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Safety Recommendation Details

Safety Recommendation R-19-007
Details
Synopsis: On December 18, 2017, at 7:34 a.m. Pacific standard time, southbound Amtrak (National Railroad Passenger Corporation) passenger train 501, consisting of 10 passenger railcars, a power railcar, a baggage railcar, and a locomotive at either end, derailed from a bridge near DuPont, Washington. When the train derailed, it was on its first revenue service run on a single main track (Lakewood Subdivision) at milepost 19.86. There was one run for special guests the week before the accident. Several passenger railcars fell onto Interstate 5 and hit multiple highway vehicles. At the time of the accident, 77 passengers, 5 Amtrak employees, and a Talgo, Inc., technician were on the train. Of these individuals, 3 passengers were killed, and 57 passengers and crewmembers were injured. Additionally, 8 individuals in highway vehicles were injured. The damage is estimated to be more than $25.8 million. The accident investigation focused on the following issues: individual agency responsibilities in preparation for inaugural service, multiagency participation in preparation for inaugural service, Amtrak safety on a host railroad, implementation of positive train control, training and qualifying operating crews, crashworthiness of the Talgo equipment, survival factors and emergency design of equipment, and multiagency emergency response. As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the United States Secretary of Transportation, the Federal Railroad Administration, United States Department of Defense Fire and Emergency Services Working Group, the Washington State Department of Transportation, the Oregon Department of Transportation, National Railroad Passenger Corporation (Amtrak), and the Central Puget Sound Regional Transit Authority. The National Transportation Safety Board also reiterates four recommendations to the Federal Railroad Administration and reclassifies three recommendations to the Federal Railroad Administration.
Recommendation: TO THE UNITED STATES DEPARTMENT OF TRANSPORTATION: Require the Federal Railroad Administration to issue regulations for inward-facing recorders that include image and audio recordings as recommended by the National Transportation Safety Board in R-10-01 and R-10-02.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
Mode: Railroad
Location: DuPont, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: RRD18MR001
Accident Reports: Preliminary Report Railroad Amtrak Passenger Train 501 Derailment DuPont, Washington December 18, 2017 RRD18MR001Amtrak Passenger Train 501 Derailment
Report #: RAR-19-01
Accident Date: 12/18/2017
Issue Date: 6/24/2019
Date Closed:
Addressee(s) and Addressee Status: DOT (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: DOT
Date: 9/16/2019
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Railroad Administration’s (FRA) notice of proposed rulemaking (NPRM) titled “Locomotive Image and Audio Recording Devices for Passenger Trains,” which was published at 84 Federal Register 35712 on July 24, 2019. The NTSB notes the FRA is (1) proposing to require the installation of inward- and outward-facing locomotive image recording devices on all lead locomotives in passenger trains and (2) addressing the use of the recordings to conduct operational tests. To the extent applicable, the NTSB is pleased that the NPRM is partially responsive to our recommendations. However, for the reasons provided in this response, we are disappointed that these long awaited proposed requirements do not include audio recordings and do not apply to freight railroads—two critical factors identified in numerous accident investigations that have prompted our existing safety recommendations. The NTSB provides comments on the following: whether to require both passenger and freight railroads to install image recording devices and whether audio recording should be included, the extent to which the proposed requirements should apply to recording devices that are voluntarily installed, whether a specific run-time or shutoff requirement should be included for recording devices, whether additional equipment is needed to address high levels of background noise inside locomotive cabs, recorder technical and crashworthiness issues, whether the recorders should only operate when a train is in motion, the appropriateness of proposed implementation dates, and whether the final rule should include a prohibition on public disclosure of any audio or video recording. Background The NTSB has determined that dozens of previous railroad accident investigations would have benefitted from inward- and outward-facing audio and image recorders. In a number of those accidents, the operator died, was seriously injured, or could not recall details from moments before the accident. However, even in the accidents in which the operator was not injured, audio and image recorders could have verified what the operator saw and heard, as well as what actions the operator took during the accident sequence. Such recorded information allows the NTSB to identify critical safety improvements and issue recommendations to prevent similar accident circumstances from reoccurring. Recorders also definitively document relevant information that regulatory agencies, such as the FRA, often state they require to help justify the costs of implementing safety improvements. This NPRM was prompted in part by NTSB Safety Recommendations R-97-9, R-07-3, R 10-1 and -2, and reiterations of these recommendations following several other investigations involving both passenger and freight railroads. The currently applicable recommendations issued to the FRA are— R-10-1 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-10-2 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. Safety Recommendations R-10-1 and -2 are classified “Open—Acceptable Response.” The FRA requested comments addressing the benefits of both inward- and outward-facing image and audio recording. These types of recording devices have been extremely beneficial in many accident investigations, including the January 4, 2017, collision of two Southeastern Pennsylvania Transportation Authority trolleys in Philadelphia, Pennsylvania, and the April 3, 2016, Amtrak (National Railroad Passenger Corporation) accident in Chester, Pennsylvania. In both of those investigations, the NTSB used the inward- and outward-facing audio and image recorders to corroborate the statements made by the operating crews and to gather additional visual information about track conditions and the accident sequences. More recently, the January 31, 2018, collision between an Amtrak passenger train and a refuse truck at an active grade crossing in Crozet, Virginia, demonstrated the benefit of outward facing image and audio recording. In that accident, the locomotive’s outward-facing image and audio recorder captured the position of the refuse truck, the weather, and the visibility conditions on the train tracks. The recorder showed that the truck was not moving in the moments before the accident; it also captured the sound of the locomotive’s horn as it approached each grade crossing leading up to the accident site. The NTSB also highlighted the benefits of inward- and outward-facing audio and image recorders in its report on the Amtrak passenger train 501 derailment in DuPont, Washington, on December 18, 2017. In that accident, the locomotive was equipped with an inward-facing image recorder that provided both a visual and audio recording of the crewmember activities during the accident trip. The device was voluntarily installed, and the recorded information proved extremely useful in the NTSB investigation. The following are important discoveries from the DuPont accident investigation that would have been impossible to determine without the inward- and outward-facing image and audio recorder data: • It was clear that neither crewmember was using a personal electronic device in the time leading up to the accident; as a result, there was no need to expend time and resources to acquire records or attempt to extract data from crewmembers’ electronic devices. • The brief conversations between the engineer and the conductor during the trip did not distract them from their operational duties or hamper their ability to identify wayside signs. • The qualification program for the Point Defiance Bypass, where the accident occurred, did not effectively train and test qualifying crewmembers on the physical characteristics of a new territory. • The engineer’s unfamiliarity with, and fixation on, the audible and visual alerts associated with the overspeed alarm reduced his vigilance of events outside the locomotive moments before the accident. In our 2019 DuPont accident report, the NTSB concluded that “the FRA has demonstrated an unwillingness to implement the recommendations and regulation that would require inward facing video and audio devices that are critical to accident investigations and improving safety on our nation’s railroads.” We further concluded that “inward-facing recorders with both image and audio capabilities can increase the understanding of the circumstances of an accident, and, ultimately, provide greater precision in safety recommendations and subsequent safety improvements.” Consequently, we issued the following recommendation to the Secretary of Transportation on June 21, 2019: R-19-7 Require the Federal Railroad Administration to issue regulations for inward-facing recorders that include image and audio recordings as recommended by the National Transportation Safety Board in R-10-1 and R-10-2. Safety Recommendation R-19-7 is classified “Open—Await Response.”

From: NTSB
To: DOT
Date: 6/24/2019
Response: On May 21, 2019, the National Transportation Safety Board (NTSB) adopted its report, Amtrak (National Railroad Passenger Corporation) Passenger Train 501 Derailment DuPont, Washington, December 18, 2017, NTSB/RAR-19/01. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issues: • Individual agency responsibilities in preparation for inaugural service • Multiagency participation in preparation for inaugural service • Amtrak (National Railroad Passenger Corporation) safety on a host railroad • Implementation of positive train control • Training and qualifying operating crews • Crashworthiness of the Talgo equipment • Survival factors and emergency design of equipment • Multiagency emergency response Accordingly, the NTSB makes the following safety recommendation to the Secretary of Transportation. Additional information regarding this recommendation can be found in the noted section of the report. • Require the Federal Railroad Administration to issue regulations for inward-facing recorders that include image and audio recordings as recommended by the National Transportation Safety Board in R-10-01 and R-10-02. (R-19-007) (See section 2.2.) The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 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. We encourage you to submit your response to correspondence@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response. The attached letter from the NTSB Chairman provides information about the NTSB’s May 21, 2019, report, Amtrak (National Railroad Passenger Corporation) Passenger Train 501 Derailment, DuPont, Washington, December 18, 2017, NTSB/RAR-19/01. 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-19-017). 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.