Saturday, January 06, 2018

Accidents that didn’t have to happen

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Accidents that didn’t have to happen

On Dec. 18, 2017, Amtrak 501, the first Cascades passenger train operating over the Point Defiance Bypass in Washington State, careened off the rails as it entered a 30-mph speed-restricted curve at 80 mph. The investigations into the accident’s cause may take a year, even two.

Meanwhile, unless something changes, FRA Safety Advisory 2015-03, Operational and Signal Modifications for Compliance with Maximum Authorized Passenger Train Speed and Other Speed Restrictions, which is intended to prevent these kinds of incidents and save lives, remains as the latest line of defense put forward by the rail industry’s regulator, the Federal Railroad Administration. Clearly, things went terribly wrong. However well-intended, SA 2015-03 failed to prevent yet another passenger train experiencing an overspeed derailment.

SA 2015-03 was issued following the overspeed derailment of Amtrak 188 on the Northeast Corridor at Frankford Curve in Philadelphia. Investigators will, eventually, determine what circumstances and factors caused 501 to derail. The question that should concern us all, in the meantime: If rail industry rules and practices following SA 2015-03 failed to prevent the derailment of 188 and 501, what’s to prevent yet another fatal derailment?

The big problem with FRA Safety Advisories is that they simply “recommend” that railroads undertake safety-risk mitigation actions outline in the advisory. FRA has no statutory authority to force compliance. So, what did SA 2015-03 recommend, and how did the parties involved in this train service respond?

SA 2015-03 recommended that all passenger and host railroads (paraphrased here): 1) Review a previous FRA SA on the importance of compliance with maximum authorized speeds; 2) Review the circumstances surrounding the 188 derailment; 3) Identify all locations that require speed reductions of more than 20 mph; 4) Make sure that any on-board speed enforcement technology is operable and able to enforce speed restriction compliance; 5) If there are no on-board speed enforcement technologies, require a second qualified crew member in the cab of the controlling locomotive, or that there is “constant communication” between the engineer and another crewmember in the body of the train; 6) Install additional wayside signage to alert engineers and conductors of maximum authorized speeds.

We do not know with certainty that Amtrak and Sound Transit (owner of 14.5-mile Point Defiance Bypass, the former BNSF Lakeview Subdivision) complied with 1 and 2, in the context of this train service. It appears they complied with 3, because a wayside speed restriction sign was in place, in advance of the incident curve, as recommended in item 6. That leaves us with 4 and 5. Many, if not all, Amtrak passenger locomotives are equipped with some form of Automatic Train Control (ATC) equipment that functions much like Positive Train Control (PTC). If these Amtrak locomotives had operable ATC equipment, a small investment in track circuitry on the Point Defiance Bypass by Sound Transit would have triggered the ATC system, stopping the train and preventing the derailment.

Amtrak installed ATC track circuitry on Frankford Curve after the 188 derailment. Would it not have been prudent for all the parties involved in the Point Defiance Bypass project to consider the safety risk associated with failing to install ATC track circuitry on the incident curve, before revenue passenger service began? That leaves us with item 5. According to the NTSB, the second person in the cab of the controlling locomotive was a conductor who was not yet qualified on the territory. This is very important, because an unqualified second person in the control cab represents a threat, a distraction, rather than a train speed compliance asset.

An even more striking example of the inadequacy of rail industry practices and FRA Safety Advisories to prevent human-factor-caused train collisions and derailments is SA 2004-04, Effect of Sleep Disorders on Safety of Railroad Operations. In it, FRA recommended several measures railroads should undertake to prevent train collisions caused by untreated sleep apnea. That SA was preceded by three head-on freight train collisions, attributed to untreated sleep apnea, and followed by four others, to date. Ten engineers and conductors perished in those accidents; eight others suffered non-fatal injuries. And, in spite of that SA, the engineers at the controls of three different commuter trains that recently derailed in the New York metropolitan area (one each on Metro-North, New Jersey Transit and the Long Island Rail Road), killing five and injuring more than 250, have all been diagnosed with severe OSA (obstructive sleep apnea) after the derailments occurred. NTSB has already determined that untreated OSA was the probable cause of one of these derailments, Metro-North’s Spuyten Duyvil Curve wreck, and will soon issue its findings on the other two.

Train crew fatigue and medical fitness-for-duty, including untreated OSA, have wrought death and destruction across the railroad industry for years. In recent years, at least 21 engineers and conductors working for freight railroads have lost their lives in train collisions caused by fatigue/OSA and other medical fitness-for-duty issues. Many more have suffered non-fatal injuries. Yet FRA has failed to take effective actions to address these well-known and well-documented safety risks. How is it, in light of all these deaths and injuries, that FRA has not taken action to impose medical fitness-for-duty standards, which would include fatigue and OSA, on the nation’s railroads? What more will it take?

In 2016, FRA took a small step forward on OSA when it joined the Federal Motor Carrier Safety Administration (FMCSA) in issuing an Advance Notice of Proposed Rulemaking (ANPRM) entitled Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea. A year and a half later, in August of 2017, it published a notice in the Federal Register withdrawing that proposed rulemaking, stating as follows: “The Agencies believe that current safety programs and FRA’s rulemaking addressing fatigue risk management are the appropriate avenues to address OSA.”


In that notice, FRA cites three things it has or will do to address safety risks associated with untreated OSA/medical fitness-for-duty problems:

• FRA had previously issued two Safety Advisories on OSA/medical fitness-for-duty. Many (most freight) railroads have failed to respond effectively to those advisories, and FRA has no statutory authority to compel them to do so.

• FRA’s knowledge that “several railroads” are in the process of initiating OSA diagnostics and treatment programs and their intention to monitor those programs in search of “best practices.” This offers no immediate, or even timely, relief from the safety risks associated untreated OSA/medical fitness-for-duty issues.

• The Risk Reduction Plan (RRP) provisions in the 2008 Rail Safety Improvement Act (RSIA). Who are they kidding? According to the RSIA, RRPs were supposed to be submitted to the DOT Secretary/FRA by October 2012. Five years hence, not one single RRP has been submitted, much less approved and implemented. According to the FRA website, FRA “hoped” to issue a Notice of Proposed Rulemaking (NPRM) on Risk Reduction Programs in “early 2017.” It has missed that self-imposed deadline as well.

Not to be presumptuous, but also not willing to go quietly into retirement, here are two viable options for FRA to undertake to address these safety risks:

• Re-open the rulemaking on OSA and move it through the regulatory process as fast as possible. This is a sub-optimal solution, since the public would remain at risk for whatever period of time is needed to complete and implement a regulatory solution.

• Should the NTSB find that sleep apnea was the probable cause of the NJ Transit Hoboken Terminal and/or the Long Island Rail Road Atlantic Terminal platform overruns, the timing would be right for FRA to issue an Emergency Order (EO) on OSA. Both the FAA and FMCSA have existing standards and protocols on OSA/medical fitness-for-duty that could serve as a pattern for an EO, protecting the public and railroad workers until a regulation is finalized and implemented.

There is recent precedence for such an action. Subsequent to the Metro-North Spuyten Duyvil derailment, FRA issue EO-29 ten days later on Dec. 11, 2013, stating in part, “… FRA finds that the recent December 1, 2013, accident on Metro-North and the lack of overspeed protection in place on Metro-North’s system created an emergency situation involving a hazard of death …” At the time that EO was issued, FRA did not know, nor had NTSB concluded, that the engineer’s untreated OSA was the probable cause of the derailment. EO-29 outlined several measures Metro-North must undertake immediately to address the lack of overspeed protection on its system. Had FRA known at the time it issued EO-29 that untreated OSA was the probable cause of the Spuyten Duyvil derailment, it could have, and should have, included OSA risk mitigation in the EO. Should NTSB find OSA to be the probable cause of one or both of the other commuter train derailments, an EO on OSA would be the optimal solution for mitigating the safety risks associated with untreated OSA, because risk mitigation measures could be implemented in a very short period of time.

Enough is enough. It is time for FRA to recognize that Safety Advisories are inadequate for protecting and public and rail worker safety. It must exercise its statutory authority to issue Emergency Orders, forcing the railroad industry to take measures to deal with speed restriction compliance and sleep apnea, unless and until adequate regulations can be finalized and implemented.

William C. Keppen, Jr.

William C. Keppen, a retired BLET (Brotherhood of Locomotive Engineers and Trainmen) Vice President and third-generation locomotive engineer at BNSF and predecessors Chicago, Burlington & Quincy and Burlington Northern, is an independent transportation advocate with experience in fatigue countermeasures programs. A railroad industry veteran of almost 50 years, Keppen provides safety analyses for Confidential Close Call Reporting System (C3RS) programs in freight, commuter, and light rail transportation. Keppen was Project Coordinator for BNSF’s Fatigue Countermeasures Program, and former BLE General Chairman for the BN Northlines GCA. “I started working on human-factor-caused train accidents in 1980,” he says. “It has been a struggle. I would like to think I have made a difference, but there are still far to many human-factor-caused train ‘accidents,’ which I prefer to refer to as preventable incidents.”

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