Remarks by James E. Hall, Chairman
National Transportation Safety Board
To the Association of American Railroads
General Claims Conference
Ponte Vedra, Florida
August 23, 1995

Good morning, ladies and gentlemen. It is indeed an honor to be here today at the Association of American Railroad's General Claims Conference.

I always enjoy meeting with railroad professionals, probably because the industry's in my blood. Before he died in 1945, my grandfather was a long-time section hand and conductor on the old L & N Railroad.

Last year was the safest year ever for the railroad industry. We saw new lows in the rate of train accidents and the number of employee fatalities. But a good safety record can sometimes be a fragile commodity. Our nation's major airlines had gone 27 months without a passenger fatality until last year's string of accidents killed more than 200. The Mobile tragedy resulted in almost as many fatalities by itself as Amtrak had experienced in its entire history up to that point.

One thing we've learned at the NTSB is that safety never takes a holiday -- it's a 365-day-a-year job.

Today, I would like to do three things. First, I would like to tell you about the Safety Board's role in railroad accident investigation. Second, I would like to give you an update on some of the Safety Board's activities and highlight what I consider to be some of the more compelling safety issues the Safety Board has recently addressed. Finally, I would like to discuss the role the NTSB and the railroad industry plays in rail transportation safety and how we can cooperate to work together more effectively.

The National Transportation Safety Board is mandated by Congress to investigate transportation accidents, determine probable cause of these accidents, perform oversight of government regulatory agencies, and issue safety recommendations to prevent similar accidents from recurring in the future.

In addition to its Washington headquarters office, the Safety Board maintains railroad regional offices in Los Angeles, Chicago, and Atlanta to address as much of this investigative mandate as possible with the currently available staff. You've all heard of our work in high-profile accidents like Mobile and Chase, Maryland, but these are just a part of our responsibilities. We conduct about 5 major investigations and 90 to 100 regional investigations each year.

The scope of a Safety Board railroad investigation differs from a Federal Railroad Administration investigation in that the Safety Board conducts an independent investigation that looks at all facets of an accident and develops probable cause without assessing blame. There is no attempt to determine violations of FRA regulations but there is a continuing assessment of the appropriateness of FRA regulations and the adequacy of state and federal agencies charged with oversight of the railroad operations. Company policies and procedures are also closely analyzed in order to go beyond the immediate cause of the accident to determine not just what happened but why it happened.

It is important for you to know that while the factual information uncovered by Safety Board investigators is a matter of public record, the Board's analysis of that data and determination of cause are not admissible in a court of law. Similarly, when assigning investigators from the various parties, we bar litigants and insurers from participation.

When a major Mobile-type accident occurs, the Board's Railroad Division shifts into high gear. The division provides an Investigator-In-Charge (IIC), who manages each major investigation and who coordinates the preparation of the Safety Board's comprehensive accident report. The group chairmen, who are NTSB investigators that work for the IIC, coordinate the efforts of participants in the accident investigations who are provided by industry and other government agencies. Each group conducts a thorough technical investigation in its area of expertise of the accident and produces separate factual and analytical reports likely to include proposed safety recommendations to correct deficiencies and prevent future accidents.

Regional investigations, involving accidents of a less catastrophic nature than major investigations, are conducted under the same rules, just on a much smaller scale.

In our 28-year history, the Safety Board has investigated over a thousand railroad accidents; accidents that have resulted in deaths, injuries, and millions of dollars in damages and settlements. I am sure that I don't have to remind anyone in this room how costly railroad accidents can be -- both in human suffering and in monetary resources.

During the past year, the Safety Board has completed investigations and adopted reports on major railroad accidents that occurred in Kelso, Washington; Lakeland, Florida; Selma, North Carolina; and Intercession City, Florida. These accidents highlight several important safety issues that I would like to discuss today:

No Safety Board discussion on railroad safety would be complete without a discussion on the merits of Positive Train Separation. We have been a strong advocate of advanced train control systems that will provide positive train separation and act as a safety net for human performance failures in the operation of trains. These systems would prevent accidents by overriding the engineer's actions or inactions, by controlling train speed and by preventing conflicts that could result in train collisions.

For example, if an engineer does not obey a restricting signal or a train does not slow for a sharp curve, the PTS system would take over and slow or stop the train.

Positive Train Separation, or PTS, has been on the Safety Board's list of Most Wanted transportation safety improvements since the list was formulated in 1990 and will remain there as long as there is progress to be made in the implementation of this important technology.

The urgency of this issue has been highlighted over and over in Safety Board investigations. The fatal train accidents that took place in Sugar Valley, Georgia; Corona, California; Knox, Indiana; Ledger, Montana; Thedford, Nebraska; and Marathon, Texas could ALL have been prevented if a fully developed PTS control system had been in place.

Our latest report involving this issue concerned the 1993 collision near Kelso, Washington, killing all 5 crew members. The silver lining in this tragedy is that since that accident, the FRA, the AAR and the railroad industry have entered into serious discussions on positive train separation systems, including the AAR's advanced train control system (ATCS) project. The discussions that took place included the resolution of some important issues that need to be fully addressed if ATCS or any other form of a PTS control system is to be implemented. The participants in these discussions have identified the desired features of PTS, and have attempted to determine the cost and the return on investment for a fully implemented system.

As most of you know, the Union Pacific and the Burlington Northern railroads are participating in a joint project to install an advanced train control system that will provide PTS on 750 miles of track in the Pacific Northwest, including Kelso. The system will use a combination of technologies to achieve positive train separation, including transponders and geosynchronous positioning satellites (GPS) to locate and monitor train movements. The test will be the first real United States field demonstration of advanced train control technology since Burlington Northern's ARES project was canceled in 1992.

The NTSB understands the reluctance of the railroad industry to invest the money required to implement PTS control systems on all mainline tracks nationwide. The technology will require a substantial investment, currently estimated to be about $1 billion. This is a large investment to make purely in the name of safety, when all businesses must be concerned with the bottom line.

But we believe that the payback on PTS control systems goes well beyond safety alone. While some groups might debate the existence of business benefits associated with PTS, we believe that there are very definite business benefits in fuel savings, dispatching, train pacing, and higher utilization of tracks that make this expensive system pay off in ways other than safety.

In summary, the Safety Board is pleased with the progress that is being made in technology and hardware needed to develop PTS. We are also pleased with the commitment made by the FRA, the AAR, and the member railroads in putting a demonstration project in place in the Pacific Northwest. On the other hand, we are disappointed -- and a little puzzled -- by the refusal of these organizations to even broach the subject of the business benefits with the Safety Board.

On another front, one of the advantages of an agency like the Safety Board is that we can handle multi-modal issues. This was shown in two recently adopted reports that highlighted the issue of pipeline safety. Many railroads share rights of way with both gas and liquid pipelines. These pipelines transport products that are flammable and pose fire or explosive hazards during derailments and derailment cleanup operations.

The issue of pipeline safety during railroad derailments was initially addressed in an accident that occurred 6 years ago in California. On May 12, 1989, a runaway Southern Pacific Transportation Company freight train derailed in San Bernardino, California, destroying the entire train and destroying or extensively damaging 11 homes located in the adjacent neighborhood. Two train crew and two local residents were killed.

A 14-inch high pressure liquid pipeline lay beneath the wreckage site. On May 25, 13 days after the train derailment, the pipeline ruptured at the derailment site, releasing pressurized gasoline that spewed over homes in the immediate area and then ignited. The resulting fires killed 2 more residents and destroyed 11 homes.

The Safety Board's investigation determined that the pipeline's 4 to 6 feet of earth cover protected it during the derailment but not during the cleanup operation, during which it was mechanically dented and gouged.

This was not an isolated incident, although it was one of the worst of its kind. The Board recently completed investigations of two accidents in Florida in which derailed trains came to rest over buried pipelines carrying hazardous petroleum products. Fortunately, there was no catastrophic failure of the pipeline in either of these accidents, but the potential for a serious incident immediately after the derailment or during the wreckage cleanup existed.

In both of these accidents, timely notification by the railroad of the derailment was not given to the pipeline company. The pipeline company depends on prompt notification so that it can act to reduce threats to rail workers and the public by reducing pressures, isolating pipe sections and checking for leakage. The Safety Board believes that the railroads have an obligation to notify pipeline companies and other companies that share their rights of way of derailments or other emergencies. Pipeline notification should be incorporated into the railroad's standard emergency notification procedures.

The Safety Board believes that there is a need for all railroads and pipeline companies with facilities along railroad rights of way to actively coordinate their emergency response activities. They need to develop a plan for effective on-scene coordination that would ensure the protection of pipelines and other facilities buried within the railroad right-of-way. The plan is necessary to abate the risk to on-scene personnel and the public. There will be no excuse for another San Bernardino-type disaster.

Another safety issue that the NTSB addressed during the past year is the issue of securement of intermodal shipments. The accident that highlighted this safety issue occurred in Selma, North Carolina, on May 16, 1994, when Amtrak train 87, the "Silver Meteor", struck an intermodal trailer, killing one of the train's engineers.

The trailer was on a railroad flatcar of a passing northbound CSXT freight train. The collision caused a subsequent derailment of all but the last car of the Amtrak train.

The NTSB determined that the probable cause of this accident was the failure of the CSX Intermodal Corporation loading crew to properly secure the intermodal trailer to the flat car on the freight train and the failure of the company to have a comprehensive inspection plan.

What quickly became apparent in the Selma investigation was that there were no standards or regulations in place to control how intermodal trailers and containers were being loaded and inspected for shipment. The railroads took it on faith that the trailer would be properly loaded and secured at the intermodal terminal. The intermodal terminals, in turn, trained their workers and performed loading operations per their own policies and guidelines with no state or federal oversight and limited railroad oversight.

The intermodal industry enjoyed a very high success rate. Compared to the number of trailers that were loaded, there were very few problems with unsecured loads that resulted in an accident. This safety issue would certainly still be unaddressed if it were not for the tragic coincidence that Amtrak train 87 was passing at the moment the trailer fell from the freight train.

Immediately after the accident, the FRA conducted a study to assess the safety of intermodal shipments. In partnership with industry, the FRA recommended seven actions to strengthen or eliminate safety weaknesses in intermodal loading operations. The recommendations were made to the railroad industry and are voluntary. The Safety Board encourages all railroads to follow these recommended actions -- ranging from more frequent inspections to better oversight of loading contractors -- to improve the safety of their intermodal operations.

One of the Florida accidents raised another issue that bears discussion. In that accident, a vehicle was stuck on a grade crossing and was subsequently struck by a train. At the time of the accident, the manager for the trucking company was searching for a telephone number so that he could call the railroad and stop any oncoming train. He was not successful for a variety of reasons, but partly because he did not have the appropriate phone number.

Three months ago, I stood among the wreckage of a similar accident. On May 2, northbound Amtrak passenger train 81, the "Silver Star," crashed into a tractor-lowboy trailer that had been stuck for up to an hour at a passive public grade crossing near Sycamore, South Carolina. As a result of the collision and derailment, over 50 passengers were transported to area hospitals.

The circumstances of these two accidents beg the question: How can a truck driver whose vehicle has become hungup at a crossing contact the railroad quickly and efficiently to stop any oncoming train? One method that the Sycamore investigative team is exploring is posting an emergency telephone number and a grade crossing identification number at each crossing. A driver that became stuck or has an emergency situation could call a telephone number posted at the crossing to contact local emergency authorities or a railroad dispatching center, citing the crossing identification number posted there to identify the location of the problem and stop traffic on the rail line.

While grade crossing accidents might be considered a highway problem, they affect railroads the most, and railroads must be part of the solution.

The Sycamore accident occurred in one of the poorest counties in South Carolina. Telephone numbers at grade crossings are a low priority when funds are needed for schools, roads, or basic public services. In these days of reduced budgets and smaller government, the railroads and other businesses that make a profit operating trains have an obligation to ensure the public is safe from accidents involving their trains.

The railroads have been generous in their support of Operation Lifesaver and other grade crossing programs in the past, but in these times of government downsizing and budget cuts, the railroads are going to have to become even more involved. They need to actively participate in the next level of safety -- whether by financing the development of positive train separation systems, cooperating with pipeline companies to ensure safe handling of accidents and cleanup, providing increased inspections for intermodal shipments, or enhancing grade crossing safety.

All of these accidents were investigated under the National Transportation Safety Board's congressional mandate. The Code of Federal Regulations stipulates that Safety Board investigations of railroad accidents are to be performed in cooperation with the owner, in such a manner so as not to interfere with the services it provides. In establishing the NTSB guidelines for investigations, Congress clearly intended that the NTSB and the railroad industry work together in a cooperative manner to investigate accidents.

That brings me to my final topic today - cooperation between the NTSB and the railroad industry. We have been working together successfully on accident investigations for many years. As a rule of thumb, the railroad is always a party to the investigation, although that decision is a matter of the chief investigator's discretion. Hundreds of railroad accident investigations have been conducted using this arrangement, which results in a smooth-running efficient investigation where all parties are satisfied with the validity of the outcome.

The majority of NTSB accident investigations end up this way. Very rarely do we have problems working with the railroads. Those problems that do crop up tend to involve unauthorized release of information by party personnel -- either railroad, union or government agency -- that have forced us to dismiss that person from the investigation.

What is our expectation for railroad cooperation? For the purposes of this discussion, the NTSB has two major points of authority -- investigate accidents and make safety recommendations. With this mission in mind, the Board has been mandated by Congress to investigate railroad accidents in which there is a fatality, substantial property damage, hazardous materials release, or which involve a passenger train.

When an accident occurs that meets one of these criteria, we are notified directly by the railroad or operating authority that owns the track and equipment involved.

This notification is extremely important. The Safety Board needs the cooperation of the railroads to, first of all, report accidents in a timely manner, and secondly, provide accurate information and a reliable point of contact -- a 24-hour phone number. Our investigators need to be able to follow up on early reports and make a decision on whether or not to launch an investigation. One time, we were notified of an accident involving a derailed locomotive and a resulting fuel spill. Follow-up with the railroad revealed that the locomotive in question derailed because it was involved in a head-on collision with another train! A total of 6 locomotives and 22 cars were actually derailed.

Another area where the NTSB and the railroad industry need to cooperate is event recorders. The use of event recorders and the possession of the recording media have been debated for a number of years. The Safety Board considers the recording medium to be crucial evidence in a federal investigation and therefore takes possession of it after an accident.

We hope that we will not have to issue our own rule on event recorder data preservation. However, that will depend on how much cooperation the NTSB receives from the railroads. The Safety Board would prefer that the event recorders on major accidents remain in place on the locomotives until investigators arrive on the scene. Once the Safety Board has possession of the event recorder, a joint readout of the data is normally arranged involving the carrier, the FRA, and the Safety Board.

The Safety Board believes that critical information like event recorder data needs to be handled carefully with a clear chain of custody. If a railroad recovers and reads out an event recorder without the NTSB and there is a problem with the data, then the railroad may be exposing itself to criticism from the general public, not to mention delaying or impeding the progress of the investigation. The Safety Board's control of these devices prevents any unnecessary questions that might arise.

The most prominent case like this was the accident in Boston's Back Bay Station in December 1990, when Amtrak removed its event recorder and, in attempting to read it out, appeared to have inadvertently obliterated some of the crucial information. Fortunately, our laboratory was able to recapture the data, and Amtrak subsequently announced a new policy that it would hold onto the recorders until we retrieved them. We have not had a similar instance involving Amtrak since.

As anyone who follows the news knows, we in Washington are in the midst of a movement to eliminate government regulations and avoid issuing new regulations. Unfortunately, this movement does not always clearly distinguish between unnecessary or obtrusive regulations, on the one hand, and regulations that are issued to address valid safety issues, on the other. As a result, some safety regulations are delayed for the wrong reasons.

One way to enhance railroad safety without waiting for regulations to be issued is for railroads to act voluntary. A good example of this stemmed from the Selma, North Carolina accident I mentioned earlier, and the FRA's list of 7 areas where improvements could be made by the railroad industry.

Rather then issuing recommendations to establish new regulations impacting intermodal operations, the Safety Board took a different approach. We contacted all of the Class I railroads in the United States and asked them to advise us of changes they would be making in their intermodal operations to address the 7 problem areas identified in the FRA's report. The letters from the Class I railroads are still coming in but all of them so far have voluntarily made substantial safety improvements to their intermodal operations without a formal regulation being issued by the FRA. The railroad industry's response proves that regulations are not always necessary to improve railroad safety.

Finally, the Safety Board would appreciate the full cooperation of the railroads in complying with the new OSHA regulations on bloodborne pathogens. When working on an accident investigation, NTSB investigators often work in areas where they may come in contact with blood or tissue from accident victims. Contact with these fluids can potentially transmit hepatitis, HIV or other diseases.

The Safety Board has put together a program that complies with OSHA regulations to prevent our investigators from being exposed to these biological hazards. In the event that there are fatalities or serious injuries in an accident where blood and tissue are found in the wreckage, the NTSB investigators will declare an area of the wreckage as a biohazard and require that anyone entering that area of the wreckage wear protective suits and follow decontamination procedures.

These precautions are useless unless all personnel involved in an accident investigation follow the same procedures. To protect our investigators, we need to ensure that no one enters these areas without protection. Individuals who come in contact with blood or other bodily fluids not only put their own health at risk but can spread disease to their fellow investigators or the general public if they do not adhere to these guidelines. We cannot force these OSHA procedures on the railroads nor can we provide protective equipment for railroad employees working with us.

But we can, and will, ensure that anyone who wishes to participate in our investigations will comply with these requirements to protect our people. We need the railroads' cooperation in training their personnel, providing them with protective clothing, and keeping nonessential personnel out of these biohazard areas.

I have told you a few ways in which the railroads can cooperate with the NTSB on railroad accident investigations. Cooperation, however, is a two-way street. I am, therefore, very interested in any comments the railroad industry may have on how we can do a better job of cooperating with you. Please speak with me after this presentation or write me a letter to let me know what is on your mind. Keep in touch with Bob Lauby, our railroad division chief.

The railroad industry and the NTSB need to work together as partners in safety. Together, we can make a difference in rail transportation safety.

Thank you for inviting me this morning, and may we continue to have a safe 1995.

 

Jim Hall's Speeches