NTSB Report_ChafeeMO_RAR1402

NTSB Report_ChafeeMO_RAR1402
Collision of Union Pacific Railroad Freight Train
with BNSF Railway Freight Train
Near Chaffee, Missouri
May 25, 2013
Accident Report
National
Transportation
Safety Board
NTSB/RAR-14/02
PB2015-102084
NTSB/RAR-14/02
PB2015-102084
Notation 8507A
Adopted November 17, 2014
Railroad Accident Report
Collision of Union Pacific Railroad Freight Train
with BNSF Railway Freight Train
Near Chaffee, Missouri
May 25, 2013
National
Transportation
Safety Board
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
i
National Transportation Safety Board. 2014. Collision of Union Pacific Railroad Freight Train with
BNSF Railway Freight Train Near Chaffee, Missouri, May 25, 2013. Railroad Accident Report
NTSB/RAR-14/02. Washington, DC.
Abstract: On May 25, 2013, at 2:30 a.m. central daylight time, near Chaffee, Missouri, a Union Pacific
Railroad (UP) freight train collided with a BNSF Railway (BNSF) freight train at Rockview Interlocking,
where tracks of the two railroads cross. The BNSF train was moving through the interlocking when the
UP train struck the 12th car behind the locomotives of the BNSF train. As a result of the collision, 13 cars
of the BNSF train derailed and two locomotives and 11 cars on the UP train also derailed. Diesel fuel
spilled from the derailed locomotives and caught fire. The engineer and the conductor on the UP train
were injured and transported to a local hospital. The Missouri State Highway M bridge crossed over the
Rockview Interlocking, and derailed train cars struck bridge supports and collapsed portions of the bridge.
After the bridge collapsed, two motor vehicles struck damaged highway elements. Five occupants of the
motor vehicles were transported to a local hospital. Damage was estimated to be more than
$11 million.
The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting
aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress
through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable
causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety
effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions
through accident reports, safety studies, special investigation reports, safety recommendations, and statistical
reviews.
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,
“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and
are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4.
Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety
by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language
prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for
damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).
For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and
search for NTSB accident ID DCA13MR004. Recent publications are available in their entirety on the Internet at
http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by
contacting:
National Transportation Safety Board
Records Management Division, CIO-40
490 L’Enfant Plaza, SW
Washington, DC 20594
(800) 877-6799 or (202) 314-6551
NTSB publications may be purchased from the National Technical Information Service. To purchase this
publication, order product number PB2015-102084 from:
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(800) 553-6847 or (703) 605-6000
http://www.ntis.gov/
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Contents
Figures .............................................................................................................................................v
Tables ..............................................................................................................................................v
Acronyms and Abbreviations ..................................................................................................... vi
Executive Summary .................................................................................................................... vii
1 Accident Information and Investigation ...................................................................................1
1.1 Accident Overview ....................................................................................................................1
1.2 Accident Narrative .....................................................................................................................1
1.2.2 BNSF Crew ......................................................................................................................4
1.2.3 Automobiles on Highway Bridge ....................................................................................4
1.3 Injuries .......................................................................................................................................5
1.4 Operations Information ..............................................................................................................5
1.4.1 General .............................................................................................................................5
1.4.2 Operating Rules Relevant to Accident ............................................................................6
1.5 Signals Information ....................................................................................................................7
1.5.1 Signal Requirements Before Collision ............................................................................8
1.5.2 Postaccident Signal System Inspection and Testing ........................................................9
1.6 Personnel Information ................................................................................................................9
1.6.1 Employment History and Qualification ...........................................................................9
1.6.2 UP Crew Performance History ......................................................................................10
1.6.3 UP Crew Schedules .......................................................................................................11
1.7 UP Crew Medical Information.................................................................................................12
1.7.1 UP Conductor ................................................................................................................12
1.7.2 UP Engineer ...................................................................................................................13
1.8 Toxicological Information .......................................................................................................17
1.9 Highway Bridge Information ...................................................................................................17
1.9.1 Construction ...................................................................................................................17
1.9.2 Damage ..........................................................................................................................17
1.9.3 Design and Construction Regulations ...........................................................................19
1.9.4 Inspection .......................................................................................................................20
1.10 Tests and Research .................................................................................................................20
1.10.1 Mechanical Condition of Trains ..................................................................................20
1.10.2 Portable Electronic Devices .........................................................................................20
1.10.3 Sight-Distance Observations .......................................................................................20
1.11 Postaccident Actions ..............................................................................................................21
1.11.1 Union Pacific Railroad ................................................................................................21
1.11.2 BNSF Railway .............................................................................................................21
1.11.3 Missouri Department of Transportation ......................................................................21
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2 Safety Issues Analysis ...............................................................................................................23
2.1 Performance of UP Train Crew ...............................................................................................23
2.2 Fatigue of UP Crew .................................................................................................................24
2.3 UP Train Crew Medical Fitness for Work ...............................................................................25
2.3.1 UP Conductor ................................................................................................................26
2.3.2 UP Engineer ...................................................................................................................27
2.3.3 Previous Rail and Transit Accidents Involving Obstructive Sleep Apnea ....................29
2.4 Crew Resource Management ...................................................................................................31
2.5 Locomotive Cab Audio and Video Recorders .........................................................................33
2.6 Positive Train Control ..............................................................................................................37
2.7 Highway Bridge Protection......................................................................................................38
3 Conclusions ................................................................................................................................40
3.1 Findings....................................................................................................................................40
3.2 Probable Cause.........................................................................................................................42
4 Recommendations .....................................................................................................................43
4.1 New Recommendation .............................................................................................................43
4.2 Previously Issued Recommendations Reiterated in This Report .............................................43
4.3 Previously Issued Recommendation Reiterated and Reclassified in this Report ....................44
Appendix A Investigation ............................................................................................................46
Appendix B UP Conductor’s Log ...............................................................................................47
References .....................................................................................................................................48
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Figures
Figure 1. Aerial view of accident scene and wreckage. ................................................................. 1
Figure 2. Accident location. ........................................................................................................... 3
Figure 3. Derailed train cars and damaged bridge supports. ........................................................ 18
Figure 4. Collapsed bridge deck. ................................................................................................. 19
Figure 5. New Highway M bridge. .............................................................................................. 22
Figure 6. Recommendations for screening commercial drivers for obstructive sleep apnea. ..... 28
Tables
Table 1. Signals encountered by striking UP train ......................................................................... 8
Table 2. Operations tests performed on UP crew......................................................................... 10
Table 3. Number of operations tests performed on UP crew ....................................................... 10
Table 4. UP engineer’s recent work/rest/sleep history ................................................................. 11
Table 5. UP conductor’s recent work/rest/sleep history .............................................................. 12
Table 6. Sight-distance measurements for both UP crewmembers .............................................. 21
v
Acronyms and Abbreviations
AASHTO
American Association of State Highway and Transportation Officials
AHI
apnea-hypopnea index
AREA
American Railway Engineering Association
AREMA
American Railway Engineering and Maintenance-of-Way Association
BMI
body mass index
BNSF
BNSF Railway
bpm
beats per minute
CFR
Code of Federal Regulations
CRM
crew resource management
CT
computed tomography
EEG
electroencephalogram
FHWA
Federal Highway Administration
FRA
Federal Railroad Administration
LRFD Manual Load Resistance Factor Design Manual
mg/dL
milligrams per deciliter
MODOT
Missouri Department of Transportation
MP
milepost
MRI
magnetic resonance imaging
NHBLI
National Heart, Blood and Lung Institute
NTSB
National Transportation Safety Board
OSA
obstructive sleep apnea
RSIA
Rail Safety Improvement Act of 2008
UP
Union Pacific Railroad
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Executive Summary
On May 25, 2013, at 2:30 a.m. central daylight time, near Chaffee, Missouri,
Union Pacific Railroad (UP) freight train 2-ASMAR-25 UP 5668 South collided with BNSF
Railway (BNSF) freight train U-KCKHKM0-05T at Rockview Interlocking, where tracks of the
two railroads cross. (See figure 1.) The BNSF train was moving through the interlocking when
the UP train struck the 12th car behind the locomotives of the BNSF train. As a result of the
collision, 13 cars of the BNSF train derailed. Two locomotives and 11 cars on the UP train also
derailed. Diesel fuel spilled from the derailed UP locomotives and caught fire. The engineer and
the conductor on the UP train were injured and transported to a local hospital.
The Missouri State Highway M bridge crossed over the Rockview Interlocking, and
derailed train cars struck bridge supports and collapsed portions of the bridge. After the bridge
collapsed, two motor vehicles struck damaged highway elements. Five occupants of the motor
vehicles were transported to a local hospital.
As a result of their variable work schedules both UP crewmembers experienced
disruptions to their normal circadian rhythms for several days before the accident, and at the time
of the accident experienced fatigue caused by circadian disruption and the requirement to operate
the train during the window of circadian low. Prior to the collision, both UP crewmembers failed
to comply with four wayside signals because of likely fatigue-induced performance degradation.
Obstructive sleep apnea likely contributed to the engineer’s fatigue. Damage was estimated to be
more than $11 million.
The National Transportation Safety Board determines that the probable cause of the
accident was the failure of the Union Pacific Railroad train crewmembers to comply with
wayside signals leading into the Rockview Interlocking as a result of their disengagement from
their task likely because of fatigue-induced performance degradation. Contributing to the
accident was the lack of: (1) a positive train control system, (2) medical screening requirements
for employees in safety-sensitive positions for sleep apnea and other sleep disorders, and
(3) action by the Federal Railroad Administration to fully implement the fatigue management
components required by the Rail Safety Improvement Act of 2008. Likely contributing to the
engineer’s fatigue was undiagnosed obstructive sleep apnea. Also contributing to the accident
was inadequate crew resource management.
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1 Accident Information and Investigation
1.1 Accident Overview
N
N
N
N
UP (striking) Train
BNSF (struck) Train
Figure 1. Aerial view of accident scene and wreckage.
1.2 Accident Narrative
The crew of the UP train, consisting of an engineer and a conductor, went on duty at
9:45 p.m. on May 24, 2013, at Salem, Illinois, and departed at 10:10 p.m. The train had
2 locomotives on the head end and 60 loaded cars. The train was scheduled to travel south to
Dexter, Missouri, on the Chester Subdivision. A qualified UP mechanical employee performed a
predeparture mechanical inspection and a brake test had been performed on the train at
9:15 p.m., and no exceptions were noted on the brake test report. The conductor did not take any
exception to the mechanical condition of the train other than the speedometer on the conductor’s
side of the locomotive cab was not working. However, the FRA only requires a working
speedometer on the engineer’s side of the cab. The conductor could have viewed the
speedometer on the other side of the cab with minimal effort.
1
According to the crew, they met one opposing train at Mt. Vernon, Illinois, and then
continued south. The conductor told investigators that on the day of the accident, the engineer
appeared to be alert. The conductor said that they called the wayside signals aloud (as UP
operating rules require), although he could not remember which of them called each of the
signals after they departed Salem. He also said that the trip was uneventful until they approached
Rockview Interlocking and the crossing with the BNSF tracks. He described nearing the
interlocking:
I was writing in my logbook. I saw that … the absolute signal at the north end was
[indicating] Approach. I called it out. [The] engineer repeated it back to me. I was
writing in my logbook, doing what I have to do as a conductor, [doing] my duties,
talking on the radio …. Nothing was out of the [ordinary].
The conductor described passing the Approach signal (yellow aspect), noting that the
signal required them to reduce speed to 30 mph and be prepared to stop at the next signal. The
conductor said he had no reason to believe that the train was not doing that:
When we passed the Approach [signal], I asked [the engineer] what our speed
was, and he responded, “30-something.” So I assume[d] that … he [was] doing
what he ha[d] to do.
The conductor also told investigators that he did not notice anything out of the ordinary until the
train got closer to the interlocking. He said that he was familiar with the Rockview Interlocking
area, which has “a sweeping curve to the right, when you’re heading south, and … the signal is
at the south end.” He said that after the train went around the corner he saw the Restricting signal
(flashing red aspect). At that point, he did not think the train was slowing down like it should
have been, so he used the emergency brake valve to place the train into emergency braking. The
UP train struck the passing BNSF train shortly thereafter. Event recorder data indicated that the
speed at impact was 43 mph. (See figure 2 for accident location.)
2
Figure 2. Accident location.
The conductor told investigators that he was writing entries in his log between the Approach
signal and the point where he pulled the valve to apply the emergency brakes:
I think the only time I looked at him was when I asked the speed at the Approach
[signal]. I don’t recall looking at him; I had my head down … writing in my book.
When I looked up [was] when I realized we were going faster … than we had
been.
In the followup interview in August, investigators asked the conductor about his
observations of the engineer. When the conductor was asked whether he believed the engineer
was asleep, the conductor said, “No.”
The conductor’s log, at appendix B, indicates the names of the “less than Clear” signal
indications the train crew encountered along with the time and speed. The distance between the
Approach signal and the Restricting signal was 10,291 feet. The Rockview Interlocking signal
was 1,215 feet from the Restricting signal. (See section 1.5 for further information about the
signal system.)
3
The UP engineer told investigators that he remembered riding on the train and calling out
signals but that his memory faded after that. The next thing he remembered was the conductor’s
leaning over him and asking whether he was all right. The engineer remembered looking up at
the conductor and answering him, saying yes, that he was all right. He also recalled wondering
why he was lying down and hearing the conductor say they had been in an accident.
Investigators showed the engineer event recorder data that had been downloaded from the
UP train after the accident. The data indicated that at 2:25 a.m., about 5 minutes before the
collision, the train was operating at 54 mph for several minutes, beyond the Approach signal
where the train should have been travelling no more than 30 mph and the crew should have been
prepared to stop at the next signal. The engineer told investigators that he should not have been
“going that fast.” The event recorder data also indicated several horn activations in an area where
blowing the horn was not required. The engineer was unable to explain why the locomotive horn
had been activated in that area. The event recorder data also indicated that the horn was not
activated at the last highway-railroad grade crossing and that it had been activated several times
immediately before the UP train struck the BNSF train. The engineer was unable to explain the
failure to activate the horn or the multiple activations just before the collision. When
investigators asked the engineer whether he fell asleep before the accident he said, “I don’t
know.”
During the followup interview in August, the engineer told investigators that he still
could not remember the final part of the accident trip. He indicated that he had discussed his
memory lapse with several medical practitioners, and he had come to believe that he had a
“diabetic blackout” on the day of the accident.
1.2.2 BNSF Crew
The crew of the BNSF train, consisting of an engineer and a conductor, took charge of
their train in Lindenwood Yard in St. Louis, Missouri, on May 24 at 7:00 p.m. and departed
about 8:32 p.m. The train had 3 locomotives on the head end and 75 loaded cars. The BNSF train
was scheduled to travel to Chaffee, Missouri, on the River Subdivision. A predeparture
mechanical inspection and a brake test were performed on the BNSF train at Kansas City,
Kansas, on May 23, 2013. No exceptions were noted on the brake test report.
According to the crew, the trip was routine until the collision. The crew told investigators
that at Rockview Interlocking (BNSF MP 141.7) the train entered the interlocking on a Clear
(green aspect) signal. The crew said that they saw the headlight of the UP train and that it was
not unusual to see a train on the UP track at this location. The southbound BNSF train was struck
by the westbound UP train after the locomotives and the first 12 cars of the BNSF train had
passed the crossing with the UP tracks, causing an emergency application of the BNSF train
brakes.
1.2.3 Automobiles on Highway Bridge
Two automobiles westbound on Route M crashed when they drove into the void created
by the collapse of highway bridge supports. (See section 1.10 for further information about the
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bridge collapse.) The first crash, which occurred 3 minutes 52 seconds after the derailment,
involved a 2010 Nissan Versa occupied by a 30-year-old male driver and a 38-year-old female
passenger. The second automobile crash, which occurred 1 minute after the first, involved a
2000 Chevrolet Malibu occupied by a 22-year-old male driver and two passengers: a 19-year-old
female seated in the right front seat and an unrestrained 19-year-old female seated in the rear.
1.3 Injuries
After the collision, both the engineer and the conductor of the UP train were transported
to the hospital by ambulance. The conductor was awake, alert, and ambulatory. He had a scalp
laceration and skinned knuckles on both hands, and he was complaining of pain in his left elbow
and right knee. The UP engineer did not remember the accident, remembering only lying on the
floor of the locomotive and the conductor’s rousing him. However, he was ambulatory by the
time the ambulance arrived. He had a laceration of the left arm, pain with some swelling on the
left chest, and pain on the right leg below the knee. The notes from ambulance personnel indicate
that he was “neuro intact” and oriented to events, person, place, and time. A Missouri State
Highway Patrol sergeant told investigators both UP crewmembers showed no symptoms of
impairment and appeared alert when he saw them at the hospital.
The five passengers in the two automobiles that struck damaged portions of the highway
bridge were transported to the hospital. The driver and passenger of the automobile in the first
crash were wearing seat belts and received minor injuries. In the automobile involved in the
second crash, the driver and the passenger in the rear received minor injuries. The passenger in
the right front seat received serious injuries that consisted of lower leg fractures.
1.4 Operations Information
1.4.1 General
UP crews were governed by the General Code of Operating Rules, 6th Edition, effective
April 7, 2010, and updated April 23, 2013 (UP 2013). The territory was designated the UP
Northern Region, St. Louis Service Unit, Chester Subdivision. At the time of the accident, the
current timetable was St. Louis Timetable No. 4, effective December 14, 2009. Four
supplemental operating rules documents were System Special Instructions, April 20, 2012,
updated April 23, 2013; Air Brake and Train Handling Rules, April 20, 2012, updated April 23,
2013; Safety Rules, July 30, 2007, revised April 23, 2013; and System General Orders, April 23,
2013.
BNSF crews were governed by the General Code of Operating Rules, 6th Edition,
effective April 7, 2010, and updated February 1, 2013 (BNSF 2013). The territory was
designated the BNSF Springfield Division, River Subdivision. At the time of the accident, the
current timetable was Springfield Division Timetable No. 8, August 15, 2012. Three
supplemental operating rules documents were System Special Instructions No. 3, July 18, 2012,
revised May 1, 2013; Air Brake and Train Handling Rules, April 7, 2010, revised May 1, 2013;
5
and TY & E (Train, Yard, and Engine) Safety Rules, October 30, 2005, revised
November 1, 2012.
Further, each train was issued track bulletins (BNSF) or track warrants (UP) for their
respective subdivisions that covered unique speed restrictions or other requirements specific to
the date of the accident. Neither railroad’s bulletins or warrants had special restrictions at
Rockview Interlocking.
The Rockview Interlocking operated on a first-come, first-served basis: the first train to
arrive received a Clear signal (green aspect) to enter the interlocking and cross the track, and a
train arriving second, on the other track, received a Stop signal (red aspect). In this case, the
southbound BNSF train arrived first and received a Clear signal to enter the interlocking, and a
Stop signal was displayed to the westbound UP train.
1.4.2 Operating Rules Relevant to Accident
The UP General Code of Operating Rules (2013), rule 1.47 C: Duties of All Crew
Members, contains the following provisions that are relevant to this accident:
1. Crew Members in Control Compartment
Crew members in the control compartment must communicate to each other any
restrictions or other known conditions and required actions that affect the safe
operation of their train sufficiently in advance of such condition to allow the
engineer to take proper action. If proper action is not being taken, crew members
must remind engineer of such condition and required action.
Crew members in the control compartment must be alert for signals. Crew
members must:

Communicate clearly to each other the name of signals affecting their train
as soon as signals become visible or audible.

Continue to observe signals and announce any change of aspect until the
train passes the signal.

Communicate clearly to each other the speed of the train as it passes a
signal with an indication other than Clear.

Immediately remind the engineer of the rule requirement if the signal is
not complied with.
3. Proper Action
If engineer and/or conductor fail to comply with a signal indication or take proper
action to comply with a restriction or rule, crew members must immediately take
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action to ensure safety, using the emergency brake valve to stop the train, if
necessary.
Additionally, the UP General Code of Operating Rules (2013) 1.47.1 establishes a cab
red zone for certain circumstances, which include when a train is operating at restricted speed
and when a train is operating on a signal that requires the train to be prepared to stop at the next
signal:
During a cab red zone, an environment must be created in the control
compartment that focuses exclusively on controlling the train and complying with
the rules. The conductor must be in the control compartment unless required by
other duties to leave (i.e., to operate switches, be at a road crossing, passenger
train duties, etc.).
The following restrictions or conditions must be met:

Cab communication is restricted to immediate responsibilities for train
operation.

A crew member other than the employee operating the controls will be
required to handle radio communications when another crew member is in
the control compartment …. Radio communication must be limited to the
train’s immediate movement and complying with the rules ….

If proper action is not being taken, crew members must remind each other
of the cab red zone condition.
Investigators asked the conductor about cab red zone. He responded that it comes into
effect anytime safety is involved, and added that in-cab communications under cab red zone
conditions applies to movement of and stopping a train. Specifically, he said cab red zone goes
into effect once a train has passed an Approach signal.
1.5 Signals Information
The Chester Subdivision in the UP St. Louis Service Unit extends from East St Louis,
Illinois, to Dexter, Missouri, in a timetable north-south direction. The maximum authorized
timetable speed on the subdivision is 70 mph for freight trains with a 40 mph restriction through
the Rockview Interlocking. In the vicinity of the accident area, the UP operates over a single
main track using a traffic control system controlled by a dispatcher at the Harriman Dispatch
Center in Omaha, Nebraska.
The Rockview Interlocking is located on the BNSF River Subdivision of the Springfield
Division. The BNSF operates through this area over a single main track using a traffic control
system controlled by a dispatcher at the Network Operations Center in Fort Worth, Texas.
Both UP and BNSF dispatchers send signal requests to Rockview Interlocking. A railroad
that wants to move a train over the interlocking sends a request to the field equipment to line a
7
signal to operate over Rockview Interlocking. The other railroad dispatcher then receives an
onscreen indication that the first railroad has requested a signal, and the dispatcher acknowledges
the request. If both railroads make this request at the same time, the first train that occupies the
Approach track circuit to the interlocking receives a signal to operate over the railroad crossing.
The signal aspect for the other train will remain red.
1.5.1 Signal Requirements Before Collision
As the BNSF train approached Rockview Interlocking, it passed signal aspects indicating
the route was aligned and maximum speed (25 mph) was authorized. A green aspect (Clear)
displayed on the Rockview Interlocking signal allowed the BNSF train to operate through the
Rockview Interlocking; event recorder data indicate that the BNSF train was traveling at 22 mph
when it was struck by the UP train.
As the UP train approached Rockview Interlocking, it passed four signals that governed
its movement and provided information to the crewmembers before the train reached the
interlocking. (See table 1.)
Table 1. Signals encountered by striking UP train.
Location
Aspect
Displayed
Aspect
Name
Indication
MP 127.7
Flashing Yellow
Advance
Approach
Reduce speed to 40 mph prepared to stop
at second signal
MP 129.1
Solid Yellow
Approach
Reduce speed to 30 mph prepared to stop
at next signal
MP 131.2
Flashing Red
Restricting
Reduce speed to restricted speed
Rockview Interlocking
Solid Red
Stop
Stop
The first of the four signals was a flashing yellow aspect (Advance Approach) on the
intermediate signal at MP 127.7, which required the train crew to reduce speed to 40 mph and be
prepared to stop at the second signal. A solid yellow aspect (Approach) on the next signal, at
MP 129.1, required the train crew not to exceed 30 mph and to be prepared to stop at the next
signal. The third signal at MP 131.2 was a flashing red aspect (Restricting) that required the train
to operate at restricted speed. Restricted speed on the UP is defined in the General Code of
Operating Rules (UP 2013) 6.27 as “a speed that allows stopping within half the range of vision
short of” the Stop signal and “the crew must keep a lookout for broken rail and not exceed 20
mph.” The fourth signal displayed a solid red aspect (Stop), which required the train to stop short
of the signal. Event recorder data indicate that the actual speed of the UP train was between 48
mph and 54 mph as it passed the final four signals.
Along with responding appropriately to the signal aspect requirements, the UP crew was
required to activate the locomotive horn at the last highway-railroad grade crossing before the
collision. The horn was not activated at that grade crossing according to locomotive event
recorder data. However, the horn was activated many times about 10 minutes before the
collision. It is unclear why the horn was activated; review of the track profile chart indicated no
8
crossings in that area, and the recording from the inboard video recorder showed no equipment
or personnel in the vicinity of the tracks.
1.5.2 Postaccident Signal System Inspection and Testing
A postaccident inspection of the signal system found all signal bungalows and signal
equipment locked and secured with no indications of tampering. Data from each signal location
were downloaded. The Federal Railroad Administration (FRA) recreated the associated track
circuit codes both in and out and verified each signal aspect displayed as intended. Ground tests
did not indicate any exceptions. The signal lenses were inspected, and no defects were noted.
Circuit plans were reviewed and all associated junction boxes inspected. No defects of the signal
system or associated appurtenances were noted during these inspection activities. Maintenance,
inspections, and tests were in accordance with FRA requirements.
The FRA measured distances from signal mast to signal mast in the direction of the UP
train approaching the accident area. The first signal encountered was at MP 127.7. No
obstructions were identified that could have interfered with the signal preview. The next signal,
at MP 129.1, was 7,164 feet from the previous signal. No obstructions were identified that could
have interfered with the signal preview. The signal at MP 131.2 was 10,291 feet from the signal
at MP 129.1. The Rockview Interlocking signal was 1,215 feet beyond the signal at MP 131.2.
No obstructions were identified that could have interfered with the signal preview.
As a result of the collision, damages to signals and signal bungalows were estimated to be
$500,000.
1.6 Personnel Information
1.6.1 Employment History and Qualification
The UP engineer was hired as a brakeman on the Chicago Eastern and Illinois Railroad in
April 1974. He began working as a freight locomotive engineer out of Salem, Illinois, in 1980
and had operated out of Salem for most of his career. Records indicate that he was qualified on
the territory at the time of the accident. His last check ride was in November 2012. He
successfully passed a Stop signal test on May 22, 2013.
The UP conductor was hired in October 2008. He has been based in Salem, Illinois, since
May 2011. His last check ride was in August 2012. He successfully passed a Stop signal test on
December 30, 2012.
The BNSF engineer was hired into train service in January 1997. Records indicate that he
worked as a conductor, brakeman, and switchman at various locations on the BNSF system until
2003. In 2004 he began working as a locomotive engineer in Gainesville, Texas. He had worked
out of Chaffee, Missouri, since June 2008. Records indicate that he was qualified on the territory
at the time of the accident. His last check ride was in March 2013 with a performance score of
98 out of 100.
9
The BNSF conductor was hired in September 2003. Since that time, he worked mostly
out of Springfield, Missouri, until he transferred to Chaffee in June 2012. He had operated over
the accident territory since January 2012. Records indicate that he was qualified on the territory
at the time of the accident. His last recertification as a conductor was on June 21, 2011.
1.6.2 UP Crew Performance History
Specific requirements for the testing and observation of operating employees while they
perform their duties are contained in Title 49 Code of Federal Regulations (CFR) 240.303
(engineers) and 242.123 (conductors). The UP maintained an operational testing program in
accordance with 49 CFR 217.9 to monitor the performance of employees operating trains and
assess their compliance with rules. Additional testing requirements that railroads must follow for
certification of locomotive engineers are at 49 CFR 240.303(d)(1)(i) and include a requirement
that locomotive engineers operating on signaled track be tested once per year on a “less than
Clear” signal.
The UP provided data covering the 12 months preceding the accident for the engineer and
the conductor of the striking train. Supervisors had observed both employees while they
performed a variety of operations. (See table 2.)
Table 2. Operations tests performed on UP crew.
Category
Total test events
Engineer
22
a
Conductor
18
Total individual tests
56
63
Total individual rules checked
128
169
Test events on Chester Subdivision
5
6
Test events at Rockview Interlocking
1
0
a
A test event may involve more than one individual test and more than one individual rule.
Several of the tests outlined in the UP Field Training Exercise Program, Manager’s Guide
(UP 2012) relate to procedures relevant to this accident. (See table 3.)
Table 3. Number of operations tests performed on UP crew.
Test Number
Test
Engineer
Conductor
1A
Stop test
4
3
3A
Stop signal
7
8
3B
Restricted proceed
0
1
4
Restricting
0
0
5A
Approach/Approach Diverge
0
0
5B
Signal less than Clear
0
0
8
Speed limit
1
1
11A
On-board assessment
10
10
10
On these tests, the UP conductor did not score below standard on any, whereas the UP
engineer scored below standard on three items. These were minor deficiencies regarding general
rules compliance, and the engineer was coached following each of these events.
1.6.3 UP Crew Schedules
UP Engineer. The UP engineer told investigators that he was unable to recall the times
he awoke and retired on May 22, and the time he awoke on May 23. (See UP engineer’s
sleep/work/rest history at table 4.) He did remember that, on May 23, he went off duty at
9:35 p.m. and retired for the evening between 11:00 p.m. and 11:30 p.m. He awoke the following
day, May 24, at 7:30 a.m., had coffee, checked train line-ups via his computer, had breakfast, and
remained home. He recalled that he napped from about 1:00 p.m. until 4:00 p.m., had dinner at
7:30 p.m. and went on duty at 9:45 p.m. At the time of the accident the UP engineer had been on
duty for 4 hours and 45 minutes, and he had been awake for about 10 hours 30 minutes.
Table 4. UP engineer’s recent work/rest/sleep history.
Date
May 19
May 22
BeginSleep
does not
recall
does not
recall
Wake Up
does not recall
does not recall
Time Asleep
does not
recall
does not
recall
Shift Start
Shift End
Time On Duty
1:15 a.m.
1:08 p.m.
11 hr. 53 min.
2:00 a.m.
2:08 p.m.
11 hr. 52 min.
May 23
11:30 p.m.
7:30 a.m. (May
24)
8:00 hr.
1:05 p.m.
9:35 p.m.
8 hrs 30 min.
May 24
1:00 p.m.
4:00 p.m.
3 hr. (nap)
9:45 p.m.
2:30 a.m. (May 25)
4 hr. 45 min.
In the 6 days preceding the accident, the UP engineer had worked two very long—nearly
12-hour—shifts that began early in the morning, about 1:00 a.m. and 2:00 a.m., respectively, and
lasted until early afternoon. Then, on the day after the second long shift, May 23, he worked an
8-hour shift that began in the early afternoon about 1:00 p.m. and ended at 9:35 at night. On
May 24–25, he worked a night shift, reporting for duty at 9:45 p.m.
UP Conductor. The UP conductor told investigators that he was unable to recall when he
awoke and retired on May 22 and the following day, May 23. (See UP conductor’s
sleep/work/rest history at table 5.) He recalled that he went off duty at 3:00 a.m. on May 24 and
retired between 3:30 a.m. and 4:00 a.m. He slept until noon, showered, had dinner, was called for
duty at 6:45 p.m., and went on duty at 9:45 p.m. At the time of the accident the UP conductor
had been on duty for 4 hours 45 minutes and, based on his recollections, awake for about
14 hours 30 minutes.
In the 6 days preceding the accident, the UP conductor had worked a number of shifts
that began at varying times, including one day when he worked two shifts. On May 19 he
worked a night shift beginning about midnight. Two days later, he worked a day shift beginning
at 7:30 a.m. Two days after that, he worked two shifts; the first shift began about midnight and
ended nearly 10 hours later at 9:52 a.m., and the second shift began at 11:00 p.m. and ended at
3:21 a.m. On the day of the accident, he worked a night shift, reporting for duty at 9:45 p.m.
11
Table 5. UP conductor’s recent work/rest/sleep history.
Date
May 19
May 21
May 23
BeginSleep
does not
recall
does not
recall
does not
recall
May 23
May 24
Wake Up
does not recall
does not recall
does not recall
-4:30 a.m.
Time Asleep
does not
recall
does not
recall
does not
recall
Shift Start
Shift End
11:55 p.m.
7:55 a.m. (May 20)
7:30 a.m.
3:00 p.m.
12:15 a.m.
9:52 a.m.
--
8:00 hr.
11:00 p.m.
3:21 a.m. (May 24)
noon
7:30 hr.
9:45 p.m.
2:30 a.m. (May 25)
Time On
Duty
8 hr.
7 hr. 30
min.
9 hr. 37
min.
4 hrs 21
min.
4 hr. 45
min.
1.7 UP Crew Medical Information
The FRA does not require a complete medical history, list of medications, or physical
exam for railroad employees in safety-sensitive positions. The UP performs a complete medical
history and physical only as part of preemployment or return-to-work examinations but limits the
triennial medical evaluation to the minimum required by the FRA: vision testing and hearing
screening.
Investigators reviewed a series of medical records for both the engineer and the
conductor. These included UP medical records and postaccident ambulance and emergency
department medical records for both crewmembers and, for the engineer, personal medical
records from before and after the accident.
1.7.1 UP Conductor
On the conductor’s initial physical on September 4, 2008, he reported only a previous
knee surgery, denied any medical problems, and answered “No” to a host of specific health
problems. At that time, he was recorded as 5 feet 10 inches tall and 200 pounds. His binocular
visual acuity was 20/15, and he passed the Ishihara color vision plate test with 13 out of 14 plates
correct.1
At the time of the accident, the UP conductor was 33 years old, and his most recent UP
physical examination was performed on May 14, 2010, when he was returning to work after a
period of furlough. At that time he was 5 feet 10 inches tall and weighed 202 pounds. During that
examination he completed an “interval medical history” form. Among the questions on the form,
he answered “No” to the following:

Was he returning to work after an illness or injury?

Did he require work restrictions or accommodations?
1
The Ishihara test is the standard protocol mentioned in 49 CFR Part 240, Appendix F (Medical Standards
Guidelines), to test for color vision deficiencies.
12

Did he have limitations to his ability to wear safety protective equipment?

Did he have a health condition, take any medications or treatment, or depend on any
medical devices that do (or might) adversely affect his judgment, alertness, balance,
coordination, or that might in any way interfere with his ability to safely and
efficiently perform his job functions?
On this visit the conductor passed the visual acuity testing without glasses or contact lenses
(20/15) and color vision testing (14/14 Ishihara plates correct). The conductor’s hearing was
tested on February 25, 2010, and he had no deficits above 10 decibels.
Postaccident Medical Information. After the collision, the conductor was ambulatory at
the crash scene but was transported to the hospital by ambulance. The ambulance run sheet notes
“no significant [past medical history]” and “None” under medications. The conductor was awake
and alert with a Glasgow Coma Scale score of 15/15.2 He was noted to have a scalp laceration
and skinned knuckles on both hands, and he was complaining of pain in his left elbow and right
knee. The narrative note from the emergency medical services provider says, “The [patient]
stated they attempted to stop but could not stop in time.” As noted previously, a Highway Patrol
sergeant told investigators the UP conductor showed no symptoms of impairment and appeared
alert when he saw him at the hospital.
In the emergency department, the conductor reported no medical history and said that he
was not taking any medications to both the triage nurse and the physician. According to the
emergency department, he weighed 210.1 pounds and was 5 feet 10 inches tall, with a calculated
body mass index (BMI) of 30.42 (NHBLI 2013).3 The conductor was diagnosed with a scalp
laceration, and the laceration was repaired. A second diagnosis was “multiple contusions.” Tests
performed in the emergency department included CT (computed tomography) scans of his head,
entire spine, chest, abdomen, and pelvis, but no significant traumatic findings were uncovered.
Laboratory testing revealed normal blood counts, electrolytes, and liver and kidney function. His
random glucose was mildly elevated at 133 milligrams per deciliter (mg/dL); normal range in the
lab was 72–113 mg/dL. The conductor was discharged from the emergency department to his
home.
1.7.2 UP Engineer
The UP engineer was 58 years old at the time of the accident. He had passed his most
recent routine medical certification exam on July 20, 2012. At that visit only vision and hearing
were tested; no questions were asked about medical problems or medications, and no other
physical examination was performed. At that time, his corrected binocular visual acuity was
20/30, and he passed the Ishihara color vision plate test with 13 correct out of 14 plates. He had
chronic partial hearing loss with a 40–55-decibel loss in the higher frequencies (>3,000 hertz) in
2
The Glasgow Coma Scale, composed of three tests—of eye, verbal, and motor responses—is used to assess
the neurological state of a patient. The number of points resulting from the assessment give a patient a score
between 3 (indicating deep unconsciousness or coma) and 15 (fully awake).
3
BMI is a measure of body fat that applies to adults. Normal BMI is between 18.5 and 24.9, overweight is
considered 25.0 to 29.9, and a BMI of more than 30.0 is considered obese.
13
the right and a 60–70-decibel loss at 4,000 hertz and above on the left.4 This approximate degree
of high-frequency hearing loss had been present for many years. (In 1994, he was able to pass at
40 decibels in every frequency from 4,000 hertz and below.) There are no measurements of
height and weight nor any mention of medication use or chronic medical problems in the last 15
years in the UP medical record.
The engineer told investigators that he had been a diabetic and using insulin to treat it
since 1997 and that he believed the railroad was aware of that diagnosis. His UP medical record
included personal medical records from 2001 and 2002. Recorded within the 2001–2002
information is the fact that the engineer had been diagnosed as diabetic and treated with insulin
beginning in 1997, when his Hemoglobin A1C was measured as high as 16 percent.5
The most complete medical history form in the UP medical record is a 1974 entry from
the Missouri Pacific and Texas Pacific Railroad. At that time, the engineer, who was then 19
years old, was asked a series of history questions that included, “Do you now or have you ever
had …” followed by a list of medical conditions, including diabetes. He responded “No” to each
question. In addition, he replied “No” to the question, “Are you taking drugs of any kind?” At
that time, the engineer was recorded at 6 feet 3 inches and 190 pounds. His examination was
otherwise unremarkable.
Investigators obtained preaccident personal medical records from the engineer’s primary
care physician. The engineer had begun to visit this physician on December 2, 2010, after his
previous physician closed his office. The engineer visited his physician about every 6 months for
routine followup of his Type II diabetes. His blood pressure was normal throughout his
outpatient care, but his heart rate (pulse) was generally measured above 100 beats per
minute (bpm), ranging from 90 bpm to 120 bpm on routine visits. Over the period that he saw the
physician, the engineer’s weight increased from 275 pounds at his initial visit to 291 pounds in
January 2013. Just after the accident, on May 28, 2013, the engineer’s weight was noted to be
287 pounds.
The engineer initially was treated for his Type II diabetes with a NovoLog FlexPen using
70/30 insulin.6 He continued to use the FlexPen as a delivery device, but his daily dosing
increased over the years from 46 units twice a day to 60 units twice a day. He did not routinely
perform blood glucose monitoring tests at home. Over the 2 1/2 years that the engineer saw his
primary physician before the accident, the engineer’s Hemoglobin A1C test result varied from a
high of 9.1 percent in July 2011 to a low of 7.2 percent in December 2012. The engineer
underwent postaccident Hemoglobin A1C testing the last week of August 2013, and at that time
his level was 7.6 percent.
Postaccident Medical Information. After the collision, the UP engineer was transported
to the hospital by ambulance. The ambulance run sheet noted Insulin under “Medications” and
4
Hertz is a unit of frequency equal to 1 cycle per second.
The Hemoglobin A1C test indicates average blood sugar level for the past 2–3 months. The higher the blood
sugar level, the more hemoglobin with sugar attached. For someone diagnosed with diabetes, a level of 7 percent or
less is a common treatment target, but higher targets may be chosen in some people.
6
NovoLog (brand name of insulin) FlexPen is a prefilled insulin syringe.
5
14
Diabetes under “Past Medical History.” The ambulance assessment identified a laceration of the
left arm, pain with some swelling on the left chest. His Glasgow Coma score was 15/15 points.
His blood pressure was measured twice, at 162/104 and 174/107, and his pulse was 113 bpm and
114 bpm. The ambulance personnel noted that “he was the conductor (sic) of the train … and
was pulled out of the train when the fire broke out by his partner.” He was ambulatory at the
scene by the time the ambulance arrived. As noted previously, a Highway Patrol sergeant told
investigators the UP engineer showed no symptoms of impairment and appeared alert when he
saw him at the hospital.
The record from the receiving emergency department includes information from the
triage nurse that states, “[Passenger], train accident – [patient] does not remember events prior to
conductor rousing him – pain left ribs/upper left [abdomen], pain [right] leg below knee with
movement.” The triage note recorded the engineer’s weight as 287.9 pounds and his height at
6 feet 4 inches, with a BMI of 35.06. NovoLog FlexPen was recorded as the engineer’s only
medication, and the medical history section noted, “History of diabetes, that is currently treated
with insulin.” In the physician’s notes on the chief complaint is the following: “Uncertain as to
whether or not loss of consciousness occurred.” In the notes from the physician’s initial physical
exam, the engineer was noted to be tachycardic and to have pain in the left chest and left upper
abdomen.7 As discussed later in this report, all of the evidence suggests his blood sugar had been
in good control for years and was normal at the time of the accident. This should not have
degraded his performance.
The engineer underwent CT scans of his head, spine, chest, abdomen, and pelvis. No
acute traumatic injuries were identified. Laboratory tests including a complete blood count,
electrolytes, and kidney and liver function tests were performed and were generally normal or
negative. His glucose was 90 mg/dL. Throughout the engineer’s emergency department stay, the
Glasgow Coma score remained 15/15; his systolic blood pressure ranged from 164 to 189 and his
diastolic from 80 to 150. He remained tachycardic with a heart rate between 109 bpm and 112
bpm. The final diagnoses were multiple contusions and multiple abrasions, and the engineer was
discharged to his home.
About 2 months after the accident, on July 18 and 29, 2013, the engineer visited a
neurologist for further evaluation. The note from the first visit includes the following as part of
the history of the present illness:
The last thing he remembers was talking to the conductor. After that, he
remembers waking up with glass at his side and [having] the conductor over him
calling his name. He states that he felt disoriented. He remembers [Emergency
Medical Services] coming and putting his neck in a brace. He denies any
headaches, vision changes, or nausea at that time. He feels that he did black out.
He has not talked to the conductor, who was the only witness, due to
investigational purposes. He states that after the accident he had bruises in the
back of his head on the right side behind his ear and on the shoulder and lower
back … he states that the total time of his memory lapse was less than 2 hours.
7
Tachycardic means affected with a faster-than-normal heart rate.
15
Prior to this incident, he states that he was having trouble with names and word
finding and would lose track of what he [was] saying during sentences ….
The neurologist recorded that the past medical history was significant for “arthritis, back
problems, diabetes, head injury, and neuropathy.” The engineer’s medications were listed as
NovoLog, tapentadol, and baby aspirin. The tapentadol had been prescribed for his postaccident
pain and is a Schedule II controlled substance that is an opioid analgesic (narcotic pain medicine)
(Drugs.com 2014).
At this exam, the engineer was noted to be 6 feet 3 inches tall and weigh 280 pounds
(BMI=35).
On the mental status exam, the engineer was oriented to person, place, and time. His
speech was described as “fluent, clear, and coherent.” To the neurologist, “the memory,
judgment, and insight seem[ed] intact.” The remainder of the physical exam was unremarkable.
Following the initial evaluation, the engineer underwent MRI (magnetic resonance
imaging) of the brain with and without contrast, which was interpreted as demonstrating “no
acute intracranial process.”8 Under findings, the MRI report states the following:
There is no restricted diffusion to suggestion hyperacute/acute ischemia or
cytotoxic edema. There was no evidence of mass, mass effect, midline shift,
hemorrhage or acute/subacute focal infarct. The ventricles and cisterns are normal
in size and configuration. There is no epidural or subdural hematoma. Significant
white matter signal abnormalities are not identified. The sella turcica and pituitary
are unremarkable. Postcontrast imaging demonstrates no abnormal enhancement.”
In addition, an EEG (electroencephalogram) performed in both awake and drowsy
states was interpreted as normal.
The engineer followed up with the neurologist after this testing was performed. The
neurologist’s notes from the second visit include the engineer’s reporting being “amnestic to the
event and 30 to 40 minutes prior to the event.”9 The final diagnosis was “Neurogenic Spell—
questionable syncope; transient global amnesia.”10
Requested Sleep Evaluation. The engineer in this accident was obese, had diabetes,
and was unable to recall events or his behavior before the accident. Other information suggested
the engineer was not operating the train as required for several minutes prior to the collision,
including failing to obey wayside signals, failing to activate the horn when required, and
activating the horn when not required. As a result, the NTSB requested that the engineer
voluntarily undergo a diagnostic evaluation by a sleep specialist including a polysomnogram (a
sleep study) for the NTSB’s investigative review in assessing the possibility that the engineer
had obstructive sleep apnea (OSA). Although the engineer initially agreed to undergo this
8
An MRI with contrast—an intravenous dye—enables certain areas to be seen more clearly.
Amnestic means affected with amnesia.
10
Syncope means fainting. Transient global amnesia is “a sudden, temporary episode of memory loss that
cannot be attributed to a more common neurological condition, such as epilepsy or stroke” (Mayo Clinic 2014).
9
16
evaluation, he did not comply with repeated requests or sign the required paperwork. No sleep
study was performed.
1.8 Toxicological Information
After the accident, toxicological specimens were obtained from the engineers and the
conductors of the BNSF and UP trains in accordance with 49 CFR Section 219, Subpart C,
“Post-Accident Toxicological Testing.” These tests screened for cannabinoids, cocaine, opiates,
amphetamines, methamphetamines, phencyclidine, barbiturates, benzodiazepines, and ethyl
alcohol. The results were negative for these drugs. Also, the four crewmembers were
administered breath analyzer tests to determine the presence or absence of alcohol. No alcohol
was detected.
1.9 Highway Bridge Information
1.9.1 Construction
Missouri State Route M travels through western Scott County, Missouri, from
Interstate Highway 55 west to the western county line near the communities of Rockview and
Chaffee. The Route M highway bridge, designed and constructed in 1988, spans the at-grade
crossing of the BNSF and UP tracks where the accident occurred. It had five spans supported by
two abutments and four intermediate column bent assemblies.11 The approach spans were
prestressed concrete, precast four-beam girders, each of which was 62 feet long on the west side
of the bridge and 58 feet long on the east side of the bridge. The main bridge span had
66-inch-deep rolled steel four-beam girders that were 125 feet long. The bent caps had concrete
diaphragms the girders were connected to. Both bents next to each abutment were steel pipes
filled with concrete. These bents were 60 feet long and embedded to a depth of 30 feet. Both
were composed of six steel columns: three concrete columns were at bents 3 and 4. Each column
was 36 inches in diameter and embedded to a depth of 41 feet below the footings.
1.9.2 Damage
As a result of the train impact after the derailment, bent 3 was sheared off at the base of
the footing. This loss of structure allowed spans 2 and 3 to collapse. (See figures 3 and 4.) The
downward vertical movement of these spans was stopped by the wreckage of the derailed train
cars underneath the structure. Several UP auto-rack cars came to rest against the fractured
columns of bent 3. Also, oval-shaped impact damage 42 inches wide and 39 inches deep,
consistent with an impact with one of the bent columns, was found on one BNSF car. This car
was the 22nd car in the BNSF train, 10 cars behind the point where the UP train struck the BNSF
train. The vertical clearance between the track elevation and the bottom of the girders was about
24.5 feet. The horizontal clearance from the center of the rails to bent 3 was 21 feet 9.75 inches.
There was no crash-protection wall shielding the bents from impact with railroad equipment.
11
A bent, part of a bridge substructure, is a rigid frame that supports a vertical load and is placed transverse to
the length of a structure. Bents support beams and girders; an end bent is a supporting part of an abutment. A column
is a vertical member of a bent; the horizontal member resting on top of the columns is a bent cap.
17
Figure 3. Derailed train cars and damaged bridge supports.
18
Figure 4. Collapsed bridge deck.
1.9.3 Design and Construction Regulations
Federal. The Federal Highway Administration (FHWA) has no pier protection
requirements for highway bridges over railroads. Because these public structures are constructed
on private railroad property under the authority of easements granted by a railroad, the governing
documents for design and construction are those of the railroad or the American Railway
Engineering and Maintenance-of-Way Association (AREMA).
State. Investigators reviewed Missouri Department of Transportation (MODOT)
documents related to pier protection. MODOT materials contain specifications for the design and
construction of bridges that addressed pier protection walls but no warrants on when the
specifications were to be used. The American Association of State Highway and Transportation
Officials (AASHTO) 2012 Load Resistance Factor Design Manual (LRFD Manual) (AASHTO
2012) advises engineers to contact AREMA for specifications and warrants for pier crash
protection near railroads.
Industry. When the Route M highway bridge was built in 1988, the 1986 edition of the
design guidelines of the American Railway Engineering Association (AREA)12 applied to its
12
AREA merged with other industry groups to form AREMA in 1997.
19
construction. This guidance recommended “heavy construction” for concrete piers if the
horizontal clearance from the centerline of the rails to the piers was less than 25 feet, but it did
not define “heavy construction.” (As noted previously, the horizontal clearance from the center
of the rails to bent 3 was 21 feet 9.75 inches.) Thus the Route M highway bridge was built to the
guidelines in effect at the time of its construction.
1.9.4 Inspection
The Route M highway bridge was subject to the bridge inspection standards required by
FHWA. The bridge was last inspected on February 25, 2013, and the deck and substructure were
rated as satisfactory and the superstructure as good. A special inspection was performed on
January 30, 2013, after a BNSF derailment that occurred on the evening of January 29, 2013.
The inspector noted that bent No. 3 had been struck in that derailment and that the impact caused
only light scraping and paint marks on the concrete bent with no structural damage.
1.10 Tests and Research
1.10.1 Mechanical Condition of Trains
Postaccident mechanical inspections were performed on both trains, and their brake test
records were reviewed. The investigation determined that the mechanical condition of both trains
was in compliance with FRA regulations. The crashworthiness inspection of the UP train
determined the interior of the lead locomotive cab was intact and no occupant space was lost.
1.10.2 Portable Electronic Devices
NTSB investigators obtained usage records for the cell phone numbers of the four
crewmembers of the two trains involved in the accident. The records revealed no portable
electronic device activity for any of the crewmembers just before or at the time of the collision.
1.10.3 Sight-Distance Observations
On the night of May 28, 2013, investigators conducted sight-distance observations to
determine the distances from the UP train at which an operating crewmember on the train could
first see and visually identify the aspects of the four signals that the train passed as it approached
the accident site. Weather and lighting conditions during the sight-distance observations were
similar to those at the time of the accident.
At the UP Illmo Yard in Scott City, Missouri, investigators boarded a locomotive that
was similar to the lead locomotive on the striking train. The locomotive was operated by an
engineer and a conductor who were qualified on and familiar with the territory. The signals were
set to display the same aspects as on the morning of the accident. The operating crew was
instructed to note when they could first determine the aspect displayed on each of the four
signals leading up to the accident location. The locomotive distance counter was used to measure
the sight distance to the four signals. Observation results are summarized in table 6.
20
Table 6. Sight-distance measurements for both UP crewmembers.
Observable Aspect
Engineer
a
Conductor
Advance Approach signal - MP 127.7
3,749 feet
3,749 feet
Approach signal - MP 129.1
3,690 feet
3,690 feet
Restricting signal - MP 131.2
4,403 feet
4,315 feet
Rockview Interlocking Stop signal
4,702 feet
4,702 feet
a
Because of track curvature, signals may become visible from one side of the cab before they are visible from the other side.
1.11 Postaccident Actions
1.11.1 Union Pacific Railroad
The UP issued an Incident Alert to all train and engine service employees on the UP
system after the accident that referenced operating rules on which crews should focus and
provided a general description of the accident so that crews and managers would be aware of
what happened. The rules referenced were: Rules 1.1.2 (Alert and Attentive), 1.47 (Duties of
Crew Members), 1.47.1 (Cab Red Zone), 6.27 (Movement at Restricted Speed), 9.12.2 (Manual
Interlockings), 70.3 (Job Briefing). The Incident Alert was also posted on the Operating Practices
Incident Alert page of the UP employee website.
1.11.2 BNSF Railway
The BNSF included discussion of the accident in safety briefings with all crews on the
Springfield Division.
1.11.3 Missouri Department of Transportation
As a result of this accident and the January 29, 2013, BNSF derailment, MODOT
incorporated crash walls in the design for the rebuilt Highway M bridge that provided about
600 kips13 of resistance to impact forces. The equivalent 600-kip static load is based on
information obtained from crash testing an 80,000-pound truck into a concrete structure at
50 mph. The redesigned and reconstructed bridge is shown in figure 5.
13
One kip (kilo-pound) equals 1,000 pounds of force.
21
Figure 5. New Highway M bridge.
22
2 Safety Issues Analysis
This issues analysis begins with a summary of the accident sequence and includes
discussion of the following safety issues identified in this report:

Fatigue awareness

The need to implement crew resource management

The need for inward- and outward-facing audio and video recorders in locomotive
cabs

Positive train control
The remainder of this introductory section discusses those elements of the investigation
that the NTSB determined were not factors in the accident. The balance of the safety issues
analysis addresses the factors that were found to have caused or contributed to the accident, or to
have contributed to its severity.
Both trains’ crewmembers were qualified and trained to perform their duties, and they
had consistently passed applicable skills and knowledge tests. Both trains were inspected before
the trips began on May 24, and no exceptions were taken to their mechanical condition.
Postaccident inspection of the trains also revealed no significant mechanical defects. The
investigation revealed that the routes and the signals had been set correctly for both trains, and
postaccident tests demonstrated that the signal systems functioned as intended. Based on the
negative results of the toxicology testing performed after the accident, alcohol and drug use were
not factors in the accident. Also, the use of personal electronic devices just before or at the time
of the accident was not a factor in the accident, because the investigation found that the cell
phones of the crewmembers on both trains had not been used while the trains were operating.
The NTSB therefore concludes that the following were not factors in the accident: the
qualification of the crewmembers on both trains; the mechanical condition of the trains; the
dispatching activities; the signal systems; and alcohol use, drug use, and the use of portable
electronic devices by the crewmembers on both trains.
2.1 Performance of UP Train Crew
The investigation examined the handling of the UP train by its crew. In particular,
investigators focused on event recorder data, wayside signal logs, and on-scene tests to
understand the crew’s performance once they encountered and passed four signals as the train
neared the Rockview Interlocking, over a distance of about 3.7 miles. The lead UP locomotive
was equipped with an alerter, although alerter acknowledgement was not a parameter that was
recorded. The locomotive was built in 2004 and had not been rebuilt. Locomotives built before
2009 are not required to have event recorders that capture alerter acknowledgement activity.
The UP crew first encountered an Advance Approach (flashing yellow aspect), which
authorized the crew to proceed at not more than 40 mph once they arrived at the signal.
23
Sight-distance tests indicate that the signal was observable at a distance of 3,749 feet (0.71 mile).
The train was operated at about 52 mph (76.4 feet per second) throughout its approach to and
upon its arrival at the Advance Approach signal. At that speed, the crew had about 49 seconds to
detect and react to the Advance Approach signal, but they did not slow the train.
The second signal was an Approach signal (solid yellow over red aspect), which
authorized the UP crew to proceed at not more than 30 mph once they arrived at and passed the
signal. Sight-distance tests indicate that the signal was observable at a distance of 3,690 feet
(0.70 mile). Data from the train’s event recorder indicate that the train was traveling 53.5 mph
(78.5 feet per second) when it passed the Approach signal. At that speed, the crew had about
86.5 seconds to detect and react to the signal, but again they did not reduce train speed.
The track was tangent (straight), the terrain was level and without obstructions, and sight
distance tests show that the next two signals could be seen from the location of the second
(Approach) signal stand.
The third signal displayed a flashing red aspect, which required the crew to reduce train
speed in preparation to stop at the next signal. Sight-distance tests indicate that the signal was
observable from the engineer’s seat at a distance of 4,403 feet (0.83 mile) and from the
conductor’s seat at 4,315 feet (0.82 mile). Locomotive event recorder data indicate the train
passed the flashing red signal aspect at 50 mph.
The fourth signal was a solid red aspect, which required the train to stop. The signal was
observable at a distance of 4,702 feet (0.89 mile). Although the UP crew was expected to
gradually slow and stop the train at the absolute signal, they operated past the signal at 48 mph
and collided with the BNSF train at about 43 mph.
Based on the UP crew’s actions from the Advance Approach signal location to the Stop
signal at Rockview Interlocking, the NTSB concludes that the UP crew failed to comply with
four wayside signals immediately preceding the collision.
2.2 Fatigue of UP Crew
The NTSB investigation examined the possibility of fatigue as a factor in the
performance of the UP engineer and the conductor, which involved a review of their work
records for the 96 hours preceding the accident, as well as a consideration of the time at which
the accident occurred.
For the UP engineer, work records indicated that he had worked two day shifts, which
began in the early morning and lasted until the early afternoon. The day before the accident, he
worked an afternoon shift, which began in the early afternoon and ended on the evening of
May 23. On the day of the accident, he worked a night shift, reporting for duty at 9:45 p.m.
For the UP conductor, work records indicated that he had worked both very early and
mid-morning hours 2 days before the accident. Then, on the day before the accident (May 23), he
was called and worked twice in the same day.
24
During the 4 days leading up to the accident, both UP crewmembers had been called to
work at different times of the day and night. These variable work schedules meant the pattern of
awake and asleep time for both UP crewmembers was unpredictable, inconsistent, and disruptive
to normal circadian rhythms. In a normal circadian rhythm, the human body naturally sleeps to
refresh its capabilities for normal physical and cognitive performance during the time between
about midnight and 6:00 a.m.; the window of circadian low generally occurs between 3:00 a.m. and
5:00 a.m. People who are awake during the window of circadian low are less alert, have degraded
performance, and are susceptible to the effects of fatigue. Further, fatigue is known to be
triggered by circadian disruption, and it can be exacerbated by ongoing circadian disruptions,
which the UP crewmembers were experiencing before the accident. Fatigue can degrade task
performance, leading to longer reaction times, memory problems, poor decision-making,
workload shedding, and inefficient information processing. (Brown 1994) The Chaffee accident
occurred at 2:30 a.m., during the window of circadian low. Therefore, the NTSB concludes that
as a result of their variable work schedules, both UP crewmembers experienced disruptions to
their normal circadian rhythms for several days before the accident, and at the time of the
accident both were experiencing fatigue caused by circadian disruption and the requirement to
operate the train during the window of circadian low.
The UP crew’s failure to take action to slow and stop their train is consistent with
fatigue-induced performance degradation. The conductor’s log shows he noted the wayside
signals, but he did not take action to respond to the signals when the engineer did not respond to
them. Additionally, the sounding of the horn multiple times before the accident suggests that the
engineer was awake, although perhaps not entirely aware of his surroundings. Fatigued operators
can become disengaged from their tasks, make mistakes in judgment and action, and lose
awareness of work contexts and demands; broadly, fatigued operators can fail to perform their
jobs. Both UP crewmembers experienced similar fatigue-inducing conditions for several days
before the accident, and then both became disengaged from safely operating the train in the time
period leading up to the accident. Therefore, the NTSB further concludes that neither of the UP
crewmembers controlled the train as they encountered and proceeded beyond the Advance
Approach signal, likely because of fatigue-induced performance degradation.
2.3 UP Train Crew Medical Fitness for Work
In this accident, the UP train failed to slow and stop appropriately as the wayside signals
indicated. The medical fitness of the BNSF train crew was not in question, and further analysis
of the BNSF crew was not performed. Title 49 CFR 240.121(c) requires railroad engineers to
meet the following vision criteria, and 49 CFR 240.201 requires railroad engineers to meet these
criteria every 3 years:
25
(1) For distant viewing either:
(i) Distant visual acuity of at least 20/40 (Snellen)14 in each eye without corrective
lenses or
(ii) Distant visual acuity separately corrected to at least 20/40 (Snellen) with
corrective lenses and distant binocular acuity of at least 20/40 (Snellen) in both
eyes with or without corrective lenses;
(2) A field of vision of at least 70 degrees in the horizontal meridian in each eye;
and
(3) The ability to recognize and distinguish between the colors of railroad signals
as demonstrated by successfully completing one of the tests in appendix F to this
part.
The FRA does not require a complete medical history, list of medications, or physical
examination for railroad employees in safety-sensitive jobs. The UP performs a complete
medical history and physical examination only as part of preemployment or return-to-work
examinations, and limits the triennial medical evaluation to the minimum required by the FRA:
vision testing and hearing screening. A review of medical records during the investigation
revealed that both UP crewmembers had current physical examinations and, according to UP
standards, were medically fit to perform their work duties.
2.3.1 UP Conductor
The conductor on the UP train was a 33-year-old man who had last undergone a railroad
physical evaluation on May 14, 2010. This evaluation included an interval medical history only
because he was returning to work after a furlough; he answered “no” to questions about events
during the furlough interval directed at issues that might have affected his ability to work safely
rather than more standard questions about his current state of health, for example, “Do you
currently take any medications? Do you have any health conditions?” At this exam, he was 5 feet
10 inches tall and weighed 202 pounds (BMI 28.7). The conductor passed his hearing and vision
testing.
Evaluation of the UP conductor in the hospital after the accident did not identify any
chronic medical problems, and the conductor denied taking any medications. Postaccident
toxicology testing required by the US Department of Transportation showed only medications
administered as part of the conductor’s postaccident medical care. In postaccident interviews
conducted by the NTSB, the conductor stated he was in good health and he was able to describe
the events that occurred in the minutes before and after the crash. The NTSB therefore concludes
that the UP conductor had no known medical problems that would have interfered with the safe
operation of the train.
14
The Snellen chart measures visual acuity by comparing a person’s ability to see relative to a person with
normal vision. A person with 20/40 vision can accurately read information at a distance of 20 feet that a person with
normal vision can accurately read at a distance of 40 feet.
26
2.3.2 UP Engineer
The UP engineer was 58 years old at the time of the accident. His last routine triennial
medical certification exam occurred on July 20, 2012. At that visit only vision and hearing were
tested; no questions were asked regarding medical problems or medications, and no other
physical examination was performed. The medical record from the routine triennial physical
examination contained no height or weight measurements nor any mention of medication use or
chronic medical problems. In fact, the only time the engineer’s UP medical record reflects the
taking of a complete medical history and physical examination was in 1974, when the engineer
was 19 years old.
Among the engineer’s medical information in the UP files were records that demonstrate
that the UP had access to evidence that the engineer had been diagnosed as diabetic and treated
with insulin beginning in 1997. No further inquiry or ongoing evaluation of the engineer’s health
was required by the FRA or performed by the UP.
Review of personal medical records for the 2 1/2 years preceding the crash demonstrated
that the engineer had good to fair control of his diabetes and did not identify any other medical
concerns. The engineer’s BMI during this period fluctuated between 34.4 and 36.4. However,
there is no evidence from these records that a health care provider ever asked the engineer any
questions about sleep disorders, fatigue, daytime sleepiness, or snoring. His neck circumference
was not measured, although a neck circumference greater than 17 inches in a man correlates with
an increased risk for the obstructive sleep apnea (Davies and Stradling 1990). He was notably
tachycardic during all but one of these visits; it is unclear from the records if the tachycardia was
noted by the physician. The source of the tachycardia was not investigated.
After the accident, the engineer stated he recalled “waking up” when the conductor shook
him to get him out of the locomotive after the collision and complained that he could not recall
events in the minutes to hours immediately before the accident. On evaluation in the ambulance
and the emergency department, the engineer’s blood sugar was normal without treatment or
intervention, and he remained awake and neurologically normal. His extensive radiology
evaluation was essentially normal. However, the engineer was persistently tachycardic in the
hospital. Postaccident toxicology testing revealed only medications provided to the engineer
during his medical care.
Postaccident evaluation by a neurologist for persistent amnesia surrounding the accident
included MRI imaging of the brain and an EEG. Both of these were normal. Of note, the
engineer discussed neurological symptoms preceding the accident including “having trouble with
names and word finding and [that he] would lose track of what he is saying during sentences.”
The neurologist did not discuss issues related to daytime sleepiness, fatigue, snoring, or sleep
disorders with the engineer, and no etiology for the amnesia was identified.
At the time of the accident, the engineer was obese with a BMI in the middle 30s. The
engineer told investigators that his ex-wife had told him that he snored, although he was not
aware of his snoring. Based on recent research on a cohort of middle-aged, mostly white,
Midwestern men with similar levels of obesity, the likelihood that the engineer had at least mild
27
OSA (AHI >5)15 at the time of the accident is about 61 percent, and the likelihood that he had
untreated moderate to severe OSA (AHI>15) is about 30 percent (Peppard et al. 2013). Although
sleep apnea has been associated with impaired glucose tolerance, the exact relationship between
OSA and diabetes remains unclear (Reutrakul and Van Cauter 2014).
People with OSA have a significantly increased risk of motor vehicle crashes and other
occupational injuries (Mulgrew et al. 2008, Lindberg et al. 2001, Basoglu and Tasbakan 2014).
According to guidelines, shown in figure 6, for evaluating sleep apnea in commercial drivers
developed by a joint task force of the American College of Occupational and Environmental
Medicine, the National Sleep Foundation, and the American College of Chest Physicians, having
an at-fault accident that may have been related to fatigue is sufficient to recommend an
immediate out-of-service evaluation by a sleep physician (Hartenbaum et al. 2006).
Figure 6. Recommendations for screening commercial drivers for obstructive sleep apnea.
As a result of determining that the engineer had several risk factors for OSA, the NTSB
asked the engineer to voluntarily undergo a polysomnogram for the NTSB’s investigative review
following the accident. Although he initially agreed to undergo this testing, the engineer did not
return the required paperwork, and the test plan proposed by the NTSB did not proceed. Based
15
The apnea-hypopnea index (AHI) sums the frequency of episodes of apnea and hypopnea. Apnea is the
complete absence of airflow though the mouth and nose for at least 10 seconds. Hypopnea is when airflow decreases
by 50 percent for at least 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen
saturation or an arousal from sleep. An AHI of less than 5 per hour is considered normal. An AHI of 5–15 is mild;
15–30 is moderate, and more than 30 events per hour is considered severe sleep apnea.
28
on the analysis above, however, and the engineer’s presentation of risk factors for OSA, the
NTSB concludes that the engineer on the UP train likely had undiagnosed OSA at the time of the
accident, and this likely resulted in fatigue that contributed to this accident. The NTSB further
concludes that there were at least a dozen opportunities for the UP engineer to have been
screened for OSA during routine occupational health evaluations, but no such screening was
performed.
2.3.3 Previous Rail and Transit Accidents Involving Obstructive Sleep Apnea
A number of previous railroad accidents investigated by the NTSB involving sleep apnea
and fatigue have led to a series of safety recommendations to the FRA and a variety of railroads
and rail transit agencies regarding the need to screen and adequately treat rail operators for the
condition. These include a head-on rail collision in Clarkston, Michigan, in 2001 that the NTSB
determined was due to “crewmembers’ fatigue, which was primarily due to the engineer’s
untreated and the conductor’s insufficiently treated obstructive sleep apnea.” (NTSB 2002) After
the Clarkston accident, the NTSB issued the following safety recommendation to the FRA:
R-02-24
Develop a standard medical examination form that includes questions regarding
sleep problems and require that the form be used, pursuant to 49 Code of Federal
Regulations 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. (The current status of this
safety recommendation is discussed below.)
Although the FRA created a medical working group as part of the Railroad Safety
Advisory Committee (RSAC), there has never been any public output from that working group,
and no action has been taken to further develop guidelines or require screening for or diagnosis
of sleep disorders among railroaders. The NTSB therefore concludes that had the FRA developed
and used a standard medical examination form that includes questions regarding sleep problems
to determine the medical fitness of locomotive engineers, as was called for in
Safety Recommendation R-02-24, the UP engineer likely would have been appropriately
screened and evaluated for sleep apnea before this accident.
In April 2011, a rear-end collision occurred between a BNSF Railway freight train and a
maintenance-of-way train near Red Oak, Iowa (NTSB 2012). The NTSB determined 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.
The medical conditions included probable sleep apnea, restless leg syndrome, and
chronic insomnia, among others. The NTSB made two main medical safety recommendations as
a result of that investigation. One safety recommendation was issued to the BNSF:
29
R-12-26
Medically screen employees in safety-sensitive positions for sleep apnea and
other sleep disorders. (Classified “Open—Acceptable Response” on
December 18, 2012)
The second safety recommendation was issued to the FRA:
R-12-16
Require railroads to medically screen employees in safety-sensitive positions for
sleep apnea and other sleep disorders. (Classified “Open—Acceptable Response”
on October 16, 2012)
An August 23, 2012, letter to the NTSB from the BNSF Vice President for Training and
Operations Support included the following paragraph in response to Safety Recommendation
R-12-26:
Previous attempts by BNSF to require additional medical information about
certain safety related medical conditions, specifically including attempts to obtain
medical information on sleep apnea, met with stiff resistance from our labor
organizations who alleged that these attempts to obtain medical information were
in violation of various federal and state laws. Indeed, 10 unions filed charges with
the Equal Employment Opportunity Commission alleging that the BNSF
requirement violated the federal Americans with Disabilities Act. Those charges
remain pending. Simply stated, until there are some federal standards on medical
qualification for such conditions as sleep apnea, other sleep disorders or, medical
conditions that affect an employee's ability to work safely, it will be difficult to
obtain and use such information without facing a variety of legal challenges.
BNSF believes such information may be lawfully used to improve safety without
violating employee rights and is an active participant in FRA's Medical Standards
Railroad Safety Advisory Council where this issue has been discussed.
Thus, at least one Class I railroad has been unable to accomplish appropriate evaluation for sleep
disorders in the absence of regulation.
In October 2008 Congress enacted the Rail Safety Improvement Act of 2008 (RSIA)
(Pub. L. No. 110-432, div. A) following a head-on collision between a passenger train and a freight
train in Chatsworth, California (NTSB 2010). Section 103(a) of the RSIA directed the Secretary of
Transportation to require that most passenger and freight railroads develop fatigue management plans
and to adopt regulations requiring creation of these plans no later than 4 years after enactment of the
Act. These fatigue management plans were to include methods to manage and reduce fatigue
experienced by railroad employees in safety-related positions and to reduce the likelihood of
accidents, incidents, injuries, and fatalities caused by fatigue. In addition, fatigue management plan
requirements specified in the RSIA include “opportunities for identification, diagnosis, and
treatment of any medical condition that may affect alertness or fatigue, including sleep
disorders” (49 United States Code § 20156(f)(3)).
30
In the FRA’s July 31, 2012, response to Safety Recommendation R-12-16, the FRA
administrator wrote, “Currently, FRA, in conjunction with a working group of members from the
Railroad Safety Advisory Committee, is developing a fatigue management regulation that will be
responsive to the requirements set forth in the RSIA.” However, the time limit set by Congress for
the Department of Transportation to create and issue this regulation passed on October 16, 2012. As
noted previously, the Railroad Safety Advisory Committee medical working group continues to
meet, but there has been no public output regarding fatigue management and no proposed changes to
existing regulations since it was created. The NTSB concludes that had the medical screening
described in Safety Recommendation R-12-16 been in place, or had the fatigue management
components required by the RSIA of 2008 been in place, the UP engineer likely would have been
identified as at high risk for sleep disorders, which may have led to appropriate medical intervention.
Therefore, the NTSB reiterates Safety Recommendation R-12-16 and reclassifies it as
“Open―Unacceptable Response.”
Most recently, the NTSB investigated a head-on collision between two freight trains in
Goodwell, Oklahoma, in 2012, which occurred as a result of the engineer’s inability to see and
interpret wayside signals due to a chronic illness and deteriorating eyesight (NTSB 2013c). After
that investigation, the NTSB classified the safety recommendation to the FRA from Clarkston
(Safety Recommendation R-02-24, noted above), previously classified “Open—Acceptable
Response,” as “Closed—Unacceptable Action/Superseded” by Safety Recommendation R-13-21
to the FRA on June 18, 2013. Safety Recommendation R-13-21 reads as follows:
R-13-21
Develop medical certification regulations for employees in safety-sensitive
positions that include, at a minimum, (1) a complete medical history that includes
specific screening for sleep disorders, a review of current medications, and a
thorough physical examination, (2) standardization of testing protocols across the
industry, and (3) centralized oversight of certification decisions for employees
who fail initial testing; and consider requiring that medical examinations be
performed by those with specific training and certification in evaluating
medication use and health issues related to occupational safety on railroads.
On February 24, 2014, the NTSB classified Safety Recommendation R-13-21
“Open―Unacceptable Response.” The NTSB therefore reiterates Safety Recommendation
R-13-21.
2.4 Crew Resource Management
The circumstances of this accident raise concerns about train crew communication,
coordination, and discipline on the UP railroad. The engineer and conductor failed to comply
with four wayside signals in 3.7 miles that instructed them to slow and stop the train, yet the train
passed all of those signals traveling about 50 mph. The UP conductor claimed that they were
calling signals, and his logbook contains the relevant entries, but neither the conductor nor the
engineer noticed or discussed the excessive speed of the train, the lack of throttle or braking
control movements, or preparations to bring the train to a stop.
31
Both crewmembers are responsible for the overall safe and efficient movement of the
train. While the engineer operates the train, the conductor ensures the train operates safely.
Conscientious, alert, and attentive conductors not only call all signals with the engineer
acknowledging, as the train proceeds, or vice versa, but they also discuss problems and
anomalies encountered along the route.
Although the UP engineer was unable to account for his actions leading up to the
accident, the UP conductor discussed his recollections of the accident trip in his interviews with
NTSB investigators. The UP conductor said that before the accident he and the engineer called
the signals, and he spent time entering signal information in his logbook, looking into the
logbook with his head down. The conductor’s logbook at appendix B indicates he noted the
required information, up to and including the red or restricted signal (“R”). The UP conductors’
log has just four columns: Location, Signal Name or Train Defect Detector announcement, Time,
and Comment & Other Delays.16 Making entries once a signal is observed and deciphered is a
relatively quick task as are hearing and noting a Train Defect Detector announcement. Thus there
does not appear to be any reason for the conductor to maintain a prolonged head-down posture
once he had completed a logbook entry, especially given his responsibility to ensure safe train
operations, which includes looking out for signals.
The conductor told investigators that he did not know the speed of the train, because the
speedometer on his side of the cab was not working. Furthermore, the speedometer on the
engineer’s side of the cab—which he could have seen with minimal effort—was working. The
NTSB is concerned that the conductor, an experienced trainman, claimed not to perceive train
speed or lack of deceleration through nonvisual sensations, including vestibular, auditory, and
proprioceptive. Further, although the conductor stated that he and the engineer called the signals
during the trip, and his log shows he had entered the signals encountered as the train approached
the Rockview Interlocking, it is unclear why the conductor did not take action sooner to slow and
stop the train.
A critical shortcoming in the safety of US freight railroads is illustrated by this accident:
crewmembers, individually or collectively, can be a single point of failure in situations requiring
strict compliance with wayside signals for safe train movements. One approach to overcoming
this safety hazard is improving crew coordination, communication, and discipline through crew
resource management (CRM). CRM promotes safe operations by emphasizing the efficient use
of all resources to achieve and maintain better coordination of activities, including crewmember
proficiency, situation awareness, effective communication and teamwork, and strategies for
appropriately challenging and questioning authority.
The NTSB has investigated railroad, marine, and aviation transportation accidents with
inadequate CRM as a causal factor. After investigating a Norfolk Southern Corporation railroad
accident in Butler, Indiana, the NTSB issued safety recommendations to the FRA, Class 1
railroads, the American Short Line and Regional Railroad Association, the Brotherhood of
Locomotive Engineers, and United Transportation Union to work together to develop and
implement CRM training for train crewmembers (NTSB 1999). More recently, the NTSB
16
Trackside train defect detectors produce audible reports by radio of hot bearings, hot wheels, dragging
equipment, or no defects.
32
concluded that the Canadian National Railway accident in Two Harbors, Michigan, and the UP
accident in Goodwell, Oklahoma, might have been avoided if crewmembers had received CRM
training (NTSB 2013b and 2013c). In these accidents, the crews had not received CRM training,
and the crews failed to demonstrate effective coordination, communication, and discipline during
critical work activities leading up to the accidents. These same characteristics were present with
the UP crew in the accident in Chaffee. Therefore, the NTSB concludes that had crewmembers
of the UP train received training in and practiced the principles of CRM, they may have
demonstrated enhanced coordination, communication, and discipline during train operations, and
the accident may have been avoided.
During the NTSB investigation of the UP accident in Goodwell, Oklahoma
(NTSB 2013c), the UP Vice President of Safety, Security and Environment/Chief Safety Officer
told the NTSB during an investigative hearing on February 26, 2013, that the company had many
programs designed to enhance safety, including CRM training. However, at the time of the
Goodwell accident, the UP had not implemented CRM for the employees who work on the
subdivision where the accident occurred. The NTSB’s investigation of the Chaffee accident has
determined that again the UP has not implemented CRM for the employees who work on the
subdivision where the accident occurred. Therefore, the NTSB concludes that the delay in
implementing CRM throughout the UP has been and is likely to continue to be a contributing
factor in accidents. The NTSB recommends that the UP develop and implement an accelerated
schedule for delivering CRM training to all employees in safety-sensitive positions. In addition,
the NTSB reiterates the following safety recommendation to the FRA:
R-13-7
Require railroads to implement initial and recurrent crew resource management
training for train crews. (Classified “Open—Acceptable Response,” June 13,
2013.)
2.5 Locomotive Cab Audio and Video Recorders
Since the 1990s, the NTSB has recommended that the FRA require audio recorders inside
locomotive cabs so that accident investigators can better understand the actions of crewmembers
during the time period before an accident. In its investigation of the February 16, 1996, collision
between a Maryland Rail Commuter train and an Amtrak train near Silver Spring, Maryland
(NTSB 1997), in which no operating crewmembers survived, the NTSB was unable to determine
whether crewmember activities leading up to the accident contributed to the accident.
Consequently, the NTSB made the following safety recommendation to the FRA:
R-97-9
Amend 49 Code of Federal Regulations Part 229 to require the recording of train
crewmembers’ voice communications for exclusive use in accident investigations
and with appropriate limitations on the public release of such recordings. (The
current status of this safety recommendation is discussed below.)
33
In the NTSB investigation of the Bryan, Ohio, railroad accident in 1999, with no
surviving crewmembers (NTSB 2001), the NTSB reiterated this safety recommendation. In its
response to the reiteration, the FRA stated that it
has reluctantly come to the conclusion that this recommendation should not be
implemented at the present time. … [The] FRA appreciates that, as time passes
and other uses are found for recording media that may create synergies with other
public and private purposes, the [NTSB’s] recommendation may warrant
reexamination.
Based on this response and further meetings, the NTSB
Safety Recommendation R-97-9 “Closed—Unacceptable Action” on August 6, 2004.
classified
Since the FRA’s refusal to act on the recommendation of in-cab recorders, the NTSB has
investigated additional accidents in which audio recorders, along with inward-facing video
recorders, would have provided information to help determine probable cause and develop
safety recommendations. For example, the NTSB investigated the July 10, 2005, collision of two
Canadian National Railroad freight trains in Anding, Mississippi (NTSB 2007), which led to the
following NTSB safety recommendation to the FRA:
R-07-3
Require the installation of a crash and fire protected locomotive cab voice
recorder, or a combined voice and video recorder, (for the exclusive use in
accident investigations and with appropriate limitations on the public release of
such recordings) in all controlling locomotive cabs and cab car operating
compartments. The recorder should have a minimum 2-hour continuous recording
capability, microphones capable of capturing crewmembers’ voices and sounds
generated within the cab, and a channel to record all radio conversations to and
from crewmembers. (The current status of this safety recommendation is
discussed below.)
Also, in the September 12, 2008, railroad accident in Chatsworth, California, a Southern
California Regional Rail Authority (Metrolink) train collided head-on with a UP freight train,
resulting in 25 fatalities (including the Metrolink engineer) and 102 injuries (NTSB 2010). From
its investigation, the NTSB made two safety recommendations to the FRA:
R-10-1
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
34
systemwide performance monitoring programs. (The current status of this
safety recommendation is discussed below.)
When the NTSB issued Safety Recommendation R-10-1 to the FRA, it reclassified Safety
Recommendation R-07-3 “Closed—Unacceptable Action/Superseded.” Safety Recommendation
R-10-2 is the second issued to the FRA after the Chatsworth accident:
R-10-2
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. (The current status of this
safety recommendation is discussed below.)
The FRA has acknowledged the value of using audio- and image-recording technology in
locomotives and cab cars; however, it has not taken action to implement the NTSB
safety recommendations. On March 6, 2014, the RSAC undertook Task No. 14-01, to develop
regulatory recommendations that address the installation and the use of recording devices in
controlling locomotive cabs. The target completion date for this task is April 1, 2015.
Safety Recommendations R-10-1 and -2 were classified “Open—Unacceptable Response” on
August 14, 2013, because the FRA has not required locomotives and cab cars operated under
49 CFR Part 229 to be equipped with crash- and fire-protected inward- and outward-facing audio
and image recorders in accordance with the NTSB’s recommendations.
The NTSB also investigated the September 30, 2010, collision of two CN trains in
Two Harbors, Minnesota (NTSB 2013b). The NTSB noted that appropriate action had not been
taken in response to Safety Recommendations R-10-1 and -2. In the investigation, the NTSB
found that crewmembers of both trains had used cell phones in moving locomotives—a violation
of railroad rules and FRA regulations. Moreover, the NTSB urged the FRA to “promptly initiate
rulemaking activity for the audio and imaging requirements outlined in Safety Recommendations
R-10-1 and -2” and reiterated these two safety recommendations, noting that FRA action on the
recommendations would require locomotive manufacturers to implement important safety
improvements. In the Two Harbors, Minnesota, accident report the NTSB reiterated
Safety Recommendations R-10-1 and -2, stating the following:
The NTSB is disappointed that more than four years after the deadliest passenger
train accident in decades, the FRA has not acted on two recommendations that
would protect railroad employees, as well as the public.
On April 17, 2011, the rear-end collision of two BNSF trains near Red Oak, Iowa
(NTSB 2012), again demonstrated the need for in-cab recording devices to better understand
railroad accidents that claim the lives of crewmembers and threaten public safety. During the
Red Oak accident investigation, the NTSB determined that the crewmembers of the striking train
had fallen asleep just before the collision. The NTSB concluded that “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
35
available.” Moreover, the NTSB stated that “while video recorders will assist in the investigation
of accidents, their value in preventing accidents cannot be overstated,” and added that the
installation of inward facing cameras could assist railroads in monitoring rules compliance and
identifying fatigued engineers, which could prevent accidents.
In its report on the May 24, 2011, collision of two CSX trains in Mineral Springs,
North Carolina (NTSB 2013a), the NTSB stated it was unable to determine why striking train
crew failed to comply with a wayside signal since the crewmembers were killed and the cab was
not equipped with either an inward-facing camera or an audio recorder. The NTSB is inhibited in
its development of effective recommendations to improve safety when important information is
unavailable to the investigation.
Many NTSB investigations since the issuance of Safety Recommendations R-10-1 and -2
have indicated that in-cab audio and video recorders could provide critical information about
crew performance and the locomotive cab environment for accident investigations. Despite
FRA’s failure to act on these recommendations, the railroad industry has recognized the value of
inward-facing cameras, and several companies have begun to implement them. After the
Chatsworth accident (NTSB 2010), Metrolink was the first railroad to install inward-facing
cameras. And in April 2013, the Kansas City Southern Railway Company announced plans to
implement inward-facing cameras in locomotives operating on its properties in Mexico and,
eventually, in the United States. In August 2013, as a result of the head-on collision at Goodwell,
Oklahoma (NTSB 2013c), which occurred as a result of the engineer’s inability to see and
interpret wayside signals due to a chronic illness and deteriorating eyesight, the UP stated it
would install inward-facing cameras in more than 5,000 locomotives, following an
implementation plan for installing cameras in 2 locomotives in 2013, about 4,300 locomotives in
2014 and 2015, and 600 locomotives in 2016.
The NTSB is encouraged by railroad company actions to implement inward-facing
cameras. However, the NTSB believes that more railroads need to install inward- and outwardfacing audio and image recorders to provide reasonable and reliable means to capture valuable
information about crewmember activities in locomotive operating compartments during the time
before an accident. In the Chaffee accident, audio recorders in the locomotive cab could have
recorded the crew calling the signals, and inward-facing cameras could have shown what the
crewmembers were doing, or at least where they were and their positions, giving investigators
insight into the cab environment and activity. The NTSB therefore reiterates
Safety Recommendation R-13-26, issued in response to the Goodwell accident, to all Class 1
railroads:
R-13-26
Install in all controlling locomotive cabs and cab car operating compartments
crash- and fire-protected inward- and outward-facing audio and image recorders.
The devices should have a minimum 12-hour continuous recording capability.
Additionally, although the RSAC recently undertook Task No. 14-01, the NTSB remains
concerned that FRA’s delayed action on Safety Recommendations R-10-1 and -2 leaves many
safety lessons unlearned and further delays improvements for the safety of railroad operations.
36
The NTSB recognizes that opportunities to understand and improve railroad safety have been
missed because vital information on crew activities is not yet available, and the missed
opportunities are not infrequent. Therefore, the NTSB reiterates Safety Recommendations
R-10-1 and -2 to the FRA.
2.6 Positive Train Control
In the NTSB’s nearly 50 years of investigating railroad accidents, including hundreds of
train collisions and overspeed derailments, accidents have been caused by mechanical defects,
maintenance issues, and track failures. However, the biggest safety challenge is human error,
which is an area where technology can be very helpful. Since 2005, the NTSB has completed
17 investigations of railroad accidents that could have been prevented or mitigated with positive
train control (PTC). These 17 accidents claimed 55 lives and injured 943 more; the damages
totaled hundreds of millions of dollars. In each of these accidents, the NTSB concluded that PTC
would have provided critical redundancy that would have prevented the accident. Had such a
system been in place where the Chaffee accident occurred, it would have intervened when the
crew of the UP train failed to slow and ultimately stop the train before the Rockview
Interlocking.
Although human error cannot be completely eradicated, PTC technology is capable of
supplementing the human operation of trains. A PTC system provides safety redundancy by
slowing or stopping a train that is not being operated in accordance with signal systems and
operating rules, as was the case in each of the 17 accidents referenced above. For years, PTC has
been in place on Amtrak trains in the Northeast and Michigan, but for PTC to reach its greatest
safety potential, it must be widely implemented across the United States.
Because of the NTSB’s repeated findings that technology-based collision avoidance
systems could provide the needed safety redundancy to prevent rail accidents, PTC was placed
on the NTSB’s Most Wanted List at the inception of that list in 1990. Following the tragic headon collision between a passenger train and a freight train in Chatsworth, California, on
September 12, 2008, which resulted in 25 fatalities and more than 100 injuries, Congress enacted
the RSIA. Section 104 of the Act requires each Class I railroad and each operator of regularly
scheduled intercity or commuter rail passenger transportation to implement a PTC system on
each main line over which intercity or commuter rail passenger transportation is operated, or
over which poisonous-by-inhalation or toxic-by-inhalation hazardous materials are transported.
The Act requires implementation by December 31, 2015. Encouraged by this legislative action,
in October 2008 the NTSB’s safety recommendation calling for PTC installation was classified
as closed and was removed from the Most Wanted List. However, as a result of the May 2011
rear-end collision between two CSX freight trains in Mineral Springs, North Carolina (NTSB
2013a), and the collision of the two UP trains in Goodwell, Oklahoma (NTSB 2013c), the NTSB
added PTC to the 2013 Most Wanted List.
The NTSB has long advocated the implementation of PTC systems to prevent train-totrain collisions. NTSB railroad accident investigations over the past 40 years have shown
conclusively that the most effective way to avoid train-to-train collisions is through the use of
37
PTC systems that will automatically assume some control of a train when the train crew does not
comply with the requirements of a signal indication.
No PTC speed enforcement or Stop-signal enforcement is installed in the area where this
accident occurred. The UP is in the process of developing a PTC system, which would have
prevented this accident had it been in operation. The NTSB concludes that had a PTC system been
installed and used on the UP’s Chester subdivision, this accident would have been prevented.
2.7 Highway Bridge Protection
The NTSB has investigated several accidents involving large trucks striking highway
bridge piers that resulted in bridge collapses. Safety recommendations were subsequently issued
to AASHTO and the Federal Highway Administration (FHWA) to develop pier protection
guidance for bridge designers. These recommendations led to increasing the static impact point
loading requirement for bridge piers; AASHTO published this requirement and a risk-based
collision investigation procedure in the 2012 LRFD Manual.
However, the 2012 LRFD Manual requirements and guidelines apply only to bridges
over highways that may be at risk for truck collisions, and similar requirements for bridges at
risk of train collisions found in previous editions were removed from recent versions of the
LRFD Manual. Older versions required bridge piers located within 30 feet of a highway or
railway to have structural capacity to resist a 400 kip static load.
The 2012 LRFD Manual states in section 3.6.5.1 that unless the owner determines that
site conditions indicate otherwise, abutments and piers located within a distance of 30 feet to the
edge of a roadway shall be investigated for collision. Collision shall be addressed either by
providing structural resistance or by redirection or by absorbing the collision load. Where the
design choice is to provide structural resistance, the pier or abutment shall be designed for an
equivalent static force of 600 kips. Where the design choice is to redirect or absorb the collision
load, protection shall consist of an embankment; a structurally independent, crashworthy groundmounted 54-inch-high barrier, located within 10 feet from the component being protected; or a
42-inch-high barrier located more than 10 feet from the component being protected.
The LRFD Manual states that one way to determine whether site conditions qualify for
exemption from protection is to evaluate the annual frequency of impact from heavy vehicles.
The LRFD Manual notes that design for vehicular collision force is not required if the annual
frequency for a bridge to be hit by a heavy vehicle is less than 0.0001 for critical or essential
bridges or 0.001 for typical bridges.17
About 4 percent of US highway bridges—24,103 bridges—span railroad tracks. The
BNSF had seven other at-grade intersections—similar to the ones at Rockview and
Chaffee―that are underneath or in proximity to highway bridges. The UP had 27 at-grade
crossings within .125 miles of a highway bridge. FRA data indicate that from February through
17
The determination of the annual frequency for a bridge pier to be hit by a heavy vehicle is derived from
limited statistical studies performed by the Texas Transportation Institute.
38
May 2013 there was only one other collision of a train with a highway bridge, and it resulted in
only minor damage.
Section 2.1.5 of the 1986 AREA Manual for Railway Engineering provided guidelines for
pier protection: “Piers supporting bridges over railways located within 25 feet of the centerline of
the railroad track shall be of heavy construction or shall be protected by a reinforced concrete
crash wall ....” The manual did not define or describe “heavy construction.” Thus the Highway M
bridge piers were designed and constructed when the AREA manual did not specify the
requirements of heavy construction. The NTSB therefore concludes that the Highway M bridge
piers met the design standards in place in 1986–1988 when the bridge was designed and
constructed.
In 2005, the AREMA manual’s section on pier protection added the definition of “heavy
construction,” added an additional requirement for a 12-foot-high crash wall if the pier was less
than 12 feet from the railroad track, and provided for pier protection when the horizontal
clearance was more than 25 feet. The replacement Highway M bridge, built with a heavily
constructed wall pier, met these new AREMA design requirements.
The new pier protection loading standard, described in the 2012 edition of the LRFD
Manual, requires bridge piers to resist an equivalent static force of 600 kips. This force is based
on information from crash tests of rigid columns by 80-kip tractor trailers at 50 mph. This is
equivalent to 6.6 million foot-pounds of kinetic energy. By comparison, the 160,000-pound UP
rail cars at 43 mph had about 9.86 million foot-pounds of kinetic energy, an increase in kinetic
energy of about 48 percent. This figure represents the equivalent of only one rail car. In this
accident, several UP cars struck the three-column bent assembly, fracturing all of the columns. It
is unlikely that even the new design could withstand multiple impacts of this magnitude.
Additionally, exemptions for collision load are not permitted in the rail environment as they are
on highways based on lower levels of heavy truck traffic.
The FRA railroad accident database indicated that on a 10-year average from 2004–2013,
about 1,319 derailments occur nationwide on all railroads. A review of the accident records
indicated only four accidents occurred in which rail equipment damaged a highway bridge
spanning railroad tracks between January and October 2013, and this was the only such accident
in which the bridge collapsed. Therefore, the NTSB concludes that current pier protection
standards adequately mitigate the risk of catastrophic bridge pier failures spanning railroad
tracks.
39
3 Conclusions
3.1 Findings
1. The following were not factors in the accident: the qualification of the crewmembers on both
trains; the mechanical condition of the trains; the dispatching activities; the signal systems;
and alcohol use, drug use, and the use of portable electronic devices by the crewmembers on
both trains.
2. The Union Pacific Railroad crew failed to comply with four wayside signals immediately
preceding the collision.
3. As a result of their variable work schedules, both Union Pacific Railroad crewmembers
experienced disruptions to their normal circadian rhythms for several days before the
accident, and at the time of the accident both were experiencing fatigue caused by circadian
disruption and the requirement to operate the train during the window of circadian low.
4. Neither of the Union Pacific Railroad crewmembers controlled the train as they encountered
and proceeded beyond the Advance Approach signal, likely because of fatigue-induced
performance degradation.
5. The Union Pacific Railroad conductor had no known medical problems that would have
interfered with the safe operation of the train.
6. The engineer on the Union Pacific Railroad train likely had undiagnosed obstructive sleep
apnea at the time of the accident, and this likely resulted in fatigue that contributed to this
accident.
7. There were at least a dozen opportunities for the Union Pacific Railroad engineer to have
been screened for obstructive sleep apnea during routine occupational health evaluations, but
no such screening was performed.
8. Had the Federal Railroad Administration developed and used a standard medical examination
form that includes questions regarding sleep problems to determine the medical fitness of
locomotive engineers, as was called for in Safety Recommendation R-02-24, the Union
Pacific Railroad engineer likely would have been appropriately screened and evaluated for
sleep apnea before this accident.
9. Had the medical screening described in Safety Recommendation R-12-16 been in place, or had
the fatigue management components required by the Rail Safety Improvement Act of 2008 been
in place, the Union Pacific Railroad engineer likely would have been identified as at high risk
for sleep disorders, which may have led to appropriate medical intervention.
10. Had crewmembers of the Union Pacific Railroad train received training in and practiced the
principles of crew resource management, they may have demonstrated enhanced
40
coordination, communication, and discipline during train operations, and the accident may
have been avoided.
11. The delay in implementing crew resource management throughout the Union Pacific
Railroad has been and is likely to continue to be a contributing factor in accidents.
12. Had a positive train control system been installed and used on the Union Pacific Railroad’s
Chester subdivision, this accident would have been prevented.
13. The Highway M bridge piers met the design standards in place in 1986–1988 when the
bridge was designed and constructed.
14. Current pier protection standards adequately mitigate the risk of catastrophic bridge pier
failures spanning railroad tracks.
41
3.2 Probable Cause
The National Transportation Safety Board determines that the probable cause of the
accident was the failure of the Union Pacific Railroad train crewmembers to comply with
wayside signals leading into the Rockview Interlocking as a result of their disengagement from
their task likely because of fatigue-induced performance degradation. Contributing to the
accident was the lack of: (1) a positive train control system, (2) medical screening requirements
for employees in safety-sensitive positions for sleep apnea and other sleep disorders, and
(3) action by the Federal Railroad Administration to fully implement the fatigue management
components required by the Rail Safety Improvement Act of 2008. Likely contributing to the
engineer’s fatigue was undiagnosed obstructive sleep apnea. Also contributing to the accident
was inadequate crew resource management.
42
4 Recommendations
4.1 New Recommendation
As a result of this investigation, the National Transportation Safety Board makes the
following new safety recommendation:
To the Union Pacific Railroad:
Develop and implement an accelerated schedule for delivering crew resource
management training to all employees in safety-sensitive positions. (R-14-56)
4.2 Previously Issued Recommendations Reiterated in This Report
As a result of this accident investigation, the National Transportation Safety Board
reiterates the following previously issued safety recommendations:
To the Federal Railroad Administration:
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)
Safety Recommendation R-10-1 is classified “Open—Unacceptable Response.”
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)
Safety Recommendation R-10-2 is classified “Open—Unacceptable Response.”
Require railroads to implement initial and recurrent crew resource management
training for train crews. (R-13-7)
Safety Recommendation R-13-7 is classified “Open—Acceptable Response.”
43
Develop medical certification regulations for employees in safety-sensitive
positions that include, at a minimum, (1) a complete medical history that includes
specific screening for sleep disorders, a review of current medications, and a
thorough physical examination, (2) standardization of testing protocols across the
industry, and (3) centralized oversight of certification decisions for employees
who fail initial testing; and consider requiring that medical examinations be
performed by those with specific training and certification in evaluating
medication use and health issues related to occupational safety on railroads.
(R-13-21)
Safety Recommendation R-13-21 is classified “Open—Unacceptable Response.”
To All Class 1 Railroads:
Install in all controlling locomotive cabs and cab car operating compartments
crash- and fire-protected inward- and outward-facing audio and image recorders.
The devices should have a minimum 12-hour continuous recording capability.
(R-13-26)
Safety Recommendation R-13-26 is classified as follows:
Recipient
Classification
Date
BNSF Railway Company
Open—Acceptable Response
December 24, 2013
Canadian National Railway
Open—Acceptable Response
March 20, 2014
Canadian Pacific Railway
Open—Await Response
CSX Transportation
Open—Acceptable Response
December 27, 2013
Kansas City Southern Railway Company
Open—Unacceptable Response
May 13, 2014
Norfolk Southern Corporation
Open—Acceptable Response
December 27, 2013
Union Pacific Railroad
Open—Await Response
--
--
4.3 Previously Issued Recommendation Reiterated and Reclassified in
this Report
As a result of this accident investigation, the National Transportation Safety Board reiterates
and reclassifies from “Open—Acceptable Response” to “Open—Unacceptable Response” the
following safety recommendation:
To the Federal Railroad Administration:
Require railroads to medically screen employees in safety-sensitive positions for
sleep apnea and other sleep disorders. (R-12-16)
44
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
CHRISTOPHER A. HART
Acting Chairman
ROBERT L. SUMWALT
Member
MARK R. ROSEKIND
Member
EARL F. WEENER
Member
Adopted: November 17, 2014
45
Appendix A Investigation
The NTSB was notified on May 25, 2013, of the collision of a UP train and a BNSF train
in Chaffee, Missouri. The NTSB launched an investigator-in-charge and two other rail
investigative team members from its headquarters and one highway investigator from its Texas
regional office. Robert L. Sumwalt accompanied the team and was the NTSB Board Member on
scene.
The FRA, the UP, the BNSF, the Brotherhood of Railroad Signalmen, the Brotherhood of
Locomotive Engineers and Trainmen, United Transportation Union, Missouri Department of
Transportation, and Scott County, Missouri, were parties to the investigation.
46
Appendix B UP Conductor’s Log
47
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50
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