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Safety Recommendation Details

Safety Recommendation R-18-005
Details
Synopsis: The National Transportation Safety Board (NTSB) is investigating a head-on collision that occurred on February 4, 2018, about 2:27 a.m. eastern standard time on the CSX Transportation (CSX) Columbia Subdivision in Cayce, South Carolina. Southbound Amtrak train 91, operating on a track warrant, diverted from the main track through a reversed hand-thrown switch into a siding and collided head-on with stationary CSX local freight train F777 03.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum-authorized speed. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Cayce, SC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: RRD18MR003
Accident Reports: Safety Recommendation Report: Train Operation During Signal Suspension​Preliminary Report Railroad: Head-on Collision Between Amtrak Passenger Train and CSX Freight Train RRD18MR003​Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train
Report #: RSR-18-01
Accident Date: 2/4/2018
Issue Date: 2/15/2018
Date Closed: 9/16/2019
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/30/2019
Response: The attached letter from the NTSB Chairman provides information about the NTSB’s July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. This letter provides information about our July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues: • The medical examination process for railroad employees. • The actions and responsibilities of the train crew handling switches. • The CSX Transportation efficiency testing program and staffing. • Operations during signal suspensions. • Implementation of a safety management system by Amtrak (National Railroad Passenger Corporation) to assess and mitigate risks for operation on host railroads. • Occupant protection in passenger railcars. Accordingly, the NTSB reiterates the following safety recommendations to the Federal Railroad Administration. Additional information regarding these reiterations can be found in the noted sections of the report. • Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) (See section 2.2.2.) • When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) (See section 2.2.2.) • Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay. (R-17-17) (See section 2.8.) • Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear. (R-18-10) (See section 2.5.) In the same report, we also classified two previously issued safety recommendations: • Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum authorized speed. (R-18-5), (classified “Closed––Unacceptable Action” in section 2.5.) • Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear. (R-18-10), (classified “Open––Unacceptable Response” in section 2.5.) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. 1.17Postaccident Actions 1.17.1 Federal Railroad Administration 1.17.1.1 Previous Recommendations to FRA As a result of information obtained early in the Cayce investigation, on February 15, 2018, the NTSB issued the following Safety Recommendation R-18-5, an Urgent Recommendation, to the FRA: Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, require the train crew to report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum-authorized speed. (R-18-5) (Urgent) In response to Safety Recommendation R-18-5, on April 23, 2018, the FRA published in the Federal Register, a notice of a draft safety advisory (SA) related to temporary signal suspensions. The notice discussed the FRA’s intent to issue an SA addressing railroad operations under temporary signal suspensions. The SA would identify the existing industry best practices that railroads use when implementing operations under temporary signal suspensions. The SA would propose that railroads conducting rail operations under temporary signal suspensions develop and implement procedures and practices consistent with identified best practices. Additionally, the notice would recommend that railroads take certain other actions to ensure the safety of railroad operations during temporary signal suspensions. On November 20, 2018, the FRA published the SA in the Federal Register (Federal Register 2018, 58685). (See appendix E.) On June 11, 2018, in comments submitted in response to the FRA’s notice, the NTSB stated that although pleased that the FRA was proposing an SA recommending that all railroads adopt the industry best safety practices regarding railroad operations under temporary signal suspensions, an SA did not require railroads to adopt the industry best practices. In its comments, the NTSB also discussed several parts of the notice that appeared to offer contradictory statements. Recommendation 6 in the notice stated that railroads should “encourage employees, in case of any doubt or uncertainty regarding the position of such switches, to immediately contact the train dispatcher or take other appropriate action to confirm the position of the switch prior to authorizing a train to operate through the limits of the area.” However, the NTSB noted that using a switch tender or switch position awareness form has been shown in NTSB investigations to be ineffective in preventing accidents. Although it concurred with the FRA’s assertion that best procedures and practices should be implemented, in its June 11, 2018, comments, the NTSB did not agree that an advisory goes far enough to ensure safety. The NTSB believed that the FRA should mandate that, if any switches within suspension limits are manipulated, railroads must establish an effective means of verifying that all switches have been returned to the proper position prior to any train traffic operating through the limits. The NTSB stated that regulatory mandates to ensure trains operate safely during temporary signal suspensions were needed. Pending strengthening the proposed advisory and converting it into a rule, Safety Recommendation R-18-5 was classified Open—Unacceptable Response. 2.5 Federal Railroad Administration Mitigation of Misaligned Switch Risk It is evident from the current accident and others, such as those that occurred in Graniteville, South Carolina; Shepard, Texas; Bettendorf, Iowa; Granger, Wyoming; and Roswell, New Mexico (NTSB 2005, 2006, 2012, 2017d, 2018) that switching operations can involve situational factors that increase the probability that humans will commit errors that result in catastrophic accidents. The NTSB has been concerned about misaligned switches since at least 1974, when it investigated a fatal accident in Cotulla, Texas, involving a misaligned switch in non-signaled territory (NTSB 1974). Thus, the NTSB has been investigating and making recommendations to prevent misaligned switch accidents for more than four decades. According to data obtained from the FRA’s website, improperly lined switches were the leading cause of accidents/incidents (not at grade crossings) in 2017.45 Moreover, further analysis by NTSB staff revealed that during the 5-year period between 2013 and 2018, there was one person who died and 65 people injured as a result of accidents where “Use of Switches” was coded as a primary or contributing cause.46 Safety Recommendation R-18-5 was an urgent recommendation to the FRA to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. As discussed in section 1.17.1.1 of this report, on April 23, 2018, the FRA published in the Federal Register, a notice of a draft SA related to temporary signal suspensions. On June 11, 2018, in comments submitted in response to the FRA’s notice, the NTSB stated that although pleased that the FRA was proposing an SA recommending that all railroads adopt the industry best safety practices regarding railroad operations under temporary signal suspensions, an SA did not require railroads to adopt the industry best practices. The NTSB noted that using a switch tender or SPAF has been shown in NTSB investigations to be ineffective in preventing accidents. The NTSB does not agree that an advisory goes far enough to ensure safety and that the FRA should mandate that, if any switches within suspension limits are manipulated, railroads must establish an effective means of verifying that all switches have been returned to the proper position prior to any train traffic operating through the limits. Pending strengthening the proposed advisory and converting it into a rule, Safety Recommendation R-18-5 was classified Open—Unacceptable Response. On November 20, 2018, the FRA issued the SA related to temporary signal suspensions, but it does not adequately address issues discussed in the NTSB’s June 11, 2018, comments. On March 14, 2019, the FRA again wrote to the NTSB noting that on March 8, 2018, the FRA and the NTSB met and discussed this recommendation. The FRA said that it was considering the recommendation to determine what measures are necessary to ensure safety when railroads temporarily suspend signal systems to implement PTC technology. Once the FRA has made that determination and decided whether additional action is necessary, the FRA would inform the NTSB of its planned action. Safety Recommendation R-18-5 was issued as an urgent recommendation, indicating that the recommended action required immediate attention to avoid imminent loss due to a similar accident. Urgent recommendations should be implemented within 1 year. More than a year after Safety Recommendation R-18-5 was issued, the FRA is still considering whether to take the needed action. Consequently, Safety Recommendation R-18-5 is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: FRA
Date: 9/16/2019
Response: On July 23, 2019, we adopted our report, Amtrak Passenger Train Head-on Collision with Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, in which Safety Recommendation R-18-5 is classified CLOSED--UNACCEPTABLE ACTION.

From: FRA
To: NTSB
Date: 3/14/2019
Response: -From Ronald L. Batory, Administrator: On March 8, 2018, FRA and the NTSB met and discussed this recommendation. The NTSB clarified the recommendation is intended to apply only to temporary signal suspensions for implementing PTC technology. FRA is considering the NTSB's recommendation to determine what measures are necessary to ensure safety when railroads temporarily suspend signal systems to implement PTC technology. Once FRA has made that determination and decided whether additional action by FRA is necessary to address the NTSB's recommendation, FRA will provide an additional response letter to the NTSB detailing FRA' s plan of action. I appreciate your interest in this important safety issue. If FRA can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer.

From: NTSB
To: FRA
Date: 6/11/2018
Response: We have reviewed the Federal Railroad Administration (FRA) notice of draft safety advisory related to temporary signal suspensions, published in the Federal Register on April 23, 2018 This notice of draft safety advisory was composed in response to Urgent Safety Recommendation R-18-5, which we issued to the FRA as a result of our ongoing investigation into the February 4, 2018, head-on collision between a National Railroad Passenger Corporation (Amtrak) train and a CSX Transportation (CSX) train in Cayce, South Carolina. In this accident, the Amtrak train, operating on a track warrant, diverted from the main track through a reversed hand-thrown switch into a siding and collided head-on with the stationary CSX freight train. We appreciate this opportunity to comment on this proposed safety advisory. This draft safety advisory provides notice of your intent to issue a safety advisory addressing railroad operations under temporary signal suspensions. The safety advisory would identify the existing industry best practices that railroads use when implementing operations under temporary signal suspensions. The advisory would propose that railroads conducting rail operations under temporary signal suspensions develop and implement procedures and practices consistent with those identified best practices. Additionally, it would recommend that railroads take certain other actions to ensure the safety of railroad operations during temporary signal suspensions. We agree with you that “these accidents show that if the increased risks associated with rail operations under a temporary signal suspension are not addressed, serious unsafe conditions and practices are introduced into rail transportation,” and we are pleased that you are proposing a safety advisory recommending that all railroads adopt the industry best safety practices regarding railroad operations under temporary signal suspensions. However, a safety advisory does not require railroads to adopt the industry best practices. Further, this notice appears to offers contradictory statements. One statement reads, “Moreover, issuance of a Safety Advisory provides all railroads the flexibility to review and revise their existing operating rules and practices as necessary to ensure the safety of their rail operations, without imposing rigid, and inherently limited, new requirements on the industry.” In contrast, three paragraphs later, you state, “Although temporary signal suspensions are necessarily common occurrences, rail operations under signal suspensions should be rare and appropriately limited.” Recommendation 6 in the notice states that railroads should “Encourage employees, in case of any doubt or uncertainty regarding the position of such switches, to immediately contact the train dispatcher or take other appropriate action to confirm the position of the switch prior to authorizing a train to operate through the limits of the area.” However, using a switch tender or switch position awareness form have shown to be ineffective in preventing accidents. For instance, in a March 14, 2016, accident in Granger, Wyoming, a conductor pilot neglected to check a switch position before authorizing a Union Pacific train to move into territory that was under a temporary signal suspension. The train traveled into a siding and collided head on with another stopped train, resulting in injuries to five employees and over $2 million in damages. In the aforementioned February 4, 2018, accident in Cayce, South Carolina, the track was under a temporary signal suspension for positive train control component implementation at the time of the accident. Despite the conductor submitting a form verifying that the switch was lined and locked in the normal position, the switch diverted the Amtrak train into the siding. Although we concur with your assertion that best procedures and practices should be implemented, we do not agree that an advisory goes far enough to ensure safety. We believe that you should mandate that, if any switches within suspension limits are manipulated, railroads must establish an effective means of verifying that all switches have been returned to the proper position prior to any train traffic operating through the limits. We agree with your suggestion in this notice that this be accomplished by requiring spiking or clamping switches, followed by locking for through movement after use; however, we specifically advocated for another method in Urgent Safety Recommendation R 18 5, which is as follows: Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum-authorized speed. (R-18-5) (Urgent) Although we support the initiative to improve railroad transportation safety during temporary signal suspensions by incorporating compliance mandates and a uniform training curriculum, more must be done. We believe that now is the time for regulatory mandates to ensure trains operate safely during temporary signal suspensions, and we encourage you to use this opportunity to move forward by strengthening the proposed advisory and converting it into a rule. Accordingly, Urgent Safety Recommendation R-18-5 is classified OPEN--UNACCEPTABLE RESPONSE. We appreciate the opportunity to comment on this proposed advisory. Please update us electronically at correspondence@ntsb.gov on your progress toward satisfying Urgent Safety Recommendation R-18-5, and do not submit both an electronic and a hard copy of the same response.

From: FRA
To: NTSB
Date: 3/14/2018
Response: -From Ronald L. Batory, Administrator: On March 8, 2018, FRA and the NTSB met and discussed this recommendation. The NTSB clarified the recommendation is intended to apply only to temporary signal suspensions for implementing PTC technology. FRA is considering the NTSB's recommendation to determine what measures are necessary to ensure safety when railroads temporarily suspend signal systems to implement PTC technology. Once FRA has made that determination and decided whether additional action by FRA is necessary to address the NTSB's recommendation, FRA will provide an additional response letter to the NTSB detailing FRA' s plan of action.

From: FRA
To: NTSB
Date: 3/14/2018
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA) interim response to the National Transportation Safety Board's (NTSB) Urgent Safety Recommendation R-18-05, contained in the NTSB's Safety Recommendation Report titled "Train Operation During Signal Suspension." The NTSB issued this recommendation following the February 4, 2018, collision on CSX Transportation (CSX) in Cayce, South Carolina between a National Railroad Passenger Corporation (Amtrak) intercity passenger train and a CSX local freight train. According to the NTSB Report, on February 3, 2018, the day before the accident, CSX signal personnel suspended the traffic control signal system to install updated traffic control system components for implementing positive train control (PTC) technology on the CSX subdivision. As a result, the Amtrak train was operating on a track warrant when it was diverted from the main track through a misaligned switch into the siding where the CSX train was parked. On March 8, 2018, FRA and the NTSB met and discussed this recommendation. The NTSB clarified the recommendation is intended to apply only to temporary signal suspensions for implementing PTC technology. FRA is considering the NTSB's recommendation to determine what measures are necessary to ensure safety when railroads temporarily suspend signal systems to implement PTC technology. Once FRA has made that determination and decided whether additional action by FRA is necessary to address the NTSB's recommendation, FRA will provide an additional response letter to the NTSB detailing FRA's plan of action. I appreciate your interest in this important safety issue. If FRA can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer.

From: FRA
To: NTSB
Date: 2/21/2018
Response: -From Karl Alexy, Director, Office of Safety Analysis: Thank you for the report, Train Operation During Signal Suspension, which was sent to the Federal Railroad Administration (FRA) on February 15, 2018. In the "Recommendations" section of the report, the National Transportation Safety Board (NTSB) issued Urgent Safety Recommendation R-18-05 to FRA requesting that FRA issue an Emergency Order. Improving safety is FRA's top priority, and we are currently considering our regulatory and enforcement options to address the safety concerns identified by these accidents in territory where signal suspensions are in effect. FRA is committed to working with NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.

From: NTSB
To: FRA
Date: 2/15/2018
Response: On February 13, 2018, the NTSB adopted its report Train Operation During Signal Suspension, RSR-18/01, which was written as part of the investigation of a February 4, 2018, head-on collision between an Amtrak passenger train and a CSX Transportation freight train in Cayce, South Carolina. The details of this and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. An urgent safety recommendation is being issued to the Federal Railroad Administration, which can be found on page 4 of the report. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 30 days, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number.