[Federal Register Volume 70, Number 9 (Thursday, January 13, 2005)]
[Notices]
[Pages 2455-2456]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-834]


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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration


Notice of Safety Advisory 2005-01; Position of Switches in Non-
Signaled Territory

AGENCY: Federal Railroad Administration (FRA), Department of 
Transportation (DOT).

ACTION: Notice of safety advisory.

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SUMMARY: FRA is issuing Safety Advisory 2005-01 to advise all railroads 
to review their operating rules and take certain other action necessary 
to ensure that train crews who operate manual (hand-operated) main 
track switches in non-signaled territory restore the switches to their 
normal position after use. FRA intends this advisory to reduce the risk 
of serious injury or death both to railroad employees and the general 
public due to not restoring such switches to their normal position 
after use.

FOR FURTHER INFORMATION CONTACT: Douglas H. Taylor, Staff Director, 
Operating Practices Division, Office of Safety Assurance and 
Compliance, FRA, 1120 Vermont Avenue, NW., RRS-11, Mail Stop 25, 
Washington, DC 20590 (telephone (202) 493-6255).

SUPPLEMENTARY INFORMATION:

Factual Background

    A review of FRA's accident/incident data shows that, overall, the 
safety of rail transportation continues to improve. However, FRA has 
particular concern that recent accidents on Class I railroads in non-
signaled territory were caused, or apparently caused, by the failure of 
railroad employees to return manual (hand-operated) main track switches 
to their normal position, i.e., lined for the main track, after use. As 
a result, rather than continuing their intended movement on the main 
track, trains approaching these switches in a facing-point direction 
were unexpectedly diverted from the main track onto the diverging 
route, and consequently derailed. Most recently:
     On January 8, 2005, a Burlington Northern and Santa Fe 
Railway Company (BNSF) freight train was unexpectedly diverted onto an 
industrial track in Bieber, California. The BNSF train struck two 
loaded grain cars, derailing seven locomotives and 14 cars. Two 
railroad employees were injured. Initial damages to equipment and track 
are in excess of $970,000.
     On January 6, 2005, a Norfolk Southern Railway Company 
(NS) freight train was apparently unexpectedly diverted from the main 
track onto an industrial lead in Graniteville, South Carolina. The NS 
train struck a standing train on the industrial lead, derailing three 
locomotives and 16 cars. One of the derailed cars that contained 
chlorine ruptured and released product. As a result, eight citizens and 
one railroad employee were killed, 5,400 local residents remain 
evacuated, and 234 people have sought medical treatment. The National 
Transportation Safety Board (NTSB) began its investigation immediately 
and will not make its findings of probable cause for some time. FRA has 
representatives at the site assisting in the investigation. By stating 
here its preliminary impression of what may have contributed to this 
tragic accident, FRA in no way intends to supersede the NTSB's thorough 
and painstaking efforts that will ultimately lead to its official 
findings of cause.
    FRA's regulations (49 CFR part 217) require each railroad to 
instruct its employees on the meaning and application of its code of 
operating rules, and to periodically test its employees to determine 
their level of compliance. Railroad operating rules provide that the 
normal position for a main track switch is lined and locked for 
movement on the main track.

[[Page 2456]]

Another related rule provides that, where trains or engines are 
required to report clear of the main track, such a report must not be 
made until the switch and derail, if any, have been secured in the 
normal position. Where no signal or other system is in service that 
indicates, through wayside or cab signals, or both, the possibility 
that a main track switch may be in other than its normal position, 
compliance with these railroad operating rules is the critical element 
in ensuring route integrity for main track movements.
    Failure to comply with these important operating rules is the 
result of various causes. Difficulties may be especially likely to 
arise where a train crew has exclusive authority to occupy a specific 
track segment until they release it for other movements, but due to 
inattention to duty, their train does not return to a main track switch 
that they may have inadvertently left lined for movement to a secondary 
track before going off duty. Some railroads have very recently amended 
their operating rules to address this issue. Two recent examples are:
     On October 1, 2004, Union Pacific Railroad Company (UP) 
adopted a requirement that before reporting clear of the limits of a 
track warrant, the crewmember releasing the track warrant must first 
advise the train dispatcher that main track switches have been restored 
to their normal position. The train dispatching system prompts the 
dispatcher to request this information if it has not been provided by 
the crew. The change was made because of a collision that occurred at 
Thomaston, Texas, on September 29, 2004. A Texas Mexican Railway 
Company (TM) crew released their main track authority, in this case a 
track warrant, without verifying that the north siding switch was 
properly lined for the main track. A southbound UP train entered the 
siding and collided with the unattended TM train. The change was issued 
by System General Order and was a change to General Code of Operating 
Rules, Rule 14.7, Reporting Clear of Limits.
     On October 31, 2004, BNSF adopted a requirement that the 
train crew report to the train dispatcher the position of the switch 
that the train is using to clear the main track when releasing the 
limits of their track warrant. The dispatching system will not allow a 
track warrant to be cleared until the dispatcher confirms the switch 
position through a job briefing with the crew. The change was not made 
because of any specific incident, but rather as the result of a 
recommendation from BNSF's Northern California Division Safety Team. 
The BNSF Team had some concerns on a particular subdivision involving 
crews forgetting to line back main track switches and asked BNSF's 
System Rules Department to adopt a rule change to eliminate the 
potential for this oversight. The Rules Department then issued this 
change across BNSF's system.

Recommended Actions

    The recent accidents have convinced FRA that, on an industry-wide 
basis, railroad operating rules need to be strengthened, clarified and 
re-emphasized so as to ensure that all main track switches are returned 
to their normal position after use, irrespective of whether or not the 
crew releases (clears) the track warrant at that time. Furthermore, it 
is essential that all crewmembers communicate to each other the fact 
that all main track switches have been properly restored after their 
use. Since this is strictly an issue of ensuring that employees 
remember to perform a simple but crucially important duty, FRA believes 
that additional procedures that serve as reminders of that duty may be 
of great value.
    Accordingly, FRA strongly urges all railroads to immediately:
    1. Ensure that their operating rules contain a provision, similar 
to that established on BNSF and UP, as described above, that clearly 
requires train crews who operate manual (hand-operated) main track 
switches in non-signaled territory to report to the dispatcher that the 
main track switches have been restored to normal position, before 
reporting clear of the limits of main track authority, such as a track 
warrant.
    2. Require the conductor of a train crew operating in non-signaled 
territory to complete and sign a Switch Position Awareness Form (Form). 
FRA recommends that the Form be completed in ink and contain the train 
symbol, date, subdivision, conductor's and engineer's names, and a 
listing by name and location of each main track switch operated by any 
member of the crew. The listing should contain the switch location and 
name, the time the switch was reversed, the time the switch was 
returned to the normal position, and the initials of the conductor and 
the engineer. Entries made with respect to a specific main track switch 
must be completed by the conductor as soon as possible after the switch 
is reversed and as soon as possible after the switch is returned to its 
normal position. The engineer's initials on the Form are intended to 
serve as a cross-check measure to reflect that the engineer has been 
advised, through a job briefing with the conductor, that the main track 
switch or switches have been restored to their normal position. The 
engineer's initials should be affixed to the Form as soon as 
practicable after the main track switch has been restored to its normal 
position. All initials required on the Form must be entered before any 
member of the crew reports clear of the limits of the main track 
authority.
    3. Require that, at the completion of each trip or tour of duty, 
the original Form be submitted to the designated railroad official(s) 
as directed.
    4. Require that railroad officers review the completed Forms for 
accuracy. The results of these reviews should be incorporated into the 
railroad's operational tests and inspections program as required by 49 
CFR 217.9.
    5. Ensure immediate dissemination of guidance on these revised 
rules and procedures and of the necessary Forms to all affected 
operating personnel.
    FRA is considering the need for any additional action to address 
this situation, such as regulatory action or additional advisories. We 
are considering the form that any additional action might take, its 
specific content, and any necessary variations based on differing types 
of operations. FRA's operating practices inspectors will determine the 
extent to which railroads have taken action in accordance with the 
measures recommended in this advisory. These findings will be one 
important factor in determining FRA's future course of action. We are 
committed to taking whatever action appears necessary to prevent any 
further death or serious injury that might arise from additional 
failures to comply with the basic operating rules concerning the proper 
positioning of main track switches.
    In the meantime, all railroads are strongly urged to immediately 
adopt and comply with the measures recommended in this advisory.

    Issued in Washington, DC, on January 10, 2005.
Robert D. Jamison,
Acting Administrator, Federal Railroad Administration.
[FR Doc. 05-834 Filed 1-11-05; 2:37 pm]
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