Safety Recommendation R-12-020
Details
Synopsis: On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway (BNSF) coal train C-BTMCNMO-26, BNSF 9159 East, travelling about 23 mph, collided with the rear end of standing BNSF maintenance-of-way (MOW) equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost (MP) 448.3 on main track number two on the Creston Subdivision of the BNSF Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require the use of positive train control technologies that will detect the rear of trains and prevent rear-end collisions.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Red Oak, IA, USA
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11FR002
Accident Reports:
Report #: RAR-12-02
Accident Date: 4/17/2011
Issue Date: 5/10/2012
Date Closed: 9/16/2019
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/16/2019
Response: Your February 19, 2019, letter said that you believe that any changes to the PTC requirement this late in the process will further delay full implementation. Additionally, you claimed that you cannot develop an effective cost-benefit analysis for any potential rulemaking. Because you have not taken the recommended action and do not intend to, Safety Recommendation R-12-20 is classified CLOSED--UNACCEPTABLE ACTION.

From: FRA
To: NTSB
Date: 2/19/2019
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA.) updated and final response to the National Transportation Safety Board's (NTSB) Safety Recommendations R-12-20 and R-12-27. The NTSB issued the former recommendation in response to the April 17, 2011 , collision between a BNSF Railway (BNSF) train and a standing BNSF maintenance-of-way equipment vehicle near Red Oak, Iowa. The NTSB issued the latter recommendation in response to the July 14, 2009, collision of a Dakota, Minnesota and Eastern Railroad freight train and loaded railcars on a yard track near Bettendorf, Iowa. On October 11 , 2018, FRA met with the NTSB concerning these and several other safety recommendations. As we discussed at the meeting and as described in the enclosure, FRA believes that, for several reasons, we should take no further action on these recommendations, and we respectfully ask that the NTSB close them. I appreciate your interest in these important safety issues. If FRA. can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer. The Federal Railroad Administration (FRA) has been assessing the efforts of the railroad industry to implement positive train control (PTC) systems by the December 31, 2018, deadline, and our determinations do not dissuade us from our previous position that we should not implement Safety Recommendation R-12-20. In March 2015, FRA informed the National Transportation Safety Board (NTSB) that we intended to take no further action on R-12-20 and requested that it be closed. FRA explained that requiring this technology would greatly increase the negative cost-benefit ratio keeping railroads from implementing PTC beyond current mandates, and that adding new requirements to PTC systems late in the process would be counterproductive by greatly delaying full implementation. In May 2016, the NTSB responded, disagreeing that a rulemaking to add new requirements would further delay implementation, since implementation had already been delayed and extended. FRA maintains that additional PTC mandate would delay implementation even further given the significant work remaining for host railroads and tenant railroads to fully implement PTC systems on approximately 58,000 route miles of railroad main lines, in accordance with the statutory mandate and FRA's existing technical specifications under 49 CFR part 236, subpart I. Furthermore, FRA faces constraints in addressing recommendations to "require" railroads to take certain actions. All Federal agencies, including the FRA, must follow the direction of Executive Orders 12866 and 13563 for rulemaking, which include quantifying costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 specifically states that: Each agency shall assess both the costs and the benefits of the intended regulation and, recognizing that some costs and benefits are difficult to quantify, propose or adopt a regulation only upon a reasoned determination that the benefits of the intended regulation justify its costs. To meet the requirements of these Executive Orders, for each proposed and final regulation issued, FRA performs a regulatory analysis to: 1. Establish whether Federal regulation is necessary and justified to achieve a social goal; and 2. Clarify how to design regulations in the most efficient, least burdensome, and most cost-effective manner. While issuing regulations to implement this recommendation could improve railroad safety in the specific railroad accident or incident from which it arose, regulatory action to implement this recommendation would result in financial and safety costs that far exceed the societal benefits of improved safety or accident avoidance. Based on the associated cost benefit analysis, implementing such a regulation (as prescribed by the recommendation) would not meet the intent of the Executive Orders listed above, and accordingly, would likely not be approved for publication by the Office of Management and Budget. Furthermore, implementing regulations with costs that far outweigh benefits would divert resources from other, more beneficial safety measures. The current PTC technologies being deployed by railroads do not necessarily detect the rear ends of trains, and we agree with the NTSB that they are unlikely to prevent rear-end train-to-train collisions that may occur when trains are operating below restricted speed. But rail accidents involving rear-end collisions are rare, and mandating additional requirements now could delay the railroads' efforts to implement PTC systems, increasing the likelihood of more common preventable accidents. Current indications show that full deployment of PTC as required by the existing statutory mandate and FRA' s implementing regulations is unlikely to be complete before December 31, 2020. As indicated in the March 2018 independent Government Accountability Office (GAO) report (GA0-18-367T Positive Train Control), severe resource constraints already face the rail industry in meeting existing deadlines to fully implement PTC systems that comply with existing technical requirements. To further delay this process without justifiable benefit does not serve public safety. PTC-preventable accidents, even including the enhancements for end-of-train detection recommended in R-12-20, represent approximately 5 percent of all rail accidents and incidents. The original estimated cost-benefit ratio for PTC, as it is currently being deployed, was approximately $20 in costs for every $1 in safety benefits. Actual implementation costs are over twice the original FRA estimate used for calculating the already adverse 20: I cost-benefit ratio, making the as-built cost-benefit ratio significantly worse than projected. Adding the new requirements ofR-12-20 would further worsen the ratio. These additional, excessive costs are not justifiable because rear-end collisions are exceedingly rare. In 2017, only 0.6 percent of rail accidents were rear-end collisions. The data from 2010 to the present is essentially the same, averaging 0.68 percent of rail accidents per year. Adding this new requirement would further reduce limited industry and government resources from other critical rail safety efforts. Given the current cost of PTC system implementation (approaching $16 billion), available resources would be better spent where they can have a greater impact: addressing issues that make up a greater percentage of rail accidents and incidents and that can be accomplished with more advantageous cost-benefit ratios. An argument could be made that adding Global Positioning System (GPS) units to the rears of trains might allow transmitting the length of trains and the end--of-train locations to other trains, thus satisfying the recommendation's intent. Unfortunately, current train designs were not intended to provide this capability, and not all PTC systems are based on using GPS. Following railroads' full implementation of PTC systems to meet the current statutory mandate and FRA's regulations, FRA will periodically re-evaluate, assess, and consider (with respect to resources available at the time and comparative cost-benefit analyses) what additional potential rail safety improvements could be implemented. However, at this time, FRA will not take any further action toward this recommendation and asks the NTSB to close it.

From: NTSB
To: FRA
Date: 5/18/2016
Response: We disagree with your position that initiating rulemaking to add additional requirements to PTC system functionality at this time would be counterproductive because Class 1 railroads would need to redesign already-approved systems; seek re-approval; and restart the testing, evaluation, and installation phases, further delaying their implementation of this technology. As discussed above, the implementation of PTC has been extended to the end of 2018. The purpose of PTC systems is to prevent train-to-train collisions. We believe that rear-end collisions are avoidable, and we urge the FRA to move forward to require this capability as soon as possible. We emphasized the importance of preventing accidents when trains are operated at restricted speed in our response to the FRA’s NPRM, Positive Train Control Systems, that was published at 74 Federal Register 138 (July 21, 2009). In that NPRM, the FRA stated that current PTC technology did not protect following trains proceeding at restricted speed into an occupied block (the circumstances in the accident near Red Oak). Our comments on the proposed rulemaking included the following: Although the NTSB recognizes that proposed PTC requirements will prevent high-speed collisions, the NTSB also recognizes that railroads may need to move trains at restricted speeds and, as noted in Subpart I, train-to-train collisions at restricted speeds could still occur. Current PTC systems do not track the location of the rear end of each train and do not use the rear location as a target to determine where following trains must stop. The NTSB urges the FRA and the railroads to work on developing technology that will improve the prevention of rear-end collisions at restricted speeds and to incorporate that technology into existing PTC systems as it becomes available. Pending your reconsideration of our request, Safety Recommendation R-12-20 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 3/11/2015
Response: -From Sarah Feinberg, Acting Administrator: This letter is to update you on the status of the National Transportation Safety Board's (NTSB) Safety Recommendations R-06-07, R-09-01, R-09-02, R-12-20, R-12-27, and R-13-23, issued to the Federal Railroad Administration (FRA). These recommendations pertain to power-assisted switch machines, uniform signal aspects, and Positive Train Control. In the enclosure, FRA responds to the safety recommendations and explains the actions it has taken in response to the recommendations. Therefore, FRA respectfully requests that the NTSB classify Safety Recommendations R-06-07 and R-12-27 as "Open-Acceptable Alternate Response." FRA does not plan to take any further action with Safety Recommendations R-09-01 and R-09-02, R-12-20, or R-13-23. Therefore, FRA respectfully requests that the NTSB classify Safety Recommendations R-09-01 and R-09-02 as "Closed Acceptable Alternate Action," R-12-20 as "Closed--Reconsidered," and R-13-23 as "Closed Acceptable Action." We look forward to continuing to work with you on important safety issues. FRA reminds the National Transportation Safety Board that FRA has promulgated a rule that requires railroads to install PTC systems on approximately 70,000 miles of track and 18,000 locomotives. At least 38 railroads will implement PTC systems on portions of their properties. The scope of deployment is approximately one-half of all route miles of track in the United States. FRA is continually working with the Association of American Railroads, the American Public Transportation Association, the American Short Line and Regional Railroad Association, and the individual railroads subject to the PTC implementation mandate to provide regulatory compliance guidance and identity and document the scope and effect of technical issues that may affect full PTC implementation by the statutory deadline. The rail industry continues to cite PTC technology's high negative return on investment as a reason not to install PTC systems on any lines where not required. Detailed cost-effectiveness studies of requiring PTC technologies to detect the rear of trains and prevent rear-end collisions at restricted speed show it will significantly add to the negative benefit-cost ratio that railroads widely state as a chief deterrent to implementing PTC technology beyond current statutory mandates. A PTC system is a system of systems. The development of PTC components requires railroads to obtain subject matter experts who can create and document component requirements, and then develop, install, and test the components. The railroads must analyze all integration issues and mitigate any potential or actual defects or risks. After PTC equipment suppliers develop and test the PTC system components, the individual railroads must integrate the components with each other and with the railroad's existing technology systems. From a timing perspective, PTC system components will not be ready for use until after development and testing by the suppliers and full-system integration and testing by each railroad. All these activities and schedules must be carefully planned, and be subject to modification based on experience gained in the development, implementation, testing, and deployment stages. As shown to date with the various railroads' installation of PTC systems, this technology is not available "off the shelf." Threats to the successful PTC system implementation include complications and reliability concerns that can increase exponentially, leading to complexities and uncertainties that compromise a safe and useful system. While progress is certainly being made across the rail industry, sincere concerns exist as to whether the railroads individually and collectively can accomplish such a mandate in the allowable timeframe. FRA submitted a formal status report to Congress on August 10, 2012, regarding the railroads' PTC implementation progress. This report identified several significant technical and programmatic obstacles that could result in the implementation deadline not being fully met. For FRA to enter into a rulemaking to add additional requirements to PTC system functionality at this late juncture would be counterproductive; railroads would have to redesign the already approved PTC systems, seek re-approval, and restart the testing, evaluation, and installation phases. This would certainly result in additional delays in PTC system development and implementation. Therefore, FRA will not consider adding additional PTC system requirements until after completion of initial implementation.

From: NTSB
To: FRA
Date: 7/2/2013
Response: The NTSB is disappointed that the FRA does not intend to implement Safety Recommendation R-12-20 at this time. PTC systems (as defined in the Rail Safety Improvement Act of 2008) are systems designed to prevent train-to-train collisions. Because the PTC designs currently being deployed are not required to detect the rear of a train as a target, rear-end collisions like that at Red Oak will continue to occur. We believe that these types of collisions are avoidable, and we urge the FRA to move forward now, without waiting until current efforts to install PTC are complete. Pending a reply from the FRA indicating that it will implement Safety Recommendation R-12-20 without delay, the recommendation is classified OPEN—UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 4/8/2013
Response: -From Joseph C. Szabo, Administrator: This letter is to update you on the status ofNational Transportation Safety Board (NTSB) Safety Recommendations R-12-04, and R-12-20 and -22, issued to the Federal Railroad Administration (FRA) on March 2, 2012, and May 10, 2012, respectively. Safety Recommendation R-12-04 was issued as a result ofthe June 19, 2009, derailment of eastbound Canadian National Railway (CN) Freight Train U70691-18 in Cherry Valley, Illinois. Safety Recommendations R-12-20 and -22 were issued as a result of the April17, 2011, rear-end collision of eastbound BNSF Railway (BNSF) Coal Train C-BTMCNM0-26, BNSF 9159 East, into standing BNSF Maintenance-of Way Equipment Train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The enclosure outlines FRA's response to each recommendation and the safety systems and regulations in place to address them. Therefore, FRA respectfully requests that NTSB classify Safety Recommendations R-12-04 as "Closed-Acceptable Action" and Safety Recommendations R-12-20 and -22 as "Closed-Reconsidered." We look forward to continuing to work with you on important safety issues. The Rail Safety Improvement Act of 2008 mandated Positive Train Control (PTC) system implementation across major portions of the Nation's railroads by December 31, 2015. With the assistance of the Railroad Safety Advisory Committee, of which the National Transportation Safety Board (NTSB) was a participating member, FRA produced the final rule addressing the statutory requirements of PTC, which was published on January 15, 2010. Subsequent final rule amendments were published on September 27, 2010, and May 14, 2012. A Notice of Proposed Rulemaking proposing additional amendments to the rule was published on December 11, 2012, and FRA will publish the final rule as soon as possible. PTC is expected to be installed on a total of approximately 70,000 miles of track and on 18,000 locomotives. A total of at least 38 railroads will implement PTC systems on portions of their properties. The scope of deployment is approximately one-half of all route miles of track in the United States. FRA is continually working with the Association of American Railroads, the American Public Transportation Association, the American Short Line and Regional Railroad Association, and the individual railroads subject to the PTC implementation mandate to provide regulatory compliance guidance, as well as to identify and document the scope and effect of technical issues that may affect full PTC implementation by the statutory deadline. The rail industry continues to cite PTC's high negative return on investment as a reason not to install PTC on any lines except where required. Detailed studies of the cost effectiveness of requiring the use of PTC technologies that will detect the rear of trains and prevent rear-end collisions at restricted speed will significantly add to the negative benefit/cost ratio that is widely stated as one of the chief deterrents to the use of this technology beyond the mandates already in place. A PTC system is a system of systems. The development of PTC components requires railroads to obtain subject matter experts with the ability to create and document component requirements, develop the components, and then install and test them. Integration issues must be analyzed and potential or actual defects or risks mitigated. After PTC equipment suppliers undertake the development and testing of PTC system components, the individual railroads integrate the components with each other and with the railroad's existing technology systems. From a timing perspective, PTC system components will not be ready until after the suppliers are finished with their testing and the railroads complete their integration and testing of each component. All of these activities must be carefully planned, and schedules must be developed and modified based on experience gained in the development; implementation, testing, and deployment stages. As has been proved to date with the various railroads' installation of PTC, this technology is not available "off the shelf." Threats to the successful implementation of PTC include complications and reliability concerns that can increase exponentially, leading to complexities and uncertainties that compromise a useful system. While progress is certainly being made across the rail industry, sincere concerns exist as to whether the railroads individually and collectively can accomplish such a mandate in the allowable timeframe. FRA submitted a formal status report to Congress on August 10, 2012, regarding the railroads' PTC implementation progress. This report identified several significant technical and programmatic obstacles that could result in the implementation deadline not being fully met. For FRA to enter into rulemaking to add additional requirements to PTC functionality at this late juncture would be counterproductive due to the railroads having to redesign the PTC systems for which they had been approved and that are in various stages of testing, evaluation, and installation. This would certainly result in additional delays in the development and implementation of PTC. In light of the above, FRA believes that adding the requirement to have PTC include the detection of the rear of a train as a target would be counterproductive at this time. Adding the technology to give PTC systems the ability to detect the rear of a train as a target and the resultant safety benefits should be studied once the current efforts to install PTC are complete.

From: NTSB
To: FRA
Date: 10/16/2012
Response: The NTSB is aware that the FRA and industry have worked on voluntary PTC technologies. However, we have recommended that the FRA require the use of PTC technologies. Accordingly, pending our receipt of a detailed reply from the FRA explaining its plans to require the use of PTC technologies as recommended, Safety Recommendation R-12-20 is classified OPEN—AWAIT RESPONSE.

From: FRA
To: NTSB
Date: 7/31/2012
Response: -From Joseph C. Szabo, Administrator: Thank you for your May 10, 2012, letter to the Federal Railroad Administration (FRA) concerning National Transportation Safety Board (NTSB) Safety Recommendations R-12-16 through -22, R-02-24 through -26, and R-10-01 and -02. These recommendations were issued as a result the April17, 2011, rear-end collision of eastbound BNSF Railway (BNSF) coal train C-BTMCNM0-26, BNSF 9159 East, into standing BNSF maintenance-of-way equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. FRA has enclosed its responses to the above-mentioned recommendations. The FRA respectfully requests that NTSB classify Safety Recommendations R -12-16 through -20 and -22 as "Open-Acceptable Response." Additionally, we request that NTSB classify Safety Recommendations R-12-21 as "Closed-Reconsidered," and R-02-24 as "Closed-Acceptable Alternative Action." Lastly, FRA requests Safety Recommendations R-02-25 and -26, and R-10-01 and -02, remain "Open-Acceptable Response." I appreciate your interest in this important transportation matter. We look forward to working with you. FRA does agree, and has previously noted, that the technology associated with currently available Positive Train Control (PTC) systems may not completely eliminate all collisions. This includes those that may occur involving a train required to be operated according to the limitations of restricted speed. There are various circumstances and conditions under which trains are operated at restricted speeds. This includes conditions in signaled territory where trains may be operated past signals displaying red, including absolute signals with verbal authority and intermediate signals, either at restricted speed or after stopping and then proceeding at restricted speed. In any circumstance requiring restricted speed, all railroads define it as essentially proceeding while being prepared to stop within one-half the range of vision short of various unsafe conditions (e.g., on track equipment, another train, misaligned switch, broken rail, etc.); but in no case in excess of either 15 mph for some railroads or 20 mph for others. To avoid rear-end collisions, available PTC technology does not generally track the rear end of each train, but instead relies on the signal system and the onboard display unit to indicate the appropriate action. The PTC system will display a constant reminder to the locomotive engineer (i.e., 15 or 20 mph, depending on the railroad). This means that, generally, the more serious rear-end collisions will be prevented, because the upper limit of restricted speed is enforced. This also means that fewer low speed rear-end collisions will occur because of the continuous reminder of the required action being displayed to the locomotive engineer (rather than the engineer relying on the aspect displayed by the last signal, which may have been passed some time ago). However, potential for a low speed rear-end collision will remain, in these cases, and the rule is clear that this limitation has been accepted, at least for the initial buildout of the mandated PTC. FRA, in partnership with the Class I railroads, has nonetheless recognized the significance of some of the restricted speed rear-end collisions that have occurred, certainly to include the tragic event on the BNSF Railway at Red Oak, Iowa. Thus, steps have been cooperatively and voluntarily taken to further mitigate the potential severity of such accidents within the design of the PTC systems being initially implemented by the Class Is. As it relates to all speed enforcements, the PTC systems being developed generally provide a warning at 3 mph above the allowable speed (i.e., target speed) and enforce at 2 additional mph above that. However, for restricted speed conditions, the railroads have modified the system software to assume a maximum allowable speed of 15 instead of 20 mph on railroads where upper limit is 20 mph; and 11 instead of 15 mph on those railroads where the upper limit is 15 mph. The warning will occur as a train nears the upper limit, and the enforcement will occur at 1 mph above that limit. This software modification is completely hidden to the crewmembers but rather works in the background within the system itself.