The Honorable Pete Buttigieg
US Department of Transportation
1200 New Jersey Ave. SE
Washington, DC 20590
Dear Mr. Secretary:
Today, the National Transportation Safety Board (NTSB) issued its final report on our investigation into the April 24, 2018, fatality of an Amtrak rail gang watchman who was struck by Amtrak train 86 in Bowie, Maryland. Regrettably, the circumstances of this roadway worker’s death were tragically familiar. The watchman—one of three tasked with protecting the safety of roadway work groups performing track maintenance on a main track—was placed near the end of a curve in the track. While the center track was occupied by maintenance equipment and no trains were operating, train movements on the two immediately adjacent tracks were allowed to continue as scheduled. The only protection for the roadway workers on the in-service tracks was the use of train approach warning (TAW). As the watchman was focused on his work crew and a southbound Maryland Area Rail Commuter (MARC) train servicing one adjacent track, he was unaware of northbound Amtrak train 86 approaching from behind him on the other adjacent track. He was struck and killed.
Just as this watchman was entrusted with the duty to protect his roadway work group, the Federal Railroad Administration (FRA) was in turn entrusted to protect him—through rule, regulation, and oversight. For nearly 25 years, however, the FRA has shifted this responsibility for roadway worker protection back onto the workers themselves, through the express sanction of TAW as an approved method of on-track safety. In doing so, the FRA failed in its responsibility to protect the watchman in Bowie, Maryland, as it has failed to protect so many roadway workers before.
The Rail Safety Improvement Act of 2008 mandated that all Class I and passenger railroads fully implement positive train control (PTC) systems. That requirement was implemented nationwide on December 31, 2020. PTC is a technology-based system to prevent train accidents caused by human error, including train-to-train collisions, overspeed derailments, incursions into established working limits, and movements of trains through a switch left in the wrong position. TAW, however, does not require the establishment of working limits and, therefore, circumvents the protections that would be provided by PTC in controlled track territory. In short, the decades of government- and industry-wide effort put into the implementation of PTC is being undone by the continued use of TAW.
In February 2017, the Fatality Analysis of Maintenance-of-way Employees and Signalmen (FAMES) Committee estimated that in the 20 years following the adoption of the Roadway Worker Protection Rule, the use of TAW was involved in 13 accidents, resulting in the deaths of 16 roadway workers. We at the NTSB have continued to investigate accident after accident in which the shortcomings of TAW as a method of on-track safety have been laid bare:
- On April 3, 2016, southbound Amtrak train 89 struck a backhoe occupied by a roadway worker in a work zone near Chester, Pennsylvania. The train had been authorized to operate at 110 mph through the work zone. Two roadway workers were killed, and 39 others were injured.
- On January 17, 2017, a BNSF Railway freight train struck and killed a watchman and one other roadway worker in Edgemont, South Dakota, as a group of three workers cleaned snow and ice from a track switch on the main track.
- On June 10, 2017, a road crew foreman stepped into the path of a Long Island Rail Road train at the Queens Interlocking in Queens Village, New York, after the train had sounded its horn to warn the roadway work group of its approach. The foreman was struck and killed.
In our final report on the Queens Village accident investigation, we sought once again to highlight the need to mitigate the risks of TAW to roadway worker safety, by issuing Safety Recommendation R-20-6 to the FRA:
Define when the risks associated with using train approach warning are unacceptable and revise Title 49 Code of Federal Regulations 214.329 to prohibit the use of train approach warning when the defined risks are unacceptable. (R-20-6)
The FRA disagreed with our suggested recommendation—not because it would fail to enhance roadway worker safety, but because the FRA rejected our underlying investigation findings from the Queens Village accident itself. The FRA stated that the roadway workers involved in the accident “did not comply with the most basic requirements” of FRA regulations governing TAW, because they failed to discuss and then occupy a predetermined place of safety from oncoming trains. Therefore, the FRA stated that it believed that these failures, not the decision to use TAW, were the cause of the accident: “If the roadway workers involved in this accident had followed the requirements of TAW, this accident would not have occurred.”
In our investigations, it is all too common for organizations to deny or deflect responsibility for their role in the chain of accident causation. At the NTSB, however, our mission is to identify every element contributing to an accident—not to lay blame at the feet of front-line workers whose errors represented the last link in that causal chain. Our safety recommendations, if implemented, serve to prevent the occurrence of similar accidents in the future, and that is precisely why we direct them to the agencies, organizations, and individuals in the best position to effect such changes. Those who ignore our recommendations do so at the expense of the very people whose safety has been entrusted to them.
At the risk of tragic repetition, the circumstances of the Bowie, Maryland, accident provide the FRA an opportunity to correct its past, and ongoing, mistake. The NTSB’s final report on the Bowie accident reiterates Safety Recommendation R-20-6 to the FRA, and further issues a new recommendation that seeks to put into clear and unambiguous language the step the FRA must take to protect on-track workers nationwide:
Modify Title 49 Code of Federal Regulations Part 214 to prohibit the use of train approach warning in controlled track territory during planned maintenance and inspection activities. (R-21-3)
The Bowie, Maryland, accident—and many others before it—prove that placing the sole responsibility for managing roadway worker risk upon lookouts and watchmen, while also requiring them to monitor, simultaneously, such dynamic elements as train speed, track characteristics, sight distance, noise, and environmental conditions, is simply untenable. When such alternatives as exclusive track occupancy, foul time, and train coordination exist, the continued use of TAW as a method of on-track safety is a deadly risk that the American rail worker cannot be asked to bear.
The NTSB looks to your leadership to protect rail workers and ensure the favorable implementation of Safety Recommendations R-20-6 and R-21-3.
Original Signed By
The Honorable Amit Bose
Federal Railroad Administration