
[Federal Register Volume 77, Number 80 (Wednesday, April 25, 2012)]
[Notices]
[Pages 24760-24762]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-9948]


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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration


Safety Advisory 2012-02; Restricted Speed

AGENCY: Federal Railroad Administration (FRA), Department of 
Transportation (DOT).

ACTION: Notice of Safety Advisory.

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SUMMARY: FRA is issuing Safety Advisory 2012-02 to remind railroads and 
their employees of the importance of compliance with relevant railroad 
operating rules when trains and locomotives are to be operated at 
restricted speed. This safety advisory contains a preliminary 
discussion of recent train accidents involving a failure to operate at 
restricted speed and makes recommendations to railroads to ensure 
employee compliance with the requirements of restricted speed operating 
rules.

FOR FURTHER INFORMATION CONTACT: Douglas H. Taylor, Staff Director, 
Operating Practices Division, Office of Railroad Safety, FRA, 1200 New 
Jersey Avenue SE., Washington, DC 20590, telephone (202) 493-6255; or 
Joseph St. Peter, Trial Attorney, Office of Chief Counsel, FRA, 1200 
New Jersey Avenue SE., Washington, DC 20590, telephone (202) 493-6047.

SUPPLEMENTARY INFORMATION:

Background

    The overall safety of railroad operations has improved in recent 
years. However, a series of accidents has highlighted the need for 
railroads to review, reemphasize, and adhere to railroad operating 
rules and procedures governing the requirements of restricted

[[Page 24761]]

speed, particularly those involving wayside signals requiring the 
operation of trains at restricted speed. Railroad operating rules 
governing restricted speed require that train crews be prepared to stop 
within one-half their range of vision. During the previous 12 months, 
the railroad industry has experienced six rear end collisions that 
resulted in four employee fatalities, eight employee injuries, and more 
than $6 million in FRA-reportable railroad property damage. It appears 
these six incidents may have occurred because the train crews did not 
properly identify and comply with block and interlocking signal 
indications that required operation of their trains at restricted 
speed.

NTSB Recommendations

    On January 12, 2012, in response to five of the six aforementioned 
rear end collisions, the National Transportation Safety Board (NTSB) 
issued two safety recommendations.\1\ NTSB Safety Recommendations R-11-
6 and R-11-7 contain descriptions of the events surrounding those five 
collisions, and recommend that FRA:
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    \1\ Available online at NTSB's Web site: http://www.ntsb.gov/doclib/recletters/2011/R-11-006-007.pdf.
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     Through appropriate and expeditious means, such as issuing 
and posting advisory bulletins on [FRA's Web site], advise all 
railroads of the occurrences of the following five recent rear end 
collisions of freight trains in which crewmembers failed to operate 
their trains at the required restricted speed: (1) Red Oak, IA, on 
April 17, 2011; (2) Low Moor, VA, on May 21, 2011; (3) Mineral Springs, 
NC, on May 24, 2011; (4) DeWitt, NY, on July 6, 2011; and (5) DeKalb, 
IN, on August 19, 2011. (R-11-6).
     Through appropriate and expeditious means, inform [FRA's] 
inspectors of the details of these accidents to ensure railroads' 
compliance with restricted speed requirements. (R-11-7).
    Publication of this safety advisory is among the ongoing efforts 
FRA has undertaken to address these NTSB recommendations and to improve 
railroad safety generally.

Recent Incidents

    The following is a brief summary of the circumstances surrounding 
each of the recent rear end collisions that appeared to involve a 
failure to comply with the requirements of restricted speed operating 
rules. Information regarding these incidents is based on FRA's 
preliminary investigations and findings to date. The probable causes 
and contributing factors, if any, have not yet been established. 
Therefore, nothing in this safety advisory is intended to attribute a 
cause to these incidents, or place responsibility for these incidents 
on the acts or omissions of any person or entity.

    1. On April 17, 2011, at approximately 7 a.m., an eastbound BNSF 
Railway coal train collided with the rear of a stopped maintenance-
of-way train at a recorded speed of 22 mph in Red Oak, Iowa. The two 
crewmembers of the striking coal train were fatally injured. Just 
prior to the collision, the coal train had passed an intermediate 
automatic block signal displaying a red aspect. This signal was 
affixed with a qualifying appurtenance (grade marker), meaning the 
signal indication required the train to proceed at restricted speed 
(without being first required to stop). As the coal train descended 
a slight grade, it impacted the rear of the standing maintenance-of-
way train. Several cars were derailed and there was a subsequent 
fire on the lead locomotive of the striking train. Event recorder 
data indicates that no manipulation of the striking locomotive's 
controls occurred prior to the collision.
    2. On May 21, 2011, at approximately 11:40 a.m., an eastbound 
CSX Transportation, Inc. (CSX) road switcher collided with the rear 
of a standing grain train at Low Moor, Virginia. The switcher was 
traveling at a recorded speed of 13 mph at the time of the 
collision. FRA's preliminary investigation indicates that the train 
had passed an intermediate automatic block signal indicating that 
the train was to proceed at restricted speed. However, the train 
crew was not prepared to stop their train within one-half the range 
of vision of the standing train. The collision resulted in the 
derailment of the lead engine of the road switcher, and the rear car 
of the grain train.
    3. On May 24, 2011, at approximately 3:45 a.m., a northbound CSX 
intermodal train collided with the rear of a standing aggregate 
(rock) train near Mineral Springs, North Carolina. The incident 
resulted in fatal injuries to the two crewmembers on board the 
striking intermodal train. The intermodal train was following the 
rock train, and had passed a dark (non-illuminated) intermediate 
automatic block signal. Under CSX operating rules, a dark signal is 
to be treated as an imperfectly displayed signal and regarded as the 
most restrictive indication that could be conveyed by that signal. 
Thus, in this case, the crew should have proceeded at restricted 
speed. However, after passing the signal, the train crew did not 
operate their train prepared to stop within one-half their range of 
vision, and subsequently struck the rear of the standing rock train 
at a recorded speed of 47 mph.
    4. On July 6, 2011, at approximately 12:20 p.m., an eastbound 
CSX merchandise train collided with the rear of a standing 
intermodal train in DeWitt, New York. Several train cars derailed, 
and both crewmembers of the striking train were seriously injured 
when they jumped from the locomotive at a speed of approximately 30 
mph immediately prior to the collision. FRA's preliminary 
investigation indicates alleged confusion on the part of the crew of 
the striking train with regard to the aspect and indication 
displayed by the last interlocking signal they had passed 
immediately preceding the collision. The preliminary investigation 
also indicates that the signal was conveying the proper indication 
for the condition of the block, i.e., ``Restricting'' (red over 
steady yellow aspect). The results of the signal download support 
this conclusion. Both employees involved in this incident had 
operated daily over this territory and should have been familiar 
with the signal aspects.
    5. On August 19, 2011, at approximately 5:45 a.m., a westbound 
Norfolk Southern Railway ballast train collided with the rear of a 
standing grain train at a speed of 20 mph in DeKalb, Indiana. The 
accident resulted in the derailment of two locomotives and 10 cars 
of the striking train, and blocked a major east/west National 
Railroad Passenger Corporation (Amtrak) passenger train route. The 
striking train had passed a controlled signal that conveyed an 
``Approach'' indication at a speed of 45 mph and subsequently an 
intermediate automatic block signal conveying a ``Restricting'' 
indication immediately preceding the accident at a speed of 50 mph. 
Prior to the collision, the crew of the striking train made an 
emergency brake application and slowed the train to approximately 20 
mph at impact.
    6. On January 6, 2012, at approximately 2:26 p.m., a westbound 
CSX merchandise train collided with the rear of a standing ethanol 
train near Westville, Indiana. The collision resulted in the 
derailment of both locomotives of the striking train and cars from 
both trains. Subsequently, an intermodal train operating in the same 
(westbound) direction on the adjacent main track encountered the 
accident and collided with derailed equipment. The ethanol train was 
standing at a controlled signal indicating ``Stop,'' waiting for the 
signal to clear. Prior to impact, the initial striking train (the 
merchandise train) had just passed an intermediate automatic block 
signal that conveyed a ``Restricting'' indication and entered the 
occupied block in excess of 40 mph. The collision resulted in a 
debris field that blocked the adjacent main track. The westbound 
intermodal train, operating on the adjacent main track on a 
``Clear'' signal indication, approached the accident site unaware of 
the impending collision. The crew of the intermodal train saw the 
wreckage and initiated an emergency application of the train's 
brakes before their train struck the derailed equipment. This 
incident resulted in serious injuries to employees and significant 
damage to property, but fortunately no fatalities.

    Historically, the railroad industry has reported the cause of these 
type of rear end collisions as ``automatic block or interlocking signal 
displaying other than a stop indication--failure to comply'', as the 
above facts indicate noncompliance with automatic block or interlocking 
signals that conveyed indications requiring the striking trains to 
proceed

[[Page 24762]]

at restricted speed. However, main track rear end collisions are seldom 
the result of a single factor or cause. Preliminary investigations of 
the above-described collisions have established that they likely 
resulted from a combination of unrelated factors, some of which 
include: employee fatigue; distraction due to the improper use of cell 
phones; work-related discussions in the cab of the controlling 
locomotive; alleged confusion over signal indications; and, what FRA 
refers to as ``self dispatching.'' Self-dispatching is the operation of 
a train based on assumptions about the locations of other trains. These 
assumptions are sometimes developed through overheard radio 
conversations among other train crewmembers.
    Operating employees must work together as a team, because they work 
in an environment which is often without on-site managerial oversight. 
Both the locomotive engineer and conductor of a train are equally 
responsible for safe operation of their train and compliance with 
railroad operating rules. Indeed, both the engineer and conductor, and 
any other crewmembers present in the controlling locomotive of a train, 
must remain vigilant and must assist each other in the safe operation 
of the train. As the above accidents indicate, even slight lapses in 
situational awareness, particularly when operating trains on 
``Approach'' and ``Restricting'' signal indications can lead to 
tragedy. An environment must be created and maintained in the 
locomotive control compartment where the crew exclusively focuses on 
properly controlling the train in compliance with the operating rules.
    A railroad's safety culture must support employees' undisturbed 
attention to the tasks at hand without the distraction of electronic 
devices or the loss of situational awareness due to fatigue. All train 
crewmembers must maintain this enhanced level of awareness. Initial 
investigations of the accidents described above indicate that the 
crewmembers involved were properly trained, experienced, and were 
qualified on the territory over which they operated. However, in every 
case, it appears that there was a lack of attentiveness to the signal 
indications being conveyed prior to the collisions. This discussion is 
not intended to place blame or assign responsibility to individuals or 
railroad companies, but simply to point out that a culture of operating 
rules compliance must be everyone's job. Peer support for the railroad 
employees who perform each task in the prescribed manner helps 
individuals maintain responsibility for their own safety.
    Recommended Railroad Action: In light of the above discussion, FRA 
recommends that railroads:
    1. Review with operating employees the circumstances of the six 
rear end collisions identified above.
    2. Discuss the requirements of restricted speed and related 
operational tests at future instructional classes (and also as part of 
ad hoc coaching and briefings) for operating employees, with a focus on 
the railroad's absolute speed limit for such operations, as well as 
requirements that ensure the ability to stop in one-half the range of 
vision. Special emphasis should be placed on situations in which the 
range of vision is limited (e.g., curves).
    3. Evaluate quarterly and 6-month reviews of operational testing 
data as required by Title 49 Code of Federal Regulations (CFR) section 
217.9, and, as appropriate, increase the level of operational testing 
with regard to the operation of trains on main tracks at restricted 
speed. A representative number of operational tests should be conducted 
on trains following other trains into an occupied block, particularly 
in high-density corridors. Operational tests should also include a 
review of locomotive event recorder data to verify compliance with 
restricted speed requirements.
    4. Reinforce the importance of communication between crewmembers 
located in the controlling locomotive, particularly during safety 
critical periods when multiple tasks are occurring, including such 
activities as copying mandatory directives; closely approaching or 
passing fixed signals that require trains to operate at restricted 
speed; approaching locations where trains' movement authority is being 
restricted; and during radio conversations with other employees or job 
briefings about work to be done at an upcoming location.
    5. Review with operating employees the requirements of subpart C of 
49 CFR part 220, and reinforce that the improper use of electronic 
devices during safety critical periods often leads to a loss of 
situational awareness and resultant dangers.
    FRA encourages railroad industry members to take actions that are 
consistent with the preceding recommendations and to take other actions 
to help ensure the safety of the Nation's railroad employees. FRA may 
modify this Safety Advisory 2012-02, issue additional safety 
advisories, or take other appropriate actions it deems necessary to 
ensure the highest level of safety on the Nation's railroads, including 
pursuing other corrective measures under its rail safety authority.

    Issued in Washington, DC, on April 20, 2012.
Robert C. Lauby,
Acting Associate Administrator for Railroad Safety/Chief Safety 
Officer.
[FR Doc. 2012-9948 Filed 4-24-12; 8:45 am]
BILLING CODE 4910-06-P


