Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the Association of American Railroads
Damage Prevention and Freight Claim Committee
July 8, 1998
Thank you for inviting me here today. This is the second time in the last 6 weeks that I am addressing an AAR audience, and, rather than considering this an endorsement for my speaking skills, I think this shows the importance the AAR and the National Transportation Safety Board place in railroad safety. Both your organization and mine are dedicated to the same goals, the avoidance of railroad accidents and the reduction of injuries to our fellow citizens.
Transportation safety problems can occur anywhere, of course. Because Amtrak will be inaugurating high-speed rail service in the Northeast Corridor as early as next year, when we heard about the terrible high-speed train accident in Germany last month, I dispatched three of our investigators to Germany to determine if any lessons learned there will have applicability here in the United States.
On arrival, our team met with the Eisenbahn-Bundesamt (EBA), essentially Germanyís version of the Federal Railroad Administration, although the EBA seems to contain elements of the NTSB, the Surface Transportation Board, the GAO and the AAR, as well. This is what we learned.
Although the catastrophe occurred at a highway overpass just outside the town of Eschede, the accident sequence actually began earlier. To understand the mechanics of what happened, you have to realize that the first generation of Germanyís ICE system, which comprises about 60 train sets, uses two-piece resilient wheels. The accident train was of this first generation.
At a point about 5.6 kilometers or 3 miles before the overpass, a rim from one of these resilient wheels on the first passenger car broke, with the tread of the wheel wrapping itself around the track brake on the trailing truck of the car. Probably because of this, in interviews after the accident, passengers from the first car reported noise and vibration about 2 minutes before the accident.
In that two minutes, the train approached a turnout, at which point the damaged wheel apparently hit a guide rail at the track switch, which penetrated the first two cars of the train. Still, the train continued to move at 180 kilometers an hour. After striking the guide rail, the train continued toward a second switch. The second passenger car was diverted to the siding track and derailed. Car 3 was forced out even farther toward the supports of a highway bridge crossing the tracks at that spot. The trailing end of car 3 knocked the bridge supports down. As an example of the forces involved, one of the concrete supports was found several hundred meters from the bridge, driven directly into the ground.
The crash dynamics were horrific. Two passenger cars were crushed by the falling bridge. The rest of the train ran into the collapsed bridge, with the heavy trailing locomotive adding to the impact forces from behind. The accident site has been compared to what one finds at a major airline accident. Nearly 100 people lost their lives.
What does this accident mean to us as we look to high speed train service in the United States? While no one can make assurances that a major accident will not occur, there are some aspects of rail service in this country that will mitigate the effects of such a calamity.
First of all, U.S. crashworthiness standards are stronger than those in Germany. Amtrak cars have the ability to withstand stronger buff forces and have crush zones at the end of the cars. They are also equipped with collision posts. The "Amtrak High Speed Train" car body is built to withstand the weight of the car without collapsing. However, any time a high-speed train is going to collide with an immovable object, the results cannot help but be catastrophic.
Second, we will not use resilient, or multi-sectional, wheels on our high-speed service. But we still have to concentrate on the critical component of the wheel/rail interface. For high-speed rail service to be successful, we have to apply great attention to checking the integrity of the rails and the rail car wheels to ensure they donít fail during use. Rail transportation is very unforgiving at the speeds that will be introduced in this new service.
The examination of the German accident will be important for application to future rail services in the United States. Iíd like to turn now to two issues on the Safety Boardís agenda dealing with rail safety now Ė improper cargo loading and operator fatigue. I know that the issue of cargo shifts or improper loading is of particular interest to this audience. The Board has seen this cause accidents in all modes of transportation, not just railroad.
Last month, the Board completed an investigation of an aviation accident caused by improper cargo loading. That accident occurred on August 7, 1997, when Fine Air flight 101, destined for Santo Domingo, crashed on takeoff from Miami International Airport. All four people on the plane and one on the ground lost their lives.
The aircraft was loaded with pallets of cut denim fabrics and accessories to make clothing. Because of a series of mistakes and poor procedures, the aircraft was loaded incorrectly, having a farther aft center of gravity than the crew calculated. In addition, those involved in loading the aircraft encountered problems with the mechanisms that secure the pallets in place. Post-accident investigation discovered 60 of the 85 pallet locks from the wreckage, 57 of which were found in the unlocked position.
In essence, the Safety Board believes that as the aircraft rotated at takeoff and began its assent, the cargo probably shifted aft a small amount, rendering the aircraft even more difficult to control. The crew could not readjust the aircraftís flight surface configuration in time to avert the accident.
Why am I telling you about a plane crash? For the simple reason that it illustrates how the Safety Board sees common issues in different transportation modes. That is certainly true for fatigue, which I will discuss later. And it appears to be true for improper cargo loading, as two railroad accidents we investigated show.
The first of these occurred on May 16, 1994, when southbound Amtrak train 87, the "Silver Meteor," struck an intermodal trailer at Selma, North Carolina. The trailer was on a railroad flatcar in the consist of the passing northbound CSX Transportation freight train. Following its investigation, the Safety Board determined that the probable cause of the accident was the failure of the CSX intermodal loading crew to properly secure the intermodal trailer to the flatcar. There was no procedure to verify that the trailer had been locked in place.
Contributing to the accident was the lack of comprehensive industry standards regarding the loading and securing of trailers onto railroad flat cars. Since the trailer was not properly secured, it shifted and fell off the railcar. The Amtrak assistant engineer was fatally injured, the Amtrak engineer was seriously injured and 120 others on that train sustained minor injuries. Damage was estimated at $3.7 million.
As an outcome of the accident, your organization, in conjunction with the FRA and industry leaders, established a method of loading and locking procedures, making the industry safer today.
But our investigators believe that more can be done to reduce improper cargo loading. One possible improvement suggested by our staff would be a more uniform hitch mechanism for the securing of trailers to flat cars. Although the current mechanisms work well when properly secured, the many types of locking mechanisms available might make it impractical for those on the intermodal ramps to know how each one works. I suggest that the industry may want to consider going to one or two types of hitch mechanisms.
Closer to home, a year ago today in Arlington, Virginia, southbound Amtrak train 91 was sideswiped by a derailed car on a northbound CSXT freight train. It appears that the load of huge paper rolls that stood about 9 feet high had shifted in a highway trailer, causing the trailer and eventually the railcar to lean to one side. Our investigation found that there were no securing mechanisms other than a fiberglass strap and rubber mats on the floor to hold the rolls in place. As the freight train passed through a double "S" curve, the excess weight on the left side might have caused one of the leading wheels on the right side to rise over the side of the rail, leading to the carís derailment.
The train proceeded north and, as fate would have it, the derailed car encountered a switch and moved westward toward the adjacent track at the same time an Amtrak train was passing the location. The derailed flat car struck the fourth passenger car in the Amtrak consist and sideswiped the last two cars. Once past the Amtrak train, the derailed freight car rolled onto its left side, derailing both the cars in front of it and behind it. Estimated damage was $1 million; fortunately, only three crewmembers on Amtrak 93 reported minor injuries. Also, the outcome caused a major headache for rail commuters traveling into and out of Virginia for the month the followed.
We continue to see accidents caused by the failure to properly secure a load. Just these three examples where improper loading was a leading causal element cost the lives of 6 people and damage approaching $10 million. We need a concerted industry effort to prevent these very preventable accidents.
When I spoke to the AAR annual conference in San Antonio last month, I spoke about the major problem of operator fatigue, and Iíd like to highlight my concerns before you as well.
Human fatigue in transportation operations is one of the most widespread safety issues in the transportation industry. It has been an item on the Safety Boardís "Most Wanted" list of transportation safety improvements since the list began in 1990. We are all subject to fatigue irrespective of age, gender or occupation. Airline pilots have no more of the "right stuff" to resist fatigue than does a truck driver or a locomotive engineer.
It is the Safety Boardís belief that the Hours of Service laws should be changed to reflect our knowledge of the sources of fatigue and the effects of fatigue on transportation safety. These laws are flawed for at least three reasons: the burdensome amount of work and the minimal amount of rest permitted, the fact that fatigue plays a part in so many accidents the NTSB investigates, and the lack of any scientific support for the work/rest provisions of the current law.
The current railroad Hours of Service laws permit, and many railroad carriers require, the most burdensome fatigue-inducing work schedule of any federally-regulated transportation mode in this country. A comparison of the modes is revealing. The aviation, highway, marine, and rail modes all have federally imposed limits on the amounts of work and rest in a 24-hour period. The aviation and highway modes also impose weekly limits. Only aviation has monthly and annual limits. To keep the comparison simple, consider the number of hours an employee is permitted to work in the course of a 30-day month:
ē A commercial airline pilot can fly up to 100 hours per month;
ē Shipboard personnel, at sea, cannot be required to operate more than 240 hours per month;
ē A truck driver can be on duty up to about 260 hours per month; and
ē Locomotive engineers can operate a train up to 432 hours per month. That equates to more than 14 hours a day for each of those 30 days.
Let me emphasize that I am not advocating cutting everybody back to 100 hours a month. My point is that allowing any transportation worker in a safety sensitive position to work over 400 hours per month is excessive and unconscionable.
We have laws limiting how much a person can drink before operating a train. FRA regulations prohibit a railroad employee from going on duty with a blood alcohol concentration of 0.04 percent or greater. We know that a personís performance can be impaired with any amount of alcohol in their system. We donít need to be reminded of the tragedies that result from drunken drivers. But for some reason, we as a society donít place the same emphasis on fatigued operators.
Studies show that people who had been kept awake for 18 hours performed as poorly on cognitive and motor skills tests as they did when their blood alcohol concentration was 0.05 percent. After 24 hours without sleep, performance of the fatigued people dropped to the level of those with a BAC of 0.096 percent. The thought of a drunken driver justifiably frightens us. This research says that we need to be just as fearful about the fatigued operator.
Changing the Hours of Service laws is not a small step, Iíll concede. But it is a change that must be accomplished. Robert Kennedy once said, "Progress is a nice word. But change is its motivator, and change has its enemies." A big change is definitely indicated here, a change to this archaic law, now in its 10th decade on the books.
The Safety Board has found that one of the best guarantors of safety is the culture of an organization. Without a safety-conscious corporate culture, accidents are all but inevitable. With the proper culture, an attitude of safety begins at the top, and emboldens employees to take the extra step for safety. This is true whether you are representing an operator, a shipper or an equipment manufacturer.
I commend the AAR for all you have done to promote safety in our nationís rail industry, and hope that we can continue to work together to prevent the kind of accidents Iíve discussed today. Thank you for your kind attention.