Category Archives: Rail Safety

Quick response to Recommendations improves safety on Chicago’s rails

By Robert Hall

Photo credit: CTA

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.

Positive Train Control Saves Lives

By Robert Sumwalt

NTSB Most Wanted List 2014 - Implement Positive Train Control
NTSB Most Wanted List 2014 – Implement Positive Train Control

Today I had the honor of representing the NTSB at a hearing before the Subcommittee on Railroads, Pipelines, and Hazardous Materials in the U.S. House of Representatives.  The topic of the hearing was passenger and freight rail safety, an issue of the utmost importance to the NTSB.  My testimony emphasized that any comprehensive approach to improving rail safety must include Positive Train Control, also called PTC.

PTC is designed to protect trains from human error. If an engineer attempts to operate past a red signal or operate too fast, a PTC system intervenes by stopping the train before a crash or derailment occurs. Simply put, widely-implemented PTC has the potential to prevent crashes and save lives.

Sadly, there are many real-world examples that demonstrate the need for PTC.  For example, in September 2008, a Metrolink commuter train collided head-on with a Union Pacific freight train in Chatsworth, California. Twenty-five people were killed in that crash, and more than 100 more were injured. The NTSB’s investigation revealed that the engineer was texting while operating the train. He ran past a red stop signal and crashed into an oncoming train. The NTSB determined that PTC would have prevented this deadly crash.

In the aftermath of that tragedy, Congress enacted the Rail Safety Improvement Act of 2008. The Act requires each Class 1 rail carrier and each provider of regularly-scheduled intercity or commuter rail passenger service to implement a PTC system by December 31, 2015.  I’m pleased to report that progress is being made toward this lifesaving goal.  Just last week, Metrolink became the first commuter rail system to implement PTC, when it began a revenue service demonstration under the authority of BNSF Railroad. While this is just a demonstration project, it certainly is a start in the right direction. Metrolink reports it will be implementing PTC fully throughout its entire system before the Congressionally-mandated deadline.  

Earlier this month, I visited a large Class 1 freight railroad to get an update on their progress toward implementing PTC. I walked away from that meeting believing this railroad is firmly committed to the project. That one company alone has invested more than $1 billion in PTC, adding over 1000 workers to devote to the project, beginning the enormous effort of retrofitting locomotives, training train and track maintenance crews, installing trackside equipment, and developing elaborate computer networks to allow PTC to work. In spite of the commitment by this railroad and others, however, an August 2013 Government Accountability Office (GAO) report to the U.S. Senate indicated that the majority of railroads will not complete PTC implementation by the 2015 deadline.  There has even been talk of extending the deadline, despite the seven year timeline provided by the original law.

As I noted in my testimony today, while NTSB commends the enormous and costly implementation efforts being made by many, we realize that for each day that goes by without PTC, the risk of more PTC-preventable accidents remains. That point was driven home again on December 1, 2013, when a Metro-North commuter train derailed in the Bronx, killing four people and injured dozens of others. While the exact cause of the accident is still under investigation, we do know the train entered a curve at approximately 82 mph, where the maximum authorized speed was 30 mph — in other words, something that PTC would prevent.

It is because of our investigations of accidents like this – and 24 others in the past decade that could have been prevented by PTC – that the NTSB would be disappointed by any delay in PTC implementation.  Implementation of PTC is needed now, not later.  Lives depend on it.

“Snow” your love for safety: Winter storm roundup edition

Traffic snarls in Atlanta due to wintery weatherToday hasn’t been a good day for traveling on the east coast, but there’s good news on the transportation safety front nonetheless.

The Port Authority of NY & NJ has announced weekend closures of two PATH stations in order to install Positive Train Control technology on the lines. NTSB has long been advocating for PTC implementation, and the issue is again on our Most Wanted List. We’re encouraged to see the steps PATH and other rail operators are taking to implement PTC systems and to make rail travel safer.

The National Safety Council released its preliminary estimate of 2013 motor vehicle fatalities, and their analysis shows a 3% decline in fatalities from 2012. Every decline in fatalities is a step toward reaching zero, but as NSC notes, more than 90% of crashes are due to human error and ultimately preventable, which is why NTSB includes eliminating both distraction and substance-impaired driving on our Most Wanted List.


Safety Requires Constant Vigilance

By Debbie Hersman

Chairman Hersman at teh unveiling of the WMATA's new 7000 series railcarOn June 22, 2009, during the afternoon rush-hour, an inbound Washington Metropolitan Area Transit Authority (WMATA) Metrorail train struck the rear of a stopped Metrorail train near Fort Totten. This wasn’t the first WMATA accident where the NTSB had identified concerns about the crashworthiness of the older cars in the fleet. In fact, it was third – the first accident occurred at Shady Grove in 1996, and the second accident took place at the Woodley Park Station in 2004.

However, the 2009 accident was a watershed moment for WMATA leadership, the policy-makers on Capitol Hill and the commuters that ride Metro every day. The subsequent NTSB investigation revealed a lack of safety culture, ineffective safety oversight by the WMATA Board of Directors and Tri-State Oversight Committee, and lack of federal oversight authority for the Federal Transit Administration. From this investigation, the NTSB issued 19 safety recommendations to WMATA addressing everything from the technical malfunction that caused the train control system to fail to maintain train separation to WMATA’s maintenance programs to necessary steps for creating a stronger safety culture.

WMATA has implemented ten of the 19 recommendations and is working to complete action on the remaining open recommendations. An example of a closed recommendation involves the reconstitution of WMATA’s Standing Safety Executive committee, now the Executive Safety Committee, which meets monthly to review all audits, major accidents, and open corrective action plans as well as any safety concerns arising from departmental level or local safety committee meetings. An example of an open recommendation that remains in progress involves an agreement reached this past summer, between WMATA management and employees, to implement a pilot non-punitive reporting system – this is a positive step in creating a safety culture that encourages communication between employees at all levels without fear of reprisal.

Yesterday, many safety and political leaders, along with the public, had the privilege of seeing WMATA’s most recent railcar design – the 7000 series railcars. This railcar incorporates safety features that were recommended as a result of past NTSB investigations. It includes improved crashworthiness features, exterior emergency door access and crash hardened event recorders. Soon, WMATA will phase out its oldest railcars, the 1000 series, with these more modern railcars, which afford greater protection to the commuters and tourists riding WMATA Metrorail every day. Obtaining the funding for these cars was no small feat and many local and national leaders deserve recognition for making this a reality. The team at Metro often has difficult days, but seeing these new test cars reminds us that in spite of the challenges they face, many different organizations and individuals chose to invest in the safety and reliability of our national transit backbone, reaffirming its value to the entire metropolitan community.

It is human nature to grow comfortable over time with repetitive tasks. Think about the last time you commuted home from work; you may not even remember the trip. Safety, however, requires constant vigilance. The NTSB has seen time and again how transportation providers are literally shocked by accidents and recognize that the cause was really a chain of events tied to a lack of vigilance. Preventing the next accident is the paramount desire, but when tragedy strikes, individuals and organizations have a choice in how they respond. I commend WMATA for engaging in a self-evaluation process and choosing to take productive action to address identified shortcomings.

Working on the Rails

By Debbie Hersman

NTSB Investigators at rail accidentWhether you are taking the subway two stops or Amtrak across the country this holiday season, think about the workers who keep the trains running. And remember those who won’t be coming home for Christmas this year.

Today, the NTSB issued urgent recommendations intended to protect track workers from their own trains. This was in response to our ongoing investigation into the deaths of two track workers in the San Francisco area in October, (as well as several other investigations on properties from Washington, D.C. to Boston).

When the two workers were struck and killed on October 19 in Walnut Creek, Calif., BART used a “simple approval” process to authorize employees to enter the train roadway. This simple process put the burden on workers to look out for trains and “provide their own protection and not interfere with mainline/yard operations.” BART has since eliminated the practice.

The NTSB recommendations strongly urge the FTA to issue directives to all transit agencies to improve the safety protections for roadway workers. The first recommendation asks FTA to require redundant protection for railway right-of-way workers such as positive train control, secondary warning devices, or the use of a shunt—a safety device that workers attach to rails that results in approaching trains receiving a stop signal. The second recommendation urges a directive to require transit agencies to review wayside worker rules and procedures to eliminate any work authorization that depends solely on the roadway worker to provide protection from trains and moving equipment.

The BART workers were not the first – and won’t be the last– track workers to be killed. Since 2006, the NTSB has investigated three fatal events on the Washington Metropolitan Area Transit Authority, another involving fatalities on the Massachusetts Bay Transportation Authority, and earlier this year a fatal accident involving a track worker for Metro-North Railroad.

Other industries have redundant protections for their workers, such as fall protection for those working above the ground and lock-out/tag-out protections for those working with high energy sources.

Having redundant protection measures in place for track workers is not only a best practice but common sense. After all, a positive safety culture is not a solo act.