
[Federal Register Volume 81, Number 233 (Monday, December 5, 2016)]
[Notices]
[Pages 87649-87653]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-29013]


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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration

[Safety Advisory 2016-03]


Mitigation and Investigation of Passenger Rail Human Factor 
Related Accidents and Operations in Terminals and Stations With Stub 
End Tracks

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

ACTION: Notice of Safety Advisory.

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SUMMARY: FRA is issuing Safety Advisory 2016-03 to stress to passenger 
and commuter railroads the importance of taking action to help mitigate 
human factor accidents, assist in the investigation of such accidents, 
and enhance the safety of operations in stations and terminals with 
stub end tracks. This safety advisory contains various recommendations 
to passenger and commuter railroads related to inward- and outward-
facing cameras, sleep apnea, and operating practices to potentially 
mitigate the occurrence and assist in the investigation of human factor 
related accidents and to enhance the safety of operations in terminals 
and stations with stub end tracks.

FOR FURTHER INFORMATION CONTACT: Christian Holt, Operating Practices 
Specialist, Office of Railroad Safety, FRA, 1200 New Jersey Avenue SE., 
Washington, DC 20590, telephone (202) 493-0978.

SUPPLEMENTARY INFORMATION:

I. New Jersey Transit Incident

    On September 29, 2016, at approximately 8:38 a.m., New Jersey 
Transit (NJT) Train 1614 travelling at 21 miles per hour (mph) impacted 
the bumping block at the end of the track No. 5 Depot, at Hoboken 
Terminal, in Hoboken, New Jersey. The cab car overrode the bumping 
block and struck the wall of the terminal building, near the ticket 
office in the corner of the building. NJT Train 1614 was occupied by 
three crew members and approximately 331 passengers. The accident 
resulted in the three crewmembers and 108 passengers being transported 
to four area hospitals. One individual who was standing on the 
pedestrian walkway between the tracks and the station was fatally 
injured from falling debris.
    The National Transportation Safety Board (NTSB) has taken the lead 
role in conducting the investigation of this accident under its legal 
authority. See 49 U.S.C. 1101 et seq.; 49 CFR 831.2(b). As is 
customary, FRA is participating in the NTSB's investigation and also 
investigating the accident under its own authority. NTSB has not issued 
its formal findings. Although the NTSB has not concluded its 
investigation of this accident, FRA believes railroads should take more 
robust action to address human factors that may cause accidents and to 
enhance protection of railroad employees and the public.

II. Other Railroad Accidents

Amtrak Accident at Philadelphia, PA

    On Tuesday, May 12, 2015, National Railroad Passenger Corporation 
(Amtrak) passenger train 188 (Train 188) was traveling from Washington, 
DC, to New York City. Aboard the train were five crew members and 
approximately 238 passengers. Shortly after 9:20 p.m., the train 
derailed while traveling through a curve in the track at Frankford 
Junction in Philadelphia, Pennsylvania. As a result of the accident, 
eight persons were killed and a significant number of persons were 
seriously injured.
    NTSB conducted an investigation of this accident under its legal 
authority and issued its findings on May 17, 2016.\1\ As Train 188 
approached the curve from the west, it traveled over a straightaway 
with a maximum authorized passenger train speed of 80 mph. The maximum 
authorized passenger train speed for the curve was 50 mph. NTSB 
determined the train was traveling approximately 106 mph within the 
curve's 50-mph speed restriction, exceeding the maximum authorized 
speed on the straightaway by 26 mph, and 56 mph over railroad's maximum 
authorized speed for the curve.\2\ NTSB concluded the locomotive 
engineer operating the train made an emergency application of Train 
188's air brake system, and the train slowed to approximately 102 mph 
before derailing in the curve.\3\ NTSB concluded that the probable 
cause of the engineer accelerating to this speed was due to his loss of 
situational awareness likely because his attention was diverted to an 
emergency situation with another train.\4\
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    \1\ 49 U.S.C. 1101 et seq.; 49 CFR 831.2(b); and NTSB, Railroad 
Accident Report, RAR-16/02, Derailment of Amtrak Passenger Train 
188, Philadelphia, Pennsylvania, May 12, 2015, http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1602.pdf.
    \2\ RAR-16/02 at 1. FRA regulations provide, in part, that it is 
unlawful to ``[o]perate a train or locomotive at a speed which 
exceeds the maximum authorized limit by at least 10 miles per 
hour.'' 49 CFR 240.305(a)(2).
    \3\ RAR-16/02 at 4-5.
    \4\ Id. at 44.
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    On July 8, 2015, NTSB sent a letter to FRA reiterating NTSB 
recommendations

[[Page 87650]]

R-10-01 & -02.\5\ The letter indicated NTSB believes inward-facing 
locomotive recorders could have provided valuable information to help 
determine the cause of the accident. After this accident occurred, 
Amtrak announced it would install inward-facing cameras on all of its 
ACS-64 locomotives on the Northeast Corridor.
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    \5\ National Transportation Safety Board, Safety Recommendation 
History for Safety Recommendation R-10-001: available online at: 
http://www.ntsb.gov/_layouts/ntsb.recsearch/Recommendation.aspx?Rec=R-10-001. NTSB's accident report also 
reiterated these recommendations. See RAR-16/02 at 46-47. NTSB also 
sent a letter regarding locomotive recorder recommendations to 
Amtrak.
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Southern California Regional Rail Authority (Metrolink) Chatsworth, CA

    On September 12, 2008, in Chatsworth, California, an accident 
occurred involving a collision between a Southern California Regional 
Rail Authority (Metrolink) passenger train and a Union Pacific Railroad 
Company (UP) freight train.\6\ The accident occurred after the 
locomotive engineer operating the Metrolink passenger train failed to 
stop his train for a stop signal. As a result of the accident, 25 
persons on the Metrolink train were killed and 102 injured passengers 
were transported to the hospital. The accident damage was estimated to 
be in excess of $12 million. The NTSB found the probable cause of that 
accident was the Metrolink locomotive engineer's distraction due to the 
use of a personal cell phone to send text messages resulting in a 
failure to comply with the signal indication.\7\
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    \6\ See National Transportation Safety Board, Collision of 
Metrolink Train 111 with Union Pacific Train LOF65-12 Chatsworth, 
California September 12, 2008, Accident Report NTSB/RAR-10/01 (Jan. 
21, 2010); available online at: http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1001.pdf.
    \7\ Id. at 66.
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    Shortly after the Metrolink accident, the Rail Safety Improvement 
Act of 2008 \8\ (RSIA) was enacted. RSIA required, among other items, 
that railroads install Positive Train Control (PTC) systems. Also after 
the accident, FRA issued its Emergency Order No. 26 (EO 26). 73 FR 
58702 (Oct. 7, 2008). EO 26 prohibited railroad operating employees 
(typically train crew members such as locomotive engineers and 
conductors) performing safety-related duties from using or turning on 
electronic devices such as personal cell phones. The requirements in EO 
26 were codified in amended form at 49 CFR part 220, subpart C, in an 
FRA final rule published on September 27, 2010, which took effect on 
March 28, 2011. 75 FR 59580. Among other requirements in the final 
rule, railroad operating employees are required to receive training on 
the regulation's requirements governing the use of electronic devices 
while on-duty and are also required to be tested by railroad 
supervisors to determine employees' compliance with such requirements. 
49 CFR 220.313-315.
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    \8\ Rail Safety Improvement Act of 2008, Public Law 110-432, 
Division A, 122 Stat. 4848 (Oct. 16, 2008); available online at 
https://www.fra.dot.gov/eLib/Details/ L03588.
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    The NTSB's report on the Chatsworth accident resulted in two new 
Safety Recommendations, R-10-01 and R-10-02.\9\ Safety Recommendation 
R-10-01 superseded Safety Recommendation R-07-003, and recommended that 
FRA:

    \9\ National Transportation Safety Board, Safety Recommendations 
R-10-01 and R-10-02 (Feb. 23, 2010); available online at: http://www.ntsb.gov/safety/safety-recs/recletters/R-10-001-002.pdf.

    Require the installation, in all controlling locomotive cabs and 
cab car operating compartments, of crash- and fire-protected inward- 
and outward-facing audio and image recorders capable of providing 
recordings to verify that train crew actions are in accordance with 
rules and procedures that are essential to safety as well as train 
operating conditions. The devices should have a minimum 12-hour 
continuous recording capability with recordings that are easily 
accessible for review, with appropriate limitations on public 
release, for the investigation of accidents or for use by management 
in carrying out efficiency testing and system wide performance 
monitoring programs.
    In addition, Safety Recommendation R-10-02 recommended that FRA:
    Require that railroads regularly review and use in-cab audio and 
image recordings (with appropriate limitations on public release), 
in conjunction with other performance data, to verify that train 
crew actions are in accordance with rules and procedures that are 
essential to safety.

Metro-North Railroad Derailment, Bronx, NY

    On December 1, 2013, at approximately 7:20 a.m. EST, southbound 
Metro-North Railroad (Metro-North) passenger train 8808 derailed as it 
approached the Spuyten Duyvil Station in New York City. All passenger 
cars and the locomotive derailed, and, as a result, four passengers 
died and at least 61 passengers were injured. The train was traveling 
at 82 mph when it derailed in a section of curved track where the 
maximum authorized speed was 30 mph. Following the accident, the 
engineer reported that: (1) He felt dazed just before the derailment; 
\10\ and (2) his wife had complained about his snoring. The engineer 
then underwent a sleep evaluation that identified excessive daytime 
sleepiness and a sleep study that diagnosed severe obstructive sleep 
apnea (OSA). Based on its investigation of the derailment, the NTSB 
concluded that the engineer had multiple OSA risk factors, such as 
obesity, male gender, snoring, complaints of fatigue, and excessive 
daytime sleepiness. Even though the engineer had these OSA risk 
factors, neither his personal health care provider nor his Metro-North 
occupational health evaluations had screened the engineer for OSA.\11\ 
NTSB determined that the probable cause of the accident was the 
``engineer's noncompliance with the 30-mph speed restriction because he 
had fallen asleep due to undiagnosed severe obstructive sleep apnea 
exacerbated by a recent circadian rhythm shift required by his work 
schedule.'' \12\
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    \10\ NTSB, Railroad Accident Brief RAB-14/12, Metro-North 
Railroad Derailment, October 24, 2014, p. 2.
    \11\ Id. at 3.
    \12\ Id. at 5.
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    Railroad safety is of the utmost importance to FRA, and, based on 
the above accidents, FRA recommends several measures discussed below, 
to address human factor-caused accidents

III. Inward- and Outward-Facing Cameras

    On December 4, 2015, the President signed into law the Fixing 
America's Surface Transportation Act, Public Law 114-94, 129 Stat. 1686 
(Dec. 4, 2015) (FAST Act). Section 11411 of the FAST Act, codified in 
the Federal railroad safety laws at 49 U.S.C. 20168 (the Statute), 
requires FRA (as the Secretary of Transportation's delegate) to 
promulgate regulations requiring each railroad carrier that provides 
regularly scheduled intercity rail passenger or commuter rail passenger 
transportation to install inward- and outward-facing image recording 
devices in all controlling locomotives of passenger trains. 49 U.S.C. 
20168(a). Although FRA is in the process of developing a regulatory 
proposal addressing this statutory mandate, FRA encourages railroads to 
accelerate the installation of the cameras. The Statute contains 
various design and operational requirements related to these cameras 
including:
     A minimum 12-hour continuous recording capability (49 
U.S.C. 20168(b)(1));
     Crash and fire protections for any in-cab image recordings 
that are stored only within a controlling locomotive cab or cab car 
operating compartment (49 U.S.C. 20168(b)(2));
     Recordings must be accessible for review during an 
accident or incident investigation (49 U.S.C. 20168(b)(3));

[[Page 87651]]

     Railroads may use the recordings to:
    [cir] Verify that train crew actions follow applicable safety laws 
and the railroad carrier's operating rules and procedures (49 U.S.C. 
20168(d)(1));
    [cir] Assist in an investigation into the causation of a reportable 
accident or incident (49 U.S.C. 20168(d)(2)); and
    [cir] Document a criminal act or monitor unauthorized occupancy of 
the controlling locomotive cab or car operating compartment (49 U.S.C. 
20168(d)(3)).
    In addition to the design and operational requirements in the FAST 
Act, the Statute also contains various other requirements regarding the 
use and maintenance of inward- and outward-facing cameras as well as 
limitations and protections on how data from the cameras can be used. 
Importantly, the Statute prohibits railroads from using image 
recordings to retaliate against their employees. 49 U.S.C. 20168(i). In 
addition, to discourage tampering with the cameras, the Statute allows 
railroads to take enforcement actions against employees that tamper 
with or disable an inward- or outward-facing image recording device. 49 
U.S.C. 20168(f). Furthermore, recording device data obtained from a 
locomotive involved in a FRA reportable accident or incident must be 
preserved by the railroad for one year after the accident or incident. 
49 U.S.C. 20168(g).
    Once FRA has acquired this data from the railroad, FRA is 
prohibited from publicly disclosing locomotive audio and image 
recordings or transcripts of oral communications between train, 
operating, and communication center employees related to the accident 
or incident FRA is investigating. However, FRA may publicly release a 
transcript of a written depiction of visual information that the agency 
deems is relevant to the accident at the time other factual reports on 
the accident are released to the public. 49 U.S.C. 20168(h). This 
restriction is similar to the prohibition on public disclosure of 
locomotive recordings that NTSB takes possession of during an 
investigation. 49 U.S.C. 1114(d).
    FRA remains concerned with the ability to fully investigate 
accidents that appear to be human factor-caused where there is 
insufficient information from the controlling locomotive cab or cab 
operating compartment to conclusively determine what caused or 
contributed to an accident. Locomotive cab recording information could 
benefit investigations and help identify necessary corrective actions 
before similar train accidents occur. Inward- and outward-facing image 
recording devices would be valuable in revealing crew actions and 
interactions before, during, and after an accident. FRA also believes 
that inward- and outward-facing cameras will give railroads the ability 
to monitor crew behavior to ensure compliance with existing Federal 
regulations and railroad operating rules and deter noncompliance. 
Existing Federal regulations at 49 CFR part 217 require railroads to 
conduct operational tests to determine the extent of employees' 
compliance with railroad operating rules, and particularly those rules 
which are most likely to cause the most accidents or incidents.

IV. Railroad Employee Fatigue

    Fatigue of railroad employees continues to be a concern of FRA, 
particularly for employees with sleep disorders who operate passenger 
trains. This Advisory contains suggested measures that railroads and 
employees should utilize to prevent work-related errors and on-the-job 
accidents as a result of sleep disorders.
    Sleep disorders represent a serious health problem and left 
untreated can result in impaired work performance, including possible 
loss of alertness and situational awareness, which could in turn 
present an imminent threat to transportation safety.\13\ In general 
terms, sleep disorders range from fairly common disorders, such as 
insomnia (the inability to initiate or maintain sleep) to relatively 
rare sleep disorders such as narcolepsy (inappropriate and 
uncontrollable sleep episodes). Railroad employees who typically work 
on-call are especially vulnerable to circadian rhythm disorders such as 
shift work sleep disorder (SWSD).\14\ SWSD symptoms include excessive 
sleepiness when a worker needs to be awake, insomnia when the worker 
needs to obtain sleep, unrefreshing sleep, and difficulty 
concentrating.\15\ One of the more common sleep disorders is 
obstructive sleep apnea (OSA). And, the lawyer representing the 
engineer of the NJT train stated the engineer had undiagnosed OSA.\16\
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    \13\ See 81 FR 12642, 12643-12644 (Mar. 10, 2016); Federal 
Railroad Administration Notice of Safety Advisory 2004-04 (Oct. 1, 
2004).
    \14\ Id.
    \15\ Id.
    \16\ See http://www.nbcphiladelphia.com/news/local/NJ-train-crash-undiagnosed-engineer-sleep-disorder-apnea-hoboken-401555955.html.
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    OSA is a respiratory disorder characterized by a reduction or 
cessation of breathing during sleep. OSA is characterized by repeated 
episodes of upper airway collapse in the region of the upper throat 
(pharynx) that results in intermittent periods of partial airflow 
obstruction (hypopneas), complete airflow obstruction (apneas), and 
respiratory effort-related arousals from sleep (RERAs) in which 
affected individuals awaken partially and may experience gasping and 
choking as they struggle to breathe. Risk factors for developing OSA 
include: Obesity, male gender, advancing age, family history of OSA, 
large neck size, and an anatomically small oropharynx (throat). 
Additionally, OSA is associated with increased risk for other adverse 
health conditions such as: Hypertension (high blood pressure), 
diabetes, cardiac dysrhythmias (irregular heartbeat), myocardial 
infarction (heart attack), stroke, and sudden cardiac death. 
Individuals who have undiagnosed OSA are often unaware they have 
experienced periods of sleep interrupted by breathing difficulties 
(apneas, hypopneas, or RERAs) when they awaken in the morning. As a 
result, the condition is often unrecognized by affected individuals and 
underdiagnosed by medical professionals.
    For individuals with OSA, eight hours of sleep can be less restful 
or refreshing than four hours of ordinary, uninterrupted sleep. 
Undiagnosed or inadequately treated moderate to severe OSA can cause 
unintended sleep episodes and resulting deficits in attention, 
concentration, situational awareness, and memory, thus reducing the 
capacity to safely respond to hazards when performing safety sensitive 
duties. Thus, OSA is a critical safety issue that can affect operations 
in all modes of travel in the transportation industry.
    On March 10, 2016, FRA published an advance notice of proposed 
rulemaking (ANPRM) requesting data and information concerning the 
prevalence of moderate-to-severe OSA of individuals occupying safety 
sensitive positions in rail transportation and the potential 
consequences for rail safety. See 81 FR 12642 (Mar. 10, 2016). The 
ANPRM also requested information on the potential costs and benefits 
from regulatory actions that would address the safety risks associated 
with rail transportation workers in safety sensitive positions who have 
OSA. The ANPRM was published jointly with the Federal Motor Carrier 
Safety Administration and requested similar information regarding 
highway transportation workers in safety sensitive positions and 
highway safety. This Advisory and accompanying recommended actions is 
not in response to the ANPRM; rather, it is an action concurrent with 
the ANPRM. FRA is currently reviewing the data and

[[Page 87652]]

information submitted in response to the ANPRM.

V. Passenger Terminals and Stations With Stub End Tracks

    The Hoboken accident involved NJT Train 1614 that was traversing a 
stub end track entering a passenger station at 21 mph-11 mph over the 
10 mph posted speed limit. FRA recommends identifying locations that 
have stub end tracks at passenger terminals and stations that are 
equipped with technology that can warn and enforce passenger trains to 
stop short of a stub end track and ensure they enforce applicable speed 
limits. If such locations are not equipped with technology that can 
warn and enforce passenger trains to stop short of a stub end track and 
ensure they enforce applicable speed limits, then FRA encourages 
railroads to take other operational actions to prevent trains from 
overrunning stub end tracks equipped with or without bumping posts. One 
such operational action would be to require communications between the 
engineer and other qualified employees that can take appropriate 
action, such as applying the emergency brakes, if necessary.

VI. Recommended Actions

    In light of the recent accident discussed above, and in an effort 
to ensure the safety of the Nation's railroads, their employees, and 
the general public, FRA recommends that intercity passenger and 
commuter railroads do each of the following:
    1. Instruct their employees during training classes and safety 
briefings on the importance of compliance with maximum authorized train 
speed limits and other speed restrictions when entering passenger 
stations and terminals;
    2. Not less than once every six months evaluate operational testing 
data as required by 49 CFR 217.9. A railroad should consider increasing 
the frequency of operational testing where its reviews show any non-
compliance with maximum authorized train speeds in passenger stations 
or terminals. Railroads should conduct a significant number of 
operational tests on trains required to operate into a station or 
terminal with stub end tracks;
    3. Adopt procedures requiring communication between crew members 
and the locomotive engineer before and during operation into a station 
or terminal and/or implement technology to appropriately control and/or 
stop the train short of the stub end track. These actions could 
include:
    a. Making modifications to automatic train control (ATC), cab 
signal, or other signal systems capable of providing warning and 
enforcement to ensure trains comply with applicable speed limits and 
stop short of stub end tracks;
    b. If a railroad does not utilize an ATC, cab signal, or other 
signal system capable of providing warning and enforcement at 
applicable passenger terminals and stations with stub end tracks 
platforms (or if a signal system modification would interfere with the 
implementation of PTC or is otherwise not viable), making all passenger 
train movements at the identified locations while in communication with 
a second qualified crew member. This will provide constant 
communication with the locomotive engineer and allow the second 
crewmember to take immediate appropriate action if the locomotive 
engineer is not responding or is unable to stop short of stub end 
tracks. This could also include making a safety stop at predetermined 
location and if the locomotive engineer does not make an appropriate 
safety stop the second qualified crew member can take appropriate 
action to stop the train;
    4. Review Safety Advisory 2004-04 (69 FR 58995, Oct. 1, 2004); 
Effect of Sleep Disorders on Safety of Railroad Operations, in its 
entirety with all operating crews. Recommended actions from Safety 
Advisory 2004-04 are listed below:
    a. Establish training and educational programs to inform employees 
of the potential for performance impairment as a result of fatigue, 
sleep loss, sleep deprivation, inadequate sleep quality, and working at 
odd hours, and document when employees have received the training. 
Incorporate elements that encourage self-assessment, peer-to-peer 
communication, and co-worker identification accompanied by policies 
consistent with these recommendations. The Railroaders' Guide to 
Healthy Sleep Web site (http://www.railroadersleep.org) has several 
educational resources to assist railroaders in improving their sleep 
health including an anonymous tool for self-screening for sleep 
disorders including OSA. This Web site is set up to disseminate 
educational information to railroad employees and their families about 
sleep disorders, the relevance of healthy sleep to railroad safety, and 
provide information about improving the quality of the railroaders' 
sleep. The Web site was developed in conjunction with the Division of 
Sleep Medicine at Harvard Medical School, WGBH Educational Foundation, 
and Volpe--The National Transportation Systems Center;
    b. Ensure that employees' medical examinations include assessment 
and screening for possible sleep disorders and other associated medical 
conditions (including use of appropriate checklists and records). 
Develop standardized screening tools, or a good practices guide, for 
the diagnosis, referral and treatment of sleep disorders (especially 
OSA) and other related medical conditions to be used by company paid or 
recommended physicians during routine medical examinations; and provide 
an appropriate list of certified sleep disorder centers and related 
specialists for referral when necessary;
    c. Develop and implement rules that request employees in safety-
sensitive positions to voluntarily report any sleep disorder that could 
incapacitate, or seriously impair, their performance;
    d. Develop and implement policies such that, when a railroad 
becomes aware that an employee in a safety-sensitive position has an 
incapacitating or performance-impairing medical condition related to 
sleep, the railroad prohibits that employee from performing any safety-
sensitive duties until that medical condition appropriately responds to 
treatment; and
    e. Implement policies, procedures, and any necessary agreements 
to--
    i. Promote self-reporting of sleep-related medical conditions by 
protecting the medical confidentiality of that information and 
protecting the employment relationship, provided that the employee 
complies with the recommended course of treatment;
    ii. Encourage employees with diagnosed sleep disorders to 
participate in recommended evaluation and treatment; and
    iii. Establish dispute resolution mechanisms that rapidly resolve 
any issues regarding the current fitness of employees who have reported 
sleep-related medical conditions and have cooperated in evaluation and 
prescribed treatment.
    5. Accelerate the installation of inward- and outward-facing 
cameras in passenger trains in the cab of the controlling locomotive or 
cab car operating compartment per the FAST Act. FRA notes that the FAST 
Act includes provisions on standards for the cameras, use of the 
cameras, and preservation and protection of data from the cameras.
    FRA encourages all intercity passenger and commuter railroads to 
take actions consistent with the preceding recommendations. FRA 
acknowledges that action on some of the

[[Page 87653]]

above recommendations may have already taken place by segments of the 
industry. If so, FRA recommends railroads review their current programs 
for relevancy and review the policies and procedures with all their 
operating employees.
    FRA may modify this Safety Advisory 2016-03, issue additional 
safety advisories, or take other appropriate action necessary to ensure 
the highest level of safety on the Nation's railroads, including 
pursing other corrective measures under its rail safety authority.

Robert Lauby,
Administrator for Railroad Safety Chief Safety Officer.
[FR Doc. 2016-29013 Filed 12-2-16; 8:45 am]
 BILLING CODE 4910-06-P


