Safety Advisory 2023-01; Evaluation of Policies and Procedures Related to the Use and Maintenance of Hot Bearing Wayside Detectors (Supplement), 38933-38935 [2023-12724]

Agencies

• Federal Railroad Administration
• DEPARTMENT OF TRANSPORTATION

[Federal Register Volume 88, Number 114 (Wednesday, June 14, 2023)]
[Notices]
[Pages 38933-38935]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[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 https://www.transportation.gov/briefing-room/us-department-transportation-fact-sheet-steps-forward-freight-rail-industry-safety.
    \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\ 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-2023-02-train-makeup-and-operational-safety-concerns; https://railroads.dot.gov/elibrary/safety-advisory-2023-03-accident-mitigation-and-train-length; https://railroads.dot.gov/elibrary/safety-bulletin-2023-01-switching-operation-accident; https://railroads.dot.gov/sites/fra.dot.gov/files/2023-03/Safety%20Bulletin%202023-02%20%28031623%29.pdf.
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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; https://railroads.dot.gov/elibrary/fra-audit-report-norfolk-southern-railway-company.
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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

[[Page 38934]]

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

[[Page 38935]]

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