Safety Recommendation R-12-021
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: Revise Title 49 Code of Federal Regulations Part 229 to ensure the protection of the occupants of isolated locomotive operating cabs in the event of a collision. Make the revision applicable to all locomotives, including the existing fleet and those newly constructed, rebuilt, refurbished, and overhauled, unless the cab will never be occupied.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Red Oak, IA, USA
Is Reiterated: No
Is Hazmat: 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)

Safety Recommendation History
From: NTSB
Date: 9/16/2019
Response: In your February 23, 2018, letter to us regarding these recommendations, you wrote that you believe you satisfied them with a final rule that was published before the recommendations were issued. We disagree that your previously published rule fulfills the intent of these recommendations; however, because you do not intend to take any further action, Safety Recommendations R-12-21 and -22 are classified CLOSED--UNACCEPTABLE ACTION.

From: FRA
Date: 5/23/2018
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA) response to twelve National Transportation Safety Board (NTSB) Safety Recommendations (see list below). Over half of these recommendations are currently classified as "Open - Acceptable Response," and because the FRA has addressed the intent of the recommendations, no further action is necessary. FRA therefore requests that these be classified as "Closed- Acceptable Action." For the remaining five, FRA has evaluated each recommendation relative to current and potential new regulations, including requirements for conducting cost-benefit analysis of each potential measure to address each recommendation, and has concluded FRA cannot reasonably take further action on them. Thus, FRA respectfully asks the NTSB to classify each of them as "Closed." Overall, the twelve Safety Recommendations in question are: • R-01-02 • R-12-21 • R-13-22 • R-14-17 • R-01-17 • R-12-22 • R-13-38 • R-14-44 • R-08-06 • R-12-41 • R-14-16 • R-14-48 In the enclosure, FRA discusses the challenges to implement these recommendations, describes what actions the agency has performed, and explains why FRA cannot proceed further, other than to audit compliance as appropriate. Each recommendation is addressed in the enclosure in the following manner: • NTSB Safety Recommendation Number; • Text of the Safety Recommendation as issued by the NTSB; • Status (e.g., "Open-Acceptable Response"); • FRA's position on the Safety Recommendation (see bolded text in shaded boxes); • A summary of the accident that led the NTSB to issue the recommendation; • A summary of the NTSB and FRA correspondence regarding each recommendation; and • FRA's explanation for why we cannot pursue any further action on the recommendation. To facilitate closure of these recommendations, FRA met with the NTSB on March 1, 2018, to expound on our reasoning and answer questions. This enclosure only includes those recommendations for which we believe we came to an understanding. If FRA can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer. Please note that Federal agencies like FRA are required to follow the direction of Executive Orders 12866 and 13563 for rulemaking, which require quantifying both 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 many of these NTSB recommendations could improve railroad safety in the specific railroad accident or incident from which each arose, regulatory action to implement these recommendations 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 regulations that are required by some of these recommendations would not meet the intent of the Executive Orders listed above, which is inconsistent with the Administration's regulatory policy. Where applicable, FRA has calculated the anticipated costs and benefits of each recommendation and included that information with each detailed response. Please also note, in the 2016 Federal Railroad Administration Report to Congress on Actions Taken to Implement Unmet Statutory Mandates and Address Open Recommendations by the National Transportation Safety Board and the Department of Transportation's Inspector General Regarding Railroad Safety, FRA informed Congress that the agency would be taking no further action on these twelve recommendations. Current Status: Open-Acceptable Response FRA has published a final rule that fulfills the intent of the recommendation. Further regulations addressing this recommendation would result in costs that overwhelmingly exceed the societal benefits. Therefore, FRA cannot reasonably take further action on this recommendation, and requests that the NTSB close this recommendation. The NTSB issued Safety Recommendation R-12-21 in response to an accident on April 17, 2011, near Red Oak, IA, in which a BNSF Railway (BNSF) coal train collided with the rear end of a standing BNSF maintenance-of-way equipment train. The collision resulted in the derailment of two locomotives and 12 cars; both crewmembers on the striking train were fatally injured, and damage exceeded $8. 7 million. FRA's actions to address R-12-21: FRA has analyzed available safety data, evaluated safety requirements, and conducted research on inhibiting colliding equipment override. On June 28, 2006, FRA issued the Locomotive Crashworthiness Final Rule ( 49 CFR parts 229 and 238). The final rule incorporates by reference AAR Standard S-580-2005, which the rule applies to all locomotives manufactured or remanufactured on or after January 1, 2009. FRA evaluated the industry's revisions to its safety standards, and concluded that the implementation of AAR Standard S-580-2005 increases the strength of the locomotive's structure and includes provisions for anticlimbers and collision posts, which are required to extend 24 inches above the finished floor and be located forward of the position of any seated crewmember. The position of the collision posts and their required height were chosen to provide survivable space for the crewmembers in the event of a frontal collision with an object above the underframe of the locomotive. FRA believes it has met the intent of the recommendation, and cannot reasonably take further action. FRA respectfully requests that the NTSB reclassify Safety Recommendation R-12-21 as, "Closed-Acceptable Action."

From: NTSB
Date: 8/11/2016
Response: We are pleased that you have initiated discussions with a working committee at the Volpe National Transportation Systems Center to address the recommendation. Further study of locomotive cab crashworthiness for occupants of an isolated locomotive cab is paramount to gaining the knowledge necessary for developing new safety requirements for occupant protection. However, this recommendation is over 4 years old; accordingly, we urge you to move as quickly as possible, once the study is concluded, to initiate the recommended rulemaking. Pending timely completion of such action, Safety Recommendation R-12-21 is classified OPEN--ACCEPTABLE RESPONSE.

From: FRA
Date: 2/12/2015
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-09-03, R-12-21 and R-1 2-22, R-12-39 through R-12-41 , and R-13-05, issued to the Federal Railroad Administration (FRA). These recommendations were assigned to our Motive Power and Equipment Division for issues pertaining to rapid egress of occupants and entry of emergency responders, crashworthiness standards, and detection of signal-emitting portable electronic devices. In the enclosure, FRA responds to the safety recommendations and explains the actions FRA has taken in response to the recommendations. Therefore, FRA respectfully requests that the NTSB classify Safety Recommendations R-09-03 and R-1 3-05 as "Closed- Acceptable Alternate Action," and Safety Recommendations R-12-22 and R-12-41 as "Closed Reconsidered." Additionally, FRA respectfully requests that Safety Recommendations R-12-21, R -12-3 9, and R -12-40 remain as "Open-Acceptable Response." I look forward to continuing to work with you on important safety issues. FRA supports the further study of isolated cab crashworthiness. Based on FRA-initiated discussions, a Volpe National Transportation Systems Center (Volpe) working committee has developed project plans to further study locomotive cab crashworthiness, specifically including the crash worthiness of isolated cabs. FRA believes that Volpe's results will provide a basis for FRA to consider appropriate regulation in this area. Therefore, it is prudent for FRA to wait for the results before revising FRA's requirements on the protection of occupants of isolated locomotive operating cabs.

From: NTSB
Date: 10/16/2012
Response: We note that the FRA is in discussion with the U.S. Department of Transportation’s Volpe National Transportation Systems Center to determine what further areas of crashworthiness research should be pursued to enhance overall locomotive crashworthiness, Accordingly, Safety Recommendation R-12-21 is classified OPEN—ACCEPTABLE RESPONSE pending a further update on this issue from the FRA.

From: FRA
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. The locomotive involved in the Red Oak collision was constructed to meet crashworthiness requirements that had been published but were not yet in effect at the time the locomotive was constructed. The anti-climber and the collision posts gave the same protection to the isolated cab as they would to a non-isolated cab, as neither has any crashworthiness requirement that applies above the top of the collision posts. Given the unusual nature of the equipment impacted, this collision scenario was not separately considered in the development of the regulations. FRA is in discussion with the U.S. Department of Transportation’s (DOT) Volpe National Transportation Systems Center to determine what further areas of crashworthiness research should be pursued to enhance overall locomotive crashworthiness.