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  • NTSB Issues 12 New Safety Recommendations as a Result of its Investigation of the 9/30/2010 Collision of Two Freight Trains near Two Harbors, MN
    Updated On: Mar 15, 2013

    The National Transportation Safety Board (NTSB) issues the following recommendations to the following organizations:

    To the Federal Railroad Administration:

    Identify, and require railroads to use in locomotive cabs, technology-based solutions that detect the presence of signal-emitting portable electronic devices and that inform the railroad management about the detected devices in real time. (R-13-005)

    Incorporate the use of handheld signal detection devices  to aid in the enforcement of Title 49 Code of Federal Regulations Part 220 Subpart C. (R-13-006)

    Require railroads to implement initial and recurrent crew resource management training for train crews. (R-13-007)

    Conduct an audit of the Canadian National Railway’s North Division program of operational tests and inspections to evaluate their effectiveness for promoting knowledge and compliance with rules regarding the execution of track authorities and the appropriate use of portable electronic devices. (R-13-008)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-005-008.pdf

    To the Canadian National Railway:

    Discontinue the use of after-arrival track authorities in nonsignaled territory not equipped with positive train control. (R-13-009)

    Develop and implement specific training that will result in operating personnel acquiring and using strategies and skills based on the principles of crew resource management. (R-13-010)

    Incorporate the use of handheld signal detection devices into your operational efficiency program on the use of portable electronic devices. (R-13-011)

    Evaluate your operational testing program, and verify that the testing of track authority procedures and unauthorized use of portable electronic devices is adequate to ensure consistent, safe operation. (R-13-012)

    Work with the Brotherhood of Locomotive Engineers and Trainmen and the United Transportation Union, to develop and implement a nonpunitive peer audit program for the North Division, focused on rule compliance and operational safety. (R-13-013)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-009-013.pdf

    To the Brotherhood of Locomotive Engineers and Trainmen:

    Work with the Canadian National Railway and the United Transportation Union, to develop and implement a nonpunitive peer audit program for the Canadian National Railway’s North Division, focused on rule compliance and operational safety. (R-13-014)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-014.pdf

    To the United Transportation Union (SMART Union):

    Work with the Canadian National Railway and the Brotherhood of Locomotive Engineers and Trainmen, to develop and implement a nonpunitive peer audit program for the Canadian National Railway’s North Division, focused on rule compliance and operational safety. (R-13-015)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-015.pdf

    To the Canadian Pacific Railway Limited:

    Discontinue the use of after-arrival track authorities for train movements in nonsignaled territory not equipped with a positive train control system. (R-13-016)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-016.pdf

    To the Kansas City Southern Railway Company:

    Discontinue the use of after-arrival track authorities for train movements in nonsignaled territory not equipped with a positive train control system. (R-13-016)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-016a.pdf

    To the Norfolk Southern Railroad:

    Discontinue the use of after-arrival track authorities for train movements in nonsignaled territory not equipped with a positive train control system. (R-13-016)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-016b.pdf

    To the Union Pacific Railroad:

    Discontinue the use of after-arrival track authorities for train movements in nonsignaled territory not equipped with a positive train control system. (R-13-016)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-016c.pdf

    The NTSB also reiterates the following recommendations to the following organizations:

    To the Federal Railroad Administration:

    Prohibit the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-010)

    Establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue. (R-12-017)

    http://www.ntsb.gov/doclib/recletters/2013/R-13-005-008.pdf

    To the BNSF Railway:

    Discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-12)

    http://www.ntsb.gov/doclib/recletters/2006/R-06-012a.pdf

    To the America Short Line and Regional Railroad Association:

    Encourage your members to discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-13)

    http://www.ntsb.gov/doclib/recletters/2006/R-06-013a.pdf

    The NTSB reclassified the following recommendations to the following organization:

    To the Federal Railroad Administration:

    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 systemwide performance monitoring programs. (R-10-001)

    Safety Recommendation R-10-001, previously classified “Open—Acceptable Response” is classified “Open—Unacceptable Response.”

    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. (R-10-002)


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