Good morning Madam Chairwoman and Members of the Subcommittee. I appreciate the opportunity to represent the National Transportation Safety Board (NTSB) before your Subcommittee to discuss mechanical issues in railroad accidents.
Thus far, 1996 has been a busy year for the NTSB, and a tragic year for the railroad and rail transit industries. Since January 1, 1996, the Safety Board has launched railroad investigators to 18 railroad accidents that resulted in 19 fatalities, 230 injuries, and over $64 million in damages. Included in these 18 accident investigations are 6 runaway trains, 6 collisions, 5 derailments, and 1 grade crossing accident.
RECENT SIGNIFICANT ACCIDENTS
Occurrences since January 1 include tragic accidents on the Washington METRO in Gaithersburg, Maryland; the Burlington Northern Santa Fe Railroad in Cajon Pass, California; New Jersey Transit in Secaucus, New Jersey; and Maryland Transit Administration's MARC Train in Silver Spring, Maryland. These four accidents are major accidents that involved launching full teams of NTSB investigators. Other important accidents involving the Burlington Northern Santa Fe Railroad in St. Paul, Minnesota, and the Southern Pacific Railroad in Tennessee Pass, Colorado, are being investigated as regional accidents by the Safety Board's regional accident investigators. These accidents all involve important railroad safety issues, and today I would like to discuss three of those issues -- two way end of train devices, air brake inspection and testing, and passenger crashworthiness and safety standards.
Two-Way End of Train Devices
The Safety Board has been interested in two-way end of train devices since the Helena, Montana accident in 1989. During the past two years, we have completed investigations on at least seven other train accidents in which a two-way end of train device would have probably prevented an accident on a runaway train. The Safety Board also believes that the accidents that took place on the Burlington Northern Santa Fe Railroad at Cajon Pass, California; the Burlington Northern Santa Fe Railroad at St. Paul, Minnesota; and the Southern Pacific Railway at Tennessee Pass, Colorado, could have been prevented had a working two-way end of train device been in place.
At one time, all of Americas freight trains were equipped with a caboose. The conductor and brakeman rode in the caboose and performed certain safety functions. Their duties included monitoring a pressure gage in the caboose and radioing the engineer when the brakes at the end of the train were applied or released. They were also required to watch out for dragging equipment and hot journal boxes.
Each caboose was also equipped with a conductor's emergency brake valve. If there was a problem or hazardous condition involving the train, the conductor had the option of venting the brake pipe air through the conductor's emergency brake valve and applying the brakes in emergency from the rear of the train.
Technology in the form of dragging equipment detectors, hot box detectors, and end of train devices took the place of the conductor when the caboose was removed from freight trains. One-way end of train devices monitored the brake pipe pressure at the end of the train and transmitted that information directly to the engineer by radio signal. In this manner, the engineer could read the brake pipe pressure at the rear of the train himself and determine if the brakes were applied or released. What was lost when cabooses were removed from service was the ability to initiate an emergency brake application from the rear of the train.
The two-way end of train device incorporates this additional feature. The engineer can command an emergency brake application at the rear of the train by flipping a toggle switch in the locomotive cab. When the toggle switch is flipped, the two-way end of train device will open the end of the brake pipe and vent all of the air, thus triggering an emergency brake application from the rear of the train. Safety Board investigators believe that two-way end of train devices are essential to the safe operation of cabooseless trains because they offer the only effective means of stopping a train if the train line is blocked by a turned angle cock, crimped air hose, frozen air line, or other such circumstances. Two-way end of train devices have been required on Canadian railroad trains since 1987.
The Safety Board's first recommendation on two-way end of train devices was a result of the February 2, 1989, Helena, Montana accident. About 4:30 a.m. local time, freight cars from Montana Rail Link Inc. westbound train 121 rolled eastward down a mountain grade and struck a stopped helper locomotive consist, Helper 1, in a Helena freight yard. The locomotive consist of train 121 included three helper units and three road units positioned at the head end of a 49-car train. The crew members of train 121 had uncoupled the locomotive units from the train to rearrange the locomotive consist while stopped on a mountain grade. In the collision and derailment, 15 cars from train 121 derailed, including three tank cars containing hydrogen peroxide, isopropyl alcohol, and acetone. Hazardous materials released in the accident resulted in a fire and explosions. About 3,500 residents of Helena were evacuated. Two crewmembers of the helper struck by the runaway train were slightly injured. The estimated damage (including clean-up and lading) as a result of this accident exceeded $6 million.
The National Transportation Safety Board determined that the probable cause of this accident was the failure of the crew of train 121 to properly secure their train by placing the train brakes in emergency and applying hand brakes when it was left standing unattended on a mountain grade. Contributing to the accident was the decision of the engineer to rearrange the locomotive consist and leave the train unattended on the mountain grade, and the effects of the extreme cold weather on the air brake system of the train and the crew members. Also contributing was the failure of the operating management of the Montana Rail Link to adequately assess the qualifications and training of employees placed in train service. Contributing to the severity of the accident was the release and ignition of hazardous materials. The Safety Board recommended that the Federal Railroad Administration (FRA):
Require the use of two-way end-of-train telemetry devices on all cabooseless trains for the safety of railroad operations.
The FRA had incorporated language in the "Power Brake Regulations" to address two-way end of train device requirements. However, the same day that the FRA was holding hearings on the revised "Power Brake Regulations," the Cajon Pass accident of December 14, 1994, occurred.
About 5:21 a.m. local time on December 14, 1994, a westbound Atchison, Topeka and Santa Fe Railway Company (Santa Fe) intermodal train, PBHLA1-10, collided with the rear end of a standing westbound Union Pacific Railroad Company (UP) unit coal train, CUWLA-10, at milepost (MP) 61.55, near Cajon, California, on the Santa Fe's San Bernardino Division's Cajon Subdivision. The two crewmembers from the Santa Fe train were injured when they jumped from the moving train before the collision. Two helper crewmembers on the rear of the UP train detrained before the collision because they had heard radio conversations among the Santa Fe crewmembers, the train dispatcher, and UP crewmembers. As a result of the collision, a fire broke out that burned the two UP helper locomotive units. Four Santa Fe locomotive units and three articulated five-pack double-stack container cars were also destroyed. Total estimated damages were $4,012,900.
The issues examined in this accident were: air brake testing in mountain-grade territory; management oversight of train handling practices; feed-valve braking; and two-way end-of-train devices.
The National Transportation Safety Board determined that the probable cause of this accident was insufficient available train braking force for the Santa Fe train due to an undetermined restriction or blockage in the trainline between the third and fourth articulated cars. The Safety Board also concluded that had the train been equipped with a two-way, end of train device, the collision could have been avoided because the engineer could have initiated an emergency brake application from the end of the train.
As a result of its investigation, the Safety Board closed Safety Recommendation R-89-82, which was issued to the FRA on December 6, 1989, and reissued the same recommendation to expedite implementation into the pending power brake law:
Separate the two-way end-of-train requirements from the Power Brake Law NPRM, and immediately conclude the end-of-train device rulemaking so as to require the use of two-way end-of-train telemetry devices on all cabooseless trains. (Urgent Action)
The FRA did take action on our recommendation, but only after the second Cajon accident on February 1, 1996. The FRA issued an emergency order for the Burlington Northern Santa Fe Railroad to immediately use two-way end of train devices and obtained agreement from the major railroads to use two-way end of train devices on all trains in mountainous territories by the end of 1996 and on all cabooseless trains by July 1997.
Air Brake Inspection and Testing
Air brake safety issues including inspection, testing, maintenance, and design are safety issues in accidents involving the Washington METRO at Gaithersburg, Maryland; the Burlington Northern Santa Fe Railroad at Cajon Pass, California; the Burlington Northern Santa Fe Railroad at St. Paul, Minnesota; and the Southern Pacific Railway at Tennessee Pass, Colorado.
Air brake inspection and safety requirements are maintained by the FRA in a section of the Code of Federal Regulations commonly known as the "Power Brake Regulations." The recommendations issued to the FRA regarding new or modified regulations contained under the "Power Brake Regulations" were the result of numerous Safety Board accident investigations. Three Safety Board accident investigations in particular provide compelling evidence to support the Safety Boards main concern about these regulations. These three accidents caused over $21.4 million in property damage and resulted in several deaths and numerous injuries to train crews, passengers, bystanders, and property owners.
The first accident was the Helena, Montana one that occurred on February 2, 1989 and was described previously. As a result of that accident, the Safety Board made the following recommendation to the FRA:
Amend the road train and intermediate terminal train air brake tests, 49 CFR 232.13, to require additional testing of a train air brake system when operating in extreme cold weather, especially when the feed valve setting is changed and the train will be operated in mountain grade territory.
The second accident that led to NTSB safety recommendations on the power brake regulations occurred near San Bernardino, California. About 7:30 a.m., local time on May 12, 1989, Southern Pacific Transportation Company freight train 111, which consisted of a four-unit locomotive, 69 hopper cars loaded with trona, and a two-unit helper locomotive on the rear of the train, derailed at milepost 486.8. The entire train was destroyed as a result of the derailment. Seven homes located in the adjacent neighborhood were totally destroyed and four others were extensively damaged. Of the five crew members on board the train, two on the head end of the train were killed. A third crewman on the head end received serious injuries, and two crewmen on the rear end of the train received minor injuries. Of eight residents in their homes at the time of the accident, two were killed and one received serious injuries as a result of being trapped under debris for 15 hours. Local officials evacuated homes in the surrounding area because of a concern that a 14-inch pipeline owned by the Calnev Pipe Line Company, which was transporting gasoline and was located under the wreckage, may have been damaged. Residents were allowed to return to their homes about 24 hours after the derailment.
About 8:05 a.m., on May 25, 1989, 13 days after the train derailment, the 14-inch pipeline ruptured at the site of the derailment, released its product, and ignited. As a result of the releases and ignition of gasoline, two residents were killed, three received serious injuries, and 16 reported minor injuries. Eleven homes in the adjacent neighborhood were destroyed, three received moderate fire and smoke damage, and three received smoke damage only. In addition, 21 motor vehicles were destroyed. Residents within a four-block area of the rupture were evacuated by local officials. Total damages as a result of the train derailment and pipeline rupture exceeded $14 million.
The National Transportation Safety Board determined that the probable cause of the train derailment on May 12, 1989, was the failure to determine and communicate the accurate trailing weight of the train, failure to communicate the status of the train's dynamic brakes, and the Southern Pacific operating rule that provided inadequate direction to the head-end engineer on the allowable speed and brake pipe reduction down the 2.2-percent grade.
As a result of the San Bernardino accident, the Safety Board made two recommendations to the FRA regarding dynamic brakes:
Study, in conjunction with the Association of American Railroads, the feasibility of developing a positive method to indicate to the operating engineer in the cab of the controlling locomotive unit the condition of the dynamic brakes on all units in the train; and
Revise the regulations to require that if a locomotive unit is equipped with dynamic brakes that the dynamic brakes function.
The Safety Board feels very strongly that dynamic brakes should be operational when locomotives are dispatched. Dynamic brakes are an extremely important tool for train handling. Engineers are taught to control the speed of their train through throttle modulation and the use of the dynamic brakes. Engineers are also taught that dynamic brakes are the "first" brake to be used when slowing a train. Therefore, dynamic brakes should be considered primary safety devices which must work properly when a locomotive is dispatched.
The third accident the Safety Board investigated that led to recommendations about the power brake regulations was the Palatka, Florida, accident. At 11:25 a.m. on December 17, 1991, National Railroad Passenger Corporation train 87, operating on CSX Transportation Inc. track, derailed at milepost A697.6 in Palatka, Florida. Train 87 consisted of a locomotive and eight cars. The locomotive and first six cars derailed. The derailment occurred while train 87 was negotiating a six degree six minute curve to the right (west). The derailed equipment struck two homes and blocked the street north of the Palatka station. Eleven passengers sustained serious injuries and 41 received minor injuries. Five operating crew members and four on-board service personnel had minor injuries.
The National Transportation Safety Board determined that the probable cause of this accident was the failure of the engineer and the fireman to maintain full attention to the train location and to slow for the speed restriction in sufficient time to safely negotiate the curve. As a result of this investigation, the Safety Board recommended to the FRA:
Amend the Power Brake Regulations, 49 Code of Federal Regulations 232.12, to provide appropriate guidelines for inspecting brake equipment on modern passenger cars.
The Safety Board issued this recommendation because the investigators found evidence that the initial terminal brake test conducted on the passenger cars was inadequate. The investigators felt that the current "Power Brake Regulations" did not adequately distinguish between passenger cars and freight cars; nor did they take into account the different methods that needed to be used to properly inspect each type of car.
Although an Advanced Notice of Proposed Rulemaking (ANPRM) was issued on December 31, 1992 and a Notice of Proposed Rulemaking (NPRM) was issued on September 16, 1994, the "Power Brake Regulations" have not yet been revised.
Passenger Car Crashworthiness and Safety Standards
The Safety Board has been interested in passenger car crashworthiness and passenger car safety standards for many years. The list of accidents where the Safety Board made recommendations in this area goes back over 25 years, from tragic accidents in Glenn Dale, Maryland, and Darien, Connecticut, in 1969. The 1996 accidents on Washington METRO at Gaithersburg, Maryland, on New Jersey Transit in Secaucus, New Jersey, and on the MARC Train in Silver Spring, Maryland again tragically point out the need for passenger car safety standards. Our past recommendations included some familiar issues:
advising passengers of emergency procedures;
seat securement and luggage retention devices;
safe window design;
elimination of sources of direct impact injury;
emergency exits and emergency lights;
car roof escape hatches;
predeparture inspection of safety devices;
emergency release mechanisms for doors that are clearly identified; and
requirements for minimum safety standards for passenger cars.
In 1985, in response to several of these recommendations, the FRA stated that they had reported to the U.S. Congress that, "... the Federal Railroad Administration concluded that passenger operations had compiled an excellent safety record and a major Federal regulatory effort was not necessary or warranted." Based on that response, many of the recommendations calling for passenger car standards were closed as "unacceptable action."
The Board then began to work with Amtrak to have its passenger cars upgraded for occupant protection. Amtrak responded by implementing almost all of the Board's recommendations on passenger car safety. This approach covers only those cars used by Amtrak and does not reach the other cars in passenger service.
The Safety Board investigated a tragic accident that occurred in Gary, Indiana in 1993. At 9:34 a.m. on January 18, 1993, Northern Indiana Commuter Transportation District (NICTD) eastbound commuter train 7, traveling from Chicago, Illinois, to South Bend, Indiana and NICTD westbound commuter train 12, travelling from South Bend to Chicago collided at milepost 61.1 in Gary, Indiana. Train 7 and train 12 consisted of two and three passenger cars respectively. Train 7 passed a stop signal at Milepost 61.2 and its lead car blocked westbound traffic where the tracks intersect. After train 12 crossed the Gary Gauntlet Bridge, it struck train 7. As a result of the collision, 7 passengers died and 95 people sustained injuries. The estimated damage for both trains was $854,000.
The National Transportation Safety Board determined that the probable cause of the collision between the two NICTD trains was the inattentiveness of the engineer on train 7, resulting in his train passing a stop signal and partially blocking the westbound track. Contributing to the severity of the accident was the failure of the engineer on train 12 to take timely action to slow or stop his train before the collision. Contributing to the severity of the injuries was the breach of the passenger compartments in the lead cars of both trains.
The major safety issues discussed in this report are the attentiveness of the engineers and the crashworthiness of self propelled passenger cars in corner to corner collisions.
As a result of this accident, the Safety Board issued Safety Recommendation R-93-24 to the Federal Railroad Administration:
In cooperation with the Federal Transit Administration and the American Public Transit Association, study the feasibility of providing car body corner post structures on all self propelled passenger cars and control cab locomotives to afford occupant protection during corner collisions. If feasible, amend the locomotive safety standards accordingly.
There are currently no Federal industry-wide standards in the railroad industry or in the rail transit industry for the design and construction of railroad passenger cars, other than an FRA requirement for 4 emergency exits on each car and for non-breakable glass in the windows.
Madam Chairwoman, we appreciate the opportunity to discuss these important issues with the Subcommittee.
That completes my statement, and I will be happy to respond to any questions the Subcommittee may have.
Jim Hall's Speeches