Notice2023-12724
Safety Advisory 2023-01; Evaluation of Policies and Procedures Related to the Use and Maintenance of Hot Bearing Wayside Detectors (Supplement)
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Published
June 14, 2023
Issuing agencies
Transportation DepartmentFederal Railroad Administration
Abstract
On March 3, 2023, in response to a series of rail accidents suspected of being caused by burnt journal bearings, FRA published Safety Advisory 2023-01 addressing the use and maintenance of hot bearing detectors (HBDs). Since publication of that Safety Advisory, FRA has continued to evaluate railroads' use of HBDs and on May 10, 2023, in New Castle, Pennsylvania, another accident occurred that is suspected of being the result of a burnt journal bearing. Preliminary information related to this most recent accident shows that the train involved passed a HBD which alarmed prior to the accident. Accordingly, FRA is issuing this Notice to supplement Safety Advisory 2023-01 with one additional recommendation. Specifically, this Notice adds a fifth recommendation to Safety Advisory 2023-01 recommending that railroads take action to evaluate the resiliency and accuracy of the overall process used to monitor and measure bearing health.
Full Text
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<title>Federal Register, Volume 88 Issue 114 (Wednesday, June 14, 2023)</title>
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[Federal Register Volume 88, Number 114 (Wednesday, June 14, 2023)]
[Notices]
[Pages 38933-38935]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-12724]
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DEPARTMENT OF TRANSPORTATION
Federal Railroad Administration
Safety Advisory 2023-01; Evaluation of Policies and Procedures
Related to the Use and Maintenance of Hot Bearing Wayside Detectors
(Supplement)
AGENCY: Federal Railroad Administration (FRA), Department of
Transportation (DOT).
ACTION: Notice of Safety Advisory; notice No. 2.
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SUMMARY: On March 3, 2023, in response to a series of rail accidents
suspected of being caused by burnt journal bearings, FRA published
Safety Advisory 2023-01 addressing the use and maintenance of hot
bearing detectors (HBDs). Since publication of that Safety Advisory,
FRA has continued to evaluate railroads' use of HBDs and on May 10,
2023, in New Castle, Pennsylvania, another accident occurred that is
suspected of being the result of a burnt journal bearing. Preliminary
information related to this most recent accident shows that the train
involved passed a HBD which alarmed prior to the accident. Accordingly,
FRA is issuing this Notice to supplement Safety Advisory 2023-01 with
one additional recommendation. Specifically, this Notice adds a fifth
recommendation to Safety Advisory 2023-01 recommending that railroads
take action to evaluate the resiliency and accuracy of the overall
process used to monitor and measure bearing health.
FOR FURTHER INFORMATION CONTACT: Karl Alexy, Associate Administrator
for Railroad Safety and Chief Safety Officer, Office of Railroad
Safety, FRA, 1200 New Jersey Avenue SE, Washington, DC 20590, (202)-
493-6282.
Disclaimer: This Safety Advisory is considered guidance pursuant to
DOT Order 2100.6A (June 7, 2021). Except when referencing laws,
regulations, policies, or orders, the information in this Safety
Advisory does not have the force and effect of law and is not meant to
bind the public in any way. This document does not revise or replace
any previously issued guidance.
SUPPLEMENTARY INFORMATION:
Background
In response to recent rail accidents, on February 21, 2023, while
calling on the freight rail industry and Congress to take action to
improve rail safety, U.S. Department of Transportation Secretary Pete
Buttigieg reiterated the Department's commitment to enhancing rail
safety through specific targeted actions.\1\ In addition to various
regulatory and other activities FRA already had underway at the time of
Secretary Buttigieg's announcement, one of the actions announced
included a focused inspection program of routes over which high-hazard
flammable trains (HHFTs) \2\ and other trains transporting large
volumes of hazardous materials travel (Route Assessment). Subsequently,
in response to continued derailments and the death of a Norfolk
Southern Railway (NS) worker, FRA launched a supplemental safety
assessment of NS, issued three safety advisories and two safety
bulletins \3\ calling attention to the risks FRA identified in the
recent accidents.
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\1\ See <a href="https://www.transportation.gov/briefing-room/us-department-transportation-fact-sheet-steps-forward-freight-rail-industry-safety">https://www.transportation.gov/briefing-room/us-department-transportation-fact-sheet-steps-forward-freight-rail-industry-safety</a>.
\2\ An HHFT is ``a single train transporting 20 or more loaded
tank cars of a Class 3 flammable liquid in a continuous block or a
single train carrying 35 or more loaded tank cars of a Class 3
flammable liquid throughout the train consist.'' 49 CFR 171.8.
\3\ <a href="https://railroads.dot.gov/elibrary/safety-advisory-2023-01-evaluation-policies-and-procedures-related-use-and-maintenance-hot">https://railroads.dot.gov/elibrary/safety-advisory-2023-01-evaluation-policies-and-procedures-related-use-and-maintenance-hot</a>;
<a href="https://railroads.dot.gov/elibrary/safety-advisory-2023-02-train-makeup-and-operational-safety-concerns">https://railroads.dot.gov/elibrary/safety-advisory-2023-02-train-makeup-and-operational-safety-concerns</a>; <a href="https://railroads.dot.gov/elibrary/safety-advisory-2023-03-accident-mitigation-and-train-length">https://railroads.dot.gov/elibrary/safety-advisory-2023-03-accident-mitigation-and-train-length</a>; <a href="https://railroads.dot.gov/elibrary/safety-bulletin-2023-01-switching-operation-accident">https://railroads.dot.gov/elibrary/safety-bulletin-2023-01-switching-operation-accident</a>; <a href="https://railroads.dot.gov/sites/fra.dot.gov/files/2023-03/Safety%20Bulletin%202023-02%20%28031623%29.pdf">https://railroads.dot.gov/sites/fra.dot.gov/files/2023-03/Safety%20Bulletin%202023-02%20%28031623%29.pdf</a>.
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HHFT Route Assessment
As noted above, in March 2023, FRA initiated a nationwide
comprehensive assessment of HHFT routes and other rail routes over
which large quantities of other hazardous materials are transported.
The Route Assessment includes all FRA technical safety disciplines
(i.e., hazardous materials, track, signal and train control,
mechanical, operating practices, and grade crossing). The Route
Assessment is designed to evaluate the overall condition of the rail
infrastructure (including, but not limited to, the track, rolling
stock, signal systems, and other equipment that affects or monitors the
safety of rail operations) and railroads' compliance with both FRA
safety regulations and the regulations of the Pipeline and Hazardous
Materials Safety Administration.
Initial observations from the Route Assessment point to significant
inconsistencies in the railroads' application of best practices
associated with the installation and maintenance of HBDs, as well as in
the assessment and use of HBD data to address failing or failed
bearings. FRA is continuing to evaluate the tools, algorithms, and
other methodologies railroads use to evaluate bearing health, and the
training practices for all railroad employees involved in monitoring
bearing health information and/or taking action in response to that
information.
Supplemental Safety Assessment of Norfolk Southern
On March 15, 2023, FRA initiated a supplemental safety assessment
of NS (NS Assessment), with a specific focus on safety culture and
training, as well as a deep dive into compliance with selected
regulations and the status of recommendations from FRA's 2022 System
Audit of NS performed January through May of 2022.\4\ The investigation
phase of FRA's NS Assessment was completed mid-May 2023, and analysis
of survey results is currently in process. While FRA continues to
analyze results to confirm FRA's findings and any recommendations,
several areas of concern have arisen, including the resiliency of NS's
processes and procedures for monitoring and actioning bearing health
information from the railroad's system of HBDs.
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\4\ FRA Audit Number: 2022-NS Special Audit -01-1; <a href="https://railroads.dot.gov/elibrary/fra-audit-report-norfolk-southern-railway-company">https://railroads.dot.gov/elibrary/fra-audit-report-norfolk-southern-railway-company</a>.
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New Castle, Pennsylvania Accident--May 10, 2023
On May 10, 2023, at 11:24 p.m., a NS general merchandise train
(i.e., not an HHFT) derailed nine cars in New Castle, Pennsylvania.
Five cars derailed on a bridge over the Mahoning River. Both the
National Transportation Safety Board and FRA are investigating the
accident and both investigations are ongoing. Although no final
conclusions as to the cause of the accident have been identified yet,
preliminary information indicates that a burnt journal bearing played a
role in the derailment and that the train involved passed at least one
HBD that alarmed before the derailment. FRA is probing the
communication and
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timing of the alarm to both the locomotive and the dispatch center, as
well as the history and performance of the bearing in question. Of
particular interest is the impact of failures or delays in the
communication of bearing health information to those involved in the
data analysis and decision-making process as to what action to take in
response to the information and to enable the crew to take appropriate
action.
Safety Advisory 2023-01 Published March 3, 2023
In Safety Advisory 2023-01, FRA recognized the value of wayside
detection systems if they are appropriately installed, maintained, and
utilized. As noted in that Safety Advisory, if implemented properly,
wayside detectors enable railroads to assess the health of rail
equipment and infrastructure to enable the early identification of
mechanical or other defects. Nonetheless, as explained in Safety
Advisory 2023-01, even with industry's widespread use of wayside
detection systems (such as HBDs), since 2021, at least five derailments
have occurred that are suspected of being caused by mechanical defects
(burnt journal bearings in particular).\5\
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\5\ The five derailments include three derailments that occurred
on NS (Warner Roberts, Georgia (July 12, 2022); Sandusky, Ohio
(October 8, 2022); and East Palestine, Ohio (February 3, 2023)) and
two derailments that occurred on the Kansas City Southern Railway
(KCS) in 2021. The three NS derailments are discussed in detail in
Safety Advisory 2023-01 and the 2021 KCS derailments occurred on
August 2, 2021, and December 3, 2021, and in both cases, a HBD
flagged a suspect bearing, but the crews were either unable to act
in time to prevent a derailment or were directed to continue the
train move resulting in a derailment.
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Each railroad involved in these five recent derailments had systems
of HBDs intended to identify defective bearings or bearings
experiencing anomalies that could lead to failures. However, in each
case, despite the fact that those HBDs flagged at least one suspected
bearing on each train, the derailments occurred. Accordingly, Safety
Advisory 2023-01, as originally published, focused its recommendations
on inspection and maintenance procedures related to the HBDs, the
thresholds at which detectors are set to flag anomalies, and the
training and qualification of personnel responsible for installing,
inspecting, and maintaining HBDs. As originally published, the Safety
Advisory also recommended that railroads ``review current procedures
governing actions responding to HBD alerts to ensure required actions
are commensurate with the risk of the operation involved,'' but the
Advisory did not make any recommendations related to ensuring the
effectiveness, reliability, and robustness of such procedures. In other
words, as originally published, Safety Advisory 2023-01 did not address
the effectiveness of railroads' established processes and procedures in
ensuring adequate and accurate bearing health data is gathered from
detectors, analyzed, and communicated to all railroad personnel
responsible for making decisions or taking action in response to that
data. FRA notes that the process of gathering, monitoring, reporting,
analyzing, and actioning information from detectors includes tasks
that, if incorrectly done, can introduce risk. For instance, an error
in HBD installation or maintenance that is not identified by
commissioning testing, may impact the reporting of HBD measurements.
Similarly, processes with insufficient redundancies or cross-checks to
ensure each necessary step or task is performed timely and accurately
may lead to failures in the processes that allow a valid detector alert
or alarm to go undetected. Accordingly, in addition to the four
recommendations contained in Safety Advisory 2023-01 as originally
published, with this supplementary notice, FRA is making a fifth
recommendation to railroads. Specifically, FRA recommends that
railroads evaluate each step and task performed by railroad personnel
to identify any potential points where non-revealing failures may occur
(i.e., any steps or tasks that, if not performed or performed
incorrectly or timely, could mislead decision makers when actioning a
HBD report or lack of a HBD report). FRA also recommends that railroads
implement appropriate safeguards to minimize the impact of any non-
revealing failures when monitoring, analyzing, and responding to
detector information.
Recommended Railroad Action
In light of the above discussion, FRA is revising the
recommendations included in Safety Advisory 2023-01 to add
recommendation number 5 below. For ease of reference, FRA's existing
recommendations 1 through 4 are reproduced below, along with additional
recommendation 5. Accordingly, FRA recommends that railroads take the
following actions:
1. Review existing HBD system inspection and maintenance policies
and procedures for compliance with existing industry standards and
manufacturer recommendations for HBDs.
2. Review existing procedures to train and qualify personnel
responsible for installing, inspecting, and maintaining HBDs to ensure
they have the appropriate knowledge and skills. Railroads should also
develop and implement appropriate training on the inspection and
maintenance requirements for HBDs and provide that training at
appropriate intervals to ensure the required knowledge and skill of
inspection and maintenance personnel. Further, railroads should
evaluate their training content and training frequency to ensure any
employee who may be called upon to evaluate a suspect bearing has the
necessary training, experience, and qualifications. FRA also encourages
railroads to ensure these individuals are available at all hours of
operations across a railroad's network.
3. Review current HBD detector thresholds in light of recent
derailments, and all other relevant available data (including data from
any close calls or near misses), to determine the adequacy of the
railroad's current thresholds. Thresholds should be established for
single measurement as well as multiple measurements of individual
bearings to enable temperature trend analysis.
4. Review current procedures governing actions responding to HBD
alerts to ensure required actions are commensurate with the risk of the
operation involved. With regard to trains transporting any quantity of
hazardous materials, FRA recommends railroads adopt the procedures
outlined in AAR's OT-55 for key trains as an initial measure.
5. Rigorously evaluate the resiliency and accuracy of the overall
process used to monitor and act upon information from wayside
detectors, with specific focus on steps and tasks that, if not
performed or performed incorrectly, could mislead decision makers. The
process of monitoring, reporting, inspecting, analyzing, and acting on
information from detectors includes tasks that, if incorrectly
executed, could introduce risk. Railroads should also evaluate each
step and task performed by railroad personnel to pinpoint any HBD
reporting failures and implement appropriate safeguards to minimize the
impact of those failures when monitoring, analyzing, and responding to
detector information.
Conclusion
In general, as noted in Safety Advisory 2023-01 as originally
published, the issues identified in this Safety Advisory and this
supplementary notice are indicators of a railroad's safety culture.
Implementing procedures that ensure safety, and training personnel so
those procedures become
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second nature, is vital. Equally important is the commitment,
throughout the organization, to safety and empowerment of personnel to
live up to that commitment. Specifically, personnel should be
encouraged and empowered to develop, implement, and comply with
procedures that may temporarily impact operations, but maximize safety,
just as those executing the procedures should be empowered to strictly
adhere to those procedures, even if it delays a train. The railroads
should evaluate their safety culture not only as it relates to the
issues indicated in this Safety Advisory, but to all aspects of their
operations.
FRA encourages railroads to continue to take actions consistent
with Safety Advisory 2023-01 as originally published and the additional
recommendation in this supplementary notice, as well as any other
complementary actions, to ensure the safety of rail transportation. FRA
may modify this Safety Advisory and supplementary notice, issue
additional safety advisories, or take other actions necessary to ensure
the highest level of safety on the Nation's railroads, including
pursuing other corrective measures under its authority.
Issued in Washington, DC.
Amitabha Bose,
Administrator.
[FR Doc. 2023-12724 Filed 6-13-23; 8:45 am]
BILLING CODE 4910-06-P
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