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.
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.
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.
Each year, Operation Lifesaver, Inc., spearheads Rail Safety Week. For 2021, Rail Safety Week runs from September 20 through 26. Operation Lifesaver and its safety partners across North America, including the NTSB, use this annual event to educate and empower the public to make safe decisions around trains and tracks and to raise awareness of the need for rail safety education.
Federal Railroad Administration (FRA) data show there were 756 total fatalities on US railroads in 2020. Most of these deaths occurred in highway–rail grade crossing and trespassing incidents. Public awareness and outreach efforts are important because, tragically, hundreds of people are fatally struck by trains in preventable collisions.
I have an especially strong interest in rail safety because, in the early 1950s, my grandfather was struck and killed in a highway–rail grade crossing crash. My grandfather was a volunteer firefighter. He and a colleague were on a call when the collision occurred. The tragedy had a devastating impact on my mother and her family. My mother was a high school student at the time, and the loss of her father changed the course of her life.
At a highway–rail grade crossing, it is our responsibility, as road users, to stop for train traffic. Trains have the right of way and will pass through the crossing without stopping for road traffic. There are two types of grade crossings. At passive crossings, signage will warn road users to be vigilant when crossing tracks and to look for oncoming trains. In more populated areas, you may be more likely to encounter active crossings, which are typically equipped with flashing lights, audible alarms, and automatic gates that warn of an approaching train. When warnings are activated at a crossing, the appropriate and safe action is to stop and wait. Trains are faster than they seem, and they don’t stop on a dime. The average freight train traveling at 55 mph can take a mile or more to stop.
So, what should you do if your vehicle becomes stuck on the tracks at a grade crossing? First, get out of your car. Then, call the number on the Emergency Notification System (ENS) sign posted near the crossing. These blue-and-white signs include a number to call and a US Department of Transportation crossing identification number. If you cannot find the sign, simply call 911. Additional information is included in this brief video produced by Operation Lifesaver. Also, the FRA developed its Crossing Locator App to help you find and call the ENS in case of an emergency or if you have a safety concern about a specific highway–rail grade crossing.
Too often, those who are struck and killed by trains near or on the tracks could have avoided putting their lives in such perilous danger. According to the FRA, more than 400 trespass fatalities occur each year, and the vast majority of them are preventable. An especially tragic example is highlighted in our investigation of a 2014 trespassing accident that involved a film crew near Jesup, Georgia, that was filming on a rail bridge without authorization when a freight train passed. One crewmember was killed, and six others were injured as a result of this preventable accident.
Whether you are taking a shortcut by crossing railroad tracks, or jogging, taking pictures (selfies included), fishing, or riding a recreational off-road vehicle, on or around tracks, you put yourself in imminent danger.
Remember, trains are faster and quieter than you think. They can’t stop quickly. They can’t swerve. They are enormously powerful machines and taking a chance on a collision with a train is risky business.
During this year’s Rail Safety Week, all of us at the NTSB join our friends at Operation Lifesaver in their mission to save lives around railroad tracks and trains. Here’s how you can do your part.
Know the signs.
Make good decisions.
Talk to your loved ones about rail safety.
Together, we can STOP track tragedies. See tracks? Think train.
I guess it all started on an overcast day in 1973, when I found myself on the scene of a fatal aviation crash for the first time. I had heard of the crash on my car radio, and, as a curious 17‑year-old, I decided to find the crash location. Once there, I saw the remains of a twin-engine airplane lodged in the bases of the surrounding pine trees. Seeing that accident scene sparked an acute interest within me for accident investigation. In college, I spent copious amounts of time in the government documents library reading NTSB aircraft accident reports. It was then, in the mid-1970s, that I began to dream of becoming an NTSB Board member. Today, as I wrap up 15 years with the agency, serving as Board member, vice chairman, and chairman, I can look back and say I have truly lived that dream.
I was sworn in as the 37th member of the NTSB in August 2006. Seven days later, I found myself on the scene of another aviation disaster. Comair flight 5191, a regional jet operated as a Delta Connection, crashed just off the departure end of a runway in Lexington, Kentucky. Forty-nine lives were lost that morning after the pilots inexplicitly attempted to take off on a short, closed, unlighted runway. The investigation found that the pilots’ casual attitude during preflight and during the brief taxi, including their engaging in nonpertinent conversation, enabled the crew’s errors. Quite simply, the crew wasn’t paying attention and lost positional awareness. As a result, we issued and reiterated several recommendations to prevent that same type of accident. Today, flights are safer because airline pilots use enhanced procedures to ensure they are aligned with the proper runway before departure, and pilots have electronic maps that provide real-time position information during taxi.
Since the Comair crash, I’ve been on the NTSB Go-Team and served as the Board member on scene for 35 transportation accidents and crashes, and I’ve been involved in the deliberation and determination of probable cause of over 250 accidents and crashes. I’ve met with grieving family members and friends of victims on the worst day of their lives. Through these interactions, the one thing that really stands out to me is just how precious life really is. I’ve often said that we are here to give a voice to those who don’t have a voice—the victims of transportation accidents and their families. I take great solace knowing our work really does make a difference and keeps others from enduring similar tragedies.
Looking back, I believe there are two things that allow the NTSB to truly be one of the “Best Places to Work in the Federal Government,” as ranked by the Partnership for Public Service: the agency’s mission, and our people.
First, the agency’s mission: Congress charged the NTSB with investigating transportation accidents and crashes, determining their cause, and issuing safety recommendations to prevent similar accidents and crashes, reduce injuries, and save lives. It’s an important calling—taking something tragic and learning from it so others don’t have to endure such a tragedy. Since the NTSB was formed in 1967, we have investigated over 150,000 aviation accidents, along with thousands of highway, marine, rail, pipeline, and hazardous materials accidents and incidents. In that period, we’ve issued over 15,000 safety recommendations, the majority of which have been successfully implemented.
Our people: Even with a respectable mission, you’re nothing without great people. Fortunately, this is where the NTSB really takes the cake. We’re able to attract and retain dedicated, bright employees who love their work. We actively promote diversity and inclusion, and my hope is that the agency will continue to expand this effort. Our investigators’ passion and determination to find the truth is uplifting. Even throughout the pandemic, although working remotely, NTSB employees found ways to continue delivering our high-quality products. For example, before the pandemic, we had never conducted virtual Board meetings, where we deliberate accident findings, determine the probable cause, and adopt safety recommendations. Even with the challenges of 2020, our employees figured a way to get it done. We held 12 virtual Board meetings in a year, which compares favorably to a normal year of in-person meetings. Although I’ve always had high expectations of the NTSB workforce, I can honestly say that, considering the challenges we all faced during the pandemic, NTSB employees surpassed all expectations.
There are several other qualities that allow the NTSB to be a highly respected federal agency. One of our core values is transparency; we are open and honest with the public about our work. We realize that, when a transportation disaster occurs, the public needs to be assured that the government is conducting an open, competent, and thorough investigation. Therefore, we deliver fact-based information as we learn it. We don’t speculate—just the facts, ma’am. All NTSB Board meetings and hearings are open to the public (literally in person when not in pandemic times, and always via webcast). We post all our accident reports and publications on our website, along with the docket for each accident, which provides reams of background information such as interviews, photos, and technical information that may not be in the final accident report.
When I was sworn in for my first term at the agency in 2006, I told the audience something I had read: “Public service is one of the highest callings in the land. You have the opportunity to make a positive impact on families, communities, states, and sometimes the world.”
I followed up by saying, “I truly believe this statement applies so well to the work of the NTSB. When my term expires, I hope we can look back and say, ‘you know, we—Board members, professional staff, industry, labor, government—we all worked together, and we did make a positive impact.”
Indeed, looking back, I truly believe we have made a difference.
I will very much miss working with the incredibly dedicated men and women of the NTSB. It will be hard to stop referring to the NTSB as “we.” Although I will no longer be part of it, the NTSB will always be part of me. For that privilege, I am forever proud and grateful. I have lived my dream.
After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country!
PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than 300 people, and injured more than 6,800 passengers, crewmembers, and track workers in major accidents stretching across the nation, from Darien, Connecticut, in 1969, to Chatsworth, California, in 2008, to Philadelphia, Pennsylvania, in 2015, and DuPont, Washington, in 2017.
But let’s step back and marvel at this real achievement—and the effort it took. Safety improvements are never easy or quick. It took more than 50 years of advocacy by the NTSB and historic action by Congress to make PTC a reality. For many of these years, the NTSB was a lonely voice for safety, pushing for PTC despite opposition from railroads over the price tag and technological hurdles.
I know how tough the battle was because I was there. As staff director for the House subcommittee charged with overseeing rail safety, I played a role in ensuring that any effort to move legislation forward to improve rail safety included the NTSB’s recommendation to implement PTC. When I got to the NTSB, one of my priorities was to ensure that mandate was implemented.
It truly is remarkable in Washington to keep such clear focus on PTC across so many administrations, through so many changes in Congress and at the NTSB.
Earlier this month, I had the honor of moderating a panel of current and former NTSB leaders and staff who recalled the long, bumpy road to PTC implementation. NTSB Chairman Robert Sumwalt and former agency heads Chris Hart, Debbie Hersman, and Jim Hall recalled their own contributions and noted how remarkable the agency’s sheer persistence was in a time of short attention spans and quickly changing priorities.
It was so uplifting to hear their personal reflections of their time on the Board fighting for PTC, and their continued commitment to the agency and its critical safety mission. But it was the staff panel that really defined persistence. Generations of rail investigators and other staff worked every one of the 154 PTC-preventable accidents over the decades, launching to horrific crash scenes only to discover similarities pointing to the same solution: PTC. They spent holidays working. Missed birthdays and anniversaries. Completed their important jobs regardless of on-scene obstacles and personal priorities.
The public doesn’t often see what goes on behind the scenes at accident investigations, after investigations are completed when recommendations need to be implemented, and the tremendous work required to keep those recommendations at the forefront of discussions to improve safety. As stated in the first panel, board members come and go, but it’s the staff that keep these critical safety issues alive. It was truly remarkable and heartwarming to hear their reflections of the agency’s work and how that work has impacted public safety, as well as how it affected them personally. I hope it gave the public a sense of what it takes to stay focused on an issue for five full decades.
Was it worth it? You bet. PTC will save lives.
Other safety improvements have also taken many years to implement. Midair collisions were dramatically reduced by the Traffic Alert and Collision Avoidance System (TCAS). That took decades to put in place. Airliner fuel-tank inerting systems, which addressed fuel tank explosions like the one that brought down TWA Flight 800 in 1996, also took years. And let’s not forget about the long fight for airbags and seat belts in passenger vehicles. All these transportation safety improvements were strongly and relentlessly advocated for by the NTSB.
We can do big things in America. We can save more lives on our rails, in the sky, in communities where pipelines are located, on the water, and on the highway. But major safety improvements like PTC take time, money and, perhaps most of all, incredible perseverance.