From the report of the Head-On Collision of Two Union Pacific Freight Trains Near Goodwell, Oklahoma, June 24, 2012, adopted June 18, 2013, RAR-13-02, issued August 14, 2013: Since the late 1990s, the NTSB has recommended that the FRA require audio recorders inside locomotive cabs so that accident investigators can understand the actions of crewmembers just before an accident. As a result of the investigation of the collision between a Maryland Rail Commuter train and an Amtrak train near Silver Spring, Maryland, on February 16, 1996 (NTSB 1997a), in which no operating crewmembers survived, the NTSB was unable to determine whether crewmember activities leading up to the accident contributed to the accident. Consequently, the NTSB made the following safety recommendation to the FRA:
Amend 49 Code of Federal Regulations Part 229 to require the recording of train crewmembers’ voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings. (R-97-9)
After the NTSB’s investigation of a Bryan, Ohio, railroad accident that occurred in 1999 (NTSB 2001), with no surviving crewmembers, the NTSB reiterated this safety recommendation. The FRA responded that it
… has reluctantly come to the conclusion that this recommendation should not be implemented at the present time. … [The] FRA appreciates that, as time passes and other uses are found for recording media that may create synergies with other public and private purposes, the [NTSB’s] recommendation may warrant re-examination.
Based on this response and further meetings, the NTSB classified Safety Recommendation R-97-9 “Closed—Unacceptable Action.”
Since the refusal by the FRA to act on the recommendation of in-cab recorders, the NTSB has continued to investigate accidents in which audio recorders, along with video recorders, would have provided valuable information to help determine probable cause and develop safety recommendations. These include the July 10, 2005, collision of two Canadian National Railroad (CN) freight trains in Anding, Mississippi (NTSB 2007), after which the NTSB made the following safety recommendation to the FRA:
Require the installation of a crash- and fire-protected locomotive cab voice recorder, or a combined voice and video recorder, (for the exclusive use in accident investigations and with appropriate limitations on the public release of such recordings) in all controlling locomotive cabs and cab car operating compartments. The recorder should have a minimum 2-hour continuous recording capability, microphones capable of capturing crewmembers’ voices and sounds generated within the cab, and a channel to record all radio conversations to and from crewmembers. (R-07-3)
The NTSB has found that in many accidents, the individuals involved either have limited recollection of events or, as at Goodwell, were killed in the accident. In the September 12, 2008, railroad accident in Chatsworth, California (NTSB 2010), a westbound Southern California Regional Rail Authority Metrolink train collided head-on with an eastbound UP freight train, resulting in 25 fatalities, including the engineer of the Metrolink train, and 101 injuries. For many accidents the NTSB has investigated, a better knowledge of crewmembers’ actions before the accident would have helped reveal key causal factors and facilitated the development of more effective safety recommendations. In the Goodwell accident, video could have shed light on the activities of the crew of the eastbound train leading up to the collision and why the crew did not respond to wayside signals.
The NTSB believes that the only reasonable and reliable mechanism for making such observations is an in-cab audio and image recorder that would capture crewmembers’ activities while in the train operating compartment. As a result of the investigation of the Chatsworth accident, the NTSB made two safety recommendations to the FRA:
Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. (R-10-1)
The NTSB reclassified Safety Recommendation R-07-3 “Closed—Unacceptable Action/Superseded” when it issued Safety Recommendation R-10-1 to the FRA. The NTSB also issued the following safety recommendation to the FRA:
Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. (R-10-2)
The FRA has acknowledged the value of using audio and imaging technology in locomotives and cab cars; however, it has not taken action to implement the safety recommendations. Until the FRA requires that locomotives and cab cars operated under 49 CFR Part 229 be equipped with crash- and fire-protected inward-facing audio and image recorders, Safety Recommendations R-10-1 and -2 are classified “Open—Unacceptable Response.”
The NTSB is concerned that the lack of action by the FRA leaves many safety lessons unlearned and thereby unnecessarily delays improvements in the safe operation of railroads. Until the actions of crewmembers during train operations can be meaningfully monitored, the NTSB recognizes that opportunities will be missed to understand and improve safety after some accidents, and the missed opportunities are not infrequent, as discussed below.
The rear-end collision of two BNSF trains near Red Oak, Iowa, on April 17, 2011, again demonstrated the need for in-cab recording devices to better understand (and thereby help to prevent) serious railroad accidents that claim the lives of crewmembers, passengers, and the public. In the report on this accident, the NTSB stated that “while video recorders will assist in the investigation of accidents, their value in preventing accidents cannot be overstated” (NTSB 2012) and added that the installation of inward-facing cameras could also assist railroads in monitoring rules compliance and identifying fatigued engineers, which could lead to interventions that could prevent accidents.
During the Red Oak accident investigation, NTSB investigators determined, based on medical records, work-rest histories, and event recorder data from the lead locomotive, that the crewmembers of the striking coal train had fallen asleep just before the collision. However, without visual evidence of the crewmembers’ actions during the trip, additional information about the crewmembers’ performance was not available for investigators. In that accident, the NTSB concluded that “had an inward-facing video and audio recorder been installed in the cab of the locomotive of the striking train, additional valuable information about the train crew’s actions before the collision would have been available” (NTSB 2012).
Also, in its report on the May 24, 2011, collision of two CSX trains in Mineral Springs, North Carolina (NTSB 2013a), the NTSB stated it was unable to determine why the crew of the striking train failed to comply with a wayside signal, because the crewmembers had been killed and the cab was not equipped with either an inward-facing camera or an audio recorder. The NTSB cannot develop effective recommendations to improve safety when critical elements of information are unavailable to the investigation.
In its recent report on the September 30, 2010, collision of two CN trains in Two Harbors, Minnesota, the NTSB noted that appropriate action had not been taken in response to Safety Recommendations R-10-1 and -2 (NTSB 2013b). In the investigation, investigators found that crewmembers of both trains had used cell phones in moving locomotives—a violation of railroad rules and FRA regulations. Moreover, the NTSB urged the FRA to “promptly initiate rulemaking activity for the audio and imaging requirements outlined in Safety Recommendations R-10-1 and -2” (NTSB 2013b) and reiterated these two safety recommendations, noting that FRA action on the recommendations would require locomotive manufacturers to implement important safety improvements. In the Two Harbors, Minnesota, accident report, the NTSB reiterated Safety Recommendations R-10-1 and -2, stating the following:
The NTSB is disappointed that more than four years after the deadliest passenger train accident in decades, the FRA has not acted on two recommendations that would protect railroad employees, as well as the public. (NTSB 2013b)
The NTSB railroad accident investigations conducted since the issuance of Safety Recommendations R-10-1 and -2 consistently indicate that in-cab audio and video recorders could provide critical information for accident investigations about crew performance and the locomotive cab environment. The Goodwell accident demonstrates clearly that in-cab audio and video data, if sufficiently protected from fire and crash damage, could have provided information for understanding the actions of the crew of the eastbound train. Therefore, the NTSB reiterates Safety Recommendations R-10-1 and -2 to the FRA.
In its most recent response to the NTSB about Safety Recommendations R-10-1 and -2, on July 31, 2012, the FRA stated that it recognizes the inherent safety value of in-cab cameras and voice recordings for use in accident investigations. However, the FRA also stated that it is aware of “significant privacy concerns” among railroad employees; more specifically, the FRA stated that it fears that implementing Safety Recommendations R-10-1 and -2 might erode railroad employee morale, because some employees suspect that inward-facing cameras and voice recordings might be used for selective enforcement and retaliation by railroad management. Although the importance of management-labor relations is understood, the NTSB has based the two safety recommendations on objective and recurring evidence of significant risks to the safety of railroad employees and the public. Moreover, these safety risks are recognized within the railroad industry itself. The NTSB is aware that the Kansas City Southern Railway Company (KCSR), a Class I freight railroad, expressed intent on April 24, 2013, to install inward-facing cameras into its U.S. locomotives to improve its operational safety by reducing and mitigating the risks of human performance errors in locomotive cabs during train movements. The KCSR has encountered resistance to implementing its plan from two railroad labor unions, the BLET and the UTU, in the U.S. District Court for the Western District of Louisiana, Shreveport Division (Civil Action No. 5:13-cv-838); the case has not yet been resolved. The NTSB is pleased by the proactive initiative of the KCSR to implement inward-facing cameras and recognizes that the inherent safety value of inward-facing cameras and audio recorders applies equally to other Class I freight railroads. Therefore, the NTSB recommends that all Class I railroads install in all controlling locomotive cabs and cab car operating compartments crash- and fire-protected inward- and outward-facing audio and image recorders. The devices should have a minimum 12-hour continuous recording capability.