The National Transportation Safety Board (NTSB) is an independent Federal agency charged by Congress to investigate transportation accidents, determine their probable cause, and make recommendations to prevent their recurrence. The recommendations that arise from our investigations and safety studies are our most important product. The Safety Board has neither regulatory authority nor grants funds. However, in our 37-year history, organizations and government bodies have adopted more than 80 percent of our recommendations.

The NTSB launched an accident investigation team to Glendale, California on January 26, 2005, to investigate the collision of a Metrolink commuter train with a highway passenger vehicle and subsequent collisions with a Metrolink train passing from the opposite direction and freight train parked on a siding, resulting in 11 fatalities. However, soon after arriving, on-scene information indicated that the highway vehicle was not struck at a grade-crossing but parked across the track some distance away from the crossing. A criminal investigation was initiated by the Glendale Police Department and the NTSB accident investigation was closed.

The Glendale collision prompted questions about the safety of push-pull operations for passenger trains and the Federal Railroad Administration (FRA) initiated an analysis of the safety of push-pull operations for passenger train service. The Safety Board does not have outstanding safety recommendations on push-pull operations for passenger trains, but we will carefully review the FRA’s current safety analysis of push-pull operations when it is completed.

The Safety Board has investigated previous passenger train accidents involving push-pull operations and issued safety recommendations for improving passenger safety. As a result of a near head-on collision between two commuter trains in Secaucus, New Jersey on February 9, 1996, the Safety Board evaluated the intrusion of the locomotive of one train into the cab car of the second train (NTSB Report RAR-97/01). The Board found that an applicable safety recommendation (R-93-24) on crashworthiness had been issued to the FRA on January 7, 1994, recommending that the FRA, in cooperation with the Federal Transit Administration and the American Public Transit Association, study the feasibility of providing car body corner post structures on all self-propelled passenger cars and control cab locomotives to afford occupant protection during corner collisions. This safety recommendation was classified “Closed--Acceptable Action” by the Board on January 4, 2000. As a result of our investigation in Secaucus, the Safety Board issued new safety recommendations related to improving engineer qualifications and carrier emergency response drills (R-97-1, 2, 3 and 4).

The Safety Board investigated a push mode train accident near Silver Spring, Maryland on February 16, 1996, involving a collision between a Maryland Rail Commuter (MARC) train and an Amtrak passenger train (NTSB Report RAR-97/02). The collision between the lead Amtrak locomotive and the MARC cab control car tore away the front left quadrant of the cab control car. The fuel tank on the Amtrak locomotive ruptured and sprayed fuel on the cab control car resulting in a fire. The lack of positive train separation controls and the adequacy of passenger safety standards were among safety issues addressed in the accident investigation. The Safety Board recommended that the FRA require positive train separation systems for all trains where commuter and intercity passenger trains operate (R-97-13); improve emergency quick-release mechanisms for passageway doors (R-97-14); improve emergency exiting through interior and exterior doors with either removable windows, kick panels, or other suitable means for emergency exiting where doors could impede passengers exiting in an emergency (R-97-15); and require improvements in emergency lighting (R-91-17).

Since 1970, the Safety Board has issued numerous safety recommendations related to positive train separation. Our most recent safety recommendation was issued in 2001, following the investigation of a collision involving three Conrail freight trains in Bryan, Ohio. The trains were operating in fog, when a faster moving train missed a stop and proceed signal and hit the rear end of a train that had slowed because of poor visibility. A third train, coming from the opposite direction, struck the two derailed trains. The Safety Board concluded that a fully implemented Positive Train Control (PTC) system would have prevented the collision and recommended that the FRA “facilitate actions necessary for the development and implementation of positive train control systems that include collision avoidance, and require implementation of positive train control systems on main line tracks, establishing priority requirements for high-risk corridors such as those where commuter and intercity passenger railroads operate” (R-01-6).

This safety recommendation was reiterated to the FRA after a Burlington Northern Santa Fe freight train collided head-on with a Metrolink passenger train in Placentia, California on April 23, 2002 (NTSB Report RAR-03/04). The probable cause of this accident was the freight train crew’s inattentiveness to the signal system. Contributing to this accident was the absence of a positive train control system that would have automatically stopped the freight train short of the stop signal and thus prevented the collision. The Metrolink train was in push mode operation and stopped immediately before the collision. The force of the striking freight train pushed the Metrolink train backward about 243 feet. The Safety Board concluded that the two fatal injuries and many of the serious abdominal injuries to passengers likely resulted from impact with workstation table edges. The FRA and the Volpe Center are evaluating crash injury hazards of workstation tables in finite element simulation modeling and physical testing.

In the past six years, the NTSB has investigated 38 railroad accidents where positive train control is a safety issue. Causal factors have often been attributed to train crew mistakes and failure to operate trains in accordance with operating rules. Human factor causes have included fatigue, sleep apnea, use of medication, reduced visibility and distractions, such as cell phone use.

Automatic train control systems are safety redundant systems that can override mistakes by human operators and prevent collision and over-speed accidents.

The FRA accident database for 2003 also attributes human factors as causal to most collision accidents. The 2003 data show that there were 146 head-on, rear-end and side collision accidents, and that 133 of those accidents, or 91 percent, are attributed to human factor causes.

The preliminary FRA accident database for 2004 also attributes human factors as causal to most collision accidents. The 2004 preliminary data shows 202 head-on, rear-end and side collision accidents (an increase of 56 accidents), and that 184 of those accidents, or 91 percent, are attributed to human factor causes.

This safety issue has been on the NTSB’s List of Most Wanted Transportation Safety Improvements since 1990.

Initiatives have been taken by some railroads to develop and install PTC systems. These include Amtrak, which has installed PTC on 436 miles of track that it owns on the Northeast Corridor and 45 miles of track on its Michigan Line; New Jersey Transit, which has installed PTC on 23 miles of its system and it expects to have PTC on all 540 miles of its system by the end of 2006; New Jersey Transit placed additional emphasis on this program following a head-on collision between 2 of its trains in 1996; and the Alaska Railroad, which operates both passenger and freight trains, is installing PTC on all 611 miles of its track. Alaska Railroad has now equipped all of its 62 locomotives. This project is funded, in part, by the FRA. Plans are to have PTC operational, system-wide, by the end of 2006.

Further, the FRA, the Association of American Railroads and the Illinois Department of Transportation are funding the North American Joint Positive Train Control Project over 120 miles of track on the St. Louis/Chicago corridor. A goal of this project is to help address equipment and operational issues that occur when different railroads use the same track.

In another Metrolink commuter train accident, which occurred on January 6, 2003, a Metrolink commuter train struck a crew cab truck at a grade crossing in Burbank, California. Upon impact the truck’s cab moved with the train until the train derailed about 1,300 feet from the crossing. The truckdriver was fatally injured. Thirty-two people on the train sustained injuries and one passenger died 15 days later from internal injuries that probably occurred during the accident.

At the time of the accident the traffic signal’s railroad preemption for the intersection included a track clearance interval followed by an all-red-flash mode. The Safety Board concluded that the use of the all-red-flash mode for traffic signals at a railroad grade crossing has ambiguous meaning, can be confusing to motorists, and as a result creates unnecessary risks to life and property (NTSB Report HAR-03/04). The Safety Board recommended that the California Department of Transportation prohibit the all-red-flash option for traffic signals indications during the railroad hold interval at grade crossings (H-03-29). On January 12, 2004, the California Department of Transportation indicated that although it takes exception to the Board’s probable cause of the accident it will review Caltrans’ guidelines for railroad preemption and will revise the guidelines as appropriate. The safety recommendation remains classified “Open--Await Response.”

Finally, the Safety Board has also recommended that the FRA require improved inspection requirements for joint bars in continuous welded rail after a January 18, 2002, train derailment in Minot, North Dakota (NTSB Report RAR-04/01). A Canadian Pacific Railway freight train traveling about 41 mph derailed 31 of its 112 cars about 1/2 mile west of the city limits of Minot. Five tank cars carrying anhydrous ammonia, a liquefied compressed gas, catastrophically ruptured, and a vapor plume covered the derailment site and surrounding area. About 11,600 people occupied the area affected by the vapor plume. One resident was fatally injured, and 60 to 65 residents of the neighborhood nearest the derailment site were rescued. As a result of the accident, 11 people sustained serious injuries and 322 people sustained minor injuries.

The Safety Board determined that the probable cause of the derailment was an ineffective Canadian Pacific Railway inspection and maintenance program that did not identify and replace cracked joint bars before they completely fractured and led to the breaking of the rail at the joint. The Safety Board recommended that the FRA require all railroads with continuous welded rail track to include procedures that prescribe on-the-ground visual inspections and nondestructive testing techniques for identifying cracks in rail joint bars before they grow to critical size (R-04-1). The Safety Board also recommended that the FRA e stablish a program to periodically review continuous welded rail joint bar inspection data from railroads and FRA track inspectors and, when determined necessary, require railroads to increase the frequency or improve the methods of inspections of joint bars in continuous welded rail (R-04-02). The FRA response to both of these safety recommendations is classified “Open—Unacceptable Response.”

On October 16, 2004, an eastbound Union Pacific Railroad freight train derailed 3 locomotives and 11 cars near Pico Rivera, California. Some of the derailed cars struck nearby residences. An estimated 5,000 gallons of diesel fuel were released from the locomotive fuel tanks when they ruptured during the derailment, and about 100 people were evacuated from the area. The probable cause of the derailment was the failure of a pair of insulated joint bars due to fatigue cracking. Contributing to the accident was the lack of an adequate on-the-ground inspection program for identifying cracks in rail joint bars before they grow to critical size. The Safety Board’s accident report (NTSB RAB-05-03) again identifies the need for improved joint bar inspection programs.

Thank you for the opportunity to provide comments on these rail safety issues.