Railroad Accident Report

Collision of Norfolk Southern Corporation Train 255L5
With Consolidated Rail Corporation Train TV 220

Butler, Indiana
March 25, 1998

NTSB Number RAR-99-02
NTIS Number PB99-916302
Adopted: July 13, 1999
PDF

Executive Summary

On March 25, 1998, about 4:48 a.m. eastern standard time, southbound Norfolk Southern Corporation (Norfolk Southern) train 255L5, which was en route to Fort Wayne, Indiana, struck eastbound Consolidated Rail Corporation (Conrail) train TV 220, which was en route to Columbus, Ohio. The collision occurred where the Norfolk Southern Huntington District and the Conrail Chicago main lines cross at grade at the east end of the town of Butler, Indiana. Both locomotives and five cars from the Norfolk Southern train derailed, and three cars from the Conrail train, two with multiple stacked platforms, derailed. The Norfolk Southern conductor was killed; the engineer and student engineer sustained minor injuries. The two Conrail crewmembers were not injured.

No hazardous materials were released, but both Norfolk Southern locomotive fuel tanks ruptured and released approximately 7,000 gallons of fuel oil. Norfolk Southern estimated total damages of $264,000 ($187,000 to equipment, $18,000 to track and signals, and $59,000 to cargo). Conrail estimated total damages of $352,200 ($314,000 to equipment, $33,500 to track and signals, and $4,700 to cargo).

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the engineer and conductor of train 255L5 to comply with operating rules (specifically, their failure to observe and confirm signal aspects and their failure to continuously and directly supervise the student engineer) and the failure of Norfolk Southern Corporation to ensure employees' compliance with operating rules. Contributing to the accident was Norfolk Southern Corporation's failure to ensure that its locomotive engineer training program provided effective, timely training; oversight; and feedback to ensure that students were adequately prepared for operational situations. Also contributing to the probability of this accident occurring was the failure of Norfolk Southern Corporation's signal maintenance program to respond to a reported signal deficiency.

As a result of its investigation of this accident, the Safety Board identified the following major safety issues:

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Review Norfolk Southern Corporation's 49 Code of Federal Regulations 240 submission, Certification of Locomotive Engineers, specifically "Section 5: Training, Testing, and Evaluating Persons Not Previously Certified," to determine whether the company's training program is adequate for training new engineers and require that any deficiencies found be corrected. (R-99-12)

In cooperation with Class I railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers, and the United Transportation Union, develop and require, for all train crewmembers, crew resource management training that addresses, at a minimum:

Direct Harmon Industries and the railroad carriers to identify and replace all faulty Electro Code 4 capacitors. Ensure, through followup inspections, that corrective actions have been taken. (R-99-14)

To Norfolk Southern Corporation:

Develop and implement methods to improve employee compliance with company rules and instructions. (R-99-15)

Develop and implement procedures that actively engage crewmembers in observing and confirming all signal aspects. (R-99-16)

Inform all operating personnel of their responsibilities regarding student engineers. (R-99-17)

Assign supervisors dedicated exclusively to student engineers who will, at a minimum:

Provide student engineers with formal training in all known or anticipated operational requirements systemwide, including operating trains with the long hood forward. (R-99-19)

Conduct a comprehensive assessment of the locomotive engineer training program and revise it, as necessary, to ensure that student engineers consistently operate with and are mentored by coach-trained engineers and that engineer training reflects actual operating conditions. (R-99-20)

Provide employees, especially trainees, with effective strategies for dealing with crewmembers who knowingly disregard the operating rules. (R-99-21)

In cooperation with the Federal Railroad Administration, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers, and the United Transportation Union, develop, for all train crewmembers, crew resource management training that addresses, at a minimum:

Designate dedicated personnel to record and track all signal malfunctions and repairs in order to identify recurring, unresolved failures. (R-99-23)

Conduct an audit to identify all communities through which you transport hazardous materials and, in coordination with those communities, develop, implement, and keep current written emergency response plans and procedures for handling hazardous material releases. The procedures should address, at a minimum, key railroad personnel and means of contact, procedures to identify the hazardous materials being transported, identification of resources for technical assistance that may be needed during the response effort, procedures for the coordination of activities between railroad and emergency response personnel, and the conduct of disaster drills or other methods to test emergency response plans. (R-99-24)

To the Class I Railroads and Amtrak:

In cooperation with the Federal Railroad Administration, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers, and the United Transportation Union, develop, for all train crewmembers, train crew resource management training that addresses, at a minimum:

To the American Short Line and Regional Railroad Association:

In cooperation with the Federal Railroad Administration, the Class I railroads, the Brotherhood of Locomotive Engineers, and the United Transportation Union, develop, for all train crewmembers, train crew resource management training that addresses, at a minimum:

To the Brotherhood of Locomotive Engineers:

In cooperation with the Federal Railroad Administration, the Class I railroads, the American Short Line and Regional Railroad Association, and the United Transportation Union, develop, for all train crewmembers, train crew resource management training that addresses, at a minimum:

To the United Transportation Union:

In cooperation with the Federal Railroad Administration, the Class I railroads, the American Short Line and Regional Railroad Association, and the Brotherhood of Locomotive Engineers, develop, for all train crewmembers, train crew resource management training that addresses, at a minimum:

To Harmon Industries:

Identify and contact all customers who purchased Electro Code 4 units manufactured from 1987 to 1988, and institute a systematic corrective program for the repair or replacement of faulty electrolytic capacitors. (R-99-29)

To the DeKalb County Emergency Management Agency:

Contact Norfolk Southern Lake Division officials to provide and keep current, points of contact for emergency response coordination. (R-99-30)