# Presentation: 865391

## Collision Between Two BNSF Railway Company Freight Trains Near 
Gunter, Texas 
May 19, 2004

**Gunter, Texas **
**May 19, 2004**

## NTSB Team

- Mike Flanigon 	IIC/Report Writer
- Russ Gober		Operations
- Rick Narvell		Human Performance
- Ruben Payan		Event Recorders
- Dave Watson 		Track & Mechanical
- Kathleen Curry 	Editor
- Dr. Mitch Garber 	Medical Officer
- Gina John 		Graphics
- Christy Spangler	Graphics
- Over 4000 staff work hours

## Parties

- Federal Railroad Administration
- BNSF Railway Company
- Brotherhood of Locomotive Engineers and Trainmen
- United Transportation Union

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## Courtesy of Dallas Morning News

## Issues Discussed

- Informal communication of proposed meeting points
- After-arrival track warrants in dark territory

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## Human Performance

## Communications Between the Dispatcher and the BNSF 6789 South Train Crew

## Track Warrant Rules

- Identify trains by:
- - railroad initials
- - engine number
- - direction
- Southbound train:
- - BNSF
- - 6789
- - South

## Nicknames

| BNSF 6789 South | BNSF 2917 North | BNSF 6351 North |
| --- | --- | --- |
| Doni Rock | 641  | Sherman Rock |
| Doni Madill | 641 Job | Sherman Rock Train |
| Doni Train | Sherman Switcher | Sherman Clark Rock Train |
|  | Road Switcher | Am Rock |
|  |  | Rock Train |

## Dispatcher Communicationswith the BNSF 6789 South

-   “I’ll roll up the **641 job** and have you meet them at Dorchester is what’s going to be.”

## Dispatcher Communicationswith the BNSF 6789 South

-   “**Sherman Switcher** is gonna clear up for you, and we’ll just take you to Prosper to meet the **Sherman Clark Rock Train**...”

## Dispatcher Communicationswith the BNSF 6789 South

-    “...you’re going to hold there till the **Sherman Rock**, excuse me, until the **Sherman Switcher** clears up at Dorchester. Then I’ll take you guys on south to Prosper to meet the **Sherman Rock Train**.”

## BNSF 6789 South Final Track Warrant

- BNSF 6789 South crew was issued their final track warrant at 5:39 p.m.
- Proceed to Hebron **after arrival** of the BNSF 6351 North.
- BNSF 6789 South proceeded south without waiting.

## BNSF 6789 South Crew’s Decision to Prematurely Depart Dorchester 

- BNSF 6789 South crew was informed on four occasions they would meet one train at Dorchester.
- Referred to as the “**641 job**,” the  “**641**,” and the “**Sherman Switcher.”**
- Never referred to by its engine number and direction.
- Crew expected to meet one train at Dorchester.

## BNSF 6789 South Crew’s Decision to Prematurely Depart Dorchester (con’t.)

- BNSF 6789 South was also informed on two occasions that beyond Dorchester they would meet a second train.
- Referred to as the “**Sherman Clark Rock Train**” and the “**Sherman Rock Train**.”
- Not told of the change in plans.

## Conclusion

-    Had the dispatcher routinely referred to the trains by their engine numbers - the identification mechanism required in mandatory directives - it would have reinforced the need to verify engine numbers when the trains met.

## Conclusion

-    Informal communications between the dispatcher and train crews regarding authority limits, train names, and meeting or stopping points may lead to misunderstandings and errors.

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## Operations

## Track Warrant Control

- Verbal directives
- After arrival, mark Box 7 on form
- Cannot move until after arrival of specific train
- Visually confirm engine number
- Confirm location by radio number

## After-Arrival Track Warrants 

- Issued in advance of train movement
- Mandatory compliance
- Errors can lead to conflicting movements

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##  After-Arrival Track Warrants

- Accurate communications
- Absolute compliance
- No real time location information

## Previous Accidents

- Smithfield, West Virginia - 1996
- Devine, Texas - 1997
- Clarendon, Texas - 2002

## Recommendation R-98-27

- Advised FRA to permanently discontinue the use of after-arrival orders in non-signaled territory.
- Closed – Unacceptable Action

## Conclusion

-    Had the FRA required railroads to permanently discontinue the use of after-arrival orders in dark territory as advised in Safety Recommendation     R-98-27, this accident would not have happened.

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