Board Meeting - Railroad Accident Report - Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train

Red Oak, Iowa
April 17, 2011

NTSB Number: RAR-12-02

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This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

Executive Summary

On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway coal train C-BTMCNM0-26, BNSF 9159 East, collided with the rear end of standing BNSF Railway maintenance of way equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost 448.3 on main track number two on the Creston Subdivision of the BNSF Railway Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million.

Conclusions

1. The following were not factors in the accident: the condition of the track, railcars, or signal system; the weather; the visibility of signals; the use of cellular telephones by crewmembers; the vision and hearing of the crew; illegal drug or alcohol use, the actions of the train dispatcher and the crew of the maintenance of way equipment train; or the mechanical condition of the locomotives of the striking coal train.
2. The striking coal train conductor's and the engineer's irregular work schedules contributed to their being fatigued on the morning of the collision.
3. Based on their medical histories, both crewmembers on the striking coal train were at high risk for sleep disorders and fatigue.
4. Based on the conductor's and the engineer's irregular work schedules, their medical histories, and their lack of action before the collision, both crewmembers on the striking coal train had fallen asleep due to fatigue.
5. Had the two crewmembers on the striking coal train completed the BNSF's fatigue training program, they would have had the opportunity to learn that they were at risk for sleep disorders, particularly obstructive sleep apnea, and the computer-based training program would have displayed a message advising them to consult with a physician.
6. Had the requirements described in Safety Recommendations R-02-24, -25, and -26 been in place, this crew would likely have been identified as at high risk for sleep disorders, which may have led to appropriate medical intervention.
7. Because biomathematical models of fatigue are relatively new to the railroad industry, the use of this technology should be evaluated for its effectiveness within the context of railroads' fatigue management plans through independent scientific peer review.
8. Had the crew of the striking coal train been alert and operated their train in accordance with restricted speed requirements, the collision would have been prevented.
9. Locomotive alerters only detect engineer inactivity and should not be used as a substitute for an effective fatigue mitigation strategy.
10. Had the positive train control/Electronic Train Management System currently in development been installed on the Creston Subdivision, it most likely would not have prevented this accident because it does not identify the rear end of a standing train as a target and because it allows following movements at up to 23 mph.
11. The positive train control designs that are being deployed and the Federal Railroad Administration's final rule on the application of positive train control are unlikely to prevent future restricted speed rear-end collisions similar to the 58 rear-end collisions reported to the Federal Railroad Administration over the last 10 years or the collision at Red Oak because train speeds at the upper limit of restricted speed are allowed.
12. Because the isolated locomotive cab module detached from the deck of the locomotive and was subsequently rotated and crushed, the crew could not have survived.
13. Although the current locomotive crashworthiness standards include a procedure to validate alternative locomotive crashworthiness designs that are not consistent with any Federal Railroad Administration-approved locomotive crashworthiness design standard, this requirement was not effective in identifying the modular operating cab as an alternate design.
14. The emergency response to the accident was timely and appropriate.
15. Had an inward-facing video and audio recorder been installed in the cab of the locomotive of the striking train, additional valuable information about the train crew's actions before the collision would have been available.
16. Because the Federal Railroad Administration developed standards and regulations for certified U.S. Department of Transportation crashworthy event recorder memory modules in response to the National Transportation Safety Board's prior recommendations, and a crashworthy event recorder was installed on the accident locomotive, information about this accident was available that otherwise would have been destroyed.
17. Because data from voluntarily installed locomotive video cameras are typically not stored in crashworthy memory modules, important operational and safety data are at risk of being lost following an accident.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.

Recommendations

New Recommendations

To the Federal Railroad Administration:

1. Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders.
2. Establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue.
3. Conduct research on new and existing methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews.
4. Require the implementation of methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews that are identified or developed in response to (Safety Recommendation 3 above).
5. Require the use of positive train control technologies that will detect the rear of trains and prevent rear-end collisions.
6. Revise Title 49 Code of Federal Regulations Part 229 to ensure the protection of the occupants of isolated locomotive operating cabs in the event of a collision. Make the revision applicable to all locomotives, including the existing fleet and those newly constructed, rebuilt, refurbished, and overhauled, unless the cab will never be occupied.
7. Revise Title 49 Code of Federal Regulations Part 229 to require crashworthiness performance validation for all new locomotive designs under conditions expected in a collision.

To the Association of American Railroads:

8. Revise Association of American Railroads Standard S-580 to provide protection for the occupants of isolated operating cabs in the event of a collision, and make the revision applicable to all locomotives, including those newly constructed, rebuilt, refurbished, and overhauled.
9. Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of on-board video and audio recorders. The memory modules should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2.

To the BNSF Railway:

10. Require all employees and managers who perform or supervise safety-critical tasks to complete fatigue training on an annual basis and document when they have received this training.
11. Medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders.

Recommendations Reclassified in this Report

To the Federal Railroad Administration:

Require railroads to ensure that the lead locomotives used to operate trains on tracks not equipped with a positive train control system are equipped with an alerter. (R-07-1)

Safety Recommendation R-07-01, previously classified "Open-Acceptable Action," is reclassified "Closed-Acceptable Action."

To All Class I Railroads:

Ensure that alerters are installed on all your lead locomotives used to operate trains on tracks not equipped with a positive train control system. (R-07-8)

Safety Recommendation R-07-8, issued to Kansas City Southern Railway Company, previously classified "Open-Await Response," is reclassified "Closed-Acceptable Action."

Recommendations Reiterated in this Report

To the Federal Railroad Administration:

Develop a standard medical examination form that includes questions regarding sleep problems and require that the form be used, pursuant to 49 CFR Part 240, to determine the medical fitness of locomotive engineers; the form should also be available for use to determine the medical fitness of other employees in safety-sensitive positions (R-02-24)

Require that any medical condition that could incapacitate, or seriously impair the performance of, an employee in a safety-sensitive position be reported to the railroad in a timely manner (R-02-25)

Require that, when a railroad becomes aware that an employee in a safety-sensitive position has a potentially incapacitating or performance-impairing medical condition, the railroad prohibit that employee from performing any safety-sensitive duties until the railroad's designated physician determines that the employee can continue to work safely in a safety-sensitive position (R-02-26)

Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. (R-10-1)

Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. (R-10-2)