Federal Railroad Administration (FRA), U.S. Department of Transportation (DOT).
Notice of Safety Advisory.
FRA is issuing Safety Advisory 2016–03 to stress to passenger and commuter railroads the importance of taking action to help mitigate human factor accidents, assist in the investigation of such accidents, and enhance the safety of operations in stations and terminals with stub end tracks. This safety advisory contains various recommendations to passenger and commuter railroads related to inward- and outward-facing cameras, sleep apnea, and operating practices to potentially mitigate the occurrence and assist in the investigation of human factor related accidents and to enhance the safety of operations in terminals and stations with stub end tracks.
Christian Holt, Operating Practices Specialist, Office of Railroad Safety, FRA, 1200 New Jersey Avenue SE., Washington, DC 20590, telephone (202) 493–0978.
On September 29, 2016, at approximately 8:38 a.m., New Jersey Transit (NJT) Train 1614 travelling at 21 miles per hour (mph) impacted the bumping block at the end of the track No. 5 Depot, at Hoboken Terminal, in Hoboken, New Jersey. The cab car overrode the bumping block and struck the wall of the terminal building, near the ticket office in the corner of the building. NJT Train 1614 was occupied by three crew members and approximately 331 passengers. The accident resulted in the three crewmembers and 108 passengers being transported to four area hospitals. One individual who was standing on the pedestrian walkway between the tracks and the station was fatally injured from falling debris.
The National Transportation Safety Board (NTSB) has taken the lead role in conducting the investigation of this accident under its legal authority.
On Tuesday, May 12, 2015, National Railroad Passenger Corporation (Amtrak) passenger train 188 (Train 188) was traveling from Washington, DC, to New York City. Aboard the train were five crew members and approximately 238 passengers. Shortly after 9:20 p.m., the train derailed while traveling through a curve in the track at Frankford Junction in Philadelphia, Pennsylvania. As a result of the accident, eight persons were killed and a significant number of persons were seriously injured.
NTSB conducted an investigation of this accident under its legal authority and issued its findings on May 17, 2016.
On July 8, 2015, NTSB sent a letter to FRA reiterating NTSB recommendations
On September 12, 2008, in Chatsworth, California, an accident occurred involving a collision between a Southern California Regional Rail Authority (Metrolink) passenger train and a Union Pacific Railroad Company (UP) freight train.
Shortly after the Metrolink accident, the Rail Safety Improvement Act of 2008
The NTSB's report on the Chatsworth accident resulted in two new Safety Recommendations, R–10–01 and R–10–02.
Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and system wide performance monitoring programs.
In addition, Safety Recommendation R–10–02 recommended that FRA:
Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety.
On December 1, 2013, at approximately 7:20 a.m. EST, southbound Metro-North Railroad (Metro-North) passenger train 8808 derailed as it approached the Spuyten Duyvil Station in New York City. All passenger cars and the locomotive derailed, and, as a result, four passengers died and at least 61 passengers were injured. The train was traveling at 82 mph when it derailed in a section of curved track where the maximum authorized speed was 30 mph. Following the accident, the engineer reported that: (1) He felt dazed just before the derailment;
Railroad safety is of the utmost importance to FRA, and, based on the above accidents, FRA recommends several measures discussed below, to address human factor-caused accidents
On December 4, 2015, the President signed into law the Fixing America's Surface Transportation Act, Public Law 114–94, 129 Stat. 1686 (Dec. 4, 2015) (FAST Act). Section 11411 of the FAST Act, codified in the Federal railroad safety laws at 49 U.S.C. 20168 (the Statute), requires FRA (as the Secretary of Transportation's delegate) to promulgate regulations requiring each railroad carrier that provides regularly scheduled intercity rail passenger or commuter rail passenger transportation to install inward- and outward-facing image recording devices in all controlling locomotives of passenger trains. 49 U.S.C. 20168(a). Although FRA is in the process of developing a regulatory proposal addressing this statutory mandate, FRA encourages railroads to accelerate the installation of the cameras. The Statute contains various design and operational requirements related to these cameras including:
• A minimum 12-hour continuous recording capability (49 U.S.C. 20168(b)(1));
• Crash and fire protections for any in-cab image recordings that are stored only within a controlling locomotive cab or cab car operating compartment (49 U.S.C. 20168(b)(2));
• Recordings must be accessible for review during an accident or incident investigation (49 U.S.C. 20168(b)(3));
• Railroads may use the recordings to:
○ Verify that train crew actions follow applicable safety laws and the railroad carrier's operating rules and procedures (49 U.S.C. 20168(d)(1));
○ Assist in an investigation into the causation of a reportable accident or incident (49 U.S.C. 20168(d)(2)); and
○ Document a criminal act or monitor unauthorized occupancy of the controlling locomotive cab or car operating compartment (49 U.S.C. 20168(d)(3)).
In addition to the design and operational requirements in the FAST Act, the Statute also contains various other requirements regarding the use and maintenance of inward- and outward-facing cameras as well as limitations and protections on how data from the cameras can be used. Importantly, the Statute prohibits railroads from using image recordings to retaliate against their employees. 49 U.S.C. 20168(i). In addition, to discourage tampering with the cameras, the Statute allows railroads to take enforcement actions against employees that tamper with or disable an inward- or outward-facing image recording device. 49 U.S.C. 20168(f). Furthermore, recording device data obtained from a locomotive involved in a FRA reportable accident or incident must be preserved by the railroad for one year after the accident or incident. 49 U.S.C. 20168(g).
Once FRA has acquired this data from the railroad, FRA is prohibited from publicly disclosing locomotive audio and image recordings or transcripts of oral communications between train, operating, and communication center employees related to the accident or incident FRA is investigating. However, FRA may publicly release a transcript of a written depiction of visual information that the agency deems is relevant to the accident at the time other factual reports on the accident are released to the public. 49 U.S.C. 20168(h). This restriction is similar to the prohibition on public disclosure of locomotive recordings that NTSB takes possession of during an investigation. 49 U.S.C. 1114(d).
FRA remains concerned with the ability to fully investigate accidents that appear to be human factor-caused where there is insufficient information from the controlling locomotive cab or cab operating compartment to conclusively determine what caused or contributed to an accident. Locomotive cab recording information could benefit investigations and help identify necessary corrective actions before similar train accidents occur. Inward- and outward-facing image recording devices would be valuable in revealing crew actions and interactions before, during, and after an accident. FRA also believes that inward- and outward-facing cameras will give railroads the ability to monitor crew behavior to ensure compliance with existing Federal regulations and railroad operating rules and deter noncompliance. Existing Federal regulations at 49 CFR part 217 require railroads to conduct operational tests to determine the extent of employees' compliance with railroad operating rules, and particularly those rules which are most likely to cause the most accidents or incidents.
Fatigue of railroad employees continues to be a concern of FRA, particularly for employees with sleep disorders who operate passenger trains. This Advisory contains suggested measures that railroads and employees should utilize to prevent work-related errors and on-the-job accidents as a result of sleep disorders.
Sleep disorders represent a serious health problem and left untreated can result in impaired work performance, including possible loss of alertness and situational awareness, which could in turn present an imminent threat to transportation safety.
OSA is a respiratory disorder characterized by a reduction or cessation of breathing during sleep. OSA is characterized by repeated episodes of upper airway collapse in the region of the upper throat (pharynx) that results in intermittent periods of partial airflow obstruction (hypopneas), complete airflow obstruction (apneas), and respiratory effort-related arousals from sleep (RERAs) in which affected individuals awaken partially and may experience gasping and choking as they struggle to breathe. Risk factors for developing OSA include: Obesity, male gender, advancing age, family history of OSA, large neck size, and an anatomically small oropharynx (throat). Additionally, OSA is associated with increased risk for other adverse health conditions such as: Hypertension (high blood pressure), diabetes, cardiac dysrhythmias (irregular heartbeat), myocardial infarction (heart attack), stroke, and sudden cardiac death. Individuals who have undiagnosed OSA are often unaware they have experienced periods of sleep interrupted by breathing difficulties (apneas, hypopneas, or RERAs) when they awaken in the morning. As a result, the condition is often unrecognized by affected individuals and underdiagnosed by medical professionals.
For individuals with OSA, eight hours of sleep can be less restful or refreshing than four hours of ordinary, uninterrupted sleep. Undiagnosed or inadequately treated moderate to severe OSA can cause unintended sleep episodes and resulting deficits in attention, concentration, situational awareness, and memory, thus reducing the capacity to safely respond to hazards when performing safety sensitive duties. Thus, OSA is a critical safety issue that can affect operations in all modes of travel in the transportation industry.
On March 10, 2016, FRA published an advance notice of proposed rulemaking (ANPRM) requesting data and information concerning the prevalence of moderate-to-severe OSA of individuals occupying safety sensitive positions in rail transportation and the potential consequences for rail safety.
The Hoboken accident involved NJT Train 1614 that was traversing a stub end track entering a passenger station at 21 mph–11 mph over the 10 mph posted speed limit. FRA recommends identifying locations that have stub end tracks at passenger terminals and stations that are equipped with technology that can warn and enforce passenger trains to stop short of a stub end track and ensure they enforce applicable speed limits. If such locations are not equipped with technology that can warn and enforce passenger trains to stop short of a stub end track and ensure they enforce applicable speed limits, then FRA encourages railroads to take other operational actions to prevent trains from overrunning stub end tracks equipped with or without bumping posts. One such operational action would be to require communications between the engineer and other qualified employees that can take appropriate action, such as applying the emergency brakes, if necessary.
In light of the recent accident discussed above, and in an effort to ensure the safety of the Nation's railroads, their employees, and the general public, FRA recommends that intercity passenger and commuter railroads do each of the following:
1. Instruct their employees during training classes and safety briefings on the importance of compliance with maximum authorized train speed limits and other speed restrictions when entering passenger stations and terminals;
2. Not less than once every six months evaluate operational testing data as required by 49 CFR 217.9. A railroad should consider increasing the frequency of operational testing where its reviews show any non-compliance with maximum authorized train speeds in passenger stations or terminals. Railroads should conduct a significant number of operational tests on trains required to operate into a station or terminal with stub end tracks;
3. Adopt procedures requiring communication between crew members and the locomotive engineer before and during operation into a station or terminal and/or implement technology to appropriately control and/or stop the train short of the stub end track. These actions could include:
a. Making modifications to automatic train control (ATC), cab signal, or other signal systems capable of providing warning and enforcement to ensure trains comply with applicable speed limits and stop short of stub end tracks;
b. If a railroad does not utilize an ATC, cab signal, or other signal system capable of providing warning and enforcement at applicable passenger terminals and stations with stub end tracks platforms (or if a signal system modification would interfere with the implementation of PTC or is otherwise not viable), making all passenger train movements at the identified locations while in communication with a second qualified crew member. This will provide constant communication with the locomotive engineer and allow the second crewmember to take immediate appropriate action if the locomotive engineer is not responding or is unable to stop short of stub end tracks. This could also include making a safety stop at predetermined location and if the locomotive engineer does not make an appropriate safety stop the second qualified crew member can take appropriate action to stop the train;
4. Review Safety Advisory 2004–04 (69 FR 58995, Oct. 1, 2004); Effect of Sleep Disorders on Safety of Railroad Operations, in its entirety with all operating crews. Recommended actions from Safety Advisory 2004–04 are listed below:
a. Establish training and educational programs to inform employees of the potential for performance impairment as a result of fatigue, sleep loss, sleep deprivation, inadequate sleep quality, and working at odd hours, and document when employees have received the training. Incorporate elements that encourage self-assessment, peer-to-peer communication, and co-worker identification accompanied by policies consistent with these recommendations. The Railroaders' Guide to Healthy Sleep Web site (
b. Ensure that employees' medical examinations include assessment and screening for possible sleep disorders and other associated medical conditions (including use of appropriate checklists and records). Develop standardized screening tools, or a good practices guide, for the diagnosis, referral and treatment of sleep disorders (especially OSA) and other related medical conditions to be used by company paid or recommended physicians during routine medical examinations; and provide an appropriate list of certified sleep disorder centers and related specialists for referral when necessary;
c. Develop and implement rules that request employees in safety-sensitive positions to voluntarily report any sleep disorder that could incapacitate, or seriously impair, their performance;
d. Develop and implement policies such that, when a railroad becomes aware that an employee in a safety-sensitive position has an incapacitating or performance-impairing medical condition related to sleep, the railroad prohibits that employee from performing any safety-sensitive duties until that medical condition appropriately responds to treatment; and
e. Implement policies, procedures, and any necessary agreements to—
i. Promote self-reporting of sleep-related medical conditions by protecting the medical confidentiality of that information and protecting the employment relationship, provided that the employee complies with the recommended course of treatment;
ii. Encourage employees with diagnosed sleep disorders to participate in recommended evaluation and treatment; and
iii. Establish dispute resolution mechanisms that rapidly resolve any issues regarding the current fitness of employees who have reported sleep-related medical conditions and have cooperated in evaluation and prescribed treatment.
5. Accelerate the installation of inward- and outward-facing cameras in passenger trains in the cab of the controlling locomotive or cab car operating compartment per the FAST Act. FRA notes that the FAST Act includes provisions on standards for the cameras, use of the cameras, and preservation and protection of data from the cameras.
FRA encourages all intercity passenger and commuter railroads to take actions consistent with the preceding recommendations. FRA acknowledges that action on some of the
FRA may modify this Safety Advisory 2016–03, issue additional safety advisories, or take other appropriate action necessary to ensure the highest level of safety on the Nation's railroads, including pursing other corrective measures under its rail safety authority.