# Presentation: 860757

## Slide 1

## Accident Train

-  61 Passengers
-  12 Amtrak employees
-  1 Fatality
-  3 Serious injuries
-  43 Minor injuries

## Launch Team

- Mark Rosenker	Vice Chairman
- Ted T. Turpin	IIC
- Dick Hipskind	Track
- Ruben Payan 	Event Recorders/Signals
- Dave Watson 	Mechanical
- George Cochran	Operations
- Joseph Kris 		Emergency Response
- Dana Sanzo		Emergency Response
- Dr. Steve Jenner	Human Factors
- Lauren Peduzzi	Public Affairs
- Brian Fiffick		Transportation Disaster Assistance

- Support Staff
- 	Margaret Athey 		Writer/Editor
- 	William Skolochenko	Graphics
- 	Alice Park			Animation
- 	Christy Spangler		Animation

## Flora Investigation

- Focused on:
- Canadian National’s Track Maintenance
- Federal Railroad Administration’s Oversight of Railroad’s Track Maintenance
- Amtrak’s Emergency Preparation
- More than 4,000 man-hours

- Parties
- Federal Railroad Administration
- Canadian National Railway Company
- Amtrak
- Madison County Sheriff
- United Transportation Union
- Brotherhood of Locomotive Engineers and Trainmen

## Slide 8

## Slide 9

## Slide 10

## Slide 11

## Safety Issue

- Canadian National Railway Company’s continuous welded rail maintenance and inspection procedures and standards.

## Safety Issue

- Amtrak’s emergency response training of its employees.

## Safety Issue

- The Federal Railroad Administration’s oversight of continuous welded rail maintenance programs and Amtrak’s emergency response training of its employees.

## Slide 15

## Track Related Safety Issues

- Track conditions at the accident site
- Maintenance history
- Federal Railroad Administration’s inspection and oversight

## Slide 17

##  Track Buckle Prevention

- Rail and track must be restrained
- Control rail temperature to prevent excessive expansion or contraction

## Preferred Rail Laying

-  Temperature
- Selection of a preferred rail laying temperature
- Maintaining continuous welded rail to the preferred rail laying temperature
- Preferred Rail Laying Temperature: 105 ̊ F

## Slide 20

## Slide 21

## Track Conditions

- Missing rail anchors and loose fasteners
- Rail anchor movement

## Slide 23

## Longitudinal Rail Movement

**Longitudinal Rail Movement**

## Slide 25

## Slide 26

## Postaccident Investigation

**  **281 ties surveyed
-   50% of anchors ineffective or missing
-   Lack of longitudinal rail restraint

## Conclusion

**Conclusion**

## Maintenance History

-   Rail section cut out and replaced
-   Non-compliance work report

## Maintenance History

- Preferred rail laying temperature 105 ̊ F
- Rail pulled apart when cut

## Maintenance History

- If rail length must be added, adjust before the onset of warm weather
- 2 1⁄2 inches of rail added

## Maintenance History

- Postaccident investigation found 50% of anchors not to standard

## 2004 Maintenance History

-   March 6 - CN track inspector
-   March 9 & 10 - CN track foreman
-   March 16 - CN track supervisor

## Conclusion

## Conclusion

## Slide 36

## Federal Railroad Administration Continuous Welded Rail Regulations

- Written procedures for continuous welded rail installation and rail adjustment
- Requirements for rail anchoring and fastening that will provide sufficient restraint

## FRA Options for Addressing Track Problems

- Note a defect for repair
- Write a comment to the railroad

-  June 2003 -  “numerous locations tie distribution is marginal, rail anchors are ineffective against longitudinal displacement”
-   February 2004 - No continuous welded rail concerns identified

- Federal Railroad Administration Preaccident Inspection Activity

## Federal Railroad Administration Postaccident Inspection Activity

- Hy-rail and walking track inspections
- Canadian National Railway Company cited for:
-   Failure to comply with procedures
-   Lack of rail anchors

## Conclusion

## Slide 42

## Safety Issue

- Amtrak’s emergency response training of its employees.

## FRA Regulations

- Passenger railroads to have an emergency preparedness plan
- Initial and refresher training for employees every two years

## Amtrak’s PREPARE Course

- Passenger evacuation procedures
- Type and location of emergency equipment
- First aid

## Flora Investigation

- Training records for the 12 employees reviewed
- 1 employee had not attended a PREPARE course
- 3 employees exceeded 2 years without refresher course

## Recommendation to Amtrak

- Implement effective controls to monitor and ensure that all train crews and on-board service personnel receive the necessary initial and recurrent emergency training to provide for passenger safety. (R-98-059)
- Closed – Acceptable Action

## Conclusion

- Amtrak is not assuring that all of its crewmembers receive emergency preparedness training.

## FRA Enforcement

- One audit of Amtrak’s emergency preparedness training records
- About 40% of the employees did not have the training as required
- Two violations filed

## Conclusion

- The Federal Railroad Administration was not conducting periodic and extensive audits of Amtrak’s passenger train emergency preparedness plan to ensure that all crewmembers were receiving the required emergency preparedness training.

## Slide 51