# Presentation: 335022

## Slide 1

## Clarendon, Texas 

- May 28, 2002
- Collision of Two Burlington Northern Santa Fe Freight Trains

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## Coal Train

- 116 cars.
- Length 6,380 feet.
- Weight 15,843 tons.
- Three 4,000 horsepower locomotives, two on the head-end and one on the rear.

## Intermodal Train

- 169 containers and 11 trailers.
- Length 7,033 feet.
- Weight 5,545 tons.
- Powered by two locomotives.

## The Collision

- The coal train was moving at 49 mph when it was placed into emergency braking.
- The intermodal train was moving at 42 mph when it was placed into emergency braking.
- The collision occurred about 16 seconds later.

## As a Result of the Collision:

- 2 locomotives and 23 cars of the coal train derailed.
- 2 locomotives and the first 12 platforms of the intermodal train derailed.
- 18 loaded containers were destroyed.
- $8 million in damages.

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## Injuries to Personnel

- Coal train engineer and conductor critically injured.
- Intermodal train engineer fatally injured.
- Intermodal train conductor minor injuries.

## Accident Discussion

- Trains were operated with track warrants.
- A track warrant may require a train to await the arrival of an opposing train before proceeding beyond a specified point.
- The train’s last track warrant contained such an “after-arrival” requirement.

## Coal train did not stop at Ashtola Siding.

Coal train traveled about 7.7 miles past Ashtola Siding.

- Coal train traveled about 7.7 miles past Ashtola Siding.

## Accident Investigation

- All track warrants were correct and complete.
- Radio communications were clear and succinct.
- All crewmembers were experienced and qualified on the territory.

- Coal train engineer made a cell phone call about the same time that the final track warrant was complete.
- Coal train passed beyond Ashtola Siding while the engineer was using his cell phone.

## Safety Issues:

- The manner in which track warrants that contain an “after-arrival” are given to trains.
- The use of cell phones by operating employees.
- The lack of positive train control.

- The Safety Issues discussed in this report are:

## Investigation Team

- Ron Hynes		Investigator-In-Charge
- Pat Sullivan		Signals
- Eric Sager		Human Factors
- Ruben Payan		Event Recorders
- Robert Moore 		Report Editor

## Additional Staff Support

- Gina John			Graphic Support
- Abdullah Kakar		Audio Support

## Parties to the Investigation

- Federal Railroad Administration
- Burlington Northern Santa Fe Railway
- The Texas Railroad Commission
- The Brotherhood of Locomotive Engineers
- The United Transportation Union

## Slide 21

## TrackWarrants

## Operating With Track Warrants

## “After-Arrival” Authority

- “After-arrival” track warrant allows a train to proceed from one location to another.
- Not in effect until after the arrival of a specified train.

## What Should Have Happened

## Slide 29

## Train Dispatcher Audio Tape 

## DISPATCHER: Eighty-eight seventy-six east by two  ninety-four now correct, over?

_**BNSF 8876**_**:** That is correct, over.

_**BNSF 8876**_**:** Ready over. Patterson.

_**DISPATCHER**_**:** And a warrant, over.

## DISPATCHER: Number two-two, twenty-two, 

- BNSF eight-eight-seven-six, eighty-eight seventy-six, east e-a-s-t

- milepost two-nine-four, two ninety-four.

- X two, t-w-o, proceed from east e-a-s-t siding switch Ashtola

- east e-a-s-t siding switch Hedley, main track.

- X box seven, s-e-v-e-n not in effect until after arrival

- BNSF forty-three eighty-five, four-three-eight-five west w-e-s-t

- at east e-a-s-t siding switch Ashtola, over.

- 16 second wait

## BNSF 8876: Track warrant number twenty-two, two-two, to the Burlington Northern Santa Fe BNSF eight-eight-seven-six, eight-eight-seven-six east e-a-s-t, 

- milepost MP 294, two-nine-four.

- X box two t-w-o proceed from east e-a-s-t siding switch Ashtola

- to east e-a-s-t siding switch Hedley, on main track.

- X box seven, s-e-v-e-n not in effect until after arrival of Burlington Northern Santa Fe BNSF forty-three eighty-five,

- four-three-eight-five west w-e-s-t at east e-a-s-t siding switch Ashtola, over.

## DISPATCHER: Correct thanks, Dispatcher out. 

**END OF TRANSCRIPT**

_**DISPATCHER**_**: **Two-two, eight forty-three, zero-eight-four-three, KCV, over.

_**BNSF 8876**_**:** OK at eight forty-three, zero-eight-four-three, Dispatcher KCV, over.

- .

## “After-Arrival” Track Warrants

- Many railroads do not use “after-arrival” authority.
- The General Code of Operating Rules permits the use of track warrants that contain an “after arrival” requirement.

## In non-signaled territory, there is no indication to the train dispatcher that a train has passed beyond the specified waiting point.

## There is also no indication to other trains that a train has passed beyond the specified waiting point.

## Consequence of Ignoring “After-arrival” Requirements

## Limiting the Use of “After-Arrivals”

- 	Prohibit the use of “after-arrival” track warrants unless the train to receive the track warrant is already stopped at the location at which it will meet the opposing train.

## Post Accident BNSF Rule

## Conclusion

-    The issuance, to moving trains, of track warrants containing an “after arrival” provision creates an unacceptable and unnecessary risk of a head-on train collision.

## Cell Phone Use

- All crewmembers had cell phones.
- Cell phone use has been shown to interfere with the perception process during the performance of operational tasks.
- The use of a cell phone by either crewmember may disrupt the normal interaction between the two.

## Coal Train Engineer

- 23-minute personal call.
- 17-minute break between calls.
- 10-minute personal call.

## Engineer’s Cell Phone Use

- 8:43 - Train dispatcher radioed track Warrant 22 to the conductor.
- 8:43:55 - Communication with dispatcher ends.
- 8:44 - Phone records indicate that the engineer placed a call.
- 8:47 - Coal train passed the location where it should have stopped.
- 8:53 - Cell phone call ends.

## Radio Communicationsvs.Cell Phone Use

## Final Minutes of Train Operation

- Coal train continued past its designated waiting point with modest control inputs.
- The phone call ended a few minutes before the collision.
- No radio communication.

## Regulation of Cell Phone Use

- Federal regulations do not prohibit an engineer from using a cell phone while at the controls of a moving locomotive.
- At the time of the accident, the BNSF had no system-wide instructions that specifically restricted cell phone use.

## BNSF Restricted Cell Phones

- As a result of an unrelated collision, BNSF issued instructions that prohibit an engineer from using a cell phone while operating a locomotive.

## Conclusion

- 	The engineer’s cell phone use likely distracted him to the extent that he did not take proper note of the “after-arrival” stipulation of Track Warrant 22 and thus was unaware of his need to prepare to bring his train to a stop.

## Slide 50

## Positive Train Control

- Technology exists to automatically enforce the operation of trains and thus prevent train collisions.
- Positive train control has been on the Safety Board’s list of “Most Wanted” transportation safety improvements since 1990.

## Positive Train Control

- 16 Major Accident Investigations
- 38 PTC Related Recommendations
- 30 Collision Accident Investigations since January 1999.

## Train Collisions

- 	40 – 60 Accidents each year could be prevented by Positive Train Control.

## BNSF’s Efforts in Positive Train Control

- BNSF is developing a system of train separation that would prevent trains from operating beyond the limits of track warrant authority.
- BNSF’s train collision avoidance system is being designed to enforce the track warrant limits or signal indications and the operating rules that are in place.

## Human Factor Causes

- Fatigue
- Sleep Apnea
- Medication
- Reduced Visibility
- Distractions

## Conclusion

- 	Had a positive train control system with collision avoidance capabilities been in place and operational on the Red River Valley Subdivision the collision probably would not have occurred.

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