Bettendorf, Iowa
July 14, 2009
NTSB Number: RAR-12-03
NTIS Number: PB2012-916303
Adopted April 30, 2012
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On July 14, 2009, about 2:08 a.m., central daylight time, southbound Dakota, Minnesota & Eastern Railroad freight train B61-13, went into Bettendorf Yard in Bettendorf, Iowa, due to a misaligned switch and struck 19 stationary railcars. The impact fatally injured the locomotive engineer and the conductor. There were no wayside signals or other devices to convey the position of the hand-operated switch on the main track leading into the north yard sufficiently in advance to allow the approaching train to stop. The train was moving at the authorized speed of 25 mph and was operating under valid track warrant authority. Track warrants are authorizations issued by a dispatcher for a train to occupy a certain segment of track for a certain period of time. Track warrant authority is obtained and released through communication between train crews and the dispatcher.
The National Transportation Safety Board determines that the probable cause of the accident was the BNSF Railway local train RCHI4274-13I crew releasing track warrant authority before returning the north yard hand-operated switch to the correct position. Contributing to the accident was the dispatcher for the Dakota, Minnesota & Eastern Railroad granting track warrant authority to Dakota, Minnesota & Eastern Railroad train B61-13 without holding a job briefing, which would confirm the accurate positions of all applicable main track switches. Also contributing to the accident was a hand-operated switch position reflector target that could not be observed by the crew of train B61-13 at a sufficient distance to stop the train and avoid the accident.
The safety issues discussed in this report are the following:
Safety recommendations are being issued to the Federal Railroad Administration and the Canadian Pacific Railway.
As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:
To the Federal Railroad Administration:
Require railroads to install, along main lines in non-signaled territory not equipped with positive train control, appropriate technology that warns approaching trains of incorrectly lined main track switches sufficiently in advance to permit stopping. (R-12-27)
Revise Title 49 Code of Federal Regulations Section 218.105(d)(1) to require that, until the appropriate switch position technology is installed on main track switches in non-signaled territories that are not equipped with positive train control, train crews releasing track authority to the dispatcher must hold job briefings with the dispatcher and clearly convey the position of all main track switches that were used prior to releasing track warrant authority. (R-12-28)
Require that until appropriate switch position warning technology is installed on main track switches (in non-signaled territory not equipped with positive train control), when a main track switch has been reported relined for a main track, the next train to pass the location approach the switch location at restricted speed. That train crew should then report to the dispatcher that the switch is correctly lined for the main track before trains are allowed to operate at maximum authorized speed. (R-12-29)
To the Canadian Pacific Railway:
Require both train dispatchers and train crews to document switch positions and to hold job briefings to ensure that all main track switches in non-signaled territories are correctly lined before releasing track warrant authority. (R-12-30)
Require that until appropriate switch position warning technology is installed on main track switches (in non-signaled territory not equipped with positive train control), when a main track switch has been reported relined for a main track, the next train to pass the location approach the switch location at restricted speed. That train crew should then report to the dispatcher that the switch is correctly lined for the main track before trains are allowed to operate at maximum authorized speed. (R-12-31)
After a similar accident on January 6, 2005, on the Norfolk Southern Railroad in Graniteville, South Carolina, in which a train cleared the main track at a hand-operated switch, the National Transportation Safety Board made the following safety recommendation:
To the Federal Railroad Administration:
Require that, along main lines in non-signaled territory, railroads install an automatically activated device, independent of the switch banner that will, visually or electronically, compellingly capture the attention of employees involved with switch operations and clearly convey the status of the switch both in daylight and in darkness. (R-05-14)
Safety Recommendation R-05-14, previously classified "Open-Acceptable Alternate Response," is reclassified "Closed-Superseded by Safety Recommendation R-12-27."
