[Federal Register Volume 69, Number 153 (Tuesday, August 10, 2004)]
[Notices]
[Pages 48560-48562]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-18193]
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DEPARTMENT OF TRANSPORTATION
Federal Railroad Administration
Notice of Safety Advisory 2004-02
AGENCY: Federal Railroad Administration (FRA), DOT.
ACTION: Notice of safety advisory.
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SUMMARY: The Federal Railroad Administration (FRA) is issuing Safety
Advisory 2004-02 to address the importance of having clear safety and
response procedures for use in the event of reports of railroad signal
system problems.
FOR FURTHER INFORMATION CONTACT: Mark Jones, Signal and Train Control
Division, Office of Safety Assurance and Compliance, FRA, 1120 Vermont
Avenue, SW., Washington, DC 20590 (telephone 202-493-6232; e-mail:
mark.jones@fra.dot.gov) or Cynthia Walters, Office of Chief Counsel,
FRA, 1120 Vermont Avenue, NW., Washington, DC 20590 (telephone 202-493-
6064; e-mail: cynthia.walters@fra.dot.gov).
SUPPLEMENTARY INFORMATION:
Background: The National Transportation Safety Board (NTSB) and FRA
conducted an investigation following a major train derailment. The
conclusions of this investigation and the report issued by the NTSB,
RAR-03/05, provide the underlying basis for the recommendations issued
in this Safety Advisory. The derailment occurred on September 15, 2002,
at Farragut, Tennessee, when a westbound Norfolk Southern train
consisting of 3 locomotives, and 142 cars, traversed a defective switch
and derailed two locomotives and the first 25 cars. This derailment
caused a tank car containing sulfuric acid to puncture. The resultant
spill produced a cloud of toxic fumes, prompting the evacuation of
approximately 2,600 residents, from a 4.4 square mile area around the
derailment site. While there were no fatalities, a number of the local
residents required treatment for minor respiratory difficulties.
Damages were estimated to be in excess of $1 million.
The post-accident investigation revealed that an eastbound freight
train traversing the territory approximately two hours prior to the
derailment received an approach and then a restricting signal
indication at the west end of a siding in approach to a spring switch.
In accordance with railroad operating instructions, the train speed was
reduced from the normal track speed of 50 m.p.h. to 30 m.p.h. and the
train crew was prepared to stop at the next signal, which was
indicating
[[Page 48561]]
``Restricting''. The train dispatcher was notified of the signal
aspects that were displayed. Upon reaching the spring switch the train
stopped and the train's conductor checked the switch. The normally
closed point of the switch was found to be gapped approximately \1/4\-
inch. The conductor manually operated the switch back and forth several
times between the normal to reverse position, attempting to properly
seat the point snugly against the stock rail. However, the point
remained gapped approximately \1/8\-inch from the normal closed
position. The train crew then notified the dispatcher that the point
was not properly seated. The dispatcher informed the train crew that
signal personnel would be notified and permitted the train to continue
its eastbound trailing movement over the switch.
A signal maintainer was called to the site. Upon his arrival at the
switch, he conducted a visual inspection from the leading edge of the
switch points to the heel blocks, noting that the point rail was snugly
seated against the stock rail. He also noted that the westward
governing signal over the switch (facing direction) was displaying a
clear indication. The signal maintainer then called to inform the
dispatcher that the switch point appeared to be properly aligned and
requested a track warrant to occupy the track so that tests could be
made on the spring switch and switch circuit controller to determine
why the point had gapped. The dispatcher informed the signal maintainer
that two westbound trains were en-route toward the switch. The signal
maintainer replied that he would wait until the two trains passed over
the switch before continuing his inspection.
While waiting to receive a track warrant to occupy the track, the
signal maintainer overheard the crew of the first train, as they were
approaching the leading edge of the switch points, call out a clear
signal over his radio. As the freight train traversed the switch point
at 38 m.p.h., the train derailed.
Post-accident investigations conducted by the NTSB and the FRA
indicated that the probable cause of the derailment could be attributed
to the point of a spring switch being obstructed by a clip bolt. The
clip bolt had apparently broken from the fourth switch-rod located
approximately 80 inches from the leading edge of the switch point and
lodged between the base of the stock rail and point rail. Inspection
and operational tests of the spring switch immediately after the
derailment revealed that the switch and the switch circuit controller
were adjusted within specification and functioned as intended. However,
there was a groove worn into the base of the stock rail along with a
flare imprinted onto the base of the point rail, indicating that the
points had been obstructed by the broken switch rod bolt, preventing
the point rail from seating snugly against the stock rail. It was
determined that when the first train traversed the switch, the tip of
the point rail was shoved over into a snug position against the stock
rail and was in this position when the maintainer observed it. However,
when the ensuing train movement was made in the facing direction, the
tip of the point rail was forced slightly open (gapped) because of a
``fulcrum'' effect introduced by the broken switch clip bolt lodged
between the stock rail and the point rail in the mid-portion of the
switch. This condition resulted in the switch point being split by a
wheel flange and caused the ensuing derailment.
In assessing the chain of events leading up to this derailment, the
NTSB concluded that the root causes of this derailment were: ``(1) The
decision by the train dispatcher and the signal maintainer to allow the
train to proceed in a facing point direction over the spring switch at
maximum authorized speed before the switch had been adequately
inspected or clamped closed; and (2) the lack of company procedures
requiring that train dispatchers, after receiving a report of a problem
involving a main track switch, to immediately stop trains or implement
an appropriate speed restriction in the affected area.'' The FRA fully
agrees with the NTSB's assessment of the probable cause of the
derailment. Federal regulations addressing this issue are found in 49
CFR 236.11 which states:
When any component of a signal system, the proper functioning of
which is essential to the safety of train operation, fails to
perform its intended signaling function or is not in correspondence
with known operating conditions, the cause shall be determined and
the faulty component adjusted, repaired, or replaced without undue
delay.
This rule requires a railroad to take action to determine the cause
of each unexpected ``stop'' or ``stop and proceed'' signal indication
and to determine if there is any failed or defective component in the
system. This requirement is used to ascertain any effect on train
movement safety and when necessary requires adjustment, repair, or
replacement of the defective component. Both aspects of the requirement
must occur without undue delay.
Signal systems are required to be installed and maintained on the
``fail-safe'' principle and to detect a number of specific conditions
that affect the safety of train operations. Many factors can be
involved in situations where the signal aspect is not in correspondence
with known operating conditions or a component is not functioning as
intended. FRA believes that adherence to the requirements of section
236.11, along with the protective measures provided by crew adherence
to the corresponding operating rules, provide the needed measure of
safety, until a qualified person can determine a cause of the problem
and its effect on train operations. The rule requires that this
determination and repairs be made ``without undue delay'' i.e., they
should be made in as timely a manner as possible. In those cases,
railroads may need to institute temporary safety measures, until the
problem can be resolved. However, FRA expects railroads to determine
the cause and restore signal systems to proper functioning without
undue delay, taking into consideration factors such as rail traffic,
whether highway/rail grade-crossings are involved, and other related
factors.
Furthermore, additional factors are involved in instances of
intermittent signal problems (e.g., signal aspects not in
correspondence with known operating conditions, track occupancy lights
(TOLs), or points of a switch not closed in proper position), which
subsequently ``clear up'' on their own. There are nearly an infinite
number of conditions that could cause intermittent signal problems,
many of which could remain a safety concern, even when seemingly
resolving themselves (e.g., a broken rail or pull-apart where the track
circuit is intermittently affected, or a switch problem similar to that
of the described accident). Signal systems are not capable of
indicating differences between the most obvious safety concerns, such
as track occupancy by a train or an improperly positioned switch and
relatively minor nuisance-type occurrences such as a momentary external
short on a track circuit, or a broken wire. In these instances, prudent
safety precautions should be followed.
FRA recognizes the circumstances under which the events unfolded
causing the subject accident, since conditions appeared to be safe and
proper to the signal maintainer upon his arrival. The decision to
immediately conduct proper inspection and testing of the switch (in
this instance) or other signal component should not be left up to the
individuals involved. That decision should instead be clearly addressed
in railroad prescribed
[[Page 48562]]
procedures which should provide priority for such inspection and
testing.
FRA has reviewed the procedures used by major railroads to
determine if they adequately address signal issues or conditions (i.e.,
switch problems, track occupancy lights, track defects, etc.) that may
interfere with the safe passage of a train or locomotive. In reviewing
these procedures, FRA has determined that although each of the
railroads have procedures in place, there are specific actions that can
be taken to improve these procedures. Therefore, FRA is recommending
that when responding to a trouble call, a railroad signal maintainer,
technician, or maintenance of way employee should receive priority in
occupying track so that inspections and operational tests can be
conducted to ensure that no unsafe conditions exist. For example,
consider the events of the aforementioned derailment. Although the
conductor reported the gapped points to the dispatcher, as required by
railroad instructions, the signal maintainer was not given priority for
track occupancy so that sufficient inspection and operational tests
could be conducted on the switch to determine the cause. Had the
maintainer tested the switch prior to the train's arrival, the
derailment may have been prevented.
It is important to note that 49 CFR 213.135(b) of the Track Safety
Standards states in part ``Each switch point shall fit its stock rail
properly, with the switch stand in either of its closed positions to
allow wheels to pass the switch point. Lateral and vertical movement of
a stock rail in the switch plates or of a switch plate on a tie shall
not adversely affect the fit of the switch point to the stock rail.''
Railroads are encouraged to have both signal and track employees
trained to comprehensively understand the interface between the point
and stock rails (tip to heel) and associated hardware.
Recommendations
Based on the above, FRA strongly recommends that:
1. Any railroad employee encountering a condition that could
interfere with the safe passage of a train should promptly report the
condition or defect to the train dispatcher. Train dispatchers, upon
receiving reports of potentially hazardous conditions involving a
signal system or component, including any track segment or switch
should immediately issue instructions to stop train movements or
immediately implement an appropriate speed restriction, not to exceed
20 mph, for the affected area. These restrictions should remain in
effect until the component or trackage in the affected area is properly
inspected and/or tested by a qualified employee to determine the cause
and make any necessary repairs, replacements or adjustments.
2. Each railroad should ensure that it has procedures for
responding to trouble calls that include providing priority in
occupying track to a signal maintainer, technician or maintenance of
way employee investigating a report of a signal system or component
failure so that proper and sufficient inspections and tests may be
conducted to determine the cause of the failure.
3. Each railroad should ensure that it has inspection and test
procedures that will assure sufficient and proper inspection and
testing to determine the cause of signal system or component failures.
For example, in the event of a found or reported switch problem, switch
inspection and tests sufficient to determine the cause of the problem
and detect any unsafe condition should be conducted. In this case, a
minimum inspection and test would include the elements of inspecting
not only the switch point rails (point to heel), but also all of the
switch rods, operation of the switch through its full range of motion
and testing the switch circuit controller or point detector for proper
adjustment.
4. Each railroad should ensure that when a signal problem is
suspected, detected, or reported, applicable signal personnel should be
notified of the occurrence and provided with any applicable information
about the circumstances. This will aid the signal department in
attempting to determine the cause of recurring signal trouble.
Issued in Washington, DC, on August 3, 2004.
Grady C. Cothen, Jr.,
Acting Associate Administrator for Safety.
[FR Doc. 04-18193 Filed 8-9-04; 8:45 am]
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