Document ID: FRA-2018-0037-0012
Agency: fra
Document Type: Notice
Title: Safety Advisory Related to Temporary Signal Suspensions
Posted Date: 2018-11-20T05:00Z

[Federal Register Volume 83, Number 224 (Tuesday, November 20, 2018)]
[Notices]
[Pages 58685-58688]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-25311]

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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration

[Docket No. FRA-2018-0037; Notice No. 2; Safety Advisory 2018-02]

Safety Advisory Related to Temporary Signal Suspensions

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

ACTION: Notice of Safety Advisory.

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SUMMARY: FRA is issuing this Safety Advisory addressing railroad 
operations under temporary signal suspensions. This Safety Advisory 
recommends the use of industry best practices when planning and 
implementing temporary signal suspensions, including when conducting 
rail operations under temporary signal suspensions. This Safety 
Advisory also recommends that railroads develop and implement 
procedures and practices consistent with the identified best practices 
and that railroads take certain other actions to ensure the safety of 
railroad operations during temporary signal suspensions. FRA believes 
that actions consistent with this Safety Advisory will reduce the risk 
of serious injury or death both to railroad employees and members of 
the public.

FOR FURTHER INFORMATION CONTACT: Douglas Taylor, Staff Director, 
Operating Practices, Office of Railroad Safety, FRA, 1200 New Jersey 
Avenue SE, Washington, DC 20590, telephone (202) 493-6255; or Carolyn 
Hayward-Williams, Staff Director, Positive Train Control/Signal & Train 
Control Division, Office of Railroad Safety, FRA, 1200 New Jersey 
Avenue SE, Washington, DC 20590, telephone (202) 493-6399.

SUPPLEMENTARY INFORMATION:

Background

    On April 23, 2018, FRA published a notice of a draft Safety 
Advisory in the Federal Register addressing railroad operations during 
temporary signal suspensions. 83 FR 17701. As stated in the draft 
Safety Advisory, a review of FRA's accident/incident data shows that 
overall, rail transportation, both passenger and freight, is safe. 
However, recent rail accidents occurring in areas where a railroad has 
temporarily suspended the signal system, typically for purposes of 
maintenance, repair, or installation of additional components for a new 
or existing system, demonstrate that rail operations during signal 
suspensions present increased safety risks. In the draft Safety 
Advisory, FRA specifically noted the February 4, 2018 accident in 
Cayce, South Carolina, in which the engineer and conductor of National 
Railroad Passenger Corporation (Amtrak) Train P09103 were killed and 
115 passengers injured,\1\ when their train collided head-on with a CSX 
Transportation, Inc. freight train (Train F77703). As noted in the 
draft Safety Advisory, while the cause of this accident has not yet 
been determined, FRA's preliminary investigation indicates that despite 
the CSX train crew reporting to the train dispatcher that the switch 
was lined correctly, the crew did not restore the main track switch to 
its normal position as required by Federal regulation (Title 49 Code of 
Federal Regulations (CFR) 218.105) and CSX's own operating rules. The 
misaligned switch diverted the next train to traverse the location (the 
Amtrak train) into the siding and into the standing CSX train parked on 
the siding.
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    \1\ Including 92 individuals who were transported to medical 
facilities for treatment and 23 people who received first aid at a 
triage area established near the accident site.
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    In the draft Safety Advisory, FRA also noted the March 14, 2016 
accident near Granger, Wyoming, which occurred when a Union Pacific 
Railroad (UP) freight train traveled from the main track through a 
misaligned switch into a controlled siding and collided head-on with 
another UP freight train standing on the siding.
    Notably, both the Cayce and Granger accidents occurred while the 
operating railroads were installing and testing positive train control 
(PTC) technology and while the railroads had temporarily suspended the 
signals in the accident areas to perform installation and testing 
activities. In the Granger accident, while the signals were suspended, 
UP established absolute blocks intended to provide for the safe 
movement of trains through the area without signals. In the Cayce 
accident, the Amtrak train was operating on a track warrant and at the 
time of the accident, signal personnel had stopped working for the day, 
yet the temporary signal suspension remained in place.
    As explained in the draft Safety Advisory, the National 
Transportation Safety Board (NTSB) determined that the probable cause 
of the Granger accident was the employee-in-charge incorrectly using 
information from a conversation with the train dispatcher as 
authorization to send a train into the area where the signal system 
suspension was in effect. The NTSB also found that a contributing 
factor was the conductor pilot's failure to check the switch position 
before authorizing the train to enter the area. Both FRA and the NTSB's 
investigations into the Cayce accident are ongoing and while neither 
agency has yet issued any formal findings, on February 13, 2018, the 
NTSB issued a Safety Recommendation Report \2\ to FRA regarding train 
operations during signal suspensions. In its report, the NTSB 
recommended that FRA issue an emergency order directing railroads to 
require train crews to approach switches at restricted speed when 
signal suspensions are in effect and a switch has been reported relined 
for a main track (NTSB Safety Recommendation R-18-005). The NTSB 
further recommended that after the switch position is verified, train 
crews should be required to report to the dispatcher that the switch is 
correctly lined for the main track before

[[Page 58686]]

subsequent trains are permitted to operate at maximum-authorized speed.
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    \2\ NTSB, Safety Recommendation Report: Train Operation During 
Signal Suspension, Report No. RSR-18/01, Recommendation No. R-18-005 
(Feb. 13, 2018), https://www.ntsb.gov/investigations/AccidentReports/Reports/RSR1801.pdf.
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    FRA issued the draft Safety Advisory consistent with the purpose of 
the NTSB's recommendation and to ensure all railroads were made aware 
of both the safety concerns identified and information and practices 
available to specifically address the issues raised. Moreover, FRA 
intended the draft Safety Advisory to provide railroads the flexibility 
to review and revise their existing operating rules and practices as 
necessary to ensure the safety of their operations, without imposing 
rigid and inherently limited, new requirements on the industry. FRA 
intended the draft Safety Advisory to provide an opportunity for 
interested parties and industry experts to provide input on potential 
ways to prevent future accidents such as those that occurred in Granger 
and Cayce by sharing known industry best practices and seeking input on 
the same.
    In the draft Safety Advisory, FRA noted the following best 
practices that some railroads were already implementing:
     Taking all practical measures to ensure sufficient 
personnel are present to continue signal work until the system is 
restored to proper operation. If sufficient personnel are not present, 
the signal suspension is terminated until such time as sufficient 
personnel are on hand.
     If a railroad elects to allow train traffic through signal 
suspension limits:
    o Establishing the smallest limits possible for the signal 
suspension (if possible, no more than three (3) control points or use 
phased limits to allow restoration of the signal system as work is 
completed);
    [cir] Minimizing the duration of the signal suspension to the 
shortest time period possible (if possible, no more than twelve (12) 
hours); and
    [cir] Taking all practical measures to ensure only through traffic 
is allowed to operate within the limits (avoiding any train meets or 
any movements requiring the manipulation of switches within the 
suspension limits).
     If any switches within the suspension limits are 
manipulated, consistent with 49 CFR 218.105, establishing an effective 
means of verifying that all switches have been returned to the proper 
position prior to any train traffic operating through the limits. (For 
example, require spiking or clamping of switches followed by locking 
for through movement after use; utilize a signal employee to tend the 
switch and to establish agreement between assigned crew members and the 
switch tender that the switch is properly lined; and/or require the 
first train through the limits after the manipulation of any switch to 
operate at restricted speed).
    Among other recommendations, in the draft Safety Advisory, FRA 
recommended that railroads develop and implement procedures and 
practices consistent with these industry best practices for operations 
conducted under temporary signal suspensions. FRA also recommended that 
railroads increase supervisory operational oversight and conduct 
operational testing on the applicable operating rules pertaining to the 
operation of hand-operated main track switches and that this increased 
oversight should include face-to-face initial job briefings with all 
train and engine crews that will operate in any area where the signal 
system will be temporarily suspended.

Discussion of Comments Received in Response To Draft Safety Advisory

    In response to the draft Safety Advisory, FRA received comments 
from the NTSB, the Association of American Railroads and the American 
Short Line and Regional Railroad Association (AAR/ASLRRA), Amtrak, the 
Brotherhood of Locomotive Engineers and Trainmen (BLET), the 
Transportation Division of the International Association of Sheet 
Metal, Air, Rail and Transportation Workers (SMART) and individuals 
involved in railroad transportation. Some commenters, including the 
NTSB, BLET, and SMART expressed the view that FRA's issuance of a 
Safety Advisory did not go far enough to address the safety issues 
associated with signal suspensions. These commenters expressed the view 
that FRA should mandate solutions through the regulatory process.\3\ 
FRA respectfully disagrees with these commenters. FRA believes that 
when properly implemented and complied with, FRA's existing regulations 
(e.g., 49 CFR part 218, subpart F) and the railroads' related operating 
rules effectively address the safety issues involved. Moreover, given 
the variety of circumstances under which railroads may need to 
temporarily suspend signal systems, FRA does not believe mandating a 
``one size fits all'' solution is practical or in the interest of 
railroad safety.
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    \3\ On June 11, 2018, recognizing FRA's publication of the draft 
Safety Advisory, the NTSB classified FRA's response to Safety 
Recommendation R-18-005 as ``Open--Unacceptable Response.'' In its 
letter to FRA, the NTSB noted that it did not agree with FRA that 
``an advisory goes far enough to ensure safety.''
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    The NTSB further commented that the draft Safety Advisory offered 
``contradictory statements'' in noting that the Advisory provided 
railroads the ``flexibility to review and revise their existing 
operating rules and practices as necessary to ensure the safety of 
their rail operations, without imposing rigid, and inherently limited, 
new requirements on the industry'' and at the same time stating that 
temporary signal suspensions ``are necessarily common occurrences'' and 
that ``rail operations under signal suspensions should be rare and 
appropriately limited.'' These statements are not contradictory. FRA 
recognizes that signal suspensions are necessary to maintain and 
upgrade signal systems. In recent years railroads have improved upon 
installation and testing processes to minimize the extent and duration 
of signal suspensions. Furthermore, some railroads have sought to limit 
or prohibit operations through signal suspensions, and FRA agrees that 
in some circumstances, limiting or prohibiting operations through 
signal suspensions may be appropriate. Accordingly, in this Safety 
Advisory, FRA is recommending that before initiating a planned 
temporary signal system suspension, a railroad conduct a risk 
assessment to, among other things, evaluate whether rail operations 
through and/or within the suspension limits should continue during the 
suspension.
    The NTSB further recommended that FRA require railroads, when 
operating trains during signal suspensions, to establish ``an effective 
means for verifying that all switches have been returned to the proper 
position prior to any train traffic operating through'' the suspension 
limits. The NTSB agreed with FRA's statement in the draft Safety 
Advisory that spiking or clamping switches, followed by locking the 
switches for through movement after use is one way to effectively 
verify switch position. In its comments, the NTSB also reiterated its 
Safety Recommendation R-18-005 recommending that FRA require train 
crews to approach switches at restricted speed when signal suspensions 
are in effect and a switch has been reported relined for a main track. 
The NTSB also recommended FRA convert the draft Safety Advisory into a 
regulation. As noted previously, FRA does not agree with this 
recommendation. FRA does, however, agree with the NTSB, and other 
commenters' recommendation that restricted speed may be an effective 
mitigation measure, and in this Safety Advisory FRA is specifically 
reiterating that as a potential best practice to be employed as 
appropriate.

[[Page 58687]]

    BLET echoed the NTSB's restricted speed recommendation and 
expressed the view that it is irrelevant that both the Granger and 
Cayce accidents occurred while signal suspensions were in effect. 
Instead, from an operational standpoint, BLET asserted that the issue 
needing to be addressed is misaligned switches in non-signaled 
territory. As such, BLET expressed the view that FRA should not only 
implement NTSB Safety Recommendation R-18-005 as a regulation, but FRA 
should also implement the NTSB's Safety Recommendation R-12-29. NTSB 
Safety Recommendation R-12-29 recommended that until appropriate switch 
position warning technology is installed on main track switches, the 
first train through any dark territory after a main track switch had 
been reported relined for the main track must approach the switch 
location at restricted speed until the train crew reported to the 
dispatcher that the switch is correctly lined for the main track.\4\
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    \4\ NTSB previously closed R-12-29 after reconsideration of the 
recommendation noting that 49 CFR part 218, subpart F addresses the 
intent of the recommendation in an alternative manner.
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    SMART urged FRA to establish ``uniform safety procedures'' noting 
that many SMART members operate trains over more than one railroad. In 
addition, SMART suggested FRA issue an emergency order requiring 
railroads to adopt the best practice of spiking and locking main track 
switches when trains operate over a section of track where a signal 
system is suspended or ``turned off and abandoned.''
    In their comments, AAR/ASLRRA expressed agreement with the draft 
Safety Advisory's recommendation that railroads develop and implement 
procedures and practices for operations under temporary signal 
suspensions consistent with industry best practices. In their comments, 
however, AAR/ASLRRA suggested that certain aspects of the best 
practices FRA identified in the draft Safety Advisory should be 
modified. Specifically, AAR/ASLRRA suggested that FRA's recommended 
best practices should not limit signal suspensions to three control 
points and 12 hours in duration. Instead, noting the often complex 
nature of signal work, AAR/ASLRRA suggested that best practices should 
simply be for railroads to limit the number of control points involved 
in signal suspensions and the duration of the signal suspensions to the 
extent practicable. AAR/ASLRRA also expressed agreement with FRA's 
recommendation for increased supervisory operational oversight of the 
application of operating rules regarding the operation of hand-operated 
switches, but suggested that face-to-face initial job briefings with 
train and engine crews operating in signal suspension areas are ``not 
always feasible'' or the most effective solution. Thus, AAR/ASLRRA 
suggested that FRA revise its recommendation to allow for job briefings 
regarding temporary signal suspensions through bulletin or notice from 
the dispatcher, as opposed to a face-to-face job briefing. Given the 
variety of reasons a railroad may choose or need to suspend its signal 
system and the variety of circumstances under which such suspensions 
are conducted, FRA generally agrees with AAR/ASLRRA's comments that no 
geographic limit or time duration should be specified as a matter of 
industry-wide best practice. Accordingly, FRA believes railroads should 
limit the geographic scope and time duration of signal suspensions to 
the extent possible given the particular circumstances, but agrees that 
no hard limit on the number of control points, specific ways of 
limiting the geographic scope (such as using phased limits), or 
duration of signal suspensions should be specified. FRA also generally 
agrees that face-to-face job briefings may not always be practical if a 
signal suspension results from an unplanned event, such as a storm as 
referenced in AAR/ASLRRA's comments. This Safety Advisory, however, is 
specifically directed to the best practices for carrying out planned 
signal suspensions and thus, AAR/ASLRRA's comment on job briefings is 
outside the scope of this Advisory.
    Amtrak generally expressed support for the recommendations in the 
draft Safety Advisory and additionally shared its experience in 
developing and implementing a Safety Management System (SMS) to enhance 
communication of safety concerns and issues. Amtrak also referenced its 
February 2018 initiation of the development of a formal risk assessment 
methodology to identify, analyze, assess, and mitigate risks due to 
human error associated with operating passenger service through 
territories in which the normal signal systems have been temporarily 
suspended. Amtrak explained that upon notification of a signal system 
suspension from a host railroad, using a collaborative process with 
departments across the railroad (including Operating Practices, System 
Safety, and local Train and Engine staff), Amtrak performs a risk 
assessment to identify appropriate operational mitigations including, 
but not limited to, speed restrictions, alternate routing, or service 
suspensions. Amtrak explained that each risk assessment and the 
mitigations prescribed are reviewed and approved by Amtrak senior 
leadership and the results of that assessment and approved operational 
mitigations are communicated to affected employees and shared with 
Amtrak's host railroad. Amtrak indicates in its comments that it has 
performed over thirty risk assessments and is committed to continuously 
improving the assessment process. FRA believes Amtrak's comments have 
merit and in this Safety Advisory is revising its recommendations to 
railroads to include a risk assessment component.

Safety Advisory 2018-02 \5\
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    \5\ The draft Safety Advisory published on April 23, 2018, was 
captioned ``Draft Safety Advisory 2018-01.'' Subsequent to 
publication of the draft Safety Advisory, however, on July 27, 2018, 
FRA published a separate Safety Advisory addressing electrode-
induced rail pitting from pressure electric welding. That Safety 
Advisory was numbered 2018-01. Accordingly, FRA has revised the 
number assigned to this Safety Advisory to 2018-02.
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    Railroads suspend signal systems for a variety of reasons, 
including for maintenance or repair purposes, to install a new system, 
or to add additional components to an existing system. As exemplified 
by the accidents described above, rail operations under the temporary 
loss of protections provided by an existing signal system have the 
potential to introduce new safety risks and amplify existing safety 
risks because railroad employees accustomed to the safety an existing 
signal system provides must operate in an environment they may not 
encounter on a regular basis. A temporary signal suspension requires 
operating employees to immediately apply operating rules and practices 
different from those to which they are accustomed. Because a person's 
routine may include learned habits that are difficult to set aside when 
a temporary condition is imposed, operating employees may also need 
specialized instruction on the applicable rules and practices. Such 
risks must be addressed to provide for the safety of train operations 
during the loss of protection afforded by the signal system.
    As discussed in detail in the draft Safety Advisory, Federal 
regulations require railroads to apply for FRA approval for certain 
discontinuances and modifications of signal systems, but Federal 
regulations do not prohibit railroads from temporarily suspending 
existing signal systems for purposes of performing maintenance, 
upgrades, repairs, or implementing PTC technology. See 49 CFR 235.7. 
FRA does

[[Page 58688]]

not believe that Federal regulations should include such a prohibition. 
FRA's regulations already require individual railroads to adopt and 
comply with operating rules addressing the operation of hand-operated 
main track switches. See 49 CFR 218.105.
    In addition to the regulatory requirements, virtually all railroads 
have adopted additional operational protections to ensure the safety of 
rail operations when an existing signal system is temporarily 
suspended. FRA believes certain operational safeguards that railroads 
already undertake constitute the best practices within the industry 
when temporarily suspending a signal system. These best practices 
include:
     Take all practical measures to ensure sufficient personnel 
are present to continue signal work until the system is restored to 
proper operation. If sufficient personnel are not present, terminate 
the signal suspension until sufficient personnel are on hand.
     If a railroad elects to allow train traffic through signal 
suspension limits:
    [cir] Establish the smallest limits possible for the signal 
suspension;
    [cir] Minimize the duration of the signal suspension to the 
shortest time period possible;
    [cir] Take all practical measures to ensure only through traffic is 
allowed to operate within the limits (avoiding any train meets or any 
movements requiring the manipulation of switches within the suspension 
limits).
     If any switches within the signal suspension limits are 
manipulated, consistent with 49 CFR 218.105, establish an effective 
means of verifying that all switches have been returned to the proper 
position prior to any train traffic operating through the limits (for 
example, require spiking or clamping of switches followed by locking 
for through movement after use; utilize a signal employee to tend the 
switch and to establish agreement between assigned crew members and the 
switch tender that the switch is properly lined; and/or require the 
first train through the limits after the manipulation of any switch to 
operate at restricted speed).
    Recommendations: After careful consideration of the comments 
received in response to the draft Safety Advisory, and to ensure the 
safety of the Nation's railroads, their employees, and the public, FRA 
recommends that railroads take immediate actions consistent with the 
following:
    1. Before initiating a planned temporary suspension of a signal 
system, perform a risk assessment to determine the most effective and 
safest way to implement the suspension. The risk assessment should 
include consideration of the need to minimize the geographic scope and 
duration of the suspension and evaluate whether rail operations through 
and/or within the suspension limits should continue during the 
suspension. If a railroad concludes operations through or within the 
suspension limits may continue, the risk assessment should identify 
appropriate operational mitigations including, but not limited to, 
speed restrictions or alternate routing. The risk assessment should be 
performed with the input of all affected railroad departments (e.g., 
Operating, Signal and Train Control, System Safety, and involved Train 
and Engine Staff), and any approved operational mitigations should be 
clearly communicated to all affected employees in advance of initiating 
the suspension or allowing the employees to operate through or within 
the suspension limits.
    2. Develop and implement procedures and practices consistent with 
the industry best practices discussed above for rail operations 
conducted under temporary signal suspensions.
    3. Inform employees of the circumstances surrounding the February 
4, 2018, accident in Cayce, South Carolina, and the March 14, 2016, 
accident near Granger, Wyoming, discussed above, emphasizing the 
potential consequences of misaligned switches and the relevant Federal 
regulations and railroad operating rules intended to prevent such 
accidents.
    4. Review, and as appropriate, revise all operating rules related 
to operating hand-operated main track switches (including operating 
rules required by 49 CFR 218.105), to enhance them to ensure (a) train 
crews and others restore switches to their normal position after use, 
and (b) the position of switches are clearly communicated to train 
control employees and/or dispatcher(s) responsible for the movement of 
trains through the area where the signal system is temporarily 
suspended. In doing so, railroads should pay particular attention to 
those main track switches where employees report clear of the main 
track to the train dispatcher.
    5. Increase supervisory operational oversight and conduct 
operational testing on the applicable operating rules pertaining to the 
operation of hand-operated main track switches. This should include 
face-to-face initial job briefings with all train and engine (T&E) 
crews that will operate in any area where the signal system will be 
temporarily suspended.
    6. Enhance instruction on the relevant operating rules concerning 
the operation of hand-operated main track switches in non-signaled 
territory, including the operating rules required by 49 CFR 218.105(d) 
during both initial and periodic instruction required by 49 CFR 217.11. 
In doing so, railroads should emphasize the applicability of the rules 
to any area(s) where the signal system is temporarily suspended and the 
need to ensure and verify that all hand-operated main track switches 
manipulated within any suspension limits have been returned to the 
proper position prior to operating any trains through the limits.
    7. Stress to T&E employees the importance of thorough and accurate 
job briefings when operating hand-operated main track switches, 
particularly in areas where the signal system is temporarily suspended, 
and specifically when releasing main track authority. Ensure adequate 
processes and procedures are in place enabling clear and timely 
communication of switch positions between and among all dispatching, 
T&E, and train control employees responsible for operating, performing 
work, or authorizing trains to operate through areas where the signal 
system is temporarily suspended. These processes and procedures should 
include processes and procedures for communicating switch position 
information during shift handovers. Encourage employees, in case of any 
doubt or uncertainty regarding the position of hand-operated switches, 
to immediately contact the train dispatcher or take other appropriate 
action to confirm the position of the switch prior to authorizing a 
train to operate through the limits of the area.
    FRA encourages railroads to take immediate action consistent with 
the recommendations of this Safety Advisory and to take any other 
actions appropriate to help ensure the safety of the Nation's 
railroads. FRA may modify this Safety Advisory or take other 
appropriate actions necessary to ensure the highest level of safety on 
the Nation's railroads.

    Issued in Washington, DC.
Ronald L. Batory,
Administrator.
[FR Doc. 2018-25311 Filed 11-19-18; 8:45 am]
 BILLING CODE 4910-06-P