Earlier this week, the NTSB met to consider the draft report on an accident at Miami International Airport (MIA). On November 28, 2008, a three-car people mover train operating along a fixed guideway failed to stop at the passenger platform and struck a wall at the end of the guideway. Six people were injured.
What happened? This accident occurred because the primary stopping mechanism failed and maintenance technicians had intentionally bypassed the secondary fail-safe system. Yet, as in so many accidents that the NTSB investigates other factors contributed to the accident. In this case, one key element was the absence of effective external oversight.
External safety oversight of public transportation systems is essential to identify and correct safety risks that may not be apparent or effectively addressed by the operator. External oversight at MIA could have detected that the maintenance company did not have formalized maintenance procedures, which allowed the trains to operate without a vital backup safety system.
Effective oversight becomes more critical as our transportation infrastructure ages. In the case of the Miami airport people mover, the train system was installed in 1980. Furthermore, the previous maintenance company expressed concerns that the trains were past their design life. We have seen the challenges of maintaining aging infrastructure in many of our investigations, including the June 2009 collision of two Washington Metro trains near the Fort Totten Station. With old and new infrastructure, we will always need proper maintenance and oversight to confirm that the system is performing to the highest safety standards.
Do you know what union station means? It’s a train station where tracks and facilities are shared by two or more railway companies allowing for more convenient passenger connections. While New York City has Pennsylvania Station and Grand Central Station, here in Washington it’s Union Station.
One-hundred and fifty-eight years ago today, on Sept. 20, 1853, the Indianapolis Union Railway opened the world’s first union station in the Wholesale District of Indianapolis. The idea was to address the growing number of competing railroads building their own stations within the city, which created problems for transferring both passengers and freight. I wonder if they knew then how integral rail transportation and these “union stations” would be to the growth of our nation and economy.
Indianapolis continues to play an important role in our nation’s rail transportation system. Today, Amtrak provides intercity rail passenger service at the historic Union Station. In addition, Indianapolis is also a hub for freight rail. The city is currently served by two Class I railroads – CSX and Norfolk Southern – and four short lines – Indiana Railroad Co., Indiana Southern, Louisville & Indiana Rail, and Central Railroad of Indiana. These freight railroads carry on the railroad tradition of helping drive our nation’s economic engine by safely and efficiently moving goods and materials to manufacturers and consumers.
I was delighted to be at the luncheon earlier this year when Norfolk Southern and CSX were recognized for their outstanding safety performance at the 2010 E. H. Harriman Awards, the nation’s top railway safety recognition program. Norfolk Southern received the Gold Award for the 22nd year in a row and CSX received the Silver Award.
Stephen Klejst is Director, Office of Railroad, Pipeline and Hazardous Materials Investigations.
The weekend is almost here, and by the end of the workweek, you may be feeling a little fatigued. Having enough time away from the office to rest is critical to performing well at work, and it is all the more important when that work involves transporting people on complex machines like trains and planes.
Earlier this month, the Federal Railroad Administration issued its final rule on hours of service for employees providing commuter and intercity rail passenger transportation. The product of several working group and task force meetings, it took less than 6 months to move from proposed to final rule. I was encouraged to see the FRA move forward with a significant change, so quickly.
Unfortunately, the Federal Aviation Administration’s efforts to establish new hours of service regulations have not met with similar good fortune. The FAA was on track to issue a final rule very close to the legislatively mandated deadline of August 1. As proposed, the rule would take into consideration key factors such as workload and time-zone changes, address the challenges of nighttime operations, and redefine off-duty time to give flight crews a better chance of sufficient rest. Moreover, it included provisions for other methods for addressing fatigue if a company’s special operations and needs made compliance with the prescribed methods unfeasible. As we noted in our comments to this proposal, “Implementation of the proposed revisions will represent a significant improvement in the regulations to prevent flight crew fatigue in Part 121 operations.”
It’s regrettable that we don’t have a final rule because some special interests are opposed to working within this proposed system for addressing fatigue and improving safety. The FAA deserves much credit for its hard work! But like a long work day, time is not our friend. I hope that the roadblocks that are preventing the FAA from finalizing this rule will be eliminated very soon.
Today, the railroad industry marks a 197th anniversary. On July 25, 1814, English engineer George Stephenson demonstrated the first steam locomotive. Stephenson did not invent the steam engine, but he developed the technology to move steam engines from hauling coalmining carts to powering the first form of commercial rapid transportation. Previously, the horse-drawn carriage was the fastest means of land travel. Now, two centuries later, railroads are essential to our lives.
Stephenson may have revolutionized land travel, but he also unwittingly introduced a new kind of transportation danger. On the maiden voyage of Stephenson’s rail line from Liverpool to Manchester, a Member of Parliament and one of several dignitaries on the train, William Huskisson, climbed onto the tracks to talk with the Prime Minister during a refueling stop. Another train pulling into the station on the same rail struck Huskisson. It may seem incredible today, but those early locomotives had no brakes. Stephenson unhooked the passenger cars from one of his trains and personally rushed Huskisson to medical attention. Without the extra weight of the passenger cars, the unburdened train was able to reach an astonishing 40 mph, then a world speed record. Unfortunately, that speed was not enough to save Huskisson, who later died of his injuries.
The Huskisson accident was the first of many. As Chairman Hersman pointed out in a speech at the U.S. railroad industry’s annual Harriman Awards, by the early 20th century, 48 percent of all deaths in the United States happened on railroads. At the turn of that century, lack of safety was an accepted cost of innovation. Today, safety is a goal of innovation. Railroads are investing in new safety technologies, such as positive train control, which gathers data about the positions of trains relative to each other, and automatically stops a train if another train is approaching on the same rail. What is good is that there are many 21st century innovators like George Stephenson, who are working to make trains better and safer.
James Southworth is the Railroad Division Chief in NTSB’s Office of Railroad, Pipeline and Hazardous Materials Investigations.
Every year, the NTSB, like many other federal agencies, prepares an annual report to Congress about our activities during the previous year. We submitted our 2010 report on June 24, detailing our many significant accomplishments across all transportation modes. During 2010, we:
launched to over 200 accidents, including launches to six major accidents;
issued 227 safety recommendations (170 in aviation, 18 in highway, 25 in railroad, 7 in marine, and 7 in pipeline);
closed 132 safety recommendations in an acceptable status;
held 5 public forums on fishing vessel safety, aging drivers, child passenger safety in the air and in automobiles, professionalism in aviation and aviation code sharing arrangements.
The accomplishments outlined in the report were realized in no small part due to our employees’ dedication to the goals of accountability, integrity, and transparency. We’re a small agency, but what we lack in numbers, we more than make up for in teamwork and a desire to leave no stone unturned in arriving at the correct probable cause of an accident or incident. Of equal importance are our safety recommendations, which stem from our investigations of accidents and incidents. Every recommendation we issue is based on our desire to prevent similar accidents or incidents from occurring in the future. I am very proud to serve as the Chairman of this remarkable agency, and I am equally proud of our mission and of the dedicated and professional employees who work to make transportation safer for all. The 2010 Annual Report may be viewed at the following link: http://www.ntsb.gov/doclib/agency_reports/2010AnnualReport.pdf.
Two years ago today, nine people lost their lives when two Washington, DC, Metro trains collided. In our accident report issued a year after the crash, the NTSB cited the failure of track circuit as the probable cause of the accident. But just as troubling as that failure was, our investigation also revealed a systemic breakdown of safety management at all levels at Metro.
Safety management is essential in transportation organizations. A robust safety management system, or SMS, helps organizations identify deficiencies and address them before they result in an accident. In addition, the discipline and standardization of an SMS sets the stage for a positive safety culture, in which employees are encouraged, even rewarded, for providing essential safety-related information. Such a safety culture would have made a huge difference at Metro.
Today is the anniversary of a very sad day for those who lost family and friends in the accident near Fort Totten and it reminds us that we cannot forget the lessons learned in the aftermath of that tragedy. Although more work needs to be done, General Manager Richard Sarles and the new Metro Board of Directors have committed to implementing all of the NTSB’s recommendations. We look forward to the day when that happens.
Today, I was pleased to attend the annual Harriman Awards luncheon. These awards recognize the U.S. railroads with the lowest employee injury rates. Congratulations to Norfolk Southern, which claimed its 22nd consecutive gold medal, and to KCS, which received its fifth straight Harriman Award for its category. The Buffalo & Pittsburgh and Gary Railway claimed the top honors in their categories.
In March, I attended Norfolk Southern’s Safety Expo and Awards and visited its export coal operations. I saw stenciled on a railroad shed: “think safe, work safe, home safe.” Yet, safety is more than a slogan at Norfolk Southern. It is a vigorous and mature safety program as well as 22 consecutive Harriman Awards.
This was the 99th year for the Harriman Awards, which started in 1913 when tens of thousands of workers, passengers, pedestrians, and assorted ‘trespassers’ perished in railroad accidents. The railroads have come a long way in safety — from thousands killed on the job a century ago to an annual average of 20 employee-on-duty fatalities over the past ten years.
Yet, as I told the luncheon audience, as we saw last month outside Red Oak, Iowa — when a train collided into a maintenance-of-way equipment train and killed two railway workers — there is more work to do, especially in addressing the human element. It’s important to always be vigilant and to never stop working on safety improvements.