safety Recommendations R-12-39 through R-12-43. These five recommendations came as a result of the report on the Miriam, Nevada, highway-railroad grade crossing collision on June 24, 2011, in which a Peterbilt truck-tractor pulling two empty side-dump trailers and traveling north on US Highway 95 struck an Amtrak passenger train. The collision destroyed the truck-tractor and two passenger railcars. Four train passengers, the train conductor, and the truck driver were killed. 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-12-39 through R-12-41 as "Closed-Acceptable Alternate Action" and R-12-42 & -43 as "Open-Acceptable Response." I appreciate your interest in this important matter. We look forward to working with you. While doors that would prevent fire and smoke from travelling between passenger railcars are not explicitly required by FRA's passenger equipment fire-safety regulations, the regulations do require design features and analysis consideration to minimize the very threat of fire and smoke transmission into passenger and crew compartments. For instance, in specifying criteria for the flammability and smoke emission characteristics of materials used in passenger cars and locomotive cabs, the regulations address the design of vehicle components that may serve to propagate or allow the passage of fire or smoke, including categories for Elastomers (e.g., door no sings and inter-car diaphragms) and Structural Components (floors and other portions of the vehicle body). (See 49 CFR § 238.103, referencing Appendix B.) Moreover, the regulations require that a safety analysis be performed on new passenger equipment (see 49 CFR § 238. 103 (c)) and on existing passenger equipment (see 49 CFR § 238.1 03( d)). The requirement for new equipment specifically directs that effective steps be taken to design the equipment and select materials which help provide sufficient fire resistance to reasonably ensure adequate time to detect a fire and safely evacuate the passengers and crewmembers (see 49 CFR § 238.l03(c)(2)). In this regard, FRA's regulations comprise a systems approach to fire safety, reflecting generally accepted fire protection engineering practices and principles to limit the overall risk of fire in a vehicle and promote the time available for passenger and crew evacuation if a fire does occur. This approach dovetails in particular with FRA' s efforts to enhance requirements for passenger car egress and rescue access, such as through the Passenger Train Emergency Systems II rulemaking (see 77 Fed. Reg. 153 (Jan. 3, 2012)). In addition to FRA's fire-safety regulations and complementary emergency systems effort, as noted, FRA's issuance of a System Safety Program proposed rule is intended to enhance the overall safety of passenger railroad operations using System Safety Program Plans to identify and then mitigate the hazards that each railroad faces. FRA believes that these rulemaking efforts, together with the requirements of FRA' s fire safety regulations, constitute acceptable alternate action to provide for overall passenger and crewmember safety, rather than a prescriptive requirement for fire doors specifically.