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Safety Recommendation Details

Safety Recommendation R-19-038
Details
Synopsis: On February 4, 2018, about 2:27 a.m., southbound Amtrak (National Railroad Passenger Corporation) train P91, operating on a track warrant, was diverted from the main track through a reversed hand-throw switch into a track and collided head-on with a stationary CSX Transportation Corporation (CSX) local freight train F777. The accident occurred on CSX’s Florence Division, Columbia Subdivision in Cayce, South Carolina. The engineer and conductor of the Amtrak train died because of the collision. Ninety-one passengers and crew members on the Amtrak train were transported to medical facilities. The engineer of the stopped CSX train had exited the lead locomotive before the Amtrak train entered the track, ran to safety, and was not injured. The conductor on the CSX lead locomotive saw the Amtrak train approaching on the track and ran to the back of locomotive. The conductor was thrown off the locomotive and sustained minor injuries. Damage was estimated at $25.4 million. The investigation focused on the following safety issues: the medical examination process for railroad employees, the actions and responsibilities of the train crew handling the switches, operations during signal suspensions, a CSX efficiency testing program, implementation of a safety management system by Amtrak, and occupant protection in passenger railcars. As a result of the investigation, the National Transportation Safety Board makes two safety recommendations to CSX and one safety recommendation to all host railroads. The National Transportation Safety Board also reiterates four recommendations to the Federal Railroad Administration and one recommendation to Amtrak. Further, the NTSB reclassifies two recommendations to the Federal Railroad Administration.
Recommendation: TO ALL HOST RAILROADS: Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
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 #: RAR-19-02
Accident Date: 2/4/2018
Issue Date: 9/30/2019
Date Closed:
Addressee(s) and Addressee Status: Belt Railway Company of Chicago (Open - Await Response)
BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Open - Await Response)
Buckingham Branch Railroad (Open - Await Response)
Canadian National Railway (Open - Await Response)
Canadian Pacific Railway (Open - Await Response)
CSX Transportation, Inc. (Open - Await Response)
Denver Regional Transportation District (Open - Await Response)
Genesee and Wyoming Railroad Company (Open - Await Response)
Iowa Interstate Railroad Ltd. (Open - Await Response)
Kansas City Southern Railway Company (Open - Await Response)
Kansas City Terminal Railway Company (Open - Await Response)
Massachusetts Bay Transportation Authority (Open - Await Response)
Metra (Northeast Illinois Regional Railroad Corporation) (Open - Await Response)
Metro North Railroad (Open - Await Response)
Minnesota Commercial Railway (Open - Await Response)
Norfolk Southern Corporation (Open - Await Response)
Pan Am Railways (Open - Await Response)
South Florida Regional Transportation Authority (Open - Await Response)
Southern California Regional Rail Authority (Open - Await Response)
State of California, County of North, North County Transit District (Open - Await Response)
State of Louisiana, City of New Orleans, Public Belt Railroad (Open - Await Response)
State of New Mexico, Department of Transportation, Rail Runner Express (Open - Initial Response Received)
SunRail (formerly Central Florida Commuter Rail) (Open - Initial Response Received)
Terminal Railroad Association of St. Louis (Open - Await Response)
Union Pacific (Open - Await Response)
Vermont Railway, Inc. (Open - Await Response)
VIA Rail Canada (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Belt Railway Company of Chicago
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge The Belt Railway Company of Chicago to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including The Belt Railway Company of Chicago. Additional information regarding this recommendation can be found in the noted sections of the report. Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge BNSF Railway to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including BNSF Railway. Additional information regarding this recommendation can be found in the noted sections of the report. Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Buckingham Branch Railroad
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Buckingham Branch Railroad to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Buckingham Branch Railroad. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Canadian National Railway
Date: 9/30/2019
Response: Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Canadian National Railway Company to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Canadian National Railway Company. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Canadian Pacific Railway
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Canadian Pacific Railway to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Canadian Pacific Railway. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: CSX Transportation, Inc.
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-36). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge CSX Transportation (CSX) to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 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 makes the following safety recommendations to CSX. Additional information regarding these recommendations can be found in the noted sections of the report. • 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 clear of the main track. (R-19-36) (See section 2.5.) • Develop and implement a safety management system that includes but is not limited to operations, training, maintenance, equipment, and medical standards. (R-19-37) (See section 2.7.) In addition, the NTSB makes the following recommendation to all of the host railroads, including CSX: • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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-19-36). 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.

From: NTSB
To: Iowa Interstate Railroad Ltd.
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Iowa Interstate Railroad, Ltd. to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Iowa Interstate Railroad, Ltd. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Kansas City Southern Railway Company
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Kansas City Southern Railway Company to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all host railroads, including the Kansas City Southern Railway Company. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Kansas City Terminal Railway Company
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Kansas City Terminal Railway Company to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Kansas City Terminal Railway Company. Additional information regarding this recommendation can be found in the noted sections of the report. ( • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Massachusetts Bay Transportation Authority
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Massachusetts Bay Transportation Authority to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Massachusetts Bay Transportation Authority. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Southern California Regional Rail Authority
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Southern California Regional Rail Authority/Metrolink to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Southern California Regional Rail Authority/Metrolink. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Metro North Railroad
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Metro-North Railroad to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the hosts railroads, including the Metro-North Railroad. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Minnesota Commercial Railway
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Minnesota Commercial Railway to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Minnesota Commercial Railway. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: State of Louisiana, City of New Orleans, Public Belt Railroad
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the New Orleans Public Belt Railroad to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including New Orleans Public Belt Railroad. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Norfolk Southern Corporation
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Norfolk Southern Railway Company to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Norfolk Southern Railway Company. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: State of California, County of North, North County Transit District
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the North County Transit District to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including North County Transit District. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Metra (Northeast Illinois Regional Railroad Corporation)
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. The attached letter from the NTSB Chairman provides information about the 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Northeast Illinois Regional Commuter Railroad Corporation to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Northeast Illinois Regional Commuter Railroad Corporation. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Pan Am Railways
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Pan Am Railways to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Pan Am Railways. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Denver Regional Transportation District
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Regional Transportation District to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Regional Transportation District. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: South Florida Regional Transportation Authority
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Florida Department of Transportation to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Florida Department of Transportation. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: SunRail (formerly Central Florida Commuter Rail)
To: NTSB
Date: 10/31/2019
Response: -From Charles M. Heffinger, Jr., P.E., FDOT CFRC/ SunRail Chief Operations Officer, Florida Department of Transportation: On behalf of the Central Florida Rail Corridor (CFRC) and the SunRail Commuter Rail System, this is in response to your letter dated September 30, 2019, concerning the host railroad recommendation from the Amtrak Passenger Train, Head-on Collision with Stationary CSX Freight Train - NTSB Accident Report (NTSB/RAR-19/02 PB2019-101398). The specific recommendation (R-19-38) states: “Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system”. Our response is as follows: • Florida’s State Safety Oversight Agency (SSOA) is required to provide safety and security oversight of the SunRail Commuter Rail System. This requirement is under the auspices of Florida Statute, Section 341.061(1), and Rule 14-15.017, Florida Administrative Code. As a result of this code, CFRC/SunRail has developed, adopted, implemented, and maintained a written System Safety Program Plan (SSPP) (see Attachment A). The Florida State Safety and Security Oversight Program Standard further details the requirements of the CFRC/SunRail SSPP. The concepts of a Safety Management System are the foundation of the SSPP and emphasize proactive hazard identification and risk management without retribution, and discussion and resolution of possible mitigations with management. The SunRail Commuter Rail’s State Safety and Security Oversight Standard and its SSPP requirements build on the Federal Transit Administration’s new regulations and the Federal Railroad Administration’s (FRA) proposed System Safety regulation. These regulations form the basis for Safety Management Systems. • CFRC/SunRail’s System Safety Program Plan (SSPP) describes a formalized hazard management process that establishes the determination and mitigation of risk. CFRC has implemented comprehensive hazard analyses throughout all phases of the design, construction, operation, and maintenance of the SunRail Commuter Rail System (see Attachments B-1 and B-2 Phase 2 South Hazard Analyses and B-3 CFRC Signal Suspension Hazard Analysis template). • CFRC conducts hazard analyses for all new systems and infrastructure as well as any modifications to the SunRail commuter system including equipment, facilities, rolling stock, procedures, plans, and training per the requirements in the SSPP. • Signal Suspensions – In particular, the CFRC team and their contractors prepare detailed Work Plans for all signal suspensions. A CFRC Work Plan describes the timeline, signal suspension procedures, communication, and workforce requirements specific to that segment of the corridor. CFRC then holds meetings with the Tenant Railroads – Amtrak, Florida Central Railroad, and CSX to review the details of the Work Plan and address any hazards (see Attachments C-1, C-2 and C-3 Signal Suspension Work Plans). CFRC will continue to use the detailed Work Plan and will implement the current hazard analysis template for signal suspensions. CFRC will brief each Tenant Railroad on the Work Plan and hazard analysis in advance of implementing the signal suspension. • Joint Efficiency Testing – Amtrak Joint Testing Sessions with CFRC has occurred twenty-five times since 2016 per CFRC’s Operational Testing and Enforcement Program Plan under FRA regulation 49 CFR Part 217. • Exercises and Drills – CFRC/SunRail invites Amtrak and CSX to all appropriate exercises. In 2018, Amtrak and CSX attended an Active Shooter Tabletop exercise, Bus Bridge Exercise, and a SunRail Train Fire. Amtrak is also a signatory to CFRC/SunRail’s Passenger Train Emergency Preparedness Plan under FRA regulation 49 CFR Part 239. • Operating Rules – Both CFRC and the Operations & Maintenance Contractor (Bombardier Mass Transit Corporation) provide CFRC Operating Rules, Bulletins, Timetable, and Notices to the Tenant Railroads. CFRC will develop a CFRC Signal Suspension Procedure to incorporate CFRC’s Signal Suspension Work Plan components, similar to the CSX Signal Suspension Operating Plan structure and shall include the following: ??Crews and Dispatchers – Hold Signal Suspension Work Plan Job Briefings for crews and dispatchers. ??Crews and Dispatchers – Implement rule modifications (Track Warrant Control - D) to provide a hold point for all crewmembers to agree on switch restoration before releasing authority or reporting by a specific location. ??Signal Department – Implement new switch locking procedures with a new signal suspension switch tag/lock. ??Operations Center – Apply electronic switch tags and include switch status in Dispatcher turnover. ??Train Operations – Eliminate unnecessary industrial and other switching. Planned train meets to occur outside signal suspension when possible. The CFRC Signal Suspension Procedure is scheduled to be completed by December 31, 2019. CFRC, CSX, and Amtrak will continue to hold meetings to discuss safety performance, speed restrictions, upcoming projects, and signal suspensions, including work plans and hazard analyses. At a minimum, these meetings will be held semi-annually but may be held more frequently before a planned signal suspension. Using a system safety approach to evaluate risks allows CFRC and its Tenant Railroads to identify weaknesses and single-point failures in procedures. With management actively involved in evaluating and identifying risk for non-routine work, both groups can then determine alternative mitigations. The review of such risks uses a forum that creates open discussion and recognition of the potential consequences of risk for both CFRC and its Tenant Railroads. CFRC has embraced the use of hazard analysis and risk evaluation, as evidenced in our SSPP, and will continue to work with our Tenant Railroads to prevent future incidents.

From: NTSB
To: SunRail (formerly Central Florida Commuter Rail)
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Central Florida Rail Corridor/SunRail to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Central Florida Rail Corridor/SunRail. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Terminal Railroad Association of St. Louis
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Terminal Railroad Association of St. Louis to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the Terminal Railroad Association of St. Louis. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Union Pacific
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Union Pacific Railway Company to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Union Pacific Railway Company. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Vermont Railway, Inc.
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Vermont Railway to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including Vermont Railway. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: VIA Rail Canada
Date: 9/30/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the VIA Rail Canada to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including VIA Rail Canada. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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.

From: NTSB
To: Genesee and Wyoming Railroad Company
Date: 10/21/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. For more information about the NTSB and our recommendation process, please see the attached one-page summary. We are providing the following information to urge the Genesee and Wyoming Railroad to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. On September 30, 2019, we erroneously transmitted this safety recommendation to the New England Central Railroad, one of your subsidiaries, rather than directly to you. We apologize for any confusion this may have caused. 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 makes the following safety recommendation to all of the host railroads, including the Genesee and Wyoming Railroad. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov, or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division.

From: State of New Mexico, Department of Transportation, Rail Runner Express
To: NTSB
Date: 11/26/2019
Response: -From Robert Gonzales, Assistant Director, New Mexico RailRunner: In response to your letter dated 09/30/2019, We the New Mexico RailRunner are committed to Working in partnership with Amtrak and will continue assist in establishing a safety management criteria that support the implementation of Amtrak’s safety management system.

From: NTSB
To: State of New Mexico, Department of Transportation, Rail Runner Express
Date: 10/21/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the New Mexico Rail Runner Express to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. 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 makes the following safety recommendation to all of the host railroads, including the New Mexico Rail Runner Express. Additional information regarding this recommendation can be found in the noted sections of the report. • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-38). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov, or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division.