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Safety Recommendation Details

Safety Recommendation R-14-074
Details
Synopsis: On December 1, 2013, at 7:19 a.m. eastern standard time, southbound Metro-North passenger train 8808, which departed Poughkeepsie, New York, with a destination of Grand Central Terminal in New York City, derailed at milepost 11.35 on main track 2 of the Metro-North Hudson Line in The Bronx, New York. The train consisted of seven passenger cars and one locomotive at the rear in a push configuration. All seven passenger cars and the locomotive derailed(see figure 1). The derailment occurred in a 6°left-hand curve where the maximum authorized speed was 30 mph. The train was traveling at 82 mph when it derailed. Of the estimated 115 passengers and 4 crewmembers onboard the train at the time of the derailment, 4 passengers were killed, and 57 passengers and 4 crewmembers were injured and transported to local hospitals. The NTSB determined that the probable cause of the accident was the engineer’s noncompliance with the 30-mph speed restriction because he had fallen asleep due to undiagnosed severe obstructive sleep apnea exacerbated by a recent circadian rhythm shift required by his work schedule. Contributing to the accident was the absence of a Metro-North Railroad policy or a Federal Railroad Administration regulation requiring medical screening for sleep disorders. Also contributing to the accident was the absence of a positive train control system that would have automatically applied the brakes to enforce the speed restriction. Contributing to the severity of the accident was the loss of the window glazing that resulted in the fatal ejection of four passengers from the train.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Develop a performance standard to ensure that windows (e.g., glazing, gaskets, and any retention hardware) are retained in the window opening structure during an accident and incorporate the standard into 49 Code of Federal Regulations(CFR) 238.221 and 49CFR 238.421 to require that passenger railcars meet this standard.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Bronx, NY, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA14MR002
Accident Reports: ​Metro-North Railroad Derailment
Report #: RAB-14-12
Accident Date: 12/1/2013
Issue Date: 12/2/2014
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
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. Bronx, New York R-14-74 (Status: Open-Acceptable Response) Develop a performance standard to ensure that windows (e.g., glazing, gaskets, and any retention hardware) are retained in the window opening structure during an accident and incorporate the standard into 49 Code of Federal Regulations (CFR) 238.221 and 49 CFR 238.421 to require that passenger railcars meet this standard. Background On Sunday, December 1, 2013, at 7:19 a.m. eastern standard time, southbound Metro-North Railroad (Metro-North) passenger train 8808 derailed at milepost 11.35 on main track 2 of the Metro-North Hudson Line. The train originated in Poughkeepsie, New York, with a destination of Grand Central Station in New York, New York. The train consisted of seven passenger cars and one locomotive; the locomotive was at the rear of the train in a push configuration. All passenger cars and the locomotive derailed. The derailment occurred in a 6° left-hand curve where the maximum authorized speed was 30 mph. The train was traveling at 82 mph when it derailed. As a result of the derailment, 4 people died and at least 61 persons were injured. Metro-North estimated about 115 passengers were on the train at the time of the derailment. The National Transportation Safety Board determined that the probable cause of the accident was the engineer’s noncompliance with the 30-mph speed restriction because he had fallen asleep due to undiagnosed severe obstructive sleep apnea exacerbated by a recent circadian rhythm shift required by his work schedule. Contributing to the accident was the absence of a Metro-North Railroad policy or a Federal Railroad Administration regulation requiring medical screening for sleep disorders. Also contributing to the accident was the absence of a positive train control system that would have automatically applied the brakes to enforce the speed restriction. Contributing to the severity of the accident was the loss of the window glazing that resulted in the fatal ejection of four passengers from the train.

From: NTSB
To: FRA
Date: 6/9/2016
Response: Safety Recommendation R-14-074 was reiterated in NTSB Railroad Accident Report RAR-16-02, concerning the May 12, 2015 accident in which Amtrak passenger train 188 derailed in Philadelphia, Pennsylvania. The NTSB has been concerned about passengers being ejected through window openings for more than 40 years. In 1972, the NTSB noted that window ejections accounted for a large portion of passenger fatalities. Because of this, the NTSB issued Safety Recommendation R-72-32 to the FRA— In establishing near-future safety standards for railroad and rail rapid-transit passenger cars, give priority to the problem of ejection of passengers through large side windows. Regulations should be promulgated on realistic performance tests. This source of fatalities, even though small in number, is of such a large proportion among passenger fatalities as to warrant action prior to the issuance of the Mechanical Standards. The problem remains serious. The Philadelphia accident was the second passenger rail accident in less than 2 years that resulted in the deaths of passengers as a result of ejection through damaged or displaced passenger car windows. Similar window separations were seen in the December 1, 2013, crash of a Metro-North passenger train near Bronx, New York.42 That train, which derailed at 82 mph, consisted of seven passenger cars and a locomotive. Four passengers were killed, and 57 passengers and 4 crewmembers were injured. In that case, the NTSB found that a contributing factor to the severity of the accident was the loss of windows that resulted in the fatal ejection of four passengers from the train. As a result of that accident, the NTSB issued the following recommendation to the FRA on December 2, 2014: Develop a performance standard to ensure that windows (e.g., glazing, gaskets, and any retention hardware) are retained in the window opening structure during an accident and incorporate the standard into 49 Code of Federal Regulations (CFR) 238.221 and 49 CFR 238.421 to require that passenger railcars meet this standard. (R-14-74) The FRA responded on March 25, 2015, that it was developing a research program to test all safety aspects of window systems, including window retention and passenger containment during potential accident scenarios, as well as emergency egress, rescue access, and impact NTSB Railroad Accident Report 26 resistance requirements. The FRA’s letter also stated that it would have to obtain more information to provide a basis before determining a research approach on this issue due to the competing expectations for railcar window performance. The letter further stated that the FRA expected this research to provide performance data on window retention and passenger containment; evaluate existing and potential designs and design methodologies for window systems; and investigate practical testing metrics and methodologies to assess and quantify containment capabilities. Once this research is complete, FRA can assess the influence of design methodologies that enhance containment capabilities while preserving the ability of window systems to provide required emergency egress and rescue access without compromising other safety purposes. The expected completion date for the research is October 2016. The FRA said it will then be able to determine proposed regulatory changes that are reasonable and practical. Safety Recommendation R-14-74 is currently classified OPEN—ACCEPTABLE RESPONSE. The NTSB recognizes that developing a performance standard and incorporating it into the federal regulations will require research and time. Nonetheless, the Philadelphia accident has again demonstrated the necessity for this standard to protect occupants during accidents; therefore, the NTSB reiterates recommendation R-14-74.

From: NTSB
To: FRA
Date: 7/23/2015
Response: We note that you are developing a research program that will test all safety aspects of window glazing systems, including glazing retention, passenger containment during potential accident scenarios, emergency egress, rescue access, and impact resistance. We also note that, once you validate the results, you will be able to determine what regulatory changes you should propose. We would appreciate receiving your anticipated timeline for this research. Pending issuance of a regulation that satisfies Safety Recommendation R-14-74, the recommendation is classified OPEN—ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 3/25/2015
Response: -From Sarah Feinberg, Acting Administrator: As the National Transportation Safety Board has noted in its recommendation; window glazing systems, specifically side-facing window glazing systems, are expected to perform several potentially conflicting, safety-critical functions. As a structural element of the carbody, windows must withstand a variety of loading conditions due to normal operation. Window systems must also provide impact protection for potential hazards from large objects to ballistics. Most importantly, they need to contain occupants and crew in the event of an accident. The Federal Railroad Administration's (FRA) regulations provide that window systems be designed to allow for rapid egress when needed for emergency window exit, and be designed to allow for removal by emergency responders when rescue access is needed. Therefore, it is essential to ensure that these and other safety-related demands on the window glazing systems are appropriately considered when exploring development or modification of requirements. FRA is developing a research program that will test all safety aspects of window glazing systems, including window glazing retention and passenger containment during potential accident scenarios, as well as emergency egress, rescue access, and impact resistance requirements. Due to the competing expectations for railcar window performance, FRA must obtain more infom1ation to provide a basis for its determination and approach for any future action on this issue. FRA expects this research to provide performance data on glazing retention and passenger containment, evaluate existing and potential designs and design methodologies for window glazing systems, and investigate practical testing metrics and methodologies that could be used to assess and quantify containment capabilities. Once this research is complete, FRA can assess the influence of design methodologies that enhance containment capabilities, while preserving the ability of window glazing systems to perform required emergency egress and rescue access functions without compromising other safety purposes. FRA will then be able to determine proposed regulatory changes are reasonable and practical.