[Federal Register Volume 69, Number 153 (Tuesday, August 10, 2004)]
[Pages 48560-48562]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-18193]



Federal Railroad Administration

Notice of Safety Advisory 2004-02

AGENCY: Federal Railroad Administration (FRA), DOT.

ACTION:  Notice of safety advisory.


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).

    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 

[[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 

    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 
    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 
    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.


    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 
    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]