Category Archives: Rail Safety

Improving Safety in the Second-Largest Continent

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

In August, 2019, I wrote that Safe Skies for Africa was ending, but that the safety journey would go on in Africa, the world’s second-largest and second-most-populous continent. Earlier this month, it was my pleasure to represent the NTSB in a presentation about best practices in safety advocacy at the Civil Aviation Operational Safety Workshop in Cape Verde.

The occasion was Aviation Safety Week, which gathered together transportation safety leaders from seven African nations, the EU, and the United States to share safety knowledge. Attendees were interested to learn from my presentation that in the United States, the accident investigator—the NTSB—has no power whatsoever to require change.

Enter Advocacy.

It’s been said that information + persuasion = advocacy. The idea is never to misrepresent; rather, it is to present information that makes the case most compellingly. If the case is compelling enough, your advocacy might inspire people to act. Then, they might influence others to act as well, creating a critical force multiplier. I spoke to my audience about advocacy methodology, messaging, and tools, and the absolute need for collaboration, working with and through others. I reminded my audience, though, that advocacy differs with the context and the organization. At the NTSB, for example, it’s the one way we can bring about change and encourage implementation of our recommendations. However, I urged safety leaders in Africa to be mindful that all advocacy is local. What might work in the United States might not necessarily work for all of Africa.

Ultimately, wherever it is done, advocacy done right moves the needle toward saving lives. As transportation safety leaders, I told my audience, we must communicate our work to gain the desired impact and outcomes. We must be proactive and go to our audience, not sit back waiting for them to come to us.

It was an honor addressing these passionate transportation safety leaders from the African region. We should always remember that our transportation safety work crosses air, land, and sea. When we share our lessons learned and best practices, and when others share theirs with us, we may save lives not just nationally, but globally, as well.

The 2021-2022 MWL After One Year: Noticeable Progress But Few Closed Recommendations

By Kathryn Catania, Acting Director, NTSB Office of Safety Recommendations and Communications

Since the unveiling a year ago of the 2021-2022 cycle of the NTSB’s Most Wanted List of Transportation Safety Improvements, we have seen increased awareness and discussion of safety items, high levels of engagement from the public, and incremental progress toward implementation of many recommendations.

In the past year, the NTSB has already successfully closed eight safety recommendations associated with this MWL cycle. But that is not enough. There are 167 other key recommendations that, if implemented, would save lives, and prevent injuries.

Soon after the unveiling of the MWL last year, NTSB Board members and staff sprang into action to educate, engage, and amplify the critical safety messages of our 10 safety improvements. Here’s a quick look by mode, starting with Highway, which makes up 5 of our 10 safety improvements. 

Highway

In recent years, we have increasingly expressed our highway safety goals in the language of the Safe System Approach—the very approach that we use in our own safety investigations. (We first discussed the approach in our 2017 report on reducing speeding.)

The Safe System Approach views every aspect of the crash as an opportunity to interrupt the series of events leading to it, and an opportunity to mitigate the harm that the crash does. People make mistakes, but safe roads, safe vehicles, safe road users, safe speeds, and post-crash care can combine to prevent the crash entirely, or failing that, to prevent the deaths or serious injuries of road users.

This paradigm shift applies to each of the highway safety improvements on the MWL, and is mentioned by name in “Protect Vulnerable Road Users Through a Safe System Approach,”

Between May 2021 and February 2022, we produced seven virtual roundtables to explain the approach and call for its adoption.  National and international experts discussed the approach and shared their successes and challenges. More than 1,000 advocates, regulators, academics, and others attended our webinars.

Included in the series hosted by Chair Homendy was a Safe Speeds Roundtable that explored the “Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes” safety improvement. Additionally, a “Behind the Scene @NTSB” podcast featured discussion on speeding and vulnerable road users.

In 2021, the Department of Transportation and Congress incorporated the approach into the DOT’s National Roadway Safety Strategy and the Infrastructure Investment and Jobs Act, respectively.

Will the new model result in lifesaving protections? Only final, and positive, closure of our recommendations will answer that. But the signs are very good, with the alignment of Congress, the DOT, and the road safety community.

Our MWL safety improvement, “Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles,” could result in far superior situational awareness on our roads… if sufficient spectrum is available for the safety improvement.

Vehicle to everything (V2X) technology can save lives but has been delayed, and might be reduced or stopped, due to FCC rulings limiting the spectrum for safety operations. We released a four-part video series in which Member Graham interviewed some of the leading experts in V2X technologies—including academics, researchers, automakers, and policymakers—to discuss what can be done to find a way forward to deployment. 

In progress toward Eliminating Distracted Driving,  Vice Chairman Landsberg and staff joined government officials, industry, academia, insurers, and transportation safety advocates to announce the launch of a new National Distracted Driving Coalition. This is the first such broad national coalition on distracted driving.

We kept working with states considering lowering their BAC limit from .08 to .05 or lower, to help Prevent Alcohol- and Other Drug-Impairment. The National Highway Traffic Safety Administration (NHTSA) has now evaluated the results from Utah, which has made the change to .05. Not surprisingly, the lower threshold prevented drinking and driving and saved lives. NHTSA’s study showed that the state’s fatal crash rate dropped by 19.8% in 2019, the first year under the lower legal limit, and the fatality rate decreased by 18.3%.

Aviation

To highlight our two aviation MWL safety items, “Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations” and “​Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs,” we met with operators and pilots from the Helicopter Association International, General Aviation Manufacturers Association, and National Business Aviation Association, among others. In webinars, podcasts, and at in-person national conferences, Board members talked with Part 135 and Part 91 operators and pilots to identify challenges. Our outreach meetings alone reached more than 1,500 operators nationwide.

Marine

With an increasing number of deadly fishing vessel accidents in recent years, Office of Marine Safety Director Morgan Turrell and Chair Homendy hosted a virtual roundtable on improving fishing vessel safety that was viewed by over 1,000 people. Panelists discussed what can be done to address commercial fishing safety, implement NTSB safety recommendations, and improve the safety of fishing operations in the United States.

Pipeline and Hazardous Materials

Our MWL calls for pipeline and hazardous materials (hazmat) stakeholders to “Improve Pipeline Leak Detection and Mitigation” by equipping all pipeline systems with leak-detection systems and automatic shutoff or remote-control valves. These valves allow for quick detection and mitigation.

Additionally, we produced a video featuring Member Michael Graham and Hazardous Materials Investigator Rachael Gunaratnam, which explores cases in which odorants failed as a natural gas leak-detection strategy, and promotes both required natural gas leak detectors, and voluntary adoption of such detectors until they are required.

Rail

To highlight the dangers to rail roadway workers and to help Improve Rail Worker Safety, Member Tom Chapman wrote a blog on rail worker safety, discussing how the railroad regulators—the Federal Railroad Administration (FRA), the Federal Transit Administration (FTA), and the Pipeline and Hazardous Material Safety Administration (PHMSA)— are in the best position to make change.

We also completed our investigation of the April 24, 2018, accident in which an Amtrak rail watchman was killed in Bowie, Maryland. As a result of this investigation, we called on the FRA and Amtrak to put an immediate end to the use of train approach warning (TAW) systems as the sole method of on-track safety in areas covered by positive train control.

To mark the anniversary of the January 2017 train collision in Edgemont, South Dakota, we also issued a media statement again urging railroads to act to better protect rail roadway workers.

Looking ahead

We are pleased by the engagement of so many of our safety advocacy partners, industry groups, and associations in the past year, to promote our recommendations and highlight transportation safety concerns. Also, we acknowledge that many industry groups and operators are making voluntary efforts to improve safety, including on some of our recommendations. However, without mandates, many others may not act.

We remain disappointed by the lack of movement by regulators to implement the safety recommendations associated with our MWL. While there has been some progress during this first year, much more needs to be done to implement the 167 remaining safety recommendations associated with the current list. The longer these authorities wait to implement our recommendations, the greater the risk to the traveling public. Safety delayed is safety denied.

The NTSB will not stand by quietly and watch as regulators, industry, and other recommendation recipients ignore and dismiss our safety recommendations—and neither should the public. As NTSB Chair Homendy expressed in recent remarks to the largest highway safety gathering in the U.S, “The horrific toll of people who’ve died on our roads and their families… millions of people who were injured… are counting on us to “fight like hell” for the next family. To give a voice to those who no longer have one.” 

All our lives are on the line, and no death in transportation is acceptable. It is our mission to advocate for the changes outlined in our safety recommendations which, if implemented, will save lives.

Safety is a shared responsibility. We all play a role in getting us to zero transportation deaths. The NTSB cannot do this alone. We need each of you, individually and collectively, to help us advocate for these critical safety improvements.

A New Year’s Resolution We All Can Make: Prioritize Safety

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the safety of our transportation system in 2022.

The NTSB recognizes the need for improvements in all modes of transportation–on the roads, rails, waterways, pipelines, and in the sky. Our 2021–2022 NTSB Most Wanted List of Transportation Safety Improvements (MWL), released in April this year, highlights the transportation safety improvements we believe are needed now to prevent accidents and crashes, reduce injuries, and save lives. We use the list to focus our advocacy efforts and to serve as an important call to action. We ask lawmakers, industry, advocacy, community organizations, and the traveling public to act and champion safety.

As a fellow safety advocate, I ask you to join me in a New Year’s resolution: I pledge to do my part to make transportation safer for all.

To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:

  1. Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations
  1. Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs
  1. Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes
  1. Protect Vulnerable Road Users through a Safe System Approach 
  1. Prevent Alcohol- and Other Drug-Impaired Driving
  1. Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles
  1. Eliminate Distracted Driving
  1. Improve Passenger and Fishing Vessel Safety
  1. Improve Pipeline Leak Detection and Mitigation
  1. Improve Rail Worker Safety

Achieving these improvements is possible; otherwise, they wouldn’t be on our list. The NTSB MWL includes tangible changes and solutions that will, undoubtedly, save lives. But it’s only words on a list if no action is taken. Unlike Times Square on New Year’s Eve, we cannot drop the ball on improvements to transportation safety. The clock is ticking, and the countdown has begun—we can’t afford to waste any more time. Make the resolution to do your part to make transportation safer for all!

In closing, I’d like to thank the transportation safety stakeholders, industry, lawmakers, and advocates we have worked with in 2021 and we look forward to working together in 2022 and beyond.

Episode 43: Improve Rail Worker Safety

In this episode of Behind-the-Scene @ NTSB, we talk with Rob Hall, Director, NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations and Railroad Accident Investigators, Tim DePaepe and Joe Gordon, about the 2021-2022 Most Wanted List safety item Improve Rail Worker Safety.

To learn more about the NTSB Most Wanted List and the Improve Rail Worker Safety item, visit our Most Wanted List web page.                                                                                                                                 

The previously released podcast episode featuring Tim DePaepe is available on our website.

The previously released podcast episode featuring Joe Gordon is available on our website.

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Improve Rail Worker Safety

By Member Tom Chapman

The Federal Railroad Administration (FRA) and the railroad industry have recently implemented new protections to make rail passenger travel and hazardous materials transportation safer. That’s great news. However, the NTSB anticipates more accidents involving passengers and the public until our safety recommendations regarding rail worker safety are implemented. Members of train crews, maintenance-of-way employees, and mechanical workers continue to be killed or injured in preventable accidents involving train or equipment movement.

Several rail workers have been struck in recent years while conducting routine maintenance, inspection, or switching operations. Other workers are vulnerable because cars carrying hazardous materials are too close to the operating cabs carrying train crew. Although rail worker fatalities have declined overall in recent years, we continue to see some recurring safety issues in our accident investigations, highlighting the need for better worker protections. Below are a few recent examples.

  • On June 10, 2017, Long Island Rail Road train 7623 approached a five-member roadway crew working on another track at the interlocking in Queens Village, New York. The foreman and three workers were inspecting and making minor repairs, and a fifth roadway worker, a lookout, was clear of the tracks, keeping pace. The lookout sounded a handheld horn, yelled at the others, and raised a disc that told the locomotive engineer to sound the train’s horn, which he did. Unfortunately, the foreman still stepped into the path of the train and was killed. The probable cause of the accident was the decision to use a train approach warning (TAW) system to protect the roadway workers on active tracks.
  • On January 17, 2017, a westbound BNSF Railway train, traveling at 35 mph, struck and killed two roadway workers, including the watchman/lookout, in Edgemont, South Dakota. The roadway work group had been cleaning snow and ice from the track switch on the main track to prepare to move a train that was to have its air brake system tested. The crew of the striking train sounded the horn and bell and applied emergency braking; however, there was no response from the roadway work group. The probable cause of this accident was the BNSF Railway roadway work group’s improper use of a TAW to provide on-track safety.
  • In several accidents, separating cars carrying hazardous materials from cars carrying crew members has been an issue, as has been the placement of DOT-111 tank cars in trains with other cars carrying flammable liquids, as I’ll describe in more detail below.

Roadway Workers

To better protect roadway workers (those who maintain the track), the Federal Railroad Administration (FRA) implemented Roadway Worker Protection Regulations in 1997. However, since then, more than 50 roadway workers have been killed on the job. Meanwhile, the Federal Transit Administration (FTA) has yet to establish any specific regulations regarding roadway worker protection.

Many of the accidents we’ve investigated have also involved train approach warning systems, which are vulnerable to human errors like miscalculating site distance and generally underestimating the time needed for workers to clear tracks. We have long been concerned with the risks of using this method as the primary form of worker protection, especially because it lacks safety redundancy. Trains travel at deceptively high speeds, and without proper warning, workers may not have enough time to react. Methods of on-track safety that keep trains and other equipment away from workers provide a higher level of protection than TAW systems, which require workers to clear the tracks prior to the arrival of trains and equipment.

Another recurrent issue that we see in our investigations involves training and scheduling practices. Industry needs to ensure that job briefings are done correctly and that procedures are in place to audit those briefings. Additionally, watchmen/lookouts should receive proper training and have the required equipment. Railroads and transit agencies must develop work schedules and limitations based on science to prevent fatigued workers from being eligible to work overtime.

Operations and Mechanical Crews

Like roadway workers, operations crews and mechanical workers have also been killed in preventable accidents. One issue requiring attention is spacing between train crews and rail cars carrying hazardous materials. Although the Pipeline and Hazardous Materials Administration (PHMSA) requires buffer cars between train crews and hazardous materials, the agency has also issued a regulatory interpretation that provides for a much shorter—and less safe—distance between hazardous materials and train crews. We believe PHMSA needs to withdraw its regulatory interpretation so railroads will be required to implement a minimum of five cars as a buffer between train crews and highly hazardous flammable material, at least until PHMSA determines the appropriate separation distance to keep train crews safe.

The Role of Regulators

Because so much in railroad safety is driven by the regulators—the FRA, the FTA, and PHMSA—they are in the best position to make change. Regulators should act expeditiously on our recommendations to establish adequate roadway worker and operations crew protections. Addressing these issues will help to ensure more preventable worker deaths are avoided.

The Role of Industry

Meanwhile, it isn’t necessary for industry to wait to protect workers. Improving training for watchmen/lookouts, for example, and more comprehensive briefings will help prevent accidents. Individual railroad workers, whether roadway workers, mechanical employees, or train crews, can learn more by reviewing NTSB railroad accident reports.

Learn More

Improve Rail Worker Safety

Long Island Rail Road Roadway Worker Fatality
Queens Village, NY | June 2017

BNSF Railway Roadway Worker Fatalities
Edgemont, SD | January 2017

Using Technology to Protect Maintenance-of-Way Employees, Amtrak/Backhoe Collision
Chester, PA | April 2016

Placement of DOT-111 Tank Cars in High-Hazard Flammable Trains and the Use of Buffer Cars for the Protection of Train Crews | December 2020