E6-20359. Safety Advisory 2006-05

AGENCY:

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

ACTION:

Notice of Safety Advisory; Passenger Train Safety—Passengers Boarding or Alighting from Trains.

SUMMARY:

FRA is issuing Safety Advisory 2006-05 recommending that each railroad operating passenger trains assess the rules, instructions, and procedures used to ensure that a train will not depart a station until all passengers successfully board or alight from the train, and ensure compliance with such rules, instructions, and procedures.

FOR FURTHER INFORMATION CONTACT:

Brenda Moscoso, Operations Research Analyst, Grade Crossing Division (RRS-23), FRA Office of Safety Analysis, 1120 Vermont Avenue, NW., Washington, DC 20590, telephone: [phone] or Anna Winkle, Trial Attorney, FRA Office of Chief Counsel, 1120 Vermont Avenue, NW., Washington, DC 20590, telephone: [phone].

SUPPLEMENTARY INFORMATION:

Although the safety of passengers traveling by rail compares extremely favorably to other modes of transportation, the recent fatality of a passenger who apparently became caught in the doors of a train from which he was alighting and was dragged as the train departed the station emphasizes the need for close adherence to certain railroad safety procedures and rules. The November 21, 2006, incident, which occurred in Bradley Beach, New Jersey on the New Jersey Transit (NJT) railroad, is currently under investigation by the FRA, and state and local agencies. The cause and contributing factors, if any, have not been established; nothing in this Safety Advisory should be construed as placing blame or responsibility for the incident on the acts or omissions of any person. FRA notes that managers and employees of NJT have cooperated in FRA's investigation of the incident and that NJT has responded positively to FRA's suggested course of action following the incident, including issuing written instructions regarding checking of seals on door bypass switches and the location of train crewmembers when trains are leaving stations.

The electrically-operated doors on the passenger car involved in this incident are equipped with flexible edges that are designed to sense an obstruction when closing. If an obstruction is detected, the door reopens. If a door does not close properly, the engineer will not be able to draw power to move the train. This safety feature can be overridden by operating a bypass switch which is located in the locomotive or control car. This switch is normally sealed until used. However, FRA is aware of instances on various railroads when this type of seal has been improperly applied and has therefore been loose enough that the switch could be operated without breaking the seal. This could result in the unintentional use or intentional misuse of the bypass switch, creating a potentially dangerous operating condition where a passenger train would be able to depart with a passenger caught in a door.

FRA also notes that there is a difference among railroads as to when this type of bypass switch may be used. Some railroads require that permission be obtained from the train dispatcher prior to using the switch; others allow crewmembers to operate the switch and then inform a designated railroad employee at some point during the tour of duty. Railroads are encouraged to review their procedures to ensure that they provide an adequate level of safety for a railroad's particular operating characteristics.

Additionally, in the event that an obstruction sensor fails or is bypassed, it is important that railroads ensure that each crewmember knows and carries out his or her role in recognizing potential door obstructions and in providing an equivalent level of safety for passengers.

An additional opportunity to assure safety of boarding and alighting passengers is provided by an employee assigned to observe the station platform while the train departs. Many commuter railroads, including NJT, have a rule or instruction requiring employees to perform this task. It is imperative that employees comply with such a rule or instruction and that railroads take appropriate steps to ensure compliance.

As a result of this incident, NJT has issued a Supplemental Bulletin Order that includes a review of the rule addressing the location of train crews when making a station stop, as well as the rule concerning sealing of protective devices. NJT also issued a notice to their mechanical staff, placing special emphasis on ensuring that the seals on all appliances are properly applied.

Recommended Action: In recognition of the need to assure railroad passenger safety, FRA recommends that railroads operating passenger equipment:

(1) Assess the current railroad rules, instructions, and procedures intended to reduce the likelihood that death or injury will result when passengers attempt to board or alight from trains at station stops. FRA recommends that this assessment include, but not necessarily be limited to assessing the adequacy of current railroad rules, instructions, and procedures:

(a) Designed to ensure passenger safety when boarding or alighting from trains;

(b) governing the override of safety systems, such as the bypass of an electrically-powered door safety device, including each crewmember's role in assessing whether to override the safety device as well as any additional steps necessary to ensure continued passenger safety following activation of the safety override device; and

(c) governing crewmember observation of boarding and alighting passengers to ensure it is safe to depart a station.

(2) Assess the extent to which compliance with the rules, instructions, and procedures in recommendations (1)(a), (1)(b), and (1)(c) are measured and recorded in the railroad's test and observation program required by 49 CFR § 217.9;

(3) Ensure compliance with the rules, instructions, and procedures in recommendations (1)(a), (1)(b), and (1)(c); and

(4) Inspect all sealed door-bypass switches on a daily basis.

Railroads operating passenger equipment are encouraged to voluntarily take action in accordance with these recommendations. If circumstances so warrant, FRA reserves the right to take other corrective action, including: modifying this Safety Advisory 2006-05; issuing additional safety advisories; taking regulatory action; or taking other appropriate action necessary to ensure the highest level of safety on the nation's passenger railroads.

Issued in Washington, DC on November 22, 2006.

Jo Strang,

Associate Administrator for Safety.