Document ID: FRA-2009-0031-0255
Agency: fra
Document Type: Notice
Title: Safety Advisory: 2023-02; Train Makeup and Operational Safety Concerns
Posted Date: 2023-04-11T04:00Z

[Federal Register Volume 88, Number 69 (Tuesday, April 11, 2023)]
[Notices]
[Pages 21736-21738]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-07579]

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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration

Safety Advisory 2023-02; Train Makeup and Operational Safety 
Concerns

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

ACTION: Notice of Safety Advisory.

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SUMMARY: FRA is issuing Safety Advisory 2023-02 to emphasize 
significant concerns related to train makeup and to ensure that all 
railroads exercise due diligence and recognize the importance of taking 
proactive measures to address potential safety risks related to 
operating train builds with varying configurations, load and empty 
placement, distributed power arrangements, and other factors. FRA has 
noticed a rising trend in recent incidents where train build and makeup 
have been identified as a potential cause or contributing factor. In 
response, FRA incorporates train simulations into its investigative 
process when it is suspected that high in-train forces may have 
contributed to train accidents. To address these concerns, FRA is 
providing recommendations for freight railroads to improve the safety 
of their train build processes and practices.

FOR FURTHER INFORMATION CONTACT: Christian Holt, Staff Director, 
Operating Practices Division, Office of Railroad Safety, FRA, 1200 New 
Jersey Avenue SE, Washington, DC 20590, telephone (202) 366-0978.

SUPPLEMENTARY INFORMATION: 

Significant Incidents

    On March 4, 2023, in Springfield, Ohio, a Norfolk Southern Railway 
(NS) 210-car mixed freight train totaling 17,966 trailing tons with 
Distributed Power Units (DPU) experienced a derailment involving 28 
cars, including 21 empty and 7 loaded cars. The train had 82 cars 
equipped with end-of-car cushioning devices, and 18 of those derailed. 
The locomotives were arranged in a 3x2x0 configuration,\1\ with

[[Page 21737]]

one headend locomotive offline. The train was traveling on an ascending 
0.6% grade with a heavier part on a 0.7% downhill grade. The weight was 
mostly concentrated at the head and rear ends of the train. During the 
accident, dynamic braking was applied only to the headend locomotive 
consist, while the DPUs were idle, making it function like a 
conventional train. The derailment happened at the sag between 
ascending and descending grades, with short, empty rail cars designed 
to ship coiled steel being the first to derail. Buff forces peaked as 
the downhill portion of the train ran-in, causing the derailment of 
cars 70-72 and the subsequent pile-up. The train was classified as a 
Key Train,\2\ with 28 loaded hazardous materials (hazmat) cars 
distributed throughout. No hazmat cars derailed.
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    \1\ 3x2x0 represents 3 headend locomotives, 2 mid DPU's, 0 rear 
DPU's.
    \2\ As defined by Association of American Railroads (AAR) 
Circular OT-55, available at https://public.railinc.com/sites/default/files/documents/OT-55.pdf, a ``Key Train'' is any train 
with: (1) One tank car load of Poison or Toxic Inhalation Hazard1 
(PIH or TIH) (Hazard Zone A, B, C, or D), anhydrous ammonia 
(UN1005), or ammonia solutions (UN3318); (2) 20 car loads or 
intermodal portable tank loads of any combination of hazardous 
material; or (3) One or more car loads of Spent Nuclear Fuel (SNF), 
High Level Radioactive Waste (HLRW).
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    On September 19, 2022, in Albers, Illinois, a NS train derailment 
occurred involving a 131-car mixed freight train (41 empty and 90 
loaded) with a DPU and totaling 11,392 trailing tons. The first 
derailed car was empty and 27 cars derailed in total. Fifty-six. cars 
were equipped with end-of-car cushioning devices. The locomotives were 
arranged in a 3x0x2 configuration, and Energy Management System (EMS) 
was active during the incident. The derailment occurred as the train 
traversed a slight descending grade and a 2-degree curve. Among the 
train's cars, 21 were carrying hazmat. Two of these hazmat cars 
derailed, and their contents were released. The assigned cause for the 
accident was excessive lateral drawbar force on the curve due to the 
train's makeup.
    On September 5, 2022, in Hampton, Iowa, a Union Pacific Railroad 
Company (UP) 165-car mixed freight train (34 empty and 131 loaded) with 
a total trailing weight of 18,479 tons experienced a derailment 
involving 44 cars. The train had 26 cars equipped with end-of-car 
cushioning devices and a 2x0x1 locomotive configuration. The head end 
of the train was ascending a 1% grade, while the rear end was 
descending a 1% grade during the incident. The derailment took place at 
the sag between the ascending and descending grades, with much of the 
train's weight concentrated at the head and rear ends. The train was a 
Key Train, carrying 26 loaded hazmat cars, of which 14 derailed and 5 
released their contents. At the time of the derailment, EMS technology 
was operating the train. The assigned cause of the incident was 
excessive buffing or slack action due to train makeup.
    On May 16, 2022, in Gravette, Arkansas, a Kansas City Southern 
Railway DPU train with a total of 125 cars (one empty and 124 loaded) 
with a total trailing weight of 17,113 tons experienced a derailment, 
which involved one car. The locomotive configuration was 2x0x3. The 
incident occurred while the train was moving uphill and negotiating a 
curve, resulting in the derailment of the single empty car on the high 
side of the curve. The root cause of the derailment was identified as 
improper train makeup.
    On February 17, 2022, in Rupert, Idaho, a UP 195-car mixed freight, 
DPU train derailed 4 cars that consisted of 106 empty and 89 loaded 
cars with 14,017 trailing tons. The first car to derail was empty. The 
locomotives were configured as 3x1x1. The train was in the process of 
stopping due to a hot box detector warning. It was using dynamic 
braking on the head and mid locomotive consists while idling down on 
the rear consist as it traveled down a descending grade. The train 
contained five HazMat cars, but none of them derailed. Nearby residents 
were evacuated as a precautionary measure. The incident was attributed 
to improper train make-up.
    On May 16, 2021, in Sibley, Iowa, a UP 159-car mixed freight train 
(43 empty and 116 loaded), weighing a total of 16,545 tons, with a 
2x1x0 DPU configuration experienced a derailment, resulting in 47 
derailed cars. The first car to derail was empty and equipped with an 
end-of-car cushioning device, as were 12 other derailed cars. At the 
time of the incident, the train navigated a grade, with the front 
section ascending and the rear section descending a grade steeper than 
1%. Dynamic braking was used before the derailment but was switched to 
idle shortly before the accident. The derailment took place in a curve 
located in a sag between the ascending and descending grades. This Key 
Train contained 26 loaded hazmat cars, of which 14 derailed and 5 
released their contents. As a result, the nearby town was evacuated for 
three days. The cause of the derailment was determined to be excessive 
buffing or slack action due to the train's makeup.
    The analysis of the recent train accidents reveals several common 
characteristics and patterns:
    1. Train Length: Each of the accident trains had 125 or more cars.
    2. Distributed Power Units (DPUs): The fact that all accident 
trains featured DPUs underscores the importance of correctly utilizing 
and managing DPUs to enhance train handling and minimize the likelihood 
of accidents. While DPUs can contribute to improved train control, they 
should not be considered a replacement for proper train car placement 
and makeup.
    3. Trailing Tons: All accident trains far exceeded 4,000 trailing 
tons, which is the maximum weight threshold established by the AAR's 
1992 Train Make-up Manual, for considering train makeup for mixed 
merchandise trains with a grade less than 2.0% and maximum track 
curvature less than 8 degrees.
    4. First Car Derailed: In each accident, the first car to derail 
was an empty car.
    5. Train Type: Five out of the six accidents involved mixed freight 
trains, which typically require more complex train makeup 
considerations.
    6. Hazmat Cars: Five out of the six accident trains contained 
hazmat cars, highlighting the potential risks associated with 
transporting hazardous materials in long, complex consists.
    7. Derailed Hazmat Cars: In three of the accidents, hazmat cars 
were derailed, increasing the risk of hazardous material release and 
environmental damage.
    8. Hazmat Release: Three of the accidents resulted in the release 
of hazardous materials, posing a threat to public safety and the 
environment.
    9. Evacuations: Two of the accidents led to the evacuation of local 
populations due to the release of hazardous materials.
    10. Key Trains: Three of the six accident trains were classified as 
Key Trains, which are trains with a higher level of potential risk due 
to the nature of the cargo they carry or their operational 
characteristics.
    Technologies such as DPUs, energy management systems, and dynamic 
braking can be used in conjunction with proper train car placement and 
makeup. While these technologies can improve train handling and fuel 
efficiency, they cannot replace the need for correct car placement and 
assembly. Railroads must prioritize proper train makeup to maintain 
safety, prevent accidents, and optimize train performance. Further, all 
operating employees must be properly trained in these technologies and 
the handling of complex trains to ensure safe operation and minimize 
human error.

[[Page 21738]]

Recommended Actions

    To improve train safety and reduce the risk of accidents, FRA 
recommends the following best practices:
    1. Review and update train makeup policies, procedures, and 
guidelines to ensure they are comprehensive, effective, and current.
    2. Ensure that all personnel involved in train makeup decisions and 
operations receive appropriate training, guidance, and supervision to 
effectively execute train makeup policies, procedures, and guidelines 
to ensure safe operations.
    3. Establish a system to regularly monitor and assess train makeup 
practices, with a focus on identifying and addressing potential safety 
risks.
    4. Encourage open communication and collaboration among all 
stakeholders, including train crews, dispatchers, yardmasters, and 
maintenance personnel, to ensure a comprehensive understanding of train 
makeup factors and their potential impact on safety. Personnel should 
be encouraged and empowered to adhere to train makeup policies, 
procedures, and guidelines, even if it delays a train.
    5. Develop and implement strategies to mitigate the risks 
associated with train build factors, such as the proper use of 
distributed power, train length limitations, and other operational 
train handling practices.
    6. Enhance incident investigation procedures to specifically 
address train makeup factors and their potential contribution to the 
cause of the incident.
    FRA encourages freight railroads to take actions consistent with 
the preceding recommendations. FRA may modify this Safety Advisory 
2023-02, issue additional safety advisories, or take other appropriate 
action necessary to ensure the highest level of safety on the Nation's 
railroads, including pursing other corrective measures under its rail 
safety authority.

    Issued in Washington, DC.
John Karl Alexy,
Associate Administrator for Railroad Safety Chief Safety Officer.
[FR Doc. 2023-07579 Filed 4-10-23; 8:45 am]
BILLING CODE 4910-06-P