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Safety Recommendation Details

Safety Recommendation R-13-005
Details
Synopsis: On September 30, 2010, about 4:05 p.m. central daylight time, a southbound Canadian National Railway freight train collided head on with a northbound Canadian National Railway freight train near Two Harbors, Minnesota. The collision occurred near milepost 13.5 on Canadian National Railway’s Iron Range Subdivision. The trains were operating in nonsignaled territory. The northbound train had 118 empty iron ore railcars and had authority to operate on the single main track. The southbound train had 116 railcars loaded with iron ore and did not have authority to operate on the single main track. The crew of the southbound train entered the main track after failing to properly execute an after-arrival track authority. A total of three locomotives and 14 railcars derailed. All five crewmembers on the two trains were injured and transported to hospitals. Four crewmembers were treated and released; one crewmember remained hospitalized for further treatment. Canadian National Railway estimated damages at $8.1 million. As a result of its investigation of this accident, the National Transportation Safety Board (NTSB) makes recommendations to the Federal Railroad Administration, Canadian National Railway, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, Canadian Pacific Railway Limited, Kansas City Southern Railway Company, Norfolk Southern Railroad, and Union Pacific Railroad. The NTSB also reiterates previous recommendations to the Federal Railroad Administration, BNSF Railway, and the American Short Line and Regional Railroad Association. The NTSB also reiterates and reclassifies recommendations to the Federal Railroad Administration.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Identify, and require railroads to use in locomotive cabs, technology-based solutions that detect the presence of signal-emitting portable electronic devices and that inform the railroad management about the detected devices in real time.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
Mode: Railroad
Location: Two Harbors, MN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10FR009
Accident Reports: Collision of Two Canadian National Railway Freight Trains
Report #: RAR-13-01
Accident Date: 9/30/2010
Issue Date: 3/8/2013
Date Closed:
Addressee(s) and Addressee Status: FRA (Open Acceptable Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 8/11/2016
Response: We note that the the Rail Safety Advisory Committee’s (RSAC) Recording Devices Working Group was tasked with considering the effects of railroads using recording devices to monitor all behavior in the locomotive cab, including crewmembers using signal-emitting portable electronic devices. We further note that you believe the technology specified in Safety Recommendation R-13-5 is not accurate enough to be effective, and that it will not identify the use of potentially distracting electronic devices that do not transmit a signal such as cellular devices in airplane (nontransmitting) mode, electronic game devices, or electronic book readers. You believe, rather, that an inward facing video recorder, as we recommended in Safety Recommendation R-10-1, would reliably identify an individual in the locomtive cab who was inappropriately using any type of electronic device. You therefore believe that the signal detection devices discussed in Safety Recommendation R-13-5 would provide redundant information, once cab video recordings become available. We understand that the RSAC working group was unable to reach a consensus and that you announced at the May 28, 2015, RSAC meeting that, in the absence of RSAC consensus recommendations, you planned to issue a notice of proposed rulemaking (NPRM) to require the installation of locomotive recording devices. Although the NPRM has not yet been published, it may propose actions that will constitute an acceptable alternate course of action, thus satisfying Safety Recommendation R-13-5. Pending completion of the recommended rulemaking, Safety Recommendation R-13-5 is classified OPEN--ACCEPTABLE ALTERNATE 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. In response to this recommendation, FRA tasked RSAC with establishing the Recording Devices Working Group to consider the effects of railroads using recording devices to monitor all behavior in the locomotive cab, including crewmembers using signal-emitting portable electronic devices. This working group is currently evaluating the potential use of audio and/or video recordings of the crew in the locomotive cab and is due to submit its recommendations to FRA within the next year. Based on the group's findings, FRA may consider establishing additional safety requirements to prevent the use of unauthorized electronic devices in locomotive cabs. However, at this time, there is not enough evidence to support the use of existing technology based solutions. FRA is aware of current railroad testing of signal detection technology that could help detect the presence of signal-emitting portable electronic devices. However, FRA believes that at this time, such technology is not accurate enough to be effective and should not be required by safety regulation. This technology will not identify use of cellular devices in airplane (nontransmitting) mode, nor will it identify use of electronic game devices or electronic book readers which can be operated without transmitting a signal. This technology would provide reliable detection only if it is combined with video recordings depicting activity inside the locomotive cab. The cab recording provides confirmation that the signal originated in the cab, and identifies the specific individual in the cab using the electronic device. Moreover, FRA believes that these signal detection devices, even if reliable, would only provide redundant information, once cab video recordings become available.

From: NTSB
To: FRA
Date: 9/23/2013
Response: We understand that the FRA recognizes that portable electronic device detectors must be designed to match the characteristics of the intended application environment—the locomotive cab, which the FRA has characterized as a confined space. We further understand that the FRA is aware that improperly tuned detectors will falsely detect signals emanating from outside the locomotive cab. However, we believe that the FRA’s considerations of the challenges inherent to Safety Recommendation R-13-5 need to be expanded. Specifically, the confined area of a locomotive cab simplifies, and does not overly complicate, some aspects of the design of portable electronic device detectors. For example, the defined boundaries of the locomotive cab, as well as the known locations of electronic device usage, allow economical antenna and power subsystems to be used. Likewise, the signals emitted by the electronic devices intended to be detected have well-defined and well-behaved characteristics, such as signal frequency, phase, and amplitude. These signal characteristics help to simplify the design of electronic filters that enable detectors to work reliably and accurately. We believe the FRA has understated several important points regarding the issue addressed by this recommendation in its letter. First, the FRA mentioned that other devices use cellular signal frequency pass bands. Indeed, wireless devices (such as Bluetooth-enabled devices and company-issued cellphones) use cellular channels, but they also are categorized as portable electronic devices intended to be detected. Second, the FRA did not mention that the design of time-based filters employing signal strength thresholds as device detection criteria are ideal for use in moving locomotives, as devices located inside the locomotive cab are detected continuously; devices located outside the locomotive cab pass in and out of detection range. Third, the FRA did not appear to recognize that signal detectors currently are available for, and used in, such varying environments as those of the military, those of building and personnel security scanners, and those of industry and manufacturing. Each of these environments possesses unique challenges, which have been met and addressed by purposeful engineering. We do not think that the FRA has supported its argument that locomotive cab environments possess unresolvable challenges for the use of portable electronic device detection technologies. The FRA believes that real-time detection of portable electronic devices requiring action by the railroad will create burdensome communication loads, especially for dispatchers. We respect that such scenarios can be envisioned, if technological solutions are thrust on end users without the consideration of appropriate human systems integration throughout the system life-cycle. While the FRA may have witnessed such shortcomings in past endeavors, contemporary approaches to systems engineering have avoided these workload problems. Of more significance, the challenge of detecting portable electronic devices in the locomotive cab is a separate issue from the challenge of determining how information about a detected portable electronic device will be used by a railroad to reestablish a safe work climate in the locomotive cab. In other words, implementing a reliable device detection system is one step toward mitigating the crew distraction safety risks; using that information about a detected device to intervene with the operating crew is another step in the system safety plan. The NTSB has a goal of zero distractions to operators of transportation systems from portable electronic devices. When this goal is achieved, there will be no communications load resulting from the portable electronic device detection system. However, both our agencies recognize that this zero distraction goal has not yet been met; rather, we are both aware of the increasing trend of the unauthorized use of these devices by railroad operating crews, along with the devastating losses and damages resulting from the distractions their use causes. Accordingly, we vitally need an immediate and effective means of processing information about detected devices in locomotive cabs to ensure the safety of crewmembers and the public; this priority warrants expeditious action by both our agencies. With the FRA’s experience, resources, and record of success in resolving human-system integration challenges, the NTSB does not believe that the task associated with developing nonburdensome communications between portable electronic device detection systems and the appropriate railroad oversight mechanisms is beyond currently available capability. Therefore, pending the FRA’s identification of, and mandate for, a successful technology based solution that detects the unauthorized use of portable electronic devices in locomotive cabs, Safety Recommendation R-13-5 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. This technology has not been specifically developed for use in a railroad environment. The existing technology is not suitable for a locomotive cab, because the cab is a small area that is open to the environment. Based on available information on other applications, FRA has concerns that the detection of the presence of signals from an electronic device in a locomotive cab could result in many false positives (i.e., the detection of signals corning from sources outside the cab, including those from off-railroad property, including potentially nearby pedestrians, drivers waiting at grade crossings, and even people in nearby buildings). Trackside devices, or even devices on a locomotive itself, which communicate on cellular frequencies, could also be falsely detected as in-cab transmissions. Depending on the sensitivity of the detection device, devices on passenger locomotives (particularly multiple unit locomotives or cab cars) could even falsely detect passenger use of cell phones. On the other hand, reducing the sensitivity of the detection device to eliminate false positives also reduces the percentage of true positives that are detected. In addition, if all such incidents of signal detection were to be detected and reported to the railroad in real time, and the railroad expected to take action, an undue communications burden could be placed on certain railroad employees, particularly dispatchers. Presumably, dispatchers would be responsible for determining whether each reported detection is a true or false positive. This distraction from their primary dispatching functions could serve to reduce the safety of operations, rather than enhance it.