
[Federal Register Volume 80, Number 216 (Monday, November 9, 2015)]
[Notices]
[Pages 69272-69275]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-28411]


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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration

[Safety Advisory No. 2015-05]


Addressing Rail Head Surface Conditions Identified During the 
Internal Rail Inspection Process

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

[[Page 69273]]


ACTION: Notice of safety advisory.

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SUMMARY: On February 16, 2015, a derailment occurred in West Virginia 
due to a broken rail that resulted from an internal rail defect, 
specifically a vertical split head (VSH). Although rail flaw detection 
equipment had indicated rail flaw conditions at the location of the 
failure in December 2014 and January 2015, the operator of the 
equipment failed to carry out an on-ground examination of the defect. 
The operator later claimed that he believed the reading on the monitor 
was a false-positive due to rail head surface conditions. FRA believes 
that if the operator better understood the indications for various rail 
flaw conditions, including the rough rail surface conditions he was to 
look for and properly identified the rail flaw indications, the 
operator would have reported the defect to the track owner. Upon 
reporting, the track owner would have been alerted to its duty under 
the Track Safety Standards (49 CFR part 213) to take remedial action 
(either repair or replacement of the rail or reduction of the maximum 
authorized train speed over the rail to the specified level). Had the 
track owner then taken proper remedial action, that action may have 
prevented the broken rail and the derailment.
    In response, FRA is issuing this Safety Advisory No. 2015-05 to 
remind track owners (typically railroads), their track maintenance 
personnel, and their rail flaw detection equipment operators of the 
importance of complying with their rail management programs and 
engineering procedures that address rail with rail head surface 
conditions while performing rail flaw inspections and track inspections 
generally. This is particularly vital on track carrying passengers and 
hazardous materials due to the catastrophic consequences that may 
result from a derailment. This Safety Advisory also contains 
recommendations to track owners to ensure their rail flaw detection 
equipment operators are properly trained and exercise due diligence 
when a rail head surface condition interferes with a valid rail 
inspection.

FOR FURTHER INFORMATION CONTACT: Carlo M. Patrick, Staff Director, Rail 
and Infrastructure Integrity Division, Office of Railroad Safety, FRA, 
1200 New Jersey Avenue SE., Washington, DC 20590, telephone (202) 493-
6399; or John Seguin, Trial Attorney, Office of Chief Counsel, FRA, 
1200 New Jersey Avenue SE., Washington, DC 20590, telephone (202) 493-
6045.

SUPPLEMENTARY INFORMATION: 

Background, Including Accident Summary and Regulatory Context

    The overall safety of railroad operations has improved in recent 
years. However, a February 2015 accident highlights the need for 
additional focus on detection of internal rail flaws by each track 
owner responsible for compliance with the Track Safety Standards, and 
its respective employees and internal rail inspection service 
providers, particularly on track that carries passengers or hazardous 
materials. See relevant sections of the regulations, for example, 49 
CFR 213.5, Responsibility for compliance; 213.113, Defective rails; 
213.237, Inspection of rail; and 213.238, Qualified operator. The 
following section summarizes the circumstances of this train derailment 
based on FRA's internal investigation and findings to date.

Accident Summary

    At 1:15 p.m., Eastern Standard Time, on Monday, February 16, 2015, 
CSX Transportation, Inc. (CSXT) Train K08014, a loaded unit train 
transporting Bakken crude oil, traveling eastward at 33 miles per hour 
(mph) on the railroad's Huntington Division, New River Subdivision, 
experienced an automated emergency brake application in Fayette County, 
west of Mt. Carbon, WV, as a result of a derailment. The derailment 
occurred on Class 4 track due to a VSH rail defect. See 49 CFR 213.09. 
Twenty-seven tank cars derailed, and 20 of the derailed tank cars 
released approximately 362,300 gallons of crude oil that immediately 
ignited. The resulting fire burned for four days, requiring an 
evacuation approximately 1,100 residents within a half-mile of the 
accident site. One occupant of a house located adjacent to the accident 
site reported an injury due to smoke inhalation, and a resident outside 
the evacuation zone was also injured (hypothermia due to a lack of heat 
from power loss). A small amount of the crude oil entered the Kanawha 
River. As a precaution, officials closed downstream water treatment 
intakes at Montgomery, WV, approximately three miles west of the 
accident site. A one-half-mile evacuation zone around the derailment 
site affected approximately 1,100 residents

Prior Rail Inspections

    As part of its derailment investigation, FRA reviewed the rail test 
data from CSXT's two most recent rail inspections in the area where the 
derailment occurred. The two most recent inspections occurred on 
December 17, 2014, and January 12, 2015, and were conducted by a CSXT 
contractor, a rail inspection provider. Those inspections included 
ultrasonic and induction equipment specially designed for the detection 
of internal rail flaws.
    During the December 17, 2014, inspection, the rail inspection 
provider's test equipment recorded indications with an icon on the 
display screen showing a vertical ultrasonic channel equipment response 
and induction test-channel responses at the point of derailment (POD). 
The test equipment recorded a similar but more significant indication 
at the same location during the next test on January 12, 2015. During 
both inspections, the test equipment also responded to a potential 
longitudinal-type rail head condition with multiple ``boxed'' equipment 
responses. The rail inspection data produced during the two inspections 
exhibited equipment responses typically indicating the presence of a 
significant rail head surface anomaly or longitudinal rail head defect 
such as the VSH defect that would become the POD on February 16, 2015.
    Despite the indications of a defect that was becoming more 
significant over time, the rail flaw detection equipment operator did 
not conduct a visual ground examination and/or hand test to meet the 49 
CFR 213.113(b) requirement to verify the multiple VSH defect 
indications the test equipment identified. Instead, the rail inspection 
operator told FRA that he looked out the window of his test equipment, 
decided a ``dirty rail'' \1\ had caused each indication.
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    \1\ During the interview of the operator, he used the term 
``dirty rail''. In this context, FRA believes the operator was 
referring to a rail that exhibits a top of rail surface condition 
that could account for the inspection equipment response. However, 
FRA notes that the term can also mean that the rail contained an 
internal metallurgical impurity that is inherent from the 
manufacturing process.
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VSH Rail Defect

    A VSH rail defect is a progressive longitudinal fracture in the 
head of the rail (i.e., the upper part of a rail, used for supporting 
and guiding the wheels of railroad cars), where separation along an 
internal seam, segregation, or inclusion propagates vertically through 
the rail head. The formation of a VSH defect is found predominantly in 
locations where the train wheel stress loads are off center on the rail 
head. Separation progresses longitudinally and vertically along the 
rail length, typically for some distance before turning to the gage or 
field side of the rail head and often progresses rapidly before 
failure. FRA's investigation

[[Page 69274]]

confirmed there was evidence of multiple, centrally located VSH defects 
at the derailment site.

Use of Rail Flaw Detection Equipment

    The railroad industry primarily uses ultrasonic test equipment to 
conduct non-destructive testing (NDT) for internal rail flaw 
inspection. As with any NDT method, ultrasonic technology contains 
physical limitations that allow certain types of rail head surface 
conditions to influence the proper transfer of sound into the rail and 
impede detection of rail flaws. The predominant types of these 
mechanically-formed conditions are referred to as shells, engine-driver 
burns, spalling, flaking, corrugation, and head checking. Other 
conditions that are encountered are heavy lubrication or debris on the 
rail head. Indeed, track owners and rail inspection providers should be 
aware that the NDT system is designed to perform optimally on an ideal 
test surface (i.e., no rail head surface conditions). Conditions such 
as extreme cyclical loading can result in head wear and rail head 
surface conditions that affect the integrity of these rail flaw 
inspections.
    Any type of surface condition can impede the transfer of sound from 
a rail inspection transducer into the rail being tested and the proper 
transfer of sound from a reflector in the rail back to the transducer. 
If the rail flaw detection equipment operator has any doubt or 
uncertainty about the integrity of the test process because of surface 
conditions, the operator should record the rail section searched as an 
invalid search for internal defects, and the track owner must take 
appropriate action under paragraph (h) of 49 CFR 213.237. Briefly 
summarized, paragraph (h) requires the track owner to conduct a valid 
search, reduce operating speed to a maximum of 25 mph until a valid 
search can be made, or replace the rail that had not been inspected.

General Responsibilities of Rail Flaw Detection Equipment Operators

    The rail flaw detection equipment operator must have the knowledge 
and experience to proficiently identify the types of rail head surface 
conditions that can result in an improper or invalid test of the rail 
section where the condition is located. See 49 CFR 213.237(i). Unless a 
rail flaw detection equipment operator has already demonstrated 
proficiency operating the equipment before January 24, 2014, and, 
therefore, satisfied the qualified operator requirement under 49 CFR 
213.238(f),\2\ FRA requires them to be specifically trained and have 
written authorization from his or her employer to: (1) Conduct a valid 
search for internal rail defects that is continuous and completely 
covers both rails of the track; (2) determine that the rail inspection 
equipment is operating within manufacturer guidelines and settings and 
performing all its required functions as designed; and (3) conduct the 
inspection according to established track owner and regulatory 
procedures and guidelines, including determining that all equipment 
responses are interpreted and attributed to a known condition that is 
not considered a rail defect. 49 CFR 213.238. Indeed, it is essential 
that the rail inspection's test integrity not be influenced by surface 
contamination, rail condition, or environmental conditions that can 
result in changes to the operational settings of the test equipment 
beyond allowable tolerances, changes to the equipment's alignment, or 
diminished equipment responses. Therefore, it is imperative that the 
track owner or rail inspection provider perform a hand test or visual 
on-ground examination of these suspect conditions to verify whether a 
defect is present.
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    \2\ The operator of the rail flaw detector equipment that 
performed the December 17, 2014, and January 12, 2015 internal rail 
inspections was deemed a qualified operator under 49 CFR 213.238(f).
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    FRA regulations specify that the rail flaw detection equipment 
operator must be trained as specified in FRA regulations to interpret 
the test data and to ``demonstrate proficiency in the rail defect 
detection process . . . .'' 49 CFR 213.238(c). Test equipment includes 
all hand-test instrumentation, recording instrumentation, front-end 
devices (roller search units, skids, induction search units, cabling, 
etc.), and detection control center (processing computer) equipment.
    Under paragraph (a) of 49 CFR 213.238, each provider of rail flaw 
detection services shall (1) have a documented training program in 
place and (2) identify the types of rail flaw detection equipment for 
which each equipment operator it employs has received training and is 
qualified. Operators who are deemed a qualified operator under 
paragraph (f) remain subject to paragraph (d), which, in part, requires 
an employer to ``reevaluate the qualifications of, and administer any 
necessary recurrent training for, the operator as determined by and in 
accordance with the employer's documented program.'' This requirement 
for recurrent training applies to operators who have completed the 
initial training program and operators who have been deemed qualified 
operators under paragraph (f).
    FRA determined during its investigation into the February 16, 2015, 
derailment that the presence of the rail head surface condition was not 
sufficient to account for the equipment response in its entirety, and 
that the rail flaw detection equipment operator should have inspected 
further. FRA believes that a visual ground examination, or hand test, 
or both, would have identified the presence of the underlying VSH 
defect at the time of the test on January 12, 2015, at what would 
become the POD.
    Recommended Action: In light of the discussion above, and to 
instill a heightened sense of vigilance in track owners and their rail 
inspection provider(s), FRA recommends that each track owner:

    1. Review with its employees and its rail inspection provider(s) 
the circumstances of the derailment described above and ensure its 
employees and rail inspection provider(s) carefully scrutinize 
occurrences of localized areas containing rail head surface 
conditions that may impede detection of an internal rail flaw and 
result in an invalid inspection;
    2. Ensure its rail inspection procedures contain specific 
instructions that make clear what its rail inspection provider(s) 
are responsible for (for example, including identifying and 
reporting defects and invalid searches) and that incentivizes its 
rail inspection provider(s) to identify and report areas where a 
valid search could not be conducted;
    3. Ensure that its employees and its rail inspection provider(s) 
follow the requirements of its own engineering instructions and 
ensure that the employees and rail inspection provider(s) can 
identify locations that exhibit excessive rail head wear and rail 
head surface conditions;
    4. Ensure that its rail flaw detection equipment operators 
perform an on-ground examination of any suspect rail defect location 
in conformance with 49 CFR 213.113(b). The operators should verify 
the suspect locations by hand as necessary, using a hand-held 
ultrasonic instrument or comparable device;
    5. Ensure that its rail flaw detection equipment operators have 
been adequately trained on its procedures, are fully capable of 
performing proficient inspections, and are fully capable of 
determining whether a rail inspection is valid;
    6. Continue the research and development of technology that will 
permit real-time comparison of the inspection data from the most 
current rail inspection with inspection data from the previous rail 
inspection to enable the operator to identify rail conditions that 
have significantly changed between inspections;
    7. Review its current engineering instructions to ensure that 
the procedures are consistent with the industry standard for rail 
replacement and repair, particularly in track

[[Page 69275]]

over which passengers or large quantities of ethanol, crude oil, or 
other hazardous materials are transported;
    8. In applying appropriate slow orders, focus on locations that 
exhibit rail head surface conditions and rail head wear loss 
approaching the limits specified in its own engineering instructions 
until the rail is replaced or repaired; and
    9. Aggressively monitor and evaluate its rail inspection 
provider's or providers' performance through a quality control 
program.

    FRA encourages railroad industry members and other track owners to 
take actions consistent with the preceding recommendations and to take 
other complementary actions to help ensure the safety of the Nation's 
railroads, its employees, and the general public. FRA may modify this 
Safety Advisory No. 2015-05, 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 November 4, 2015.
Robert C. Lauby,
Associate Administrator for Railroad Safety Chief Safety Officer.
[FR Doc. 2015-28411 Filed 11-6-15; 8:45 am]
BILLING CODE 4910-06-P


