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From:
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NTSB
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To:
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FRA
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Date:
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9/30/2019
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Response:
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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 recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.
The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). 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.
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 reiterates the following safety recommendations to the Federal Railroad Administration. Additional information regarding these reiterations can be found in the noted sections of the report.
• Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) (See section 2.2.2.)
• When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) (See section 2.2.2.)
• Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay. (R-17-17) (See section 2.8.)
• Require railroads to 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 in the clear. (R-18-10) (See section 2.5.)
In the same report, we also classified two previously issued safety recommendations:
• Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum authorized speed. (R-18-5), (classified “Closed––Unacceptable Action” in section 2.5.)
• Require railroads to 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 in the clear. (R-18-10), (classified “Open––Unacceptable Response” in section 2.5.)
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-16-35). 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.
1.17Postaccident Actions
1.17.1 Federal Railroad Administration
1.17.1.1 Previous Recommendations to FRA
As a result of information obtained early in the Cayce investigation, on February 15, 2018, the NTSB issued the following Safety Recommendation R-18-5, an Urgent Recommendation, to the FRA:
Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, require the train crew to report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum-authorized speed. (R-18-5) (Urgent)
In response to Safety Recommendation R-18-5, on April 23, 2018, the FRA published in the Federal Register, a notice of a draft safety advisory (SA) related to temporary signal suspensions. The notice discussed the FRA’s intent to issue an SA addressing railroad operations under temporary signal suspensions. The SA would identify the existing industry best practices that railroads use when implementing operations under temporary signal suspensions. The SA would propose that railroads conducting rail operations under temporary signal suspensions develop and implement procedures and practices consistent with identified best practices. Additionally, the notice would recommend that railroads take certain other actions to ensure the safety of railroad operations during temporary signal suspensions. On November 20, 2018, the FRA published the SA in the Federal Register (Federal Register 2018, 58685). (See appendix E.)
On June 11, 2018, in comments submitted in response to the FRA’s notice, the NTSB stated that although pleased that the FRA was proposing an SA recommending that all railroads adopt the industry best safety practices regarding railroad operations under temporary signal suspensions, an SA did not require railroads to adopt the industry best practices. In its comments, the NTSB also discussed several parts of the notice that appeared to offer contradictory statements. Recommendation 6 in the notice stated that railroads should “encourage employees, in case of any doubt or uncertainty regarding the position of such switches, to immediately contact the train dispatcher or take other appropriate action to confirm the position of the switch prior to authorizing a train to operate through the limits of the area.” However, the NTSB noted that using a switch tender or switch position awareness form has been shown in NTSB investigations to be ineffective in preventing accidents. Although it concurred with the FRA’s assertion that best procedures and practices should be implemented, in its June 11, 2018, comments, the NTSB did not agree that an advisory goes far enough to ensure safety. The NTSB believed that the FRA should mandate that, if any switches within suspension limits are manipulated, railroads must establish an effective means of verifying that all switches have been returned to the proper position prior to any train traffic operating through the limits. The NTSB stated that regulatory mandates to ensure
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