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Safety Recommendation Details

Safety Recommendation R-13-018
Details
Synopsis: On Sunday, June 24, 2012, at 10:02 a.m. central daylight time, eastbound Union Pacific Railroad (UP) freight train ZLAAH-22 and westbound UP freight train AAMMLX-22 collided head-on while operating on straight track on the UP Pratt subdivision near Goodwell, Oklahoma. Skies were clear, the temperature was 89°F, and visibility was 10 miles. The collision derailed 3 locomotives and 24 cars of the eastbound train and 2 locomotives and 8 cars of the westbound train. The engineer and the conductor of the eastbound train and the engineer of the westbound train were killed. The conductor of the westbound train jumped to safety. During the collision and derailment, several fuel tanks from the derailed locomotives ruptured, releasing diesel fuel that ignited and burned. Damage was estimated at $14.8 million. The National Transportation Safety Board determines that the probable cause of this accident was the eastbound Union Pacific Railroad train crew’s lack of response to wayside signals because of the engineer’s inability to see and correctly interpret the signals; the conductor’s disengagement from his duties; and the lack of positive train control, which would have stopped the train and prevented the collision regardless of the crew’s inaction. Contributing to the accident was a medical examination process that failed to decertify the engineer before his deteriorating vision adversely affected his ability to operate a train safely.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Determine what constitutes a reliable, valid, and comparable field test procedure for assessing the color discrimination capabilities of employees in safety-sensitive positions.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Goodwell, OK, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA12MR005
Accident Reports: Head-On Collision of Two Union Pacific Railroad Freight Trains
Report #: RAR-13-02
Accident Date: 6/24/2012
Issue Date: 8/14/2013
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/5/2018
Response: We note that you established what you consider to be a valid color vision test with assistance from the American Academy of Ophthalmology and the American Optometric Association, who provided medical information regarding testing and evaluating color perception. Your use of scientific study and peer review in vision testing fulfills the intent of Safety Recommendation R-13-18, which is classified “Closed—Acceptable Action.” We also note that you have reviewed comments to the interim interpretation you published in the Federal Register on November 24, 2015, which addresses further evaluating people who do not meet the regulatory vision threshold. Although your interpretation concludes that scientific and field testing are best practices, as a result of your review, you have chosen not to mandate that railroads prohibit locomotive engineers and conductors who do not meet the vision threshold from performing their duties. We acknowledge your efforts so far, but we point out that this recommendation calls for set standards, not a “best practices” document. You wrote in your 2016 letter that the interpretation would be finalized by the “end of the year.” Please notify us if you intend to require railroads to prohibit employees who do not meet the vision thresholds from performing safety-sensitive duties. In the interim, Safety Recommendation R-13-19 is classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 6/20/2018
Response: -From Ronald L. Batory, Administrator: In November 2015, the NTSB classified R-13-18 as "Open-Acceptable Response," pending FRA's publication of our interpretation of the recommended procedure. In March 2016, FRA informed the NTSB that, in addition to clarifying our locomotive engineer and conductor qualification and certification regulations with respect to vision standards and testing, FRA issued an interim interpretation of its regulations pertaining to these topics. The interpretation was published in the Federal Register on November 24, 2015, and can be found here: https://www.gpo.gov/fdsys/pkg/FR-2015-11-24/pdf/2015-29640.pdf. This agency interpretation addresses how to further evaluate persons who do not meet the regulatory vision threshold. The document also provides best practices guidance for designing valid, reliable, and comparable vision field tests for assessing whether persons who do not meet regulatory vision thresholds can perform safely as locomotive engineers and conductors. This published interpretation satisfies the NTSB's recommendation for FRA to determine what constitutes a reliable, valid, and comparable test and, importantly, had the additional desired effect of causing railroads to review their procedures for vision field testing. For example, the National Railroad Passenger Corporation (Amtrak) and UP have each greatly improved their field testing procedures for locomotive engineers and conductors. Some railroads, e.g. New Jersey Transit, have abandoned conducting vision field testing on their locomotive engineers and conductors, and are instead opting to enact company policies that require these employees to pass medical tests. Because FRA has addressed the recommendation and there has been evidence of positive change in response to FRA's actions, FRA respectfully requests that the NTSB reclassify Safety Recommendation R-13-18 as "Closed-Acceptable Action." I appreciate your interest in this important safety issue.

From: FRA
To: NTSB
Date: 3/23/2016
Response: -From Sarah E. Feinberg, Administrator: In addition to clarifying its locomotive engineer and conductor qualification and certification regulations with respect to vision standards and testing, FRA issued an interim interpretation of its regulations pertaining to these topics. The interpretation was published in the Federal Register on November 24,2015, and addresses further evaluation of persons who do not meet the regulatory vision threshold. It also provides best practices guidance for designing valid, reliable, and comparable vision field tests for assessing whether persons who do not meet those thresholds can perform safely as locomotive engineers and conductors. FRA is currently reviewing comments on its interpretation and will respond to them and finalize the interpretation later this year.

From: NTSB
To: FRA
Date: 11/19/2015
Response: We understand that you have been collecting and analyzing information to address these recommendations. We are pleased that FRA representatives have participated in several telephone conferences with experts from the American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) and two major railroads, in which the railroads briefed FRA, AAO, and AOA representatives on field test procedures those railroads use. We note that you will use all the data gathered?including information from industry, labor, and other experts—to establish what constitutes a valid, reliable, and comparable field test procedure for assessing the color discrimination capabilites of employees in safety sensitive positions, which you anticipated publishing this year. We commend your collaborative approach to establishing scientifically based color discrimination testing procedures to ensure the safe operation of railroad crews. We also understand that, once you have published your interpretation of the recommended procedure, you intend to require all railroads to implement it. Pending completion of these efforts, Safety Recommendations R 13 18 and -19 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 2/18/2015
Response: -From Sarah Feinberg, Acting Administrator: The Federal Railroad Administration (FRA) is taking actions consistent with its January 2, 2014, letter (Response) to the National Transportation Safety Board in response to Safety Recommendations R-13-18 and R-13-19. FRA is collecting and analyzing information that will allow it to establish its interpretation of what constitutes a valid, reliable, and comparable field test procedure for assessing the color discrimination capabilities of locomotive engineers and conductors. FRA intends to publish its interpretation in 2015. The interpretation will provide notice to railroads that if a railroad intends to conduct field testing for assessing color discrimination capabilities of locomotive engineers and conductors, the railroad must ensure that the procedures for the testing are included in its FRA-approved locomotive engineer and conductor certification programs. If the testing is not outlined in a railroad's existing programs, the railroad will need to amend its programs to specify the procedures that it will use. FRA will use the existing regulatory requirements for approving material modifications to certification programs to approve or disapprove each railroad's field testing procedures, thereby ensuring that vision field testing is reliable, valid, and comparable. Since FRA's Response, FRA has held five telephone conferences with vision experts representing the American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) and two major railroads. The experts participating in these conferences discussed a variety of issues including: safety-critical aspects and indications of color light and color-position light railroad signals; the size, chromaticity, and intensity of color signal lights; and certain variations in signal hardware and operating rules that exist on different railroad properties. During these calls, the two major railroads briefed FRA and the AAO and AOA representatives on the field test procedures that those railroads currently use. FRA plans to utilize all the data gathered to date through these efforts and obtain and analyze additional information from industry, labor, and other experts to establish its interpretation of what constitutes a valid, reliable, and comparable field test.

From: NTSB
To: FRA
Date: 2/24/2014
Response: We are aware of your current requirements that railroad personnel demonstrate their ability to recognize and distinguish the colors of railroad signals by successfully completing tests specified in appendices to FRA certification regulations in Title 49 Code of Federal Regulations (CFR) Section 240.121(c)(3) and Appendix F, also 49 CFR § 242.117(h)(3) and Appendix E, as well as the alternative processes for a person that cannot successfully complete one of the medical tests, stated in 49 CFR § 240.12l(e) and 242.117G. We are encouraged that you are in the process of seeking and collecting information to establish best practices for conducting field tests, that you are working with the American Academy of Ophthalmology and the American Optometric Association, and that you will consider the various signal system arrangements and displays, as well as other operating characteristics that may differ from railroad to railroad, when developing testing guidance. Pending completion of these efforts, Safety Recommendation R-13-18 is classified OPEN—ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 1/2/2014
Response: -Joseph C. Szabo, Administrator: The Federal Railroad Administration (FRA) requires each railroad to train and certify each of its locomotive engineers and conductors. FRA also requires each railroad to submit its certification programs to FRA for approval. As part of the certification process, FRA requires that a railroad determine whether the person seeking certification or recertification has "[t]he ability to recognize and distinguish between the colors of railroad signals as demonstrated by successfully completing one of the tests" specified in appendices to FRA's certification regulations. See Title 49 Code of Federal Regulations (CFR) Section 240.121(c)(3) and Appendix F, also 49 CFR § 242.117(h)(3) and Appendix E. However, if a person cannot successfully complete one of the medical tests that would clearly establish that the person can discriminate among the colors of railroad signals, FRA's certification regulations permit a railroad's medical examiner to determine whether the person can otherwise safely operate a locomotive or safely perform as a conductor by allowing operating supervisors to conduct a field test. See 49 CFR §§ 240.12l(e) and 242.117G). FRA is in the process of seeking and collecting information that will allow it to establish best practices for conducting field tests involving color discrimination capabilities. In determining what constitutes appropriate field test procedures, FRA intends to consult with and obtain information from various resources, including medical experts, signal and train control experts, railroad management, and labor representatives. FRA has already contacted the American Academy of Ophthalmology and the American Optometric Association for information. FRA will also consider the various signal system arrangements and displays, as well as other operating characteristics that may differ from railroad to railroad, when developing testing guidance. FRA expects that the advice and information it receives from these experts, stakeholders, and FRA investigations will aid FRA in developing best practices for conducting field tests involving individuals' color discrimination capabilities. FRA believes that field testing for color discrimination capabilities primarily involves the job responsibilities of operating employees, as they evaluate signals, rather than other employees engaged in safety-sensitive positions (e.g., track employees). Therefore, FRA is planning to continue its focus on conductors and locomotive engineers and FRA does not plan to expand its color discrimination field testing review beyond those employees. However, the guidance documents discussed below will be available for use by the railroads, if they elect, to use with employees in other safety-sensitive positions.