Good afternoon Mr. Chairman. I appreciate the opportunity to appear
before your Committee to discuss Railroad Safety.
The year 1996 has been a busy year for the National Transportation Safety Board (NTSB) and a tragic year for the railroad and rail transit industries. Since January 1, 1996, the Safety Board's Railroad Division has launched on 14 railroad accidents resulted in 19 fatalities, 226 injuries, and over $62 million in damages. Included in these 14 accident investigations are 6 runaway trains, 4 collisions, 3 derailments, and 1 grade crossing accident.
RECENT SIGNIFICANT ACCIDENTS
Accidents on the Washington METRO in Gaithersburg, Maryland; the Burlington Northern Santa Fe Railroad in Cajon Pass, California; New Jersey Transit in Secaucus, New Jersey; and Maryland Transit Administration's MARC Train in Silver Spring, Maryland are major accident investigations involving full teams of NTSB investigators. Other important accidents involving the Burlington Northern Santa Fe Railroad in St. Paul, Minnesota and the Southern Pacific Railroad in Tennessee Pass, Colorado are currently being investigated as regional accidents by the Safety Board's regional accident investigators. Each of these accidents involves important railroad safety issues.
Washington METRO, Shady Grove, Maryland
On Saturday, January 6, 1996 at about 10:40 pm a four car Washington Metropolitan Transit Authority train, Train No. 111, operating on the Red line, from Rockville to Shady Grove, collided head-on with a six car "Gap" train which was standing on number 2 track beyond the end of the Shady Grove Station platform. The operator of train 111 was killed in the collision. Two passengers in the third car of train 111 were uninjured. The standing "Gap" train, a train used to replace a train that has operational problems and must be taken out of service, was unoccupied at the time of the collision. At the time of the accident, the sky was cloudy with moderate to heavy snow fall.
The operator of Train 111 was 48 years old and had only been a train operator since October 27, 1995. Train 111 was being operated in Automatic Mode (also known as Mode 1) on the surface section of the Red Line in Montgomery County. According to transcripts of the communications tapes, at about 10:25 pm, the operator of Train 111 reported by radio to the Operations Control Center (OCC) controller that upon entering the Twin Brook station, he had overrun the station platform by four car lengths. The OCC controller instructed the train operator to continue to the next station in Mode 1 Operation. A short time later at 10:31 pm, the operator of train 111 reported to the OCC control operator that he had overrun the Rockville Station platform by one car length. The operator was told to disable the doors on the first car and to service the Rockville Station. The TWC computers show that train to wayside communications with Train 111 were lost for one minute 58 seconds at the Rockville station. It is believed that this interruption was due to the Operator "Keying OFF" and then "Keying ON" his train. "Keying OFF" is normally performed when the operator switches control ends or needs to leave the control cab. "Keying OFF" disables the propulsion system and applies the brakes. "Keying on" brings all car systems on line and ready for operation.
When the operator "Keyed OFF", Train 111 lost the Automatic Train Supervision (ATS) information that was stored in its computer. The ATS system was set to limit the train's speed to 59 mph, which is the normal maximum speed for the run between Rockville and Shady Grove. ATS information is updated at each station stop and is used to pace train traffic and control the arrival time of the train at the next station. Because the operator "Keyed OFF" at the Rockville station, the ATS information was lost and the Automatic Train Protection equipment limited the speed of the train to a higher speed of 75 mph between the Rockville and Shady Grove stations. Washington Metro considers 75 mph to be a safe operating speed for this section of the Red Line - even under adverse weather conditions.
About 10:34 pm, the operator of Train 111 reported to OCC that he had a 75/75/75 - a 75 mph limiting speed; regulated at 75 mph; with an actual speed of 75 mph.
About 10:37 pm, the OCC Controller asked Train 111 if his limiting speed had dropped. The operator of Train 111 responded that the limiting speed was down to 35 mph. This was the last communication with the operator before the collision. The train overran the Shady Grove Station by over 470 feet and collided with the standing "Gap" train. The front of the unoccupied "Gap" train was deformed ten inches. The striking train, however, telescoped onto the standing train about 21 feet, killing the operator.
The Washington Metro system has had a policy of operating in Manual Mode during inclement weather for the past 20 years. In memos issued on November 17, 1995 and January 4, 1996, this policy was rescinded. The memos essentially required that train operations remain in Automatic Mode (Mode 1) during inclement weather.
The Safety Board is addressing the following issues in the Washington METRO accident investigation:
Positive Train Separation (Control systems used to prevent train collisions)
Performance of the Brake and Slip Slide Systems
Crashworthiness of Passenger Cars
Interface between the Transit Car and the ATC Equipment
Washington METRO's Safety Policies and Procedures
Operator and Controller Training and Experience
Burlington Northern Santa Fe Railroad, Cajon Pass, California
On February 1, 1996 a Burlington Northern Santa Fe (BNSF) freight train, HBALT1-31, consisting of four locomotives and 49 cars (5,025 tons) was travelling westward, between Barstow and San Bernardino, California on the Cajon Division when the train "ran away". The train derailed at MP 60.7 after descending the Cajon Pass at a speed of about 55 to 60 mph on a three percent downgrade. The accident occurred about 4:10 am pst.
Two crewmen on board the BNSF train were killed in the accident. The conductor and brakeman jumped or fell from the moving train and sustained fatal injuries. The engineer stayed on the lead locomotive and was seriously injured in the general derailment. Two pipelines were located about 200 feet from the nearest wreckage. The pipelines both carry jet fuel. The pipeline owners came to the scene and clearly marked the pipeline location so that the pipeline would not be damaged during wreck clearing operations.
Although the train was equipped with a two-way end of train device, the device was not armed. The engineer and carman who performed brake tests on the accident train before it began its descent down the Cajon Pass stated to investigators that they attempted, but were not successful in arming the two-way end of train device. Arming the two-way end of train device enables the engineer to put the train air brakes in emergency at the rear end of the train by positioning a toggle switch in the lead locomotive. If the device is not armed, the two-way end of train device acts as a one-way end of train device where the engineer still receives brake pipe air pressure readings, but cannot initiate an emergency brake application at the rear of train.
Forty-five of the 49 cars derailed. The first and second locomotives rolled over on their sides. All four locomotives and the derailed equipment caught fire. Four of the cars that burned contained hazardous materials. The derailed cars contained petroleum distillates, butyl acetate, denatured alcohol, and trimethyl phosphate. Some product spilled into the dry river bed of the Cajon River. An evacuation of 1-1/2 mile radius was made involving about 60 people. Interstate 15 was initially closed for over 48 hours immediately after the accident. Interstate 15 was closed again two days later due to fear that one of the hazardous material tank cars involved in the accident might explode.
NTSB investigated a rear-end collision between a Union Pacific freight train and a Santa Fe freight train on the Cajon Division near this same location on December 14, 1994. The Board's report of this accident (Report number NTSB/RAR-95/04) was adopted by the Board on November 21, 1995, and will be discussed later in this testimony.
The Safety Board investigators are pursuing the following issues in the Cajon Pass, California accident:
Air Brake Inspection and Testing
Use of Two-Way End of Train Devices
Oversight of BNSF Operations
New Jersey Transit, Secaucus, New Jersey
About 8:40 am est, on February 9, 1996, New Jersey Transit Commuter Train 1254, operating eastbound from Waldwick to Hoboken, New Jersey, collided head-on with the lead locomotive of New Jersey Transit Commuter Train 1107. Train 1107 was a westbound train operating between Hoboken, New Jersey and Suffern, New York. Train 1107 consisted of a diesel locomotive and six passenger cars. The train was configured with the diesel locomotive in front and was manned by an operating crew of three. The collision took place at Bergen Junction on the border line between Secaucus and Jersey City, New Jersey.
The westbound train was operating on a clear signal and travelling at about 53 mph in an area authorized for 60 mph. The eastbound train left Harmon Cove station, accelerated to 53 mph, reduced speed to 30 mph, then to 19 mph, and impacted the westbound train at about seven mph. Train 1254 had passed a stop signal and fouled the mainline when the collision took place.
There were over 400 passengers on the two trains. Three fatalities and 162 injuries resulted from the collision. The engineers on both trains were killed. One passenger who was riding in the cab car at the leading end of the train 1254 was also killed. Of the 162 injuries, 75 were transported to local hospitals and seven were admitted.
The operator of train 1254 was working a split shift. He reported to work at 6:00 pm Thursday evening and operated trains until about 1:00 am Friday morning. He was rested from 1:00 am until 5:40 am when he went back on duty operating trains. He was scheduled to get off work at 7:30 am but he worked overtime and was assigned to operate one more train. He "dead-headed" to Waldwick, New Jersey and operated the accident train from Waldwick to the collision site. The engineer's work schedule was in compliance with the Federal Hours of Service regulations. The regulations allow an engineer to work a 12 hour split shift provided that the engineer is given a continuous rest period of at least 4 hours duration between shifts.
On this part of the system, New Jersey Transit controls trains through the engineer and the signal system. There are no automatic stop features on this part of the system. New Jersey Transit relies on the engineer adhering to the signal aspects to maintain safe train operations.
The investigative team is looking into a variety of issues on the Secaucus, New Jersey accident including:
Positive Train Separation
Signal Calling by Train Operators
Crashworthiness of Passenger Cars
Operator Fatigue and Rest Facilities
Operator Fitness for Duty
Maryland Transit Administration - MARC, Silver Spring, Maryland
On Friday, February 16, 1996, at about 5:38 pm, eastbound MARC Train 286 consisting of three passenger cars and a locomotive, collided nearly head on with westbound Amtrak Train 29, the Capital Limited. The MARC train was operating in scheduled commuter service between Brunswick, Maryland and Washington's Union Station. The MARC train is a "push-pull" train with a locomotive on one end and a cab car on the other which allows the train to be operated from either end. The engineer was operating the train from the cab car at the time of the collision. Amtrak Train 29, the Capital Limited, consisted of two locomotives and 15 cars. The train was travelling between Washington, D.C. and Chicago Illinois. The Amtrak train departed from Washington's Union Station about 20 minutes late due to a delay in servicing and coupling the locomotives to the train.
At the time of the collision, the Amtrak train was travelling west on track 2. The Train had been routed on track 2 to pass a standing CSXT Freight train. According to signal records and interviews with the crew of the standing freight train, the Amtrak train was operating on an approach medium signal and just beginning to negotiate a crossover from track 2 to track 1 at the time of the collision.
At this time, signal tests are continuing, however, based on the position of the crossover, the MARC train should have had an approach signal about 2.6 miles before the accident scene and a stop signal 170 feet prior to the point of collision. If the signal system was working properly, the MARC engineer should have received an approach signal just before the Kensington Station. The approach signal indicates that the engineer should not exceed 30 mph in the signal block and be prepared to stop at the next signal. The MARC Train passed this signal and immediately made a stop at the Kensington Station. According to statements from a MARC train operating in the opposite direction, the operator of Train 286 acknowledged the signal over the radio. The other MARC operator, however, did not remember if the operator indicated that the signal was clear or approach. The operator of train 286 made a short station stop at Kensington. After he made the stop, he accelerated his train to normal track speed. He did not limit his speed to 30 mph as would have been required if he had an approach signal.
According to the event recorder, the MARC train operator applied emergency brakes about 1100 feet before the collision. At the time he applied emergency brakes, the MARC train was travelling about 63 mph. The train had slowed to about 40 mph at the time of the collision. The Amtrak train was travelling at about 30 mph at the time of the collision. The stopping distance of the MARC train from 63 mph is estimated to be about 2000 feet.
There were 164 passengers, 13 On Board Service personnel, four operating crew, and one mechanical rider on the Amtrak train. The Amtrak engineer and assistant engineer were injured in the accident. There were three crewmembers and about 19 passengers on board the MARC train. All three crew members and eight passengers were killed in the accident and resulting fire.
The collision between the Amtrak locomotive and the MARC cab car tore away the front left quadrant of the MARC cab car. At the same time, the locomotive fuel tank on the lead Amtrak locomotive ruptured and likely sprayed fuel in the vicinity of the MARC cab car. All three MARC cars and the MARC locomotive were derailed in the accident. Both Amtrak locomotives and the first eight cars were derailed. The derailed Amtrak equipment consisted of six Mail cars, one baggage car, and a transition dorm car. The transition dorm car was the only occupied Amtrak car to derail.
The issues the Safety Board is pursuing in the Silver Spring, Maryland accident are:
Positive Train Separation
Passenger Car Safety Standards
Emergency Exit Windows
Emergency Door Operations
Flammability of Car Components
Crashworthiness of Passenger Cars and Locomotive Fuel Tanks
Signal System Reliability
Attentiveness of Train Operators
Burlington Northern Santa Fe, St. Paul, Minnesota
On Wednesday, February 14, 1996, at 11:50 pm, Burlington Northern Santa Fe Railroad freight train BN 01-144-14 (Extra 8572 East), consisting of two locomotives and 89 cars, derailed 31 cars at the Canadian Pacific Rail System (CPRS) Pig's Eye yard just east of downtown St. Paul, Minnesota. The train was equipped with a one-way end of train device. As a result of this accident, 11 persons were injured, two of them seriously. Preliminary estimates of damage are in excess of $2 million.
The BNSF freight train had departed its initial terminal, Northtown yard, which is about 12 miles from the accident site, and made a brief stop about seven miles west of the CPRS yard. The engineer used the train's air brakes to make this stop. The stop was made at the top of a descending grade on the instructions of the train dispatcher because of train movements routed into the CPRS yard. When the dispatcher cleared the train to continue east, the engineer started the train down the grade. When the train speed reached 30 mph, the engineer applied the dynamic brake. The engineer then made a series of brake applications, but the speed of the train increased.
The engineer placed the train air brakes in emergency and radioed to the dispatcher and trains ahead that his train was out of control at a speed of 49 mph. The train passed a signal displaying a "STOP" indication about one mile from the entrance to the CPRS yard.
The BNSF freight train entered the CPRS yard and collided with two standing, unoccupied CPRS locomotives and a standing, unoccupied CPRS train which consisted of two locomotive units and 31 freight cars. The BNSF train derailed on impact with the CPRS equipment and then crashed into a yard office, destroying it. The building was occupied by at least nine railroad employees, who were all injured in the crash. Two of the railroad employees were injured seriously.
Post accident inspection of the wheels on the first seven cars of the Extra 8572 East exhibited indications of thermal distress, commonly referred to as "blueing". A car inspector's original record form indicated that the seventh head car had the "A" end air brake pipe repaired prior to the train departing the BNSF Northtown yard. The accident is still under investigation, however, the Safety Board is examining a hose from the seventh head car which may have been crimped closed.
The Safety Board is addressing the following issues in the St. Paul, Minnesota accident:
Use of Two-Way End of Train Devices
Air Brake Inspection and Maintenance
Maintenance and Repair of Freight Cars
Southern Pacific Railway, Tennessee Pass, Colorado
On Wednesday, February 21, 1996, at about 5:47 am, mst, Southern Pacific (SP) freight train 1-ASRVM-18 derailed two locomotives and 39 cars at Tennessee Pass, Colorado. This accident resulted in two fatalities and one serious injury. Preliminary damage estimates exceed $10 million. The weather at the time of the accident was snow with an ambient temperature of 32 degrees fahrenheit.
The SP freight train had made a running brake test, as required by carrier operating rules, before cresting the summit at Tennessee Pass. Event recorder information indicates that a brake application was made and the train was brought to a stop before the train began its descent down the 15 mile, 3% grade.
The event recorder readout also indicates that dynamic brake and additional brake pipe reductions were utilized as the train proceeded down the grade, but the speed of the train was not sufficiently retarded and the train went into runaway condition.
The train derailed a total of 39 cars and both locomotives in three locations; the general derailment occurred about eight miles down the grade. The train had achieved a speed of 64 mph before the general derailment occurred. The maximum authorized speed in this area is 20 mph.
The train consisted of two locomotives and 82 freight cars, was 5614 tons, and 5800 feet in length. The operating crew consisted of an engineer, a student engineer and a conductor. The engineer and student engineer were in the operating compartment of the lead locomotive and suffered fatal injuries; the conductor was in the 2nd locomotive and was seriously injured. The conductor stated to Safety Board investigators that the student engineer was operating the locomotive when the train began its descent.
The train carried six cars of sulfuric acid; four of these cars are known to have ruptured and released their entire contents. The two additional cars were buried in the wreckage of the general derailment. As a result of the hazardous material release, state highway 24 was closed. Twenty-two motorists have reported injury due to toxic fumes. A total of 12 residents were evacuated from this rural area.
The Safety Board is addressing the following issues in the Tennessee Pass, Colorado accident:
Use of Two-Way End of Train Devices
Air Brake Inspection and Maintenance
Engineer Training and Qualification
Release of Hazardous Substances
COMMON SAFETY ISSUES
The specific conditions under which these six accidents occurred are all quite different. The safety issues, however, are very similar. The safety issues that have been initially identified in these accidents are not new safety issues, but safety issues that the Safety Board has been addressing in their accident reports and safety recommendations for years. Today, I would like to take a minute to talk about five safety issues that appear in these six accidents. The issues I will discuss are:
Positive Train Separation
Two-Way End of Train Devices
Air Brake Inspection and Testing
Passenger Car Crashworthiness and Safety Standards
Positive Train Separation
The urgency of this issue has been highlighted over and over in Safety Board Investigations since 1969. The more recent train accidents that took place in Sugar Valley, Georgia; Corona, California; Knox, Indiana; Ledger, Montana; Kelso, Washington; and Thedford, Nebraska; could have all been prevented if a fully developed positive train separation (PTS) system had been in place. And now, after the tragic accidents that have occurred in the last two months, we must add two other accidents to this list. Based on the factual evidence gathered at the scene, the Safety Board investigators feel that the accidents that occurred on New Jersey Transit in Secaucus, New Jersey, and on the MARC Train in Silver Spring, Maryland could have been prevented if a fully developed positive train separation control system had been in place.
The Safety Board has long been an advocate of advanced control systems that will provide positive train separation and act as a safety net for human performance failures in the operation of trains. Positive train separation is also on the NTSB's list of Most Wanted Transportation Safety Improvements. About 70 to 80 percent of the railroad accidents investigated by the Safety Board can be attributed to human error. The Safety Board believes that new technology in the form of an advanced electronic system can reduce the severity of human performance train operations accidents by overriding the train operator's actions to prevent train collisions and overspeed derailments.
Up until December of 1993, the NTSB was very discouraged with the pace at which the railroad industry was developing an advanced train control system that could provide positive train separation. Since that time, however, there have been some important developments.
First, the Association of American Railroads and the railroads they represent have entered into serious discussions on the AAR's advanced train control system (ATCS) project. The discussions addressed some important issues that need to be fully addressed if ATCS or any other form of positive train separation system is to be implemented. The participants in these discussions have tried to define the system and identify its features. They have also tried to determine the cost and the return on investment for a fully implemented system.
Secondly, the Union Pacific and the Burlington Northern Santa Fe railroads are working on a joint project to install an advanced train control system that will provide positive train separation on 750 miles of track in the Pacific Northwest. The system is to use a combination of technologies to achieve positive train separation including transponder and global positioning satellites (GPS) to locate and monitor train movements. The test will be the first real world field demonstration of advanced train control technology since Burlington Northern's ARES project was cancelled in 1992. The NTSB is very encouraged with these developments and is anxious to see the actual system in operation.
In the Kelso, Washington report, the Safety Board reiterated Safety Recommendations R-87-16 and R-93-12, made to the Federal Railroad Administration on May 19, 1987 and July 29, 1993, respectively. These recommendations form the foundation of the Safety Board's effort to achieve Federal standards that will require the installation and operation of a train control system on main line tracks that will provide for positive separation of all trains. These recommendations also call for the establishment of a firm timetable that includes at a minimum, dates for implementation of a fully developed advanced train control system, and commitment to a date for having the advanced train control system ready for installation on the general railroad system. These recommendations are classified Open--Acceptable Response, based primarily on FRA's July 1994 report to Congress entitled Railroad Communications and Train Control.
The Safety Board also made new positive train separation recommendations to the FRA and the AAR in the Kelso, Washington report. Safety Recommendations R-94-16 asked the Association of American Railroads to identify and evaluate, in conjunction with the FRA, all of the potential benefits of positive train separation and include them in any cost benefit analysis conducted on positive train separation control systems. AAR's initial response stated that it was not possible to determine any business benefit from the PTS test project being conducted in the Pacific Northwest. The AAR went on to say that:
the Federal Railroad Administration (FRA) agrees that
railroads are "justified in insisting that the PTS debate include a clear focus on safety costs and benefits". With the proper focus on safety benefits, the Report to Congress correctly evaluated the potential benefits of PTS and concluded that it cannot be economically justified at this time.
The Federal Railroad Administration was also asked to evaluate the business benefits of PTS in Safety Recommendation R-94-14. This recommendation asked the Federal Railroad Administration, in conjunction with the Association of American Railroads to identify and evaluate all of the potential benefits of positive train separation and include them in any cost benefit analysis conducted on positive train separation control systems.
The Federal Railroad Administration responded to this recommendation that evaluation of the nonsafety business benefits associated with the UP/BN pilot project will not be feasible. The FRA went on to support the AAR and the railroad's position that business benefits should not be assessed. They also conclude that it is not government's role to "substitute our judgement for the judgment of senior railroad managers regarding matters within their special expertise and responsibilities as corporate officers."
The Safety Board believes that the business benefits associated with PTS are real and need to be included in the cost benefit analysis. If safety is the only criteria for justifying PTS, then the growth of PTS will be very slow. The Safety Board is concerned that lack of understanding of the business benefits of PTS may be used to label PTS control systems as - rightly or wrongly - too costly for implementation.
While slow progress is being made, we would hope that the recent rash of tragic accidents will spur the Federal Railroad Administration and the industry to make a firm commitment to positive train separation and establish a firm timetable for its implementation. The Safety Board was pleased to see in the Federal Railroad Administration's February 20, 1996 Emergency Order that "... the most effective preventative measure is a highly effective train control system," especially automatic systems. We hope that these words can be translated into action.
Another safety issue that the Safety Board feels was involved in at least two of these recent accidents involves signal calling. Signal calling is an activity that can help keep train crews alert and focused on safe operation of the train. Calling signals over a radio also provides management with the opportunity to monitor compliance with signal calling activity. The Safety Board feels that requiring signals to be called over the radio may have helped control distractions that may have been present in the New Jersey Transit accident in Secaucus, New Jersey and the Maryland Transit Administration MARC Train accident in Silver Spring, Maryland.
In recommendations made in 1976 and 1984, the Safety Board recommended that engine crews communicate fixed signal aspects to other crew members. The Federal Railroad Administration did not act on these recommendations, instead opting to evaluate and improve the use of radios for communication in the railroad industry. Nothing concrete resulted from that project and the recommendation was subsequently closed as unacceptable action.
In its February 20, 1996 Emergency Order, the Federal Railroad Administration requires engineers on trains exceeding 30 mph and not equipped with cab signals or automatic train control, to call out to other crew members on the train, for acknowledgement, the displayed aspect of restrictive signals that are passed.
Two-Way End of Train Devices
The Safety Board has been interested in two-way end of train devices since the Helena, Montana accident in 1989. During the past two years the Safety Board has completed investigations on at least seven other train accidents in which a two-way end of train device would have probably prevented an accident on a runaway train. The Safety Board also believes that the accidents that took place on the Burlington Northern Santa Fe Railroad at Cajon Pass, California; the Burlington Northern Santa Fe Railroad at St. Paul, Minnesota; and possibly, the Southern Pacific Railway Tennessee Pass, Colorado accident could have been prevented had a working two-way end of train device been in place.
At one time, all of Americas freight trains were equipped with a caboose. The conductor and brakeman rode in the caboose and performed certain safety functions. Their duties included monitoring a pressure gage in the caboose and radioing the engineer when the brakes at the end of the train were applied or released. They were also required to watch out for dragging equipment and hot journal boxes.
Each caboose was also equipped with a conductor's emergency brake valve. If there was a problem or hazardous condition involving the train, the conductor had the option of venting the brake pipe air through the conductor's emergency brake valve and applying the brakes in emergency from the rear of the train.
Technology in the form of dragging equipment detectors, hot box detectors, and end of train devices took the place of the conductor when the caboose was removed from freight trains. One-way end of train devices monitored the brake pipe pressure at the end of the train and transmitted that information directly to the engineer by radio signal. In this manner, the engineer could read the brake pipe pressure at the rear of the train himself and determine if the brakes were applied or released. What was lost when cabooses were removed from service was the ability to initiate an emergency brake application from the rear of the train.
The two-way end of train device incorporates this additional feature. The engineer can command an emergency brake application at the rear of the train by flipping a toggle switch in the locomotive cab. When the toggle switch is flipped, the two-way end of train device will open the end of the brake pipe and vent all of the air, thus triggering an emergency brake application from the rear of the train. Safety Board investigators believe that two-way end of train devices are essential to the safe operation of cabooseless trains because they offer the only effective means of stopping a train if the train line is blocked by a turned angle cock, crimped air hose, frozen air line, or other such circumstances. Two-way end of train devices have been required on Canadian railroad trains since 1987.
The Safety Board's first recommendation on two-way end of train devices was a result of the February 2, 1989 Helena, Montana accident. About 4:30 am mst, freight cars from Montana Rail Link Inc. westbound train 121 rolled eastward down a mountain grade and struck a stopped helper locomotive consist, Helper 1, in a Helena freight yard. The locomotive consist of train 121 included three helper units and three road units positioned at the head end of a 49-car train. The crew members of train 121 had uncoupled the locomotive units from the train to rearrange the locomotive consist while stopped on a mountain grade. In the collision and derailment, 15 cars from train 121 derailed, including three tank cars containing hydrogen peroxide, isopropyl alcohol, and acetone. Hazardous materials released in the accident resulted in a fire and explosions. About 3,500 residents of Helena were evacuated. Two crewmembers of the helper struck by the runaway train were slightly injured. The estimated damage (including clean-up and lading) as a result of this accident exceeded $6 million.
The National Transportation Safety Board determined that the probable cause of this accident was the failure of the crew of train 121 to properly secure their train by placing the train brakes in emergency and applying hand brakes when it was left standing unattended on a mountain grade. Contributing to the accident was the decision of the engineer to rearrange the locomotive consist and leave the train unattended on the mountain grade, and the effects of the extreme cold weather on the air brake system of the train and the crew members. Also contributing was the failure of the operating management of the Montana Rail Link to adequately assess the qualifications and training of employees placed in train service. Contributing to the severity of the accident was the release and ignition of hazardous materials.
The Safety Board recommended that the Federal Railroad Administration:
Require the use of two-way end-of-train telemetry devices on all cabooseless trains for the safety of railroad operations.
The Federal Railroad Administration had incorporated language in the "Power Brake Regulations" to address two-way end of train device requirements. However, the same day that the Federal Railroad Administration was holding hearings on the revised "Power Brake Regulations," the Cajon Pass accident of December 14, 1994 occurred.
About 5:21 am pst, on December 14, 1994, a westbound Atchison, Topeka and Santa Fe Railway Company (Santa Fe) intermodal train, PBHLA1-10, collided with the rear end of a standing westbound Union Pacific Railroad Company (UP) unit coal train, CUWLA-10, at milepost (MP) 61.55, near Cajon, California, on the Santa Fe's San Bernardino Division's Cajon Subdivision. The two crewmembers from the Santa Fe train were injured when they jumped from the moving train before the collision. Two helper crewmembers on the rear of the UP train detrained before the collision because they had heard radio conversations among the Santa Fe crewmembers, the train dispatcher, and UP crewmembers. As a result of the collision, a fire broke out that burned the two UP helper locomotive units. Four Santa Fe locomotive units and three articulated five-pack double-stack container cars were also destroyed. Total estimated damages were $4,012,900.
The issues examined in this accident were: Air brake testing in mountain-grade territory; management oversight of train handling practices; feed-valve braking; and two-way end-of-train devices.
The National Transportation Safety Board determined that the probable cause of this accident was insufficient available train braking force for the Santa Fe train due to an undetermined restriction or blockage in the trainline between the third and fourth articulated cars. The Safety Board also concluded that had the train been equipped with a two-way, end of train device, the collision could have been avoided because the engineer could have initiated an emergency brake application from the end of the train.
As a result of its investigation, the National Transportation Safety Board closed Safety Recommendation R-89-82, which was issued to the Federal Railroad Administration on December 6, 1989, and reissued the same to expedite implementation into the pending power brake law:
Separate the two-way end-of-train requirements from the Power Brake Law NPRM, and immediately conclude the end-of-train device rulemaking so as to require the use of two-way end-of-train telemetry devices on all cabooseless trains. (Urgent Action)
The Federal Railroad Administration took action on our recommendation, but only after the second Cajon accident on February 1, 1996. The Federal Railroad Administration issued an emergency order for the Burlington Northern Santa Fe Railroad to immediately use two-way end of train devices and obtained agreement from the major railroads to use two-way end of train devices on all trains in mountainous territories by the end of 1996 and on all cabooseless trains by July 1997.Air Brake Inspection and Testing
Air brake safety issues including inspection, testing, maintenance, and design are safety issues in accidents involving the Washington METRO at Gaithersburg, Maryland; the Burlington Northern Santa Fe Railroad at Cajon Pass, California; the Burlington Northern Santa Fe Railroad at St. Paul, Minnesota; and the Southern Pacific Railway at Tennessee Pass, Colorado.
Air brake inspection and safety requirements are maintained by the Federal Railroad Administration in a section of the Code of Federal Regulations commonly known as the "Power Brake Regulations." The recommendations issued to the Federal Railroad Administration (FRA) regarding new or modified regulations contained under the "Power Brake Regulations" were the result of numerous Safety Board accident investigations. Three Safety Board accident investigations in particular, however, provide compelling evidence to support the Safety Boards main concern about these regulations. These three accidents caused over $21.4 million in property damage and resulted in several deaths and numerous injuries to train crews, passengers, bystanders, and property owners.
The first accident was the Helena, Montana one that occurred on February 2, 1989 and was described previously. As a result of that accident, the Safety Board made the following recommendation to the FRA:
Amend the road train and intermediate terminal train air brake tests, 49 CFR 232.13, to require additional testing of a train air brake system when operating in extreme cold weather, especially when the feed valve setting is changed and the train will be operated in mountain grade territory.
The second accident that led to NTSB safety recommendations on the power brake regulations occurred near San Bernardino, California. About 7:30 am, Pacific daylight time, on May 12, 1989, Southern Pacific Transportation Company freight train 111, which consisted of a four-unit locomotive, 69 hopper cars loaded with trona, and a two-unit helper locomotive on the rear of the train, derailed at milepost 486.8. The entire train was destroyed as a result of the derailment. Seven homes located in the adjacent neighborhood were totally destroyed and four others were extensively damaged. Of the five crew members on board the train, two on the head end of the train were killed. A third crewman on the head end received serious injuries, and two crewmen on the rear end of the train received minor injuries. Of eight residents in their homes at the time of the accident, two were killed and one received serious injuries as a result of being trapped under debris for 15 hours. Local officials evacuated homes in the surrounding area because of a concern that a 14-inch pipeline owned by the Calnev Pipe Line Company, which was transporting gasoline and was located under the wreckage, may have been damaged. Residents were allowed to return to their homes about 24 hours after the derailment.
About 8:05 am, on May 25, 1989, 13 days after the train derailment, the 14-inch pipeline ruptured at the site of the derailment, released its product, and ignited. As a result of the releases and ignition of gasoline, two residents were killed, three received serious injuries, and 16 reported minor injuries. Eleven homes in the adjacent neighborhood were destroyed, three received moderate fire and smoke damage, and three received smoke damage only. In addition, 21 motor vehicles were destroyed. Residents within a four-block area of the rupture were evacuated by local officials. Total damages as a result of the train derailment and pipeline rupture exceeded $14 million.
The National Transportation Safety Board determined that the probable cause of the train derailment on May 12, 1989, was the failure to determine and communicate the accurate trailing weight of the train, failure to communicate the status of the train's dynamic brakes, and the Southern Pacific operating rule that provided inadequate direction to the head-end engineer on the allowable speed and brake pipe reduction down the 2.2-percent grade.
As a result of the San Bernardino accident, the Safety Board made two recommendations regarding dynamic brakes:
Study, in conjunction with the Association of American Railroads, the feasibility of developing a positive method to indicate to the operating engineer in the cab of the controlling locomotive unit the condition of the dynamic brakes on all units in the train; and
Revise the regulations to require that if a locomotive unit is equipped with dynamic brakes that the dynamic brakes function.
The Safety Board feels very strongly that dynamic brakes should be operational when locomotives are dispatched. Dynamic brakes are an extremely important tool for train handling. Engineers are taught to control the speed of their train through throttle modulation and the use of the dynamic brakes. Engineers are also taught that dynamic brakes are the "first" brake to be used when slowing a train. Therefore, dynamic brakes should be considered primary safety devices which must work properly when a locomotive is dispatched.
The third accident the Safety Board investigated that led to recommendations about the power brake regulations was the Palatka, Florida accident. At 11:25 am on December 17, 1991, National Railroad Passenger Corporation train 87, operating on CSX Transportation Inc. track, derailed at milepost A697.6 in Palatka, Florida. Train 87 consisted of a locomotive and eight cars. The locomotive and first six cars derailed. The derailment occurred while train 87 was negotiating a six degree six minute curve to the right (west). The derailed equipment struck two homes and blocked the street north of the Palatka station. Eleven passengers sustained serious injuries and 41 received minor injuries. Five operating crew members and four on-board service personnel had minor injuries.
The National Transportation Safety Board determined that the probable cause of this accident was the failure of the engineer and the fireman to maintain full attention to the train location and to slow for the speed restriction in sufficient time to safely negotiate the curve.
As a result of this investigation, the Safety Board recommended to the FRA:
Amend the Power Brake Regulations, 49 Code of Federal Regulations 232.12, to provide appropriate guidelines for inspecting brake equipment on modern passenger cars.
The Safety Board made this recommendation because the investigators found evidence that the initial terminal brake test conducted on the passenger cars was inadequate. The investigators felt that the current "Power Brake Regulations" did not adequately distinguish between passenger cars and freight cars; nor did they take into account the different methods that needed to be used to properly inspect each type of car.
Although an Advanced Notice of Proposed Rulemaking (ANPRM) was issued on December 31, 1992 and a Notice of Proposed Rulemaking (NPRM) was issued on September 16, 1994, the "Power Brake Regulations" have not yet been revised.
Passenger Car Crashworthiness and Safety Standards
The Safety Board has been interested in passenger car crashworthiness and passenger car safety standards for many years. The list of accidents where the Safety Board made recommendations in this area goes back over 25 years, from tragic accidents in Glenn Dale, Maryland and Darien, Connecticut in 1969. The 1996 accidents on Washington METRO at Gaithersburg, Maryland, on New Jersey Transit in Secaucus, New Jersey, and on the MARC Train in Silver Spring, Maryland again tragically point out the need for passenger car safety standards.
Our past recommendations included some familiar issues:
advising passengers of emergency procedures
seat securement and luggage retention devices
safe window design
elimination of sources of direct impact injury
emergency exits and emergency lights
car roof escape hatches
predeparture inspection of safety devices
emergency release mechanisms for doors that are clearly identified
requirements for minimum safety standards for passenger cars
In 1985, in response to several of these recommendations, the FRA wrote to the Board and stated that they had reported to the U.S. Congress that, "¼the Federal Railroad Administration concluded that passenger operations had compiled an excellent safety record and a major Federal regulatory effort was not necessary or warranted." Based on that response, many of the recommendations calling for passenger car standards were closed as "unacceptable action."
The Board then began to work with Amtrak to have its passenger cars upgraded for occupant protection. Amtrak responded by implementing almost all of the Board's recommendations on passenger car safety. This approach covers only those cars used by Amtrak and does not reach the other cars in passenger service.
The Safety Board investigated a tragic accident that occurred in Gary, Indiana in 1993. At 9:34 am on January 18, 1993, Northern Indiana Commuter Transportation District (NICTD) eastbound commuter train 7, traveling from Chicago, Illinois, to South Bend, Indiana and NICTD westbound commuter train 12, travelling from South Bend to Chicago collided at milepost 61.1 in Gary, Indiana. Train 7 and train 12 consisted of two and three passenger cars respectively. Train 7 passed a stop signal at Milepost 61.2 and its lead car blocked westbound traffic where the tracks intersect. After train 12 crossed the Gary Gauntlet Bridge, it struck train 7. As a result of the collision, 7 passengers died and 95 people sustained injuries. The estimated damage for both trains was $854,000.
The National Transportation Safety Board determined that the probable cause of the collision between the two NICTD trains was the inattentiveness of the engineer on train 7, resulting in his train passing a stop signal and partially blocking the westbound track. Contributing to the severity of the accident was the failure of the engineer on train 12 to take timely action to slow or stop his train before the collision. Contributing to the severity of the injuries was the breach of the passenger compartments in the lead cars of both trains.
The major safety issues discussed in this report are the attentiveness of the engineers and the crashworthiness of self propelled passenger cars in corner to corner collisions.
As a result of this accident, the National Transportation Safety Board issued safety recommendation R-93-24 to the Federal Railroad Administration:
In cooperation with the Federal Transit Administration and the American Public Transit Association, study the feasibility of providing car body corner post structures on all self propelled passenger cars and control cab locomotives to afford occupant protection during corner collisions. If feasible, amend the locomotive safety standards accordingly.
Currently, there are no Federal industry-wide standards in the Railroad industry or in the Rail transit industry for the design and construction of railroad passenger cars, other than an FRA requirement for 4 emergency exits on each car and for non-breakable glass in the windows.
In its February 20, 1996 Emergency Order, the Federal Railroad Administration required commuter and passenger railroads to ensure that emergency window exits actually open and operate as intended in emergencies and that they are clearly marked and visible both inside and outside the coach.
In the order, the Federal Railroad Administration describes a related rulemaking required by Congress that will lead to rules on passenger equipment safety standards. The rules will cover many of the issues recommended by the Safety Board over the years including: crashworthiness, emergency lighting, operation of doors, roof hatches, passenger car interiors, and on-board emergency equipment. The FRA has indicated that they expect to issue an Advanced Notice of Proposed Rulemaking (ANPRM) in the next few months with final rules due by 1997. The Federal Transit Administration and the American Public Transit Association is working with the Federal Railroad Administration group. It is unclear at this time how these new standards will effect rail transit cars not currently under FRA jurisdiction.
The Safety Board appreciates the opportunity to discuss Railroad Safety issues with the committee. Our visit, however, has been short and there has only been time to discuss the issues of the hour which are related to these recent tragic accidents. We hope to eventually have the opportunity to talk to the committee about other important railroad safety issues such as grade crossing safety, locomotive conspicuity, whistle bans, track safety standards, engineer fatigue and hours of service, and crashworthiness of locomotives, locomotive fuel tanks, and locomotive event recorders.
In its continuing investigations, the Safety Board has frequently encountered recurring safety issues. Those with the authority to regulate the railroad and rail transit industry have numerous rulemaking initiatives in progress. It seems, however, to take a very long time to complete these rulemakings. In the meantime, the Safety Board continues to investigate tragic accidents where appropriate safety regulations could have prevented the accident.
The Federal Railroad Administration has issued several emergency orders in response to the recent Cajon Pass, California accident and the Silver Spring, Maryland MARC Train accident. The Safety Board has not completed either one of these investigations and is therefore, not in a position to determine if these emergency orders are appropriate or if they will be fully effective in addressing the safety issues related to these specific accidents. A number of the actions covered in the Federal Railroad Administration's Emergency Order, however, do address Safety Board recommendations made many years ago.
The Safety Board believes that safety regulations are sometimes necessary to ensure that a consistent level of safety is maintained throughout the railroad and rail transit industries. Voluntary compliance to safety bulletins is admirable, but in the long term, voluntary compliance can be set aside as management styles and business conditions change.
The Safety Board encourages the Federal Railroad Administration and the Federal Transit Administration to take all necessary actions, not just through emergency orders, but through rulemaking as well. Completion of rulemaking processes on Two-way End of Train Devices, Power Brake Regulations, Passenger Car Safety Standards, Track Safety Standards, and other activities are vital to the safety of railroad employees, passengers, and the public. The NTSB encourages the FRA to complete these activities as quickly as possible. The FRA should consider the safety ramifications of further delay and establish a plan to complete these rulemakings to save Americans from death or injury in future railroad accidents.
The recent accidents have been tragedies. It would be an additional tragedy if we do not seize this window of opportunity and move forward with a sense of urgency to make the safety improvements necessary to make our rail system as safe as it can be. We at the Safety Board believe that now is the time for all interested parties to act decisively on behalf of safety.