The NTSB’s role in the investigation rail accidents and accident prevention

Max train

This article will discuss statistical and philosophical rail safety.  While rail accidents generally do not garner a great deal of media attention unless, say, a school bus is involved, the NTSB’s role in the investigation rail accidents allows for the compilation of valuable information for those in the rail industry and can assist them with developing solutions for accident avoidance.

The National Transportation Safety Board (NTSB)’s Unique Role In Rail Accident Investigation

The practical reality is that most media attention as it relates to the NTSB is focused on plane crashes.  Plane crashes are unique in their ability to capture the average person’s attention.  While we will not delve into every statutory or regulatory provision or procedure employed by the NTSB, some key elements are worth noting here.  The NTSB is a completely unique federal agency, consisting of five members, one of whom serves as the chair.  The NTSB is congressionally chartered and has subpoena and prosecutorial powers, but it is not an agency supervised by the Executive branch of the U.S. Government.  Its sole and unique mission is to investigate every transportation disaster in the United States, make a probable cause determination, and, if appropriate, issue safety regulations.  It is the only government agency authorized to investigate the causes of transportation accidents and make safety recommendations.  The NTSB’s authority is set out at 49 U.S.C. §§ 1101-1155.

The origin of the NTSB was the Air Commerce Act of 1926.  (NTSB, History of The National Transportation Safety Board, http://www.ntsb.gov/about/history.html (accessed 5/10/13)).  The NTSB was established in 1967 as the federal government’s primary accident investigation agency for all modes of transportation.  The core of the new agency was the Civil Aeronautics Board’s Bureau of Safety (closed due to the Airline Deregulation Act of 1978).  (Id.)  Originally established with strong ties to the Department of Transportation, these ties were later severed under the Independent Safety Board Act 1974 when the provisions of 49 U.S.C. §§ 1101-1155 enabled the agency.  (Id.)

The NTSB division that handles rail accident investigations is the Office of Railroad, Pipeline and Hazardous Materials Investigations (“the Office”).  (NTSB, Office of Railroad, Pipeline and Hazardous Materials Investigations, http://www.ntsb.gov/about/office_rph.html (accessed 11/15/13)).  The NTSB makes safety recommendations based on the rail accident investigations it conducts.  (Id.)  The Railroad Division of the Office conducts investigations “involving passenger railroads, freight railroads, commuter rail transit systems and other transportation systems operating on a fixed guideway.  These accidents typically involve collisions or derailments; some of these accidents lead to the release of hazardous materials.”  (Id.)

Rail Fatality Statistics

In 2011, the most recent year for which NTSB statistics for fatal accidents are available, there were 759 rail accidents.  The accident data for 2011 was comprised of trespassers and nontrespassers (499); light, heavy, and commuter rail (230); employees and contractors (24); and passengers (6).  (NTSB, Data & Statistics: 34,434 Transportation Fatalities In 2011http://www.ntsb.gov/data/index.html (accessed 10/27/13)).

Information regarding NTSB reports concerning rail accidents going back to the 1970s can be found on the NTSB website at http://www.ntsb.gov/investigations/reports_rail.html.

Causes of Rail Accidents

Fatigue

In September of this year, NTSB Board Member Dr. Mark Rosekind made a presentation to a workshop of locomotive engineers and trainmen.  Mark Rosekind, The NTSB Safety Mission: From Investigation to Recommendation, https://www.ntsb.gov/doclib/speeches/rosekind/rosekind_09232013.pdf (last accessed Nov. 15, 2013).   One of the causes of rail accidents that Dr. Rosekind identified is fatigue, about which the NTSB feels strongly and almost constantly designates as a cause of accidents.  As Dr. Rosekind stated in his remarks, “fatigue can degrade the very aspect of human capability”.  (Id.)

On April 17, 2011, there was a collision between two BNSF railway freight trains in Red Oak, Iowa.  (Id.)  The cause of the accident was found to be fatigue.  (Id.)  Specifically, the crew of the striking train was so fatigued that they failed to comply with the signal indication requiring them to stop before colliding with the standing train.  (Id.)  The crew had fallen asleep “‘due to fatigue resulting from their irregular work schedules and their medical conditions.'”   (Id.)

Based on some of the NTSB investigations pinpointing fatigue as the cause of rail accidents, Dr. Rosekind recommends that “fatigue management systems” be developed for operators and that such systems be monitored and continually improved upon in order to reduce fatigue-related accidents.  (Id.)

Distraction 

Another cause of rail accidents is distraction.  (Id.)   In Chatsworth, California, on September 12, 2008, a Metrolink train collided with a Union Pacific train due to an engineer’s texting.  (Id.)  Metrolink’s engineer’s phone records on the day of the accident showed that 95 text messages were sent or received.  (Id.)  During the time the engineer was responsible for operating the train, he sent 21 texts, received 21 texts and made four telephone calls.  (Id.) Upon investigation it was found that the engineer’s phone usage on the day of the accident was consistent with his previous use, so this accident was simply waiting to happen.  (Id.) The cause of the crash was found to be the failure of the Metrolink engineer to observe and respond to the red signal.  (Id.)  Although the Metrolink engineer was prohibited from using his phone while operating the train, he did so anyway, causing the accident.  (Id.)

NTSB Investigations as a Useful Tool for Avoiding Future Rail Accidents

NTSB investigations into rail accidents can serve as useful  tools for avoiding accidents in the future.  Because valuable information is compiled and because the NTSB makes a causation determination for each accident, future rail accidents can be avoided by looking at the causal mechanisms of the accident and implementing systems to avoid such accidents in the future.