By Robert Hall
In our almost 50-year history, the NTSB has issued 13,945 safety recommendations. Admittedly, sometimes the recommendations go unaddressed. Most of the time, however, changes are made and safety is improved. In fact, of the 13,945 safety recommendations, only 2,077 (about 18 percent) have not been implemented.
Here’s a story about two recommendations and the quick response from the recipient. On September 30, 2013 during rush hour, an unoccupied Chicago Transit Authority (CTA) train collided with a CTA train in revenue service carrying about 40 passengers. Although 2 CTA employees and 33 passengers were transported to local hospitals, all were treated and released, and thankfully no one died.
Very early in our investigation, we learned that the unoccupied train had been stored at a terminal awaiting repairs when it began moving under power and entered main line track. Despite repeated attempts by the automated system to apply brakes when the train passed a stop signal, the train resumed each time because the master lever on the operator console had been left in a setting that allowed the train car brakes to recover and reset from the emergency brake application and proceed through a mechanical train stop mechanism after a momentary stop.
On October 4, we issued two urgent safety recommendations addressing the need for redundant protection to prevent unintended train movements. Less than one month later, the CTA released three Rail Operations Service Bulletins and one Rail Maintenance General Bulletin as an expedient means to safeguard against future occurrences. By December 5, the CTA had fully implemented policies requiring that all unmanned consists are shut down and the motor cabs secured to ensure that unoccupied CTA trains are not powered up while stored or on hold for service and to ensure that the propulsion and brake systems are left in a condition that would not facilitate unintended movement. The CTA would also now mandate the use of wheel chocks and other operating safeguards against unintended train movements. Moreover, the CTA had identified 39 locations at 10 yards where the CTA would install derails to prevent unintended movement on to main lines.
Our investigation into the cause of the accident is ongoing, but we have learned in almost 50 years of investigations that often a series of events leads to an accident and multiple opportunities to improve safety exist. The CTA didn’t hesitate when presented with the facts, and Chicago is safer.
Robert Hall is the Director of the Office of Railroad, Pipeline and Hazardous Materials Investigations.