Posts Tagged ‘NTSB’

NTSB member displeased FRA omitted fatigue in risk-reduction rule

Jennifer Homendy, a member of the National Transportation Safety Board (NTSB), said that the Federal Railroad Administration (FRA) final rule for Class I railroads and certain smaller railroads to establish risk-reduction safety plans issued Feb. 18 falls well short of the intent of the Rail Safety Improvement Act (RSIA) that was passed by Congress in 2008.

NTSB member Jennifer Homendy

“As the lead @TransportDems staffer who drafted the Act, I’m glad the rule’s out but it doesn’t comply with the RSIA,” Homendy said on Twitter. “It leaves out commuter and passenger railroads (that rule has been stayed 9 or 10 times now) and it fails to require freight railroads to implement fatigue management plans as part of their risk reduction program (which was required in RSIA).”

Later in her Twitter thread, she cited five accidents investigated by NTSB involving both freight and passenger rail that were linked to fatigue and reminded her followers that fatigue management is on the NTSB’s most-wanted list in preventing railroad accidents.

She also mentioned that FRA has seemed to reverse course over the years as in 2015, agency leadership had told NTSB that fatigue management would be addressed in a final rule.

The final rule as published requires Class I railroads to compose an FRA-approved RRP plan.

“These comprehensive, system-oriented safety plans are required to identify and analyze hazards and their associated risks, and develop and implement plans to eliminate or mitigate those risks,” FRA said in a release announcing the final rule. “An RRP is designed to improve operational safety, complementing a railroad’s adherence to all other applicable FRA regulations. Each railroad must tailor an RRP for its individual operations, and the RRP must reflect the substantive facts on any hazards associated with each railroads’ operations.”

“Railroads’ ongoing evaluation of their asset base and employee performance associated with operations and maintenance, under FRA regulations, can now follow a more uniform path of standardization, towards further reducing risks and enhancing safety,” FRA Administrator Ronald L. Batory said in the release.

Transportation Secretary Elaine Chao said the final rule will improve freight rail safety in America in the same release.

It remains to be seen whether fatigue management will be addressed in a future rulemaking.

Read FRA’s final rule on risk-reduction programs as published in the Federal Register.

FRA chief of safety Bob Lauby retires

The Federal Railroad Administration (FRA) will have some major shoes to fill with the April 13, 2019, retirement of Robert “Bob” Lauby, the agency’s chief safety officer.

Lauby had served in that capacity for FRA since September 2013. He was a frequent presenter at SMART Transportation Division regional meetings and worked to provide regulatory oversight for rail safety in the United States while overseeing the development and enforcement of safety regulations and programs related to the rail industry.

Lauby

“Serving as the associate administrator for Railroad Safety and FRA’s chief safety officer is one of the highlights of my career,” Lauby said. “The job has been both challenging and fulfilling.

“Over the years, we grappled with many important issues and have significantly changed the industry for the better.”

Lauby had a hand in several regulatory safety efforts at FRA such as Positive Train Control, conductor certification, training requirements, drug and alcohol testing for maintenance of way employees, roadway worker protection, passenger equipment standards, system safety and others.

Other safety oversight improvements happened as a result of major accidents. Some of the major ones included crude-oil accidents at Lac Megantic, Ontario, Canada; Mount Carbon, W.Va.; and other locations; commuter train accidents at Spuyten Duyvil and Valhalla, N.Y.; and Amtrak passenger train accidents in Philadelphia and Chester, Pa.; Dupont, Wash.; and Cayce, S.C.

“No matter the challenges swirling around him, Bob had safety in mind,” said National Legislative Director John Risch. “He’s been great to work with and one of the most committed, level-headed professionals in the rail industry.”

Lauby said that he treasured any interaction he could have with members of rail labor as these helped to broaden his perspective about whom he was working to protect.

“I always took time to talk to the SMART TD membership to get their complaints, opinions, and perspectives on the latest industry issues,” Lauby said. “I often left enlightened or with a new perspective.

“Railroad managers are experts on what is supposed to happen. SMART TD members are experts on what actually happens. They always know what works and what does not work.”

In his more-than-40-year career, Lauby’s railroad and transit experience included safety, security, accident investigation, project management, project engineering, manufacturing and vehicle maintenance.

He joined the FRA in August 2009 as staff director of its newly established Passenger Rail Division in the agency’s Office of Safety and was later promoted to deputy associate administrator for regulatory and legislative operations at FRA. One of his responsibilities in that role was to oversee the Rail Safety Advisory Committee (RSAC).

Prior to his time at FRA, Lauby was director of the National Transportation Safety Board’s Office of Railroad Safety, overseeing hundreds of rail accident investigations for NTSB and coordinating with our union’s Transportation Safety Team in many investigations. He was NTSB’s representative on RSAC.

Lauby addressed SMART TD members in a workshop at the 2018 Seattle, Washington, regional meeting.

“At our regional meetings, I would introduce Bob and tell the troops that Bob was the big gun and can handle all the tough questions, which he always did,” Risch said at a party celebrating Lauby’s retirement in late March.

Lauby said he took his multiple presentations at TD regional meetings, including at the Seattle regional meeting last July, seriously — he felt he owed it to the attendees to give them useful information.

“I looked forward to the meetings each year and spent hours preparing my presentation and preparing for the questions I would get at the end – during the Q and A session,” he said. “I wanted the material I presented to be timely and useful to the membership, and I always tried to include the inside scoop – the stuff nobody else would talk about!”

But the benefits from his visits and interactions went both ways, he said, and showing up at the meetings gave him a fresh perspective on the industry.

“I always enjoyed speaking to the SMART TD membership – both at the Regional Meetings and when they were on their jobs,” Lauby said. “Whenever I traveled by train, I tried to spend time with the train crew or ride the head end to find out the issues of the day.

“I learned more about railroading from the working men and women of the railroad industry than from anyone else.”

Lauby’s departure is leaving a vacancy that FRA will have a difficult time filling, Risch said.

“No one will really fill your shoes because there is no one with the knowledge and experience to do that,” he told Lauby at his retirement party. “You committed your working life to rail safety, you have been a good friend of mine and a good friend to railroad workers everywhere.

“We wish you all the best as you enter this next stage of your life.”

Lauby said his career leaves him with a sense of gratitude.

“I will always be grateful to have had the opportunity to work in the industry I love, in a role where I felt I could make a difference,” Lauby said. “I will miss the thousands of people I interacted with each year. That includes the FRA employees and railroad industry labor and management … all the folks I dealt with at the various RSAC meetings. People are the most important part of any organization and the railroad industry is no different.”

NTSB rules on cause of Washington D.C. accident that killed two

The National Transportation Safety Board (NTSB) ruled last month on the probable cause of a fatal accident in June 2017 that killed both a CSX conductor and a conductor trainee.

The men were struck from behind at 11:18 p.m. June 27, 2017, by an Amtrak train while walking to the cab of their train in Ivy City, a neighborhood in Washington, D.C.

The men had just completed a railcar inspection.

The NTSB report, released April 9, stated that there had been no rail traffic for about an hour on the active tracks upon which the men were walking as they returned.

As they walked, a pair of Amtrak trains, one northbound and one southbound, approached the men, the report stated.

NTSB said the northbound Amtrak train approached the men from the front on tracks to the left of those upon which they were walking, and that both trains sounded their horns and bells at virtually the same time in attempts to alert them.

“Given the simultaneous and similar horn and bell sounds from the two trains, the conductors may not have discerned two sources of the sounds and, consequently, concluded that the sounds originated from only one train — the one that they had detected ahead of them.

“As a result, it appears the conductors were unaware that a second train was approaching them from behind,” the report stated.

NTSB issued a new safety recommendation to the two carriers involved in the accident at the conclusion of its report:

“Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads.”

Read the full NTSB report here.

Preliminary report issued by NTSB on accident that killed two Local 446 members

The National Transportation Safety Board (NTSB) has released a preliminary report on the Oct. 4 collision of two Union Pacific (UP) trains in Granite Canyon, Wyo., that killed SMART Transportation Division Local 446 members Jason Vincent Martinez, 40, and Benjamin “Benji” George Brozovich, 39.

The report states that data retrieved from the event recorder of the train indicated that an emergency brake application failed to slow the train as it descended a grade west of Cheyenne before striking the rear of a stationary train.

“Normally, the locomotive would send a message to the end-of-train device to also apply the brakes with an emergency brake application,” NTSB said in the preliminary report. “According to the event recorder, the end-of-train device did not make an emergency application of the brakes. Investigators are researching the reason for the communication failure. After the engineer applied the emergency application, the train continued to accelerate until reaching 56 mph as the last recorded speed.”

Positive train control (PTC) was active at the time of the accident, NTSB said.

NTSB said further investigation will focus on components of the train’s air brake system, head-of-train and end-of-train radio-linked devices, train braking simulations and current railroad operating rules. Investigators will also determine if the railroad’s air brake and train handling instructions address monitoring air flow readings and recognizing the communication status with the end-of-train device, the report stated.

Three locomotives and 57 cars of the striking train derailed. Nine cars of the stationary train derailed.

The investigation into the collision is continuing, and a final report will be released by NTSB at a later date.

Follow this link to read the preliminary report.

NTSB identifies causes of 2017 ethanol train derailment in Iowa

The National Transportation Safety Board (NTSB) on Oct. 30 ruled that flaws in Union Pacific’s approach to inspecting, maintaining and repairing defects on the Estherville Subdivision helped to cause a March 2017 derailment that resulted in multiple tank cars spilling undenatured ethanol in Graettinger, Iowa.

A rail near a transition onto a bridge broke, causing 20 tank cars to derail in the accident that happened at 12:50 a.m. local time March 10, 2017. Fourteen of the tank cars spilled 322,000 gallons of ethanol, causing a fire that burned for more than 36 hours. Three nearby homes were evacuated as a result of the accident, which caused an estimated $4 million in damage, including the destruction of 400 feet of track and a 152-foot railroad bridge.

NTSB investigators survey the March 2017 derailment of a Union Pacific train carrying undenatured ethanol in Graettinger, Iowa.

During the NTSB hearing, board member Jennifer Homendy said she made a review of a decade’s worth of accident data for UP and the numbers showed one thing in common.

“Every year, track defects are the chief cause of accidents with UP,” she said.

Along Estherville’s 79-mile stretch, Homendy said that 102 defects of “marginal” and “poor” crossties were identified over a two-year period from 2015-17.

After the carrier received the reports of rail or crosstie defects, chief accident inspector Michael Hiller said UP didn’t take enough steps to fix the problems prior to the accident.

“The inspectors were going out and they were doing their inspections, and they were reporting the conditions of the tie,” Hiller said. “In many cases – more than 100, as member Homendy pointed out – there were remediation efforts, and it’s clear based on our observations post-accident that the remediation efforts restored the track back to its minimum condition that it needed to sustain traffic.

“We’re looking to see that things are not just restored back to the minimum…we know that doesn’t work. If you’re finding 10 or 12 crossties in a 39-foot section of track that are defective, it’s not a good practice to go in and replace two or three just to restore the track.”

Also contributing to the accident was what NTSB described as “inadequate oversight” on the part of the Federal Railroad Administration (FRA).

While FRA inspectors raised the carrier’s attention to track defects — the agency had just initiated a compliance agreement in late 2016 as a result of a fiery oil train derailment in Mosier, Ore. — and some action was taken, Hiller said not all enforcement measures, such as civil penalties, were used.

NTSB investigators also noted that FRA inspectors neglected to report some defective crosstie conditions.

After the Graettinger accident, Hiller said that the carrier has shown “very good response” to reports of tie defects and maintenance and has performed twice-weekly inspections on the subdivision in a post-accident agreement with FRA.

However, the NTSB did note that there was one week where the carrier inspected the subdivision only once.

“The extent of post-accident actions, while welcome, hints at the inadequacy of UP’s pre-accident maintenance and inspection program,” NTSB Chairman Robert Sumwalt said. “The railroad is supposed to look for and fix unsafe conditions as a matter of course.”

Finally, the use of U.S. DOT 111 tanker cars to transport the ethanol also worsened the environmental impact of the accident, investigators said.

Hiller said that 10 of the 14 tankers that breached met old DOT 111 specifications “identified as having a high probability of releasing hazardous materials.”

DOT 117 specifications established by the Pipeline and Hazardous Material Safety Agency (PHMSA) add reinforcement and other design features to cars transporting both crude oil and ethanol.

“The tougher design would have prevented the release,” Sumwalt said.

FRA identifies ethanol as the most hazardous material that is transported by rail in the United States. The denaturing process adds toxic compounds to make it unfit for human consumption and also lessens the tax burden for the carriers transporting it because it is not a beverage.

In the Graettinger accident, the ethanol was undenatured, meaning that the toxins were not added to the alcohol being transported.

“This seems to have had a beneficial effect on safety,” Sumwalt said. “Investigators found milder damage in this accident than in previous accidents with the same type of tank cars, but those involved denatured alcohol.”

It was suggested that a safety benefit might be achieved by getting rid of denaturants when transporting ethanol.

“Never before have I seen a regulation to make a hazardous material more hazardous,” Robert Hall, an expert in hazardous materials transport, said of the denaturing process. “It doesn’t make sense.”

A May 1, 2023, regulatory deadline has been set for all DOT 111 tank cars that carry ethanol to be changed over or retrofitted to meet the higher DOT 117 standards. In order to achieve that deadline, about 350 tank cars per month must be changed over.

Recommendations

At the hearing, NTSB issued three new safety recommendations and reiterated one safety recommendation to the FRA, PHMSA and UP. They address training on safety standards and available enforcement options for federal track inspectors, the need for research to determine if safety would be improved by transporting ethanol in an undenatured state, and the need for Union Pacific to re-examine track maintenance and inspection program standards on all routes carrying high hazardous flammable materials.

“The recommendations just issued, if acted upon, will result in better training for FRA track inspectors and clear guidance involving available enforcement options,” Sumwalt said. “They will result in UP re-examining its track maintenance and inspection program standards. Today’s recommendations will result in research by PHMSA into whether alcohol — ethanol — should be transported in an undenatured state and furthermore, a recommendation first issued in 2015 and reiterated today will result in progress milestone schedules for the phasing out of the DOT 111 tank cars for ethanol service by 2023, if acted upon.

“Otherwise, we risk a so-called sudden realization that isn’t sudden at all. We could have seen this train coming down the track.”

NTSB’s report states alcohol or drug use, and cell phone use were not factors in the accident, nor was the mechanical condition of the train, the performance of the train crew or the emergency response a factor. The full report will be available on the NTSB website when finalized.

Cost of sleepiness too pricey to ignore

by The National Healthy Sleep Awareness Project

Sleep deprivation impacts workplace safety, productivity and individual health

(DARIEN, Ill.) March 2018 – Getting insufficient sleep and working while fatigued have become commonplace in the modern 24/7 workforce, with more than 37 percent of workers sleep-deprived.[i] Over-worked and over-tired employees experience cognitive declines and present employers with heightened safety risks and increased economic costs. The National Healthy Sleep Awareness Project – including partners the American Academy of Sleep Medicine (AASM), the Centers for Disease Control and Prevention (CDC), the Sleep Research Society (SRS) and the National Safety Council (NSC) – is launching the “Sleep Works for You” campaign, encouraging employers to help workers avoid fatigue and develop healthy sleep habits for long-term success and well-being.

“Working long hours and sleeping less than the recommended seven or more hours has become a badge of honor in many industries, despite evidence that proves a lack of sleep hurts productivity, safety and overall health,” said AASM President Dr. Ilene Rosen. “It is essential for employers to promote health and safety by creating a workplace culture that values the importance of sleep.”

The National Healthy Sleep Awareness Project encourages employers to promote sleep health in the workplace with three steps:

  1. Learn about sleepiness in the workplace, its costs, its causes and how fatigue can lead to a higher rate of safety incidents
  2. Educate employees on fatigue, sleep health and sleep disorders, as well as strategies to improve alertness on the job, as part of a comprehensive employee wellness program
  3. Investigate the causes of fatigue in the workplace and implement fatigue risk management as part of a safety management system

“Nearly 70 million Americans suffer from a sleep problem, and nearly 60 percent of them have a chronic disease that can harm their overall health,” said Janet B. Croft, PhD, senior chronic disease epidemiologist in CDC’s Division of Population Health. “Lack of sleep and sleep disorders, including stops in breathing during sleep (sleep apnea), excessive daytime sleepiness (narcolepsy), restless legs syndrome, and insomnia, are increasingly recognized as linked to chronic disease, including obesity, high blood pressure, and cancer.”

The Cost of Fatigue

According to the NSC, fatigued workers cost employers about $1,200 to $3,100 per employee in declining job performance each year, while sleepy workers are estimated to cost employers $136 billion a year in health-related lost productivity.

To help employers gauge how much fatigue may be adding to annual expenditures, NSC and Brigham and Women’s Hospital created an online Fatigue Cost Calculator.

“Sleepless nights hurt everyone,” said NSC President and CEO Deborah A.P Hersman. “Many of us have been conditioned to just power through our fatigue, but worker health and safety on the job are compromised when we don’t get the sleep we need. Doing nothing to address fatigue costs employers a lot more than they think.”

Impact of Sleepiness on Safety

Sleepiness causes decreased performance capacity, and tired workers become slower, more error prone and less productive. Research shows that fatigue impairs employees’ ability to function properly and puts them at a greater risk of a safety incident.[ii] In fact, about 13 percent of work injuries are attributable to sleep deprivation.[iii]

Sleepiness also impacts safety for those who drive as part of their job or commute to and from work. The National Transportation Safety Board (NTSB) estimates that fatigue has been a contributing factor in 20 percent of its investigations over the last two decades. That’s why the NTSB included “reduce fatigue-related accidents” on its 2017 – 2018 Most Wanted List of transportation safety improvements. 

In February, the AAA Foundation for Traffic Safety released a research brief estimating that drowsy driving is involved in up to 9.5 percent of all motor vehicle crashes. Projections from the AAA Foundation indicate that drowsy driving causes an average of 328,000 motor vehicle accidents in the U.S. each year, including 6,400 fatal crashes.

Maximizing Health of Shift Workers

The effects of sleepiness are exacerbated and pose a constant struggle for workers who work night shifts or rotating shifts, and for those who work long hours or have an early morning start time. U.S. Bureau of Labor statistics show about 15 percent of full-time employees in the U.S. perform shift work, many of whom suffer from chronic sleep loss caused by a disruption in the body’s circadian rhythm. Chronic sleep deprivation is associated with an increased risk of depression, obesity, cardiovascular disease and other illnesses that negatively impact a worker’s well-being and long-term health.

There are significant differences in the rate of insufficient sleep among occupations. A recent CDC analysis found that the jobs with the highest rates of short sleep duration were communications equipment operators (58.2%), other transportation workers (54.0%) and rail transportation workers (52.7%).

Night shift workers and those driving during nighttime hours are most at risk for chronic sleep loss. The NSC found that 59 percent of night shift workers reported short sleep duration compared to 45 percent of day workers, while the risk of safety incidents was 30 percent higher during night shifts compared to morning shifts.

Employers with personnel in safety-sensitive positions are urged to implement a fatigue risk management system. The National Institute for Occupational Safety and Health (NIOSH) provides educational resources on sleep, shiftwork, and fatigue for employees and managers involved in aviation, emergency response, healthcare, railroads and trucking.

Employers can help shift workers fight fatigue by implementing the following strategies:

  • Avoid assigning permanent night-shift schedules
  • Assign regular, predictable schedules
  • Avoid long shift lengths
  • Give employees a voice in their schedules
  • Rotate shifts forward when regularly changing shifts
  • Provide frequent breaks within shifts

For more information on how to keep employees safe from risks and costs of fatigue, please visit www.projecthealthysleep.org.   


###

About the National Healthy Sleep Awareness Project

The National Healthy Sleep Awareness Project was initiated in 2013 and is funded by the Centers for Disease Control and Prevention through a cooperative agreement with the American Academy of Sleep Medicine. The project involves collaboration with the Sleep Research Society and other partners to address the sleep health focus area of Healthy People 2020, which provides science-based, 10-year national objectives for improving the health of all Americans. The sleep health objectives are to increase the medical evaluation of people with symptoms of obstructive sleep apnea, reduce vehicular crashes due to drowsy driving and ensure more Americans get sufficient sleep. For more information, visit www.projecthealthysleep.org.

 


[i] Yong LC, Li J, Calvert GM. “Sleep-related problems in the US working population: prevalence and association with shiftwork status.” Occup Environ Med Published Online First: 08 September 2016. doi: 10.1136/oemed-2016-103638

[ii] Lombardi, D. A., Folkard, S., Willetts, J. L., & Smith, G. S. (2010). Daily sleep, weekly working hours, and risk of work-related injury: US National Health Interview Survey (2004–2008). Chronobiology international, 27(5), 1013-1030

[iii] Uehli, K. “Sleep problems and work injuries: a systematic review and meta-analysis.” Sleep Med Rev. 2014 Feb;18(1):61-73. doi: 10.1016/j.smrv.2013.01.004. Epub 2013 May 21.

NTSB releases report on Amtrak/CSX collision

On February 4, 2018, southbound Amtrak train 91, operating on a track warrant, diverted from the main track through a hand-thrown switch into a siding and collided head-on with stationary CSX Transportation local freight train F777 03 on the CSX Columbia Subdivision in Cayce, S.C.

The engineer and conductor of the Amtrak train died as a result of the collision and at least 92 passengers and crewmembers 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 siding, ran to safety, and was not injured. The conductor of the CSX lead locomotive saw the Amtrak train approaching in the siding and ran to the back of locomotive. The conductor was thrown off the locomotive and sustained minor injuries.

The normal method of train operation on the subdivision was a traffic control system with wayside signals. Signal indications authorize movement in either direction. On the day before the accident, CSX signal personnel suspended the traffic control signal system to install updated traffic control system components for implementing positive train control (PTC) on the subdivision. During the suspension, scheduled to last through February 4, 2018, dispatchers would use track warrants to move trains through absolute blocks in the work territory.

National Transportation Safety Board (NTSB) investigators inspected the track structure, signal system and mechanical equipment; collected and are examining records for operations, signal systems, mechanical equipment, and track and engineering; and interviewed train crewmembers, train dispatchers and other personnel from CSX and Amtrak. In addition, investigators are reviewing the emergency response to the accident. Members of the NTSB investigative team traveled to Jacksonville, Fla., to investigate the dispatching aspects of the accident, to test the CSX signal system and to conduct additional interviews.

While on-scene, NTSB investigators located and removed the undamaged event data recorder from the destroyed Amtrak locomotive. The event data recorder was successfully downloaded and an initial review of the data revealed the following information:

  • From the train’s last stop, the maximum speed reached 57 mph, which was below the 59 mph limit allowed under signal suspension rules.
  • About 7 seconds before the end of the recording, the train was moving at 56 mph and the train’s horn was activated for 3 seconds.
  • The brake pipe pressure began decreasing 2 seconds later.
  • The following second, the throttle transitioned from full throttle to idle, while the train was moving at 54 mph.
  • The engineer induced emergency braking one second later, while the train was moving at a speed of 53 mph.
  • The recording ended 2 seconds later, as the train’s air braking system was approaching maximum braking effort and the train’s speed was 50 mph.

The Amtrak locomotive’s forward-facing video recorder hard drive was recovered and downloaded. The initial review of the recording indicated that it ended prior to the collision. NTSB engineers are attempting additional forensic efforts to determine if additional information can be recovered. Other investigative efforts included the download of information from the forward-facing video recorder and the extraction of the event recorder from the CSX lead locomotive.

Parties to the investigation include the Federal Railroad Administration, CSX, Amtrak, Brotherhood of Locomotive Engineers and Trainmen; International Sheet Metal, Air, Rail, and Transportation Workers-Transportation Division; Brotherhood of Railroad Signalmen, and the State of South Carolina Office of Regulatory Staff.

In response to this accident, the NTSB issued an urgent recommendation requesting that the Federal Railroad Administration issue an emergency order providing instructions for railroads to follow when signal suspensions are in effect and a switch has been reported relined for a main track.

***

These are the preliminary findings of the NTSB and will be either supplemented or corrected during the course of the investigation.

 

NTSB Figure – A view of the accident scene

NTSB issues urgent safety recommendations

The National Transportation Safety Board (NTSB) issued three urgent safety recommendations to the Federal Railroad Administration (FRA), acting upon the agency’s findings in two ongoing railroad accident investigations.

The Federal Railroad Administration (FRA) received one urgent safety recommendation based on NTSB findings in the agency’s investigation of the Feb. 4, 2018, collision of an Amtrak train and a CSX train near Cayce, S.C. The conductor and engineer of the Amtrak train died as a result of the collision. The NTSB issued two urgent safety recommendations to the Metropolitan Transportation Authority (MTA) based on findings from its investigation of the June 10, 2017, Long Island Rail Road (LIRR) accident in which a roadway worker died near Queens Village, N.Y.

In the investigation of the train collision in Cayce, South Carolina, investigators found that on the day before the accident, CSX personnel suspended the traffic control signal system to install updated traffic control system components for the implementation of positive train control (PTC). The lack of signals required dispatchers to use track warrants to move trains through the work territory.

In this accident, and in a similar March 14, 2016, accident in Granger, Wyo., safe movement of the trains, through the signal suspension, depended upon proper switch alignment. That switch alignment relied on error-free manual work, which was not safeguarded by either technology or supervision, creating a single point of failure.

The NTSB concludes additional measures are needed to ensure safe operations during signal suspension and so issued an urgent safety recommendation to the FRA seeking an emergency order directing restricted speed for trains or locomotives passing through signal suspensions when a switch has been reported relined for a main track.

“The installation of the life-saving positive train control technology on the CSX tracks is not the cause of the Cayce, S.C. train collision,” said NTSB Chairman Robert Sumwalt.

“While the collision remains under investigation, we know that signal suspensions are an unusual operating condition, used for signal maintenance, repair and installation, that have the potential to increase the risk of train collisions. That risk was not mitigated in the Cayce collision. Our recommendation, if implemented, works to mitigate that increased risk.” said Sumwalt.

During the investigation of the LIRR accident, the NTSB identified an improper practice by LIRR roadway workers who were working on or near the tracks. LIRR employees were using “train approach warning” as their method of on-track safety, but they did not clear the track, as required, when trains approached and their “predetermined place of safety” did not comply with LIRR rules and procedures.

The NTSB is concerned LIRR management is overlooking and therefore normalizing noncompliance with safety rules and regulations for proper clearing of tracks while using “train approach warning” for worker protection. The two urgent safety recommendations to the MTA call for MTA to audit LIRR’s use of “train approach warning” for worker protection, and, to implement corrective action for deficiencies found through the audit.

The full safety recommendation reports for these urgent safety recommendations are available online at https://goo.gl/z87Dpz and https://goo.gl/LVVef3.

NTSB finds nearly identical cause of two commuter rail accidents

The National Transportation Safety Board (NTSB) determined that two commuter railroad terminal accidents in the New York area were caused by engineer fatigue resulting from undiagnosed severe obstructive sleep apnea.

The Sept. 29, 2016, accident on the New Jersey Transit railroad at Hoboken, New Jersey, killed one person, injured 110, and resulted in major damage to the station. The Jan. 4, 2017, accident on the Long Island Rail Road at the Atlantic Terminal in Brooklyn, New York, injured 108 people. Both accidents involved trains that struck end-of-track bumping posts and crashed into stations.

The NTSB found the two accidents had “almost identical” probable causes and safety issues. The board also determined that these safety issues were not unique to these two properties, but exist throughout the country at many intercity passenger and commuter passenger train terminals.

When operating a train into a terminating track, the engineer’s actions, or lack thereof, solely determine whether the train stops before the end of the track. According to the Federal Railroad Administration (FRA), there are currently no mechanisms installed in the U.S. that will automatically stop a train at the end of the track if the engineer is incapacitated, inattentive or disengaged. Some railroads have overspeed capabilities, including New Jersey Transit and the LIRR. However, as shown in these two accidents, once the engineer slowed the train to the prescribed speed, the system did not stop the trains before they reached the end of the track.

In addition to recommending safety-sensitive personnel be screened for obstructive sleep apnea, the board recommended the use of technology, such as positive train control (PTC), in terminal stations and improving the effectiveness of system safety program plans to improve terminal operations. The NTSB made two recommendations to New Jersey Transit, and the Metropolitan Transportation Authority (the parent company of the Long Island Rail Road) and two to the FRA.

“Today’s new recommendations, if acted upon, have the potential to eliminate end-of-track collisions,’’ Sumwalt said. “That translates to protection for passengers on trains, and for people standing on terminal platforms.”

The complete accident report will be available in several weeks. The findings, probable cause, safety recommendations, Chairman Sumwalt’s prepared remarks and PowerPoint presentations used in a board meeting are all available at https://go.usa.gov/xnscj.

The New Jersey Transit Hoboken accident docket, containing more than 1,100 pages of supporting factual material, is available at https://go.usa.gov/xnAGJ.

The Long Island Rail Road Brooklyn accident docket, containing more than 1,400 pages of supporting factual material, is available at https://go.usa.gov/xnAGe.

 

New Jersey Transit train #1614 after crashing into the NJT Hoboken Terminal, Sept. 29, 2016. (NTSB photo taken by Chris O’Neil)

NTSB issues update on Amtrak Train 91 collision

Sumwalt

Robert Sumwalt, chairman of the National Transportation Safety Board (NTSB), reported some preliminary findings Monday afternoon of his agency’s investigation into the Amtrak-CSX train collision that occurred Feb. 4 near Cayce, S.C.

The train had 139 passengers and eight crewmembers on board. The engineer and conductor in the cab of the locomotive were killed and six passengers remain hospitalized, two in critical condition. SMART TD conductor Michael Cella of Local 30 in Florida was one of two Amtrak crewmembers killed in the accident.

Based upon the event data recorders located within the Amtrak locomotive, Sumwalt said, Amtrak Train 91 was not speeding at the time of the collision.

He said Amtrak’s data recorder had the following information:

  • The train horn was sounded for three seconds at the seven second mark before the collision.
  • The train was traveling at a maximum speed of 57 mph in a 59-mph zone.
  • The engineer moved the throttle to idle and had applied the emergency brakes before the collision.
  • At the time of the collision, the train had reduced its speed to 50 mph.

Sumwalt stated that the reason for the 59-mph speed limit in the area was attributable to track signals being inoperable due to CSX performing upgrades to their track signal system to switch over to positive train control (PTC). He said a track warrant system was in place, and Amtrak had been given clearance to operate in the area.

As previously reported by Sumwalt, a switch had been thrown to allow a CSX train to back into a side track. The switch had never been released back to its original position, and the Amtrak train entered the track where the CSX freight train was parked instead of continuing on the main track.

Sumwalt said that the CSX dispatcher had been notified that the siding operation had been completed and so gave Amtrak clearance to proceed through.

Typically, when the dispatcher is given notification that such a proceeding has been completed, it means that the switch has been moved back into position. The NTSB is investigating as to why the switch had been locked into position for the siding.

Sumwalt reported that interviews with CSX’s engineer, conductor, trainmaster and dispatcher had been conducted Monday along with some of Amtrak’s crew.

Additional interviews are planned for Tuesday. No information about the content of the interviews was released.

The information provided in Monday’s press conference is considered preliminary, and no conclusions should or can be drawn until the NTSB’s investigation is complete and official causes are released by the agency.

SMART TD member killed in Amtrak crash

A current SMART Transportation Division conductor and a former member were killed when Amtrak Train 91 traveling from New York to Miami collided early Feb. 4 with a stationary CSX freight train east of Columbia, S.C.

Brother Michael Cella, 36, of Orange Park, Fla., was a conductor out of Local 30 in Jacksonville, Fla. He, along with the train’s engineer, Michael Kempf, a former SMART TD member out of Georgia, died in the accident, which injured more than 100 passengers, in Cayce, S.C.

Cella hired on with Amtrak as an assistant conductor in July 2008 and became a full member of SMART TD in September of that year.

The National Transportation Safety Board (NTSB) is investigating the collision that happened about 2:30 a.m. Feb. 4 when the Amtrak locomotive hit the locomotive of the parked CSX train head-on.

Train 91 was carrying eight crew members and 139 passengers, Amtrak said on a posting on its website.

“We are cooperating fully with the NTSB, which is leading the investigation, as well as working with FRA and CSX. CSX owns and controls the Columbia Subdivision where the accident occurred,” Amtrak said in a statement on Twitter. “CSX maintains all of the tracks and signal systems. CSX controls the dispatching of all trains, including directing the signal systems which control the access to sidings and yards.”

NTSB Chairman Robert Sumwalt also said during a news conference that CSX owns and operates the tracks that the Amtrak train was traveling. A switch that was “lined and locked” in the position to divert traffic onto the track where the CSX train was parked is being considered a cause of the accident.

“Key to this investigation is learning why the switch was lined that way,” Sumwalt said.

“We were able to see that it was actually literally locked with a padlock,” he said when asked by a reporter if there was any physical indication that the switch was faulty.

A statement issued by CSX offered condolences to the families of Cella and Kempf and said that the carrier was focused on providing assistance and support to those affected by the accident.

Sumwalt said that the forward-facing video recorder from the Amtrak locomotive had been recovered and was already transported to the NTSB offices in Washington D.C. for investigation.

The event recorders from both trains were still being sought, he said.

“Fully operational positive train control could have avoided this accident,” Sumwalt said.

In a tweet, NTSB said it expected to release additional information at 4 p.m. Eastern Feb. 5.

The Cayce accident is the third fatal incident in three months involving Amtrak trains. A derailment off an overpass in Washington state in December killed three passengers, and an occupant of a garbage truck that was struck by an Amtrak train Jan. 31 near Charlottesville, Va., also died.

Follow this link for video of the NTSB investigation.

Railroad Safety Subject of four NTSB Safety Recommendations

WASHINGTON (Jan. 11, 2018) — The National Transportation Safety Board (NTSB) issued four railroad related safety recommendations in concert with the agency’s publication of two railroad accident briefs Thursday, Jan. 11.

The recommendations and briefs stem from the NTSB’s investigations of a railroad employee fatality in Kansas City, Kansas, and a derailment near Heimdal, N.D. The accidents are unrelated.

Recommendation to Union Pacific concerning employee fatality

A Union Pacific Railroad (UP) foreman died after being struck by a remote-control train during switching operations at the east end of Armourdale Yard, Kansas City, Sept. 29, 2015. The NTSB determined the probable cause of the accident was the foreman being in the gage of the track, for unknown reasons, while a train switching movement was being performed by another crew. The report also states inadequate radio communications and inadequate work coordination between crews working in the yard contributed to the accident.

In the course of the investigation the NTSB learned Union Pacific employees received frequent, non-critical, man-down alarms which the NTSB believes likely reduced the attention and reaction crewmembers made to actual critical alarms.

A man-down alarm is an audible warning transmitted of the yard’s radio channels from a remote-control unit (used to remotely control locomotives in the yard) indicating the remote-control unit is not in a vertical position and its operator may be in danger. As a result of the investigation the NTSB issued a safety recommendation to the Union Pacific Railroad to develop and implement a modification to the man-down alarms that would allow workers to differentiate between legitimate and non-critical alarms.

Recommendation to BNSF concerning derailment

A broken wheel led to the derailment of six of the 107 loaded tank cars carrying crude oil in a Burlington Northern Santa Fe crude (BNSF) oil unit train May 6, 2015, near Heimdal, N.D. No injuries or fatalities were reported in connection with the derailment, however five of the derailed tank cars breached, releasing about 96,400 gallons of crude oil. A fire ensued, forcing the evacuation of about 30 people from Heimdal and the surrounding area due to the smoke plume.

The NTSB determined the left wheel, in the second position on car 81 was broken due to a vertical split rim which led to catastrophic failure of the wheel due to multiple overstress fractures.

As a result of the investigation the NTSB issued two safety recommendations to the Federal Railroad Administration (FRA) to research and evaluate wheel impact load thresholds and to mandate remedial actions for railroads to avoid or identify mechanical defects identified by wheel impact load detectors.

A third recommendation was issued to both the FRA and the Association of American Railroads (AAR) seeking collaboration in evaluation of safe peak vertical load thresholds to determine remedial actions for suspected defective wheel conditions in high-hazard flammable train service.


The Heimdal, North Dakota, railroad accident brief is available online at http://go.usa.gov/xndbK and the Kansas City, Kansas, railroad accident brief is available at https://go.usa.gov/xndbN.