Rosedale, MD: NTSB report includes wide-ranging recommendations

3 Nov

The National Transportation Safety Board (NTSB) has published its report into the May 28th, 2013 collision on  private passive level crossing in Rosedale, Maryland. The collision occurred at about 13.59 when a three axle truck crossed into the path of a freight train running on the CSX Transportation (CSX) right-of-way. The truck did not stop and was hit by a CSX train formed of  two locomotives, 31 empty cars, and 14 loaded cars. The train was running at a recorded speed of 49 mph. As the train approached the crossing, the train horn sounded three times. The collision caused the truck to rotate and overturn The first 15 cars of the 45-car train derailed as a consequence of the collision.

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Three of the 15 rail cars (cars 7, 8, and 15) contained hazardous materials. The seventh car (loaded with sodium chlorate crystal)—and the ninth through twelfth cars (loaded with terephthalic acid)—released their products. Following the derailment, a postcrash fire resulted in an explosion at 14.04. The overpressure blast from the explosion shattered windows and damaged property as far as approximately 0.5 miles from the site. The fire remained confined to the derailed train cars. The truck driver was seriously injured in the collision. Three workers in a building adjacent to the railway and a Maryland Transportation Authority police officer who responded to the initial incident received minor injuries as a result of the explosion.

The NTSB has determined the probable cause of the collision was the truck driver’s failure to ensure that the tracks were clear before traversing the level crossing. Contributing to the crash were:

  • The truck driver’s distraction due to a hands-free cell phone conversation;
  • The limited sight distance due to vegetation and roadway curvature
  • The Federal Motor Carrier Safety Administration’s (FMCSA) inadequate oversight of the truck’s operator, which allowed the new entrant motor carrier to continue operations despite a serious and consistent pattern of safety deficiencies.

Contributing to the severity of the damage was the post-crash fire and the resulting explosion of a rail car carrying sodium chlorate, an oxidiser.

The crash investigation focused on the following safety issues:

  • Distraction due to hands-free cell phone use.
  • FMCSA oversight of new entrant motor carriers.
  • Systems to prevent drivers with untreated obstructive sleep apnea from being granted unrestricted medical certification.
  • Systems to address safety at private highway–railroad grade crossings.
  • Proximity of oxidizing and flammable or combustible materials in a train

Recommendations arising from this NTSB investigation are as follows:

  • To the state of Maryland: 
    • Work with CSX Transportation Company and private landowners to conduct engineering studies of the accident grade crossing (140833J) and the three other private highway–railroad grade crossings (140831V, 140828M, and 140829U) evaluated in this investigation, and take actions to improve their safety, such as removing visual obstructions, installing signage, and altering roadway geometry. (R-14-51)
  • To the 50 states, the District of Columbia, and the Commonwealth of Puerto Rico: 
    • Enact legislation adopting all elements of the Federal Railroad Administration’s model law known as the “Adequate Sight Distance at Passive Highway–Rail Grade Crossings Act.” (R-14-50)
  • To the Federal Motor Carrier Safety Administration: 
    • Modify Title 49 Code of Federal Regulations 392.82 to prohibit any use of a hands-free portable electronic device by a commercial driver’s license holder while the driver is operating a commercial vehicle, except in emergencies. (H-14-26)
    • Require a full compliance review of new entrants that fail their safety audits, fail their corrective action plans, or are issued expedited action letters. (H-14-27)
    • Establish criteria for revoking the certification of any new entrant that demonstrates a pattern of safety deficiencies. (H-14-28)
    • Develop a system whereby the authority responsible for issuing commercial driver medical certification will be notified when Federal Motor Carrier Safety Administration investigators discover violations that could result in a driver’s medical disqualification. (H-14-29)
  • To the Federal Railroad Administration: 
    • Require equivalent levels of reporting for both public and private highway-railroad grade crossings. (R-14-48)
    • Develop an algorithm using grade crossing inventory and accident history data to provide annual crash prediction estimates for private highway–railroad grade crossings, similar to your WBAPS tool for public grade crossings, and make the results easily accessible to states, railroads, and the public. (R-14-49)
  • To the Association of American Railroads and the American Short Line and Regional Railroad Association: 
    • Develop and disseminate to your members a model program for railroads to (1) evaluate the safety of private highway–railroad grade crossings in their territories, including identifying visibility obstructions and other factors that increase the risk of grade crossing collisions; and (2) work with landowners and communities to mitigate that risk. (R-14-52)
  • To the National Fire Protection Association: 
    • Notify your members of the circumstances of the Rosedale, Maryland, crash and advise them of the potential sudden and catastrophic consequences when oxidizing materials are exposed to heat or to combustible or flammable materials. (R-14-53)
  • To CSX Transportation Company: 
    • Assist the state of Maryland in taking actions identified by the state to improve the safety of the accident grade crossing (140833J) and the three other private highway–railroad grade crossings (140831V, 140828M, and 140829U) evaluated in this investigation. (R-14-54)
    • Until the improvements cited in Safety Recommendation R-14-54 are made, take action to reduce the risk of grade crossing accidents through the corridor comprising highway–railroad grade crossings 140833J, 140831V, 140828M, and 140829U. (R-14-55)

The NTSB also reiterated the following safety recommendations:

  • To the Federal Motor Carrier Safety Administration: 
    • Require all new motor carriers seeking operating authority to demonstrate their safety fitness prior to obtaining new entrant operating authority by, at a minimum: (1) passing an examination demonstrating their knowledge of the Federal Motor Carrier Safety Regulations; (2) submitting a comprehensive plan documenting that the motor carrier has management systems in place to ensure compliance with the Federal Motor Carrier Safety Regulations; and (3) passing a Federal Motor Carrier Safety Administration safety audit, including vehicle inspections. (H-03-2)
    • As a component of your new entrant safety audits, review with each new entrant motor carrier a structured process, such as the Safety Management Cycle, to (1) identify the root cause of safety risks and (2) maintain an effective safety assurance program. (H-12-31)
  • To the 50 states and the District of Columbia: 
    • (1) Ban the nonemergency use of portable electronic devices (other than those designed to support the driving task) for all drivers; (2) use the National Highway Traffic Safety Administration model of high visibility enforcement to support these bans; and (3) implement targeted communication campaigns to inform motorists of the new law and enforcement, and to warn them of the dangers associated with the nonemergency use of portable electronic devices while driving. (H-11-39)

The full report can be found at: http://www.ntsb.gov/doclib/reports/2014/HAR1402.pdf

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