(

PB98-916302

NTSB/RAR-98/02

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, DC 20594

RAILROAD ACCIDENT REPORT

COLLISION AND DERAILMENT

OF UNION PACIFIC RAILROAD

FREIGHT TRAINS 5981 NORTH AND 9186 SOUTH

IN DEVINE, TEXAS

ON JUNE 22, 1997

6889A
Abstract: On June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided

head-on in Devine, Texas. The conductor from 5981 North, the engineer from 9186 South, and two

unidentified individuals who may have been riding on 5981 North were killed. The engineer from 5981 North

received minor injuries, and the conductor from 9186 South was seriously burned.

The major safety issues discussed in this report are the train dispatcher’s performance and workload, the

adequacy of management oversight of the dispatcher apprentice program and dispatching operations, the

sufficiency of the Federal Railroad Administration (FRA) oversight of dispatching operations, the

effectiveness of conditional track warrant control authority, the adequacy of disaster preparedness, the

crashworthiness of locomotives and event recorders, and the merits of positive train separation control systems.

As a result of its investigation, the National Transportation Safety Board issued safety recommendations

to the UP, the FRA, and the Texas Railroad Commission. In addition, the Safety Board reiterated a safety

recommendation to the FRA.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation,

railroad, highway, marine, pipeline, and hazardous materials 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 Safety Board makes

public its actions and decisions through accident reports, safety studies, special investigation reports, safety

recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, SW

Washington, DC 20594

(202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 605-6000
COLLISION AND DERAILMENT

OF UNION PACIFIC RAILROAD

FREIGHT TRAINS 5981 NORTH AND 9186 SOUTH

IN DEVINE, TEXAS

JUNE 22, 1997

RAILROAD ACCIDENT REPORT

Adopted: May 19, 1998

Notation 6889A

NATIONAL

TRANSPORTATION

SAFETY BOARD

	
 
 

iii

CONTENTS

EXECUTIVE SUMMARY........................................................................................................... v

INVESTIGATION

Accident Narrative ........................................................................................................................................1

Injuries..........................................................................................................................................................6

Railroad Damage...........................................................................................................................................6

Personnel Information...................................................................................................................................6

Third-Shift Dispatcher............................................................................................................................6

5981 North Traincrew ............................................................................................................................7

9186 South Traincrew ............................................................................................................................7

Train Information..........................................................................................................................................8

5981 North..............................................................................................................................................8

9186 South..............................................................................................................................................8

Postcollision Train Information ....................................................................................................................8

5981 North..............................................................................................................................................8

9186 South............................................................................................................................................10

Track and Signal Information .....................................................................................................................10

Operations Information ...............................................................................................................................10

Dispatching Information .............................................................................................................................12

Responsibilities and Duties ..................................................................................................................12

Workload ..............................................................................................................................................12

Apprentice Program..............................................................................................................................13

Violations .............................................................................................................................................15

Meteorological Information ........................................................................................................................16

Medical, Pathological, and Toxicological Information ..............................................................................16

Third-Shift Dispatcher..........................................................................................................................16

5981 North Traincrew ..........................................................................................................................16

9186 South Traincrew ..........................................................................................................................16

Emergency Response ..................................................................................................................................16

Survival Aspects..........................................................................................................................................17

Locomotive Cab Survivability..............................................................................................................17

Fire and Rescue Services......................................................................................................................17

Municipal Disaster Plan .......................................................................................................................17

Tests and Research......................................................................................................................................18

Sight Distance.......................................................................................................................................18

Train Brake Controls ............................................................................................................................18

Locomotive Event Recorders ...............................................................................................................18

Other Information........................................................................................................................................19

Nonsignalized Territory Accident Risk................................................................................................19

Federal Railroad Administration ..........................................................................................................20

Union Pacific Railroad Postaccident Actions ......................................................................................20

Safety Board Public Hearing ................................................................................................................21
iv

ANALYSIS

General Factors ...........................................................................................................................................22

Accident Narrative ......................................................................................................................................22

Dispatcher Performance and Workload ......................................................................................................23

Management Oversight ...............................................................................................................................25

Dispatcher Apprentice Program ...........................................................................................................25

Dispatching Operations ........................................................................................................................26

After-Arrival Conditional Authority ....................................................................................................26

Federal Railroad Administration Train Dispatching Oversight..................................................................27

Emergency Response and Disaster Preparedness .......................................................................................28

Crashworthiness ..........................................................................................................................................29

Locomotives .........................................................................................................................................29

Event Recorders....................................................................................................................................29

Positive Train Separation Control Systems ................................................................................................30

CONCLUSIONS

Findings.......................................................................................................................................................32

Probable Cause............................................................................................................................................33

RECOMMENDATIONS.............................................................................................................34

APPENDIXES

Appendix A—Transcript of Track Warrants 8289 and 8290 .....................................................................37

Appendix B—Acronyms and Abbreviations ..............................................................................................39
v

EXECUTIVE SUMMARY

At 10:52 p.m. on June 22, 1997, Union

Pacific Railroad (UP) freight trains 5981 North

and 9186 South collided head-on in Devine,

Texas. The trains were operating on a single main

track with passing sidings in dark (nonsignalized)

territory in which train movement was governed

by conditional track warrant control authority

through a dispatcher. The conductor from 5981

North, the engineer from 9186 South, and two

unidentified individuals who may have been

riding on 5981 North were killed in the

derailment and subsequent fire. The engineer

from 5981 North received minor injuries, and

the conductor from 9186 South was seriously

burned. Estimated damages exceeded $6 million.

The National Transportation Safety Board

determines that the probable cause of this accident was the failure of the third-shift dispatcher

to communicate the correct track warrant information to the traincrew and to verify the accuracy of the read-back information because the

UP management had not established and implemented workload policies and operational procedures to ensure a safe dispatching system and

the Federal Railroad Administration (FRA) had

failed to provide standards and oversight in all

aspects of train dispatching operations. Contributing to the accident was the lack of an installed

positive train separation control system that

would have prevented the trains from colliding

by automatically intervening in their operation

because of inappropriate actions being taken.

The major safety issues discussed in this report are the train dispatcher’s performance and

workload, the adequacy of the UP management

oversight of the dispatcher apprentice program

and dispatching operations, the sufficiency of

the FRA oversight of dispatching operations, the

effectiveness of conditional track warrant control authority, the adequacy of disaster preparedness, the crashworthiness of locomotives and

event recorders, and the merits of positive train

separation control systems.

As a result of its investigation, the Safety

Board makes recommendations to the UP, the

FRA, and the Texas Railroad Commission. In

addition, the Safety Board reiterates a safety

recommendation to the FRA.

1

Accident Narrative

About 10:52 p.m. on June 22, 1997, Union

Pacific Railroad (UP) freight trains 5981 North

and 9186 South1

 collided head-on in dark

(nonsignalized) territory at milepost (MP) 290.4

in Devine, Texas.2

 The collision occurred on a

single main track at the north end of a concrete

ballast deck bridge. (See figure 1.) Five

locomotive units and 20 freight cars derailed,

and a fire ensued. The engineer from 9186

South, the conductor from 5981 North, and two

unidentified individuals received fatal injuries.

The conductor from 9186 South sustained

serious injuries, and the engineer from 5981

North received minor injuries.

Earlier that day at 2:30 p.m., train 5981

North had departed Laredo. (See figure 2.) Train

5981 North was given authorization by track

warrant3

 from the second-shift train dispatcher4

to proceed to Callaghan (MP 385.3), the first

station after Laredo. (See figure 3 for blank

standard UP track warrant form.) At Callaghan,

the 5981 North met a southbound train and was

authorized by the dispatcher to proceed to

Gardendale (MP 339.5), where it was stopped

and met another southbound train. While 5981

North was stopped, the U.S. Border Patrol

 

1

The UP designated them as freight trains MLDLI and

ZYCMX, respectively.

2

All train movements and locations are within Texas

except where specified otherwise.

3

A track warrant is given via radio by or through

proper railroad personnel to govern train movements. The

Federal Railroad Administration interprets track warrants

as train orders by radio. Until 1985, train orders were

written instructions to govern the movements of a train

issued by the train dispatcher through the telephone to online train order operators, who in turn typed these

instructions for delivery to the traincrews of passing trains.

These instructions involved the transmitting, typing, and

repeating of their contents. In 1985, the train order method

for train movements was discontinued and replaced by the

track warrant system on most railroads.

4

Dispatchers for the Austin subdivision work either a

first (6:30 a.m. to 2:30 p.m.), second (2:30 to 10:30 p.m.),

or third (10:30 p.m. to 6:30 a.m.) shift at the UP Harriman

Dispatch Center in Omaha, Nebraska.

apprehended two suspected illegal immigrants

who were riding the train. Leaving Gardendale

about 6:45 p.m., train 5981 North proceeded to

the side track at Derby (MP 321.5), where eight

ballast cars were added to the train. The

engineer said that after these cars were added

and the proper air test was performed, the train

proceeded to and entered the siding at Melon

(MP 318.0).

At that time, the engineer of train 5981

North requested automobile transportation and

was driven to a nearby store to purchase food.

The conductor remained with train 5981 North.

As the engineer was returning to the train, he

overheard an exchange on a railroad radio

installed in the car; in this exchange, the

dispatcher authorized the second of the two

trains being met at Melon to proceed farther

south beyond Melon. The engineer stated that

after he boarded the locomotive, the conductor

received the track warrant authorization from

the second-shift train dispatcher at 9:18 p.m.

instructing the train to depart Melon and

proceed to Gessner (MP 278.5), where 5981

North would be required to take (enter) the

siding.

At 10:30 p.m., the third-shift train

dispatcher issued a track warrant instructing

5981 North to proceed from Gessner to San

Antonio after meeting 9186 South at Gessner.

Train 5981 North was instructed to enter the

siding at Gessner so that 9186 South could pass

on the main track. At Devine, the 5981 North

crew noted a bright glow on the horizon, and

both the engineer and the conductor rose from

their respective seats trying to identify this

glow. At that moment, the headlight of an

oncoming locomotive came into view. The

engineer of 5981 North said he placed the train

into emergency braking, exited the rear door of

the control compartment, and jumped from the

locomotive. The conductor exited the forward

door of the control compartment and either

jumped or was thrown from the locomotive.

Earlier at 9:56 p.m. on June 22, 1997, train

9186 South had been authorized by track

INVESTIGATION



5

warrant 8261 from the second-shift train

dispatcher to proceed to Gessner, departing San

Antonio about 10:10 p.m. The train was

authorized by track warrant 8289 (see figure 4)

from the third-shift dispatcher at 10:28 p.m. to

proceed from Gessner to Melon. Train 9186

South passed the Gessner siding and entered the

city of Devine. At some point, the crew saw the

oncoming northbound train, and both the

engineer and the conductor jumped from the

lead locomotive as the trains collided.

The printed copy5

 of track warrant 8289 (see

figure 4) contained four elements: (box 2)

Proceed from Gessner to Melon on main track,

(box 7) Not in effect until after arrival of 5981

North at Gessner, (box 8) Hold the main track at

last named point [Melon], and (box 15) Flag

protection not required against following trains

on the same track. According to the voice

recordings between the 9186 South crew and the

third-shift train dispatcher, the instructions

contained three elements: (box 2) Proceed from

Gessner to Melon on main track, (box 8) Hold

the main track at last named point, and (box 15)

Flag protection not required against following

trains on the same track. In the voice recordings,

9186 South was authorized to proceed from

Gessner to Melon (box 2); absent from the voice

recordings was “not in effect until after arrival

of 5981 North at Gessner” (box 7).

The third-shift (relieving) dispatcher

reported that during the shift changeover

between 10:15 and 10:20 p.m., he discussed

with the second-shift (departing) dispatcher how

many trains were operating and their status. The

majority of the UP trains on the Austin

subdivision at that time were on the San

Antonio to Laredo territory, and a National

Railroad Passenger Corporation (Amtrak) train

was operating from Temple to Taylor. The

third-shift dispatcher stated that several radio

calls were coming in and “it was busy,” which

was “probably an average night for that

position.” His first radio conversation was at

10:20:37 p.m. with the Amtrak traincrew.

During this conversation, the third-shift

dispatcher cleared and voided the track bulletin

 

5

Generated from the train dispatcher’s work station

computer, as displayed on the screen when the instructions

were radio-issued to the crew.

item that had been previously issued to the

Amtrak train. The conversation ended at

10:21:50 p.m. The next radio communication

was initiated at 10:24:10 p.m. by the traincrew

of UP IYCLD, which was operating on the

Austin subdivision. The traincrew “gave up” its

track warrant to the dispatcher, who then created

a new track warrant directing the train to

proceed from Gardendale on the main track of

the Austin subdivision. This conversation ended

at 10:26:03 p.m.

At 10:26:05 p.m., the dispatcher called train

9186 South, and the conductor responded

immediately. The dispatcher said, “Yeah, let me

get you an ‘after-arrival’ there at Gessner while

I have a minute, over.” The conductor

responded, “All right, ready.” When

communicating track warrant instructions to a

traincrew, dispatchers are required to read the

information, as it is presented on the screen, and

to verify the accuracy of the information,

comparing the oral read-back from the traincrew

with the information shown on the screen. The

third-shift dispatcher then transmitted the track

warrant information to 9186 South, omitting the

instruction “not in effect until after arrival of

5981 North at Gessner” (the box 7 instruction

on the track warrant). The third-shift dispatcher

later said that he could not recall whether he had

included the box 7 instruction (to remain at

Gessner) on the track warrant when formally

transmitting authorization to 9186 South by

voice. The recorded radio transcripts of the

transmission of this track warrant between the

dispatcher and the 9186 South traincrew did not

include this instruction. The conductor repeated

the information to the dispatcher, and the

dispatcher okayed the read-back information

despite the omission of the box 7 instruction that

was on the computer screen display. Their

conversation ended at 10:28:10 p.m. Four

seconds later, the dispatcher called train 5981

North and accurately relayed the track warrant

(8290) information for that train to its

conductor. Their conversation ended at 10:30:04

p.m. (See appendix A for transcript of track

warrants 8289 and 8290.)

See the Operations Information section for

more information about UP dispatching

techniques.
6

Injuries*

Type 5981 North

 Crew

 9186 South

 Crew

Unidentified Total

Fatal 1 1 2 4

Serious 0 1 0 1

Minor 1 0 0 1

Total 2 2 2 6

*Based on the injury criteria (49 Code of Federal Regulations 830.2) of the International Civil

Aviation Organization, which the National Transportation Safety Board uses in accident reports for all

transportation modes.

Railroad Damage

Two locomotive units and 14 cars were

derailed from train 9186 South; both locomotive

units and 2 cars were destroyed. Three

locomotive units and six cars were derailed from

train 5981 North; one locomotive unit and five

cars were destroyed.

The estimated costs were:

Locomotives $ 4,150,000

Cars 501,300

Track 40,000

Structures 900,000

Lading 320,000

Clearing 103,767

Total $ 6,015,067

Personnel Information

Third Shift Dispatcher -- The 39-year-old

train dispatcher began working for UP as a

section man in 1975, and he transferred in 1979

to the signal department, where he worked as

the systems signal man in Salt Lake City, Utah.

He became a signal maintainer in Caliente,

Nevada, in April 1990; an electronics technician

at the Harriman Dispatch Center (HDC)6

 in

February 1994; and then an apprentice train

dispatcher in May 1996.

 

6

Opened in 1989, the dispatch center houses the entire

UP main track operations system and the dispatchers who

oversee train operations.

According to the third-shift dispatcher, his

training began at the HDC with a 3-week class

in the railroad operating rules, including the

dispatching and air brake rules. He stated that

because he had replaced a trainee who had

dropped out, his training had been shorter than

that of other dispatchers and he had missed the

basic railroading review, which was primarily

designed for apprentice train dispatchers lacking

a background in railroading. He then had 1

month of training in dispatcher duties using a

simulator to become familiar with the computeraided dispatching (CAD) system.7

 In July, he

started 1-month on-the-job training (OJT),

during which he observed an experienced

dispatcher operate the line and later operated the

line while being observed by the OJT dispatcher

trainer. Afterwards, as part of the qualifying

period, the manager of train dispatchers

observed him as a trainee performing dispatch

duties during a shift. He became a qualified

dispatcher on August 17, 1996, and since then

had worked on the Austin subdivision. Before

June 22, 1997, he had not been cited for any

dispatching rules violations.

After the Devine accident, the third-shift

dispatcher stated that he believed that he had

been adequately trained to operate as a

dispatcher. He added that the simulator and OJT

were not equal to handling the dispatching

demands and said, “How can training be equal

 

7

Supports the track warrant system that is unique to

the UP.
7

to . . . a dozen radios going off and 10 people

yelling at you at the same time. . . . I guess the

main thing that would be missing from all of

that would be really interaction with somebody

out in the field . . . especially when you’re new.

. . . Having to deal with that sort of thing is

hard.”

The third-shift dispatcher reported that he

was in good health, and, according to his

medical records, he had normal vision, with no

color-vision problems, and normal hearing. His

last UP physical was in 1989. He reported that

he was not taking any prescription or over-thecounter medications at the time of the accident.

He stated that he did not smoke tobacco or drink

alcohol.

The third-shift dispatcher had not worked on

Friday, June 20, 1997. On Saturday, June 21, he

woke about 9 a.m., remained at home

performing chores, left for work about 9:40

p.m., and arrived there at 10:15 p.m. He started

his shift about 10:20 p.m. and worked until 6:20

a.m. on Sunday, June 22. After returning home,

he retired at 7 a.m. and slept until about 12:30

p.m. He remained at home during the day, left

for work about 9:40 p.m., arrived about 10:15

p.m., and started his shift.

5981 North Traincrew -- The UP records

indicated that the crew of train 5981 North met

the requirements as prescribed in the Hours-ofService Act.

The 27-year-old engineer was hired in July

1989 by the UP as a trainman at San Antonio. In

June 1993, he transferred to engine service and

worked as a fireman while participating in the

training program to become a locomotive

engineer. In December 1993, he was promoted to

locomotive engineer. He had passed his most

recent physical examination in March 1995. His

vision and hearing were normal. He reported

being well-rested before the accident. The

engineer had worked the previous 3 days before

the accident. He was a certified locomotive

engineer under the regulations found in 49 Code

of Federal Regulations (CFR) Part 240, was

current on the UP operating rules, and had passed

his last rules examination in January 1995.

The 48-year-old conductor was hired in May

1973 by the UP as a trainman at San Antonio. In

May 1975, he was promoted to conductor. He

passed his last physical examination in May

1996. According to the guidelines established by

UP, the conductor was qualified to perform the

duties of a conductor on the Austin subdivision.

He was current on the UP operating rules and had

passed his last rules examination in April 1995.

The conductor had worked the previous 2 days

before the accident.

9186 South Traincrew -- The UP records

indicated that the crew of train 9186 South met

the requirements as prescribed in the Hours-ofService Act.

The 39-year-old engineer was hired in

August 1976 by the UP as a laborer at San

Marcos. In May 1985, he transferred to a clerical

position; moving to Omaha in July 1989, he

worked in a crew dispatching position. He

transferred to San Antonio in May 1993 as a

trainman and in October 1994 was promoted to

conductor. In March 1995, he transferred to the

position of student engineer to learn the craft of

locomotive engineer; on May 12, 1995, he was

promoted to locomotive engineer. He passed his

last physical examination on September 12, 1996.

According to the UP guidelines, the engineer was

qualified to perform the duties of a locomotive

engineer on the Austin subdivision. He was a

certified locomotive engineer under the

regulations found in 49 CFR Part 240, was

current on the UP operating rules, and had passed

his last rules examination on June 10, 1997. The

engineer had worked the previous 2 days before

the accident.

The 37-year-old conductor was hired in June

1996 by the UP as a brakeman at San Antonio.

Within 3 weeks, he received formal training, with

examinations, that would later qualify him as a

conductor. In February 1997, he was qualified as

and promoted to conductor; during the previous 6

months, he had worked primarily in yard service.

In April 1997, he was assigned to work as a

freight conductor. For the 60 days before the

collision at Devine, he worked as a freight

conductor, alternating his duty cycles with yard

service positions. He passed his last physical

examination in December 1996. According to the

UP guidelines, the conductor was qualified to

perform the duties of a conductor on the Austin

subdivision. He was current on the UP operating

rules and had passed his last rules examination on
8

June 27, 1996. The conductor had worked the

previous 2 days before the accident.

Train Information

Train 5981 North -- The train consisted of

locomotive units UP5981 (a 3,800-horsepower

EMD8

 SD60), UP4211 (a 3,000-horsepower

EMD SD-40-2), and UP5084 (a 3,500-

horsepower EMD SD50M) and 83 loaded and

11 empty freight cars. On June 22, 1997, at

7,200 feet long and drafting 8,200 tons, train

5981 North originated at Laredo, where it was

inspected at 12:20 p.m. An initial terminal air

brake test was successfully completed at 2:20

p.m., and the train departed at 3 p.m. Eight

loaded ballast cars were added at Derby.

Train 9186 South -- The train consisted of

locomotive units UP9186 (a 4,000-horsepower

General Electric C40-8) and UP6143 (a 3,800-

horsepower EMD SD60-M) and 62 loaded

freight cars. At 4,071 feet long and drafting

3,284 tons, train 9186 South originated at the

UP Yard Center near Chicago, Illinois, on June

21, 1997. Two carmen inspected the train and

then assisted in performing a successful initial

terminal air brake test, and the train departed at

6:03 a.m. On June 22 at 2:40 a.m., the train was

given an intermediate (1,000-mile) air brake test

at Texarkana. The air brake test was

successfully completed, and 9186 South

departed at 4:09 a.m.

Train 9186 South arrived at 8:48 p.m. at San

Antonio, where it was to receive another air

brake test. The outbound traincrew reported that

the radio was defective on the lead locomotive

unit, and the radio was subsequently replaced.

The air brake test was successfully completed

by the traincrew, and 9186 South departed at

10:10 p.m.

Postcollision Train Information

The three-unit locomotive consist of train

5981 North remained on the bridge, but the twounit locomotive consist of train 9186 South

toppled from the bridge onto the road below. A

 

8

Electro-Motive Division of General Motors.

number of trailing freight cars in each train piled

up on and around the locomotive wreckage on

the bridge and in the street below. Diesel fuel

spilled, and a fire ensued, extensively damaging

most of the equipment in the immediate

proximity of the overpass. (See figure 5.)

Train 5981 North -- The lead locomotive

unit UP5981 exhibited massive catastrophic

structural damage; the short-hood structure, cab

assembly, and electrical cabinet were effectively

sheared off horizontally at the top of the frame

assembly deck plate surface. The diesel engine

was found to have been displaced aft about 8

feet, and the main generator had separated from

the engine. The frame had bowed downward,

displaying a bend estimated at 1 foot. The

remaining car body (sheet metal) was heavily

deformed, and the entire unit had been

consumed by the fire.

The trailing locomotive unit UP4211 also

exhibited massive damage; the cab assembly

and electrical cabinet were found to be sheared

off level with the top deck of the short-hood

structure, which remained relatively structurally

undamaged. The car body (sheet metal) and

internal machinery on the aft-end of the unit

were compressed in a forward direction, having

been contacted by the third locomotive in the

consist, which overrode this unit.

Approximately one-third of the front of the unit

exhibited fire damage.

The trailing locomotive unit UP5084

overrode the aft-end of the succeeding unit and

came to rest with its lead-end resting on top of

the frame of the locomotive in the number two

position. The leading truck assembly had

detached from its mounting and was wedged

between the two locomotive structures. The

trailing truck remained attached. The fuel tank

was detached from its normal mounting position

and came to rest on the ballast beneath the unit.

The locomotive, which exhibited fire damage on

its exterior surfaces, was the least damaged of

the units involved.
9

Figure 5 - Photograph of trains 5981 North and 9186 South after impact.
10

Train 9186 South -- The lead locomotive

unit UP9186 traveled down the northwest

embankment slope and landed upright on the

road, approximately parallel to the bridge, with

the aft-end of the unit resting on the northwest

embankment slope. The unit lost its front truck

assembly, exhibited inward deformation to its

front pilot plate and short-hood structure, and

was consumed by the fire. The cab structure

remained intact and was not crushed by the

impact.

The trailing locomotive unit UP6143 fell

toward the pavement on the east side of the

bridge, landed cab-end down, and oriented

slightly on its right side on top of derailed

freight car wreckage, with the aft-end raised up

and the left side resting on wreckage that

remained on the bridge. The front truck

assembly had separated, and the fuel tank

showed massive deformation damage. The front

pilot plate and short-hood structure were

substantially deformed inward; the cab remained

structurally intact. The remainder of the unit

exhibited extensive car body panel (sheet metal)

deformation, and the entire unit was consumed

by the fire.

Track and Signal Information

The track in the area of the collision was

constructed with 112-pound rail, which was

manufactured and laid in 1943, and later

restructured into continuous-welded-rail. The

rail rested in double shoulder tie-plates secured

to 9-foot timber cross ties with 5/8- by 6-inch

cut track spikes. The ties were supported in 2-

inch crushed rock ballast and maintained with

12-inch shoulders to restrain lateral movement.

Longitudinal movement was restricted with

channel lock rail anchors base-applied to every

cross tie in a box pattern.

The southbound alignment for the

undulating track was tangent at the point of

impact (POI). Train 9186 South negotiated a 1°

23′ left-hand curve at MP 289.5, ascended a

0.51-percent grade before cresting the hill at MP

290, and was descending the 0.82-percent grade

leading to the POI. At MP 290.4, 5981 North

negotiated the 3° 11′ right-hand curve at MP

293 before entering the long tangent approach to

the POI.

The track is maintained to meet or exceed

the Federal Railroad Administration (FRA)

standards for a class 4 track.9

 The UP track

personnel inspect the track 7 days a week. The

weekly inspection records between May 1 and

June 3, 1997, indicate no FRA track defects

were found. An inspection of the track was

conducted on the day of the accident, and no

FRA defects were discovered.

The 140-foot concrete ballast deck bridge at

the POI consisted of two 30-foot approach spans

and an 80-foot main span extending over the

highway. The bridge had extensive damage as a

result of the collision and was replaced with a

similar structure on the approach spans. The

main span was changed from built-up beam

sections over the highway to welded beams over

the highway. The concrete deck was replaced

with a steel deck to hold the ballast and ties.

The accident territory did not employ a

block signal system (wayside signals) to govern

train movements and was called dark

(nonsignalized) territory; the movement of trains

was controlled by a track warrant system.

Operations Information

According to the UP, 12 or 13 trains in both

directions pass through the Devine area daily.

The movement of trains over the territory is

governed by the UP operating rules, timetable

instructions, and general orders. The operating

rules were provided by the Third Edition of the

General Code of Operating Rules, dated April 10,

1994. Any rule modifications or revisions to the

operating rules were part of the UP Timetable No.

2, effective October 29, 1995, that included the

“System Special Instructions,” which provided

general revisions, and the “Service Unit San

Antonio, Austin Subdivision,” which contained

information specific to operating trains through

the territory where this accident occurred. The

 

9

Maintained to accommodate passenger and freight

trains at maximum allowable speeds of 80 and 60 mph,

respectively.
11

permanent track speeds for the trains were

designated in the timetable, and temporary speed

restrictions were issued through the train

dispatcher by track bulletin.10

The train movements were controlled by the

train dispatcher, who issued instructions in the

form of track warrants. Track warrants evolved

from train orders and are not addressed in the

CFR. Each train received its original movement

instructions at the initial station of the train.

Subsequently, the train dispatcher issued

additional track warrants by radio to the

traincrews at intermediate locations. The

receiving crewmember was required to write

down the track warrants, as received over the

radio, on a standard UP form and to read them

back to the train dispatcher. This method of

operation allowed the train dispatcher to establish

or change the meeting locations of trains and add

movements on the territory.

To establish a meeting point between

opposing trains, the train dispatcher issued a track

warrant (see figure 3) to one train that included,

at a minimum, a box 2 that stated the “proceed

from” and “to” limits being granted and a box 10

that instructed “clear main track at last named

point” as prescribed in box 2. The train traveling

in the opposite direction was issued a track

warrant that included, at a minimum, a box 2 that

stated the “proceed from” and “to” limits being

granted and a box 8 that instructed “hold main

track at last named point” (the “to” limit granted

in box 2). The train instructed to clear the main

track at the station where the meet was to take

place was not authorized to proceed on the main

track beyond the initial switch of the siding

without additional track warrant authority. The

train instructed to hold the main track was not

authorized to proceed beyond the switch at the

end of the last named point for the “to” station

until additional track warrant authority was

issued. This system protected the two opposing

trains, and the physical passing of the trains was

accomplished.

 

10Track bulletins are addressed to trains that operate

through the dispatcher’s assigned territories and contain

temporary speed restrictions, locations of personnel and

equipment working, and possible safety hazards.

When one train arrived at a station earlier

than the other train, the dispatcher had two

options for giving the first train further

instructions. The dispatcher could either wait

until the meet had taken place and then authorize

both trains to proceed beyond this station in the

opposite directions or authorize the train that had

arrived at the station early to proceed to the next

station but not leave that station until “after the

arrival” (after-arrival) of the opposing train. The

dispatcher gave movement instructions to trains,

but the trains could not act on these instructions

until a prescribed event occurred, such as the

arrival of another train. This method (conditional

track warrant control authority)11 allowed the

train dispatchers to prepare the train movements

in advance and pace their workloads.

All track warrants that were issued by the

train dispatcher were created on a computer

screen using the CAD system. The dispatcher

requested a track warrant by entering the train’s

ID (mainframe computer symbol) and the

subdivision on the computer screen menu. The

CAD system then generated a track warrant

screen displaying a box 1 (to void a previously

issued track warrant), a box 2 (to establish

directional authority limits), and a box 4 (to

establish “work between” or nondirectional

limits). Should the train dispatcher choose to

establish directional authority, the dispatcher

would place an “x” in box 2 and type the

“proceed from” and “to” locations (specifying the

limits the train was being granted). (See figure 3

for the blank UP track warrant form.) Trains were

authorized from station to station, moving

through the territory in short segments, which

gave the dispatcher flexibility in establishing a

meeting location between opposing trains.

A conflict resolution logic had been

developed for the CAD system to prevent two

trains from receiving nonconditional

authorization onto the same segment of track at

the same time. For example, if a train dispatcher

authorized a southbound train from station A to

station B, the computer accepted this as a valid

track warrant. If the train dispatcher subsequently

issued a track warrant authorizing a northbound

 

11Although authority for the train movement has been

issued, a specific condition must be met before the authority

is acted on.
12

train from station B to station A, the CAD system

detected the conflict, and the screen immediately

displayed the required conditional authority

instruction (box 7) that the northbound train not

leave station B until after-arrival of the

southbound train. At the same time, a third screen

displayed a conflict between the two trains. After

interviews with several dispatchers, the Safety

Board found that dispatchers were aware that this

protection was available in the system.

During an interview with the third-shift train

dispatcher, he recalled mentioning to the 9186

South traincrew that he intended to issue an afterarrival authority. During the formal transmission

of track warrant 8289, the dispatcher failed to

orally communicate the box 7 requirement (not in

effect until after the arrival of 5981 North at

Gessner) even though the CAD system had

generated the box 7 after-arrival instruction on

the screen. When the train dispatcher was later

asked how he had determined that the track

warrant would be an after-arrival, he stated that

he had logically come to that conclusion because

of the train movements in the territory and,

specifically, the conflict with the northbound

train.

Dispatching Information

Responsibilities and Duties -- Train

dispatchers at the HDC are responsible for

scheduling the movement of trains over a

specified segment of railroad. Their duties

include arranging train meets and passes with

minimum delays, managing unexpected delays

and emergency situations, and issuing track

warrants to traincrews. The track warrant

information is conveyed by using various types

of signaling equipment and radios to

communicate with maintenance-of-way

employees or operating personnel. Dispatchers

formulate and transmit track warrants by typing

information into their computer terminals and

then orally issuing the track warrants to

traincrews.

Both dispatchers and traincrews are

instructed to follow proper radio procedures

when communicating track warrants to ensure

that train movement information is accurately

exchanged. The dispatcher’s primary task is to

read the track warrant data as they are presented

on the computer screen. After receiving and

recording the data, a train crewmember is

required to read them back to the dispatcher for

verification. During the repeat for verification,

the dispatcher compares the oral information

being received with the data on the computer

screen. The dispatchers also record information

on paper, such as the train ID and the

conductor’s name.

Several dispatchers reported that the most

difficult time for a dispatcher was during the

first 30 minutes of the shift, when a dispatcher

was “trying to assimilate everything” and

mentally planning the operation of the territory

during that shift. At this time, the relieving

dispatcher has to process the information just

received from the briefing of the departing

dispatcher, prioritize the tasks that are to be

performed during the current shift, and respond

to radio transmissions received from traincrews

that could not be responded to during the shift

changeover. In addition, supervisors often called

the dispatchers during the first 10 to 15 minutes

to be apprised of operations on the territory.

Dispatchers at the HDC operate inside a

station with waist-high walls partitioning one

dispatcher from another. Several dispatchers,

including the third-shift dispatcher, stated that

radio conversations between other dispatchers

and operating crews can be overheard, that

adjacent dispatchers also converse with each

other about train movements and other

operational matters, and that conversations and

other noise are greatest during shift changeover.

Intercoms are available for communications but

are generally not used. Many dispatchers

reported that they find the noise distracting and

believed that glass barriers to muffle sounds

would decrease the noise and provide a better

working environment.

Workload -- The UP told the Safety Board

that a workload study team began assessing the

dispatcher workload in the third quarter of 1997

with the intent to conduct ongoing studies of

positions with high workload issues. The UP

management indicated that the dispatcher

workload was determined, first, by the time

dispatchers spend in communication with train

and maintenance-of-way employees and,

second, by the number of CAD functions

performed by a dispatcher in a given period of

time. According to the UP management, “there
13

is no specific information available which

would determine what constitutes high

workload, as a rule of thumb, . . . a position [is

considered] to be a possible high workload if the

data indicates a consistent pattern of

quantifiable activity in excess of six hours.”

The Safety Board reviewed data, provided

by the UP, on the Austin subdivision. The

average number of trains each day from January

to June 1997 was 12.5. During the same time in

1996 and 1991, respectively, the average

number of trains each day was 10.8 and 6.47.

The third-shift dispatcher reported that he

usually directs between 15 and 20 trains on the

three subdivisions in his territory. The UP

indicated that, on average, dispatchers deal with

21 telephone and radio calls each hour, talking

to traincrews, track maintenance workers, and

dispatch center supervisors. It added that when

discussing track warrant information, dispatcher

and traincrew conversations typically take about

2 minutes. According to the FRA, one

dispatcher stated that he spends about 6 hours of

his shift on the telephone and radio.

According to dispatchers interviewed at the

HDC, because of the high workload on several

territories, some dispatchers issuing track

warrants may be mentally or physically

attending to their next task and not

concentrating on the read-back communication

from the traincrew. The dispatchers also stated

that newly qualified dispatchers were involved

in territories of high-operating demands. Several

dispatchers reported experiencing increased

stress while on duty and specifically cited the

following as contributing factors to the elevated

stress levels: increased workload due to

increased train volume and congestion, the lack

of support from management in recognizing the

dispatching challenges, the management

requirement that they work on scheduled offdays, and the frustrated attitude of the

traincrews.

The UP management reported that some of

the recent concerns expressed by the dispatchers

were volume-related issues. Dispatchers stated

that the workload continued to increase after the

Devine accident due to increased train volume.

Their duties focused on moving trains in and out

of sidings, dispatching vans to pick up

crewmembers who had reached the maximum

hours-of-service time, dispatching relief

crewmembers, and responding to increased

numbers of phone calls from the field personnel.

Apprentice Program -- The UP

management indicated that it tries to select

people to become train dispatchers who have

been associated with the railroad industry, such

as those working in the maintenance-of-way,

signal, and communications departments; in the

customer service center; and in crew

management placement. Some dispatchers

expressed concern that apprentice dispatchers

are being selected without having a railroad

background. The UP management reported that

because of technological changes, they have had

to expand the applicant pool to include engine

crew employees and college-educated people

from outside the rail industry.

The UP management stated that it uses a

screening method to select apprentice (trainee)

dispatchers. Prospects from outside the industry

are required to take and pass a series of tests

that include a learning abilities test, as well as

math, typing, and psychological profile tests.

Applicants who pass these tests then undergo an

interview process before being considered for

training.

The apprentice dispatchers receive training

in the fundamental workings of the UP, the

operating rules, and the CAD system; they also

receive a training manual and OJT with a

dispatcher trainer. (Safety Board investigators

found that the training manual lacked

organizational structure, a class syllabus or

outline, student objectives, a focus for major

points, and summaries for reviewing important

areas.) Apprentice dispatchers are placed on a

territory, where they will later dispatch full

time, and observe one or more qualified

dispatchers during each of the three shifts. As

apprentice dispatchers become more familiar

with the operations, they perform OJT

dispatcher duties under the supervision of an

OJT dispatcher trainer. At the time of the

Devine collision, the training process to become

a qualified dispatcher took about 3 months to

complete. Since March 1998, the UP has

extended this program to 6 months, increasing

the rules part of the training from 2 to 3 weeks
14

and requiring more on-the-job and simulator

training.

Like many other railroads, the UP has no

formal training or procedures for the dispatcher

trainers who oversee the apprentice dispatchers

during OJT. As reported in the FRA 1995 Train

Dispatchers Follow-up Review,12 the FRA

detected inconsistencies in many railroads in the

area of OJT and found that

OJT, in some instances, has been

delegated to subordinates without

adequate direction, control or

evaluation methodology. Additionally,

some management officials did not

have definitive opinions, nor did they

provide direct guidance, regarding

necessary components of dispatcher

training programs. This leads to

unstructured training and inconsistent

training.

The FRA found no evidence during its

1987-88 and 1993 train dispatcher reviews that

inadequate dispatcher training directly resulted

in train accidents. Nevertheless, the FRA noted

that training directly impacts train dispatcher

efficiency and productivity, which have the

potential to impact safety, and that the failure to

provide well-defined training may also

contribute to train dispatcher stress, fatigue, and

work overload.

The FRA advised that within 36 months of

its 1995 dispatchers review, it would

[p]ublish an ANPRM [advanced

notice of proposed rulemaking]

proposing minimum training standards

for train dispatchers, to include initial,

periodic, refresher, and physical

characteristic training; and minimum

operating rule training and testing

standards. These standards will be

based upon data developed through the

partnership between FRA, BN[SF],

ATSF [Atchison, Topeka and Santa Fe

 

12This report responds to the congressional mandate to

assess corrective actions taken by the rail industry in

addressing concerns identified in the FRA National Train

Dispatcher Safety Assessment of 1987-88.

Railway] and Amtrak. As part of the

review, FRA will examine railroad

operating rules to assess consistency,

standardization, and applicability to

today’s railroad environment.

The FRA also reported that it established a

Railroad Safety Advisory Committee (RSAC),

consisting of representatives from government,

industry, and unions, to address issues of train

dispatching. The FRA noted that dispatcher

training standards have been developed and

published, that it anticipated the formal

presentation of those standards at an RSAC

meeting in 1998, and that it expected the

standards to be voluntarily adopted by the

railroads.

The UP management stated that before the

Devine accident, OJT dispatcher trainers had at

least 5 years of experience working as

dispatchers. The UP reported that since the

Devine accident, OJT dispatcher trainers with

between 15 and 20 years of experience are

preferred, although some UP dispatchers have

reported that on several occasions dispatchers

with less than 5 years of experience have served

as OJT dispatcher trainers. Several OJT

dispatcher trainers have been reported to have

less than 2 years of experience, and some

dispatcher trainers occasionally performed OJT

duties only a few months after becoming

qualified dispatchers themselves. Several

dispatchers told Safety Board investigators that

they believed OJT dispatcher trainers should

have a minimum 5 years of dispatching

experience before assuming training duties.

Apprentice dispatchers take direction from

qualified dispatchers who are directly

supervised by corridor managers. According to

the UP, a train dispatching background and field

experience are the two attributes that make

better supervisory corridor managers. However,

corridor managers are not required to have been

qualified dispatchers.

Those involved in the UP training process

are the director of train dispatching personnel

and hiring, two rules instructors at the HDC, a

rules instructor from Salt Lake City, the

manager of train dispatching, the corridor

manager, the region director of the apprentice
15

area, and the dispatcher trainer. The UP

management stated that all of these individuals

must generally agree that a dispatcher trainee

has qualified as a dispatcher. The UP reported

that in April 1997, it incorporated changes

requiring a formal qualification process that

takes place over a 4-day period. According to

the UP management, this 4-day qualification

process is performed only after an apprentice

train dispatcher has demonstrated the knowledge

and ability to qualify. During those 4 days, the

apprentice dispatcher is evaluated in 16

dispatching-specific areas and is not allowed to

perform solo train dispatching service until

acceptable proficiency has been demonstrated in

all areas. The UP stated that this evaluation

process “will be followed in all instances.”

Several UP dispatchers reported that on

occasion management had determined an

apprentice dispatcher was qualified for a

specific territory despite the OJT dispatcher

trainer’s conclusion that the apprentice needed

additional supervision. Moreover, one

dispatcher stated that management pressured

him to start dispatching duties despite his own

belief that he was not yet fully trained. The UP

management has stated that when a qualified

dispatcher fills a new position, “the person is

provided training until she or he feels ready to

work the position.”

Following the Devine accident, the UP

management scheduled daily safety and

production meetings for dispatchers before the

start of each shift. The guidelines for these

meetings, according to the UP, require the

“meetings to focus on ‘safety issues, rules and

the state of the railroad’.” The UP management

stated that meetings, which last up to 15

minutes, are supervised by a corridor manager

or the region director or both. The manager of

train dispatching publishes a monthly outline for

the corridor managers to review, which includes

suggested subject matter, such as recent rules,

issues, and general operating concerns. The UP

dispatchers reported that initially during these

meetings, management discussed the Devine

accident and emphasized safe dispatching

operations. Several UP dispatchers have since

reported that the subsequent meetings focused

more on operations and less on safety and that

because management often did not attend, the

meetings were cancelled. According to the UP

management on March 30, 1998, the

requirement to conduct these meetings remains

in effect.

Violations -- The UP management reviews

the dispatching tapes and produces a rules

violation report13 when a dispatching error has

occurred. According to the UP, before June 22,

1997, it had no formal process to monitor the

issuance of track warrants containing a box 7

after-arrival order. Safety Board investigators

examined the UP violation reports for the 6

months before and 1 month after the Devine

accident. Four different dispatchers on five

occasions, including the Devine accident, failed

to read all or parts of the box 7 instruction of the

track warrant. Three of these four dispatchers,

including the third-shift dispatcher, had been

trained in the last year before the Devine

accident. The UP management reported that

each of the box 7 rule violations was handled

independently over a period of time and “each

of these incidents was looked at from a global

perspective” by the UP management. According

to the UP, it noted that a possible common

thread between these incidents was the

experience level of the dispatchers involved and,

as a result, it reviewed and expanded the section

of its apprentice dispatcher program that

focused on track warrant control authorities.

The FRA review of the UP violation

incidents occurring at the HDC from January

through August 1997 indicated that 52 percent

of all rule violations were by 7 of the 43

dispatching positions. The FRA reported that

these seven dispatching positions typically had

multiple authority territories or an unusually

high number of track warrants, or both. The UP

violation data also indicated that about 30

percent of the violations occurred within the

first hour of an 8-hour shift.

The UP reported that in July 1997, it

implemented a track warrant audit process that

involves the daily retrieval of printed copies of

recent track warrants to compare with the

issuing dispatcher’s audio recording. According

to the UP, five track warrant issuances for each

of three different train dispatchers are audited to

determine whether the track warrant is issued

 

13Document generated by the UP for its use only.
16

and repeated exactly as it appears on the printed

copy. The UP stated that it defined 13 categories

of potential errors and that each track warrant is

checked for compliance with these failure

categories. Three failure categories were defined

as “cardinal rules” that, if not met, require the

immediate notification of the regional director

for train handling with the involved train

dispatcher.

Meteorological Information

At 10:51 p.m., the weather station at Hondo,

which is 19 nautical miles northwest of Devine,

reported clear skies with 10-mile visibility, 78°-

F temperature, 71°-F dew point, and 11-knot

winds.

Medical, Pathological, and Toxicological

Information

Third-Shift Dispatcher -- Following the

accident, the third-shift dispatcher was removed

from service. Consistent with FRA regulations,

he took a breath test and provided blood and

urine specimens for postaccident alcohol and

drug testing. About 2 a.m. on June 23, a breath

test was administered to the dispatcher, who was

then taken to a local hospital, where at 3:45

a.m., he provided blood and urine specimens,

which were sent to and analyzed by Northwest

Toxicology, Incorporated. The results of the

urine analysis and the blood and breath test

analyses were negative for drugs and for

alcohol.

5981 North Traincrew -- The engineer was

transported to an area hospital for treatment of

superficial abrasions and released the same day.

His postaccident toxicological testing was

negative for drugs and alcohol.

The body of the conductor of 5981 North

was found adjacent to the track beneath

wreckage debris. The autopsy report indicated

that he had received severe chest and abdominal

injuries, that he had sustained severe burn

trauma, and that his right arm had been severed.

The postaccident toxicological testing indicated

the presence of ethyl alcohol in his blood (0.011

w/v%) and urine (0.024 w/v%). Northwest

Toxicology, Incorporated, concluded,

Based upon the information provided

by the FRA regarding the putrefaction

of the body and the low concentration

of ethyl alcohol found, it cannot be

determined whether the ethyl alcohol

present in the blood and urine is due to

antemortem consumption or

postmortem production. 14

The severely burned and mangled bodies of

two unidentified people, believed to have been

the individuals who may have been riding on

one of the 5981 North locomotive units, were

found beneath wreckage debris on the pavement

under the bridge near the POI.

9186 South Traincrew -- The body of the

9186 South engineer was found adjacent to the

track about 126 feet north of the north bridge

abutment. The autopsy report indicated that he

had sustained severe chest injuries and blunt

force trauma to the head. His postaccident

toxicological testing was negative for drugs and

alcohol.

Within minutes after the collision, a

firefighter found the conductor of 9186 South

standing on the road on the east side of the

overpass near the burning wreckage. He had

sustained first and second degree burns to the

face, torso, and leg, and was helicoptered to the

U.S. Army Hospital in San Antonio for

treatment. His postaccident toxicological testing

was negative for alcohol but indicated the

presence of morphine in both the urine (107,929

ng/ml) and blood (45 ng/ml). Morphine was

administered to the conductor at the medical

facility to which he was admitted.

Emergency Response

Shortly before 11 p.m. on June 22, 1997, a

Devine Police Department (DPD) officer, on

routine motor patrol near the UP track south of

the railroad bridge at MP 290.4, reported that he

observed a passing northbound train, heard a

loud explosion sound, and noted that the passing

train was rapidly decelerating. Seeing flames

and black smoke at the railroad overpass in his

 

14The postmortem production of alcohol can occur

during the decomposition process with no prior alcohol

consumption.
17

rear view mirror, he radioed the DPD dispatch

desk, which received the transmission at 10:52

p.m. and notified the Devine Volunteer Fire

Department (DVFD) and the DPD with an “allhands” respond request. Numerous 911 phone

calls were also received from concerned

residents reporting a loud explosion sound.

While driving to the accident scene, the

officer who had witnessed the event

encountered the engineer of 5981 North, who

had been injured after jumping from the

northbound train; the engineer indicated that the

other train possibly contained hazardous

materials. Other police officers and an

emergency medical service (EMS) ambulance

and staff soon arrived at that location, which

later functioned as the medical staging area for

the accident. The EMS ambulance staff

determined that the engineer of 5981 North did

not have life-threatening injuries, and he was

later transported by ambulance to a local

hospital. The chief of the DVFD activated the

Incident Command System and assumed control

as the incident commander. A temporary

command post was established on the west side

of the overpass.

Because the 5981 North engineer had

indicated that hazardous materials may have

been on board a train, the community disaster

plan was implemented, and the Devine

Emergency Management Coordinator was

dispatched. The Chemical Transportation

Emergency Center15 was contacted about 11:06

p.m. by the DPD, which also contacted the

railroad to request hazardous materials consist

information. The UP responded by phone and

fax that no hazardous materials products were

on board either train. Because of the concern

about a toxic materials release, the DVFD chief

had directed an evacuation of all residences

within a 1/4-mile radius of the fire. The DPD

had closed roads around the fire scene to all

traffic but emergency vehicles. Between 75 and

100 residents were sheltered at the local high

school and were permitted to return to their

residences when the UP confirmed that no

 

15The center, operated by the Chemical Manufacturers

Association, was established to provide initial and

immediate information about handling hazardous materials

and other chemicals.

hazardous materials products were involved in

the fire.

The firefighting suppression effort

continued to focus on the blaze, which

reportedly flared several hundred feet high and

was seen up to 30 miles away. About 1 a.m. on

June 23, the fire had been substantially

suppressed, and the DVFD chief directed that all

water lines be shut down. About 1:37 a.m., the

fire was declared under control.

Survival Aspects

Locomotive Cab Survivability -- On the

northbound train, the operating cab had

separated from the lead unit (UP5981) and was

found crushed beneath the wreckage debris. The

cab had been fully consumed by fire, and no

survival space remained. On the southbound

train, the operating cab of the lead unit

(UP9186) had not been significantly crushed

during the collision, but the cab and the entire

unit were fully consumed by the fire.

Fire and Rescue Services -- The 29-

member DVFD provides exclusive firefighting

support to Devine, a rural community of about

4,000 people. Supplementary firefighting

support is available through mutual aid requests

to neighboring communities. The DVFD is

commanded by the chief (he works

professionally for and in the city of San Antonio

as a trained, full-time firefighter) and is

supported by three assistant chiefs. At the time

of the accident, the DVFD fire suppression

equipment consisted of two conventional pump

trucks (750 gpm and 1000 gpm) and three small

support trucks. The DVFD’s support apparatus

included ladders, nozzles and hoses, lights, selfcontained breathing equipment, and a small

stock of fire suppression foam.

Municipal Disaster Plan -- The city of

Devine has a comprehensive, documented plan

(issued in 1990 and revised in August 1996),

based on the State model, which is coordinated

by the Emergency Management Coordinator and

an assistant staffer of the Devine Emergency

Management Agency. Under the plan, Devine

conducts an annual simulated live-disaster

exercise and a semiannual table-top drill. All the

Devine municipal agencies (fire, police,

emergency management, and public works)
18

participated in the most recent simulation

exercise, which occurred about 6 months before

the train accident. The exercise involved a

hazardous materials truck fire in a congested

residential neighborhood and the hazardous

materials cleanup. The most recent table-top

drill occurred about 1 year before the train

accident.

Tests and Research

Sight Distance -- Sight distance tests,

conducted from 10:15 p.m. on June 24 until

12:10 a.m. on June 25, 1997, indicated that

given the topography of the area, visibility from

the POI was unrestricted for a minimum of

4,000 feet for train 5981 North and of 6,400 feet

for train 9186 South.

Train Brake Controls -- Because of the

accident damage to the lead locomotive unit on

5981 North, the control positions could not be

determined. On the lead locomotive unit of 9186

South, the observed control positions were:

automatic brake valve, handle in emergency;

independent brake, applied; reverser, forward;

throttle, idle; and dynamic brakes, off.

Locomotive Event Recorders -- On

August 11, 1997, the Safety Board laboratory

received the Pulse Data Pack event recorder, the

Pulse Data Pack DP-400 event recorder

cartridge, and the speed indicator from

locomotive UP4211 of train 5981 North; the QTron event recorder, the UP event recorder

download diskette, and the speed indicator from

locomotive UP5084 of train 5981 North; and the

burned remains of the event recorder from

locomotive UP9186 of train 9186 South.

The Pulse Data Pack event recorder from

locomotive UP4211 was designed to record the

time, distance traveled (miles), speed (mph),

traction motor current (load amps), automatic

brake setting, throttle position, independent

brake pressure (psi), and reverser position.

These digitally encoded parameters were

sampled every 5 3/4 seconds. The data were

then written to the magnetic tape in two

consecutive and identical records of 2 7/8

seconds in length during the 5 3/4-second period

between the samples.

The data from the cartridge of the Pulse

Data Pack event recorder from locomotive

UP4211 were found to be anomalous when read

out using equipment in the Safety Board

laboratory. The recorder and its magnetic tape

were taken to the manufacturer16 for analysis.

The manufacturer indicated that the event

recorder appeared to be operating properly and

the magnetic tape could be read, but no input

signals concerning traction motor current or

brake reduction levels could be found.

Locomotive UP5084 was equipped with a

Q-Tron Datacord 5000 solid-state recording

system that was designed to record the time,

date, unit number, distance traveled (miles),

speed (mph), traction motor current (load amps),

brake pipe pressure (psi), throttle position, and

brake cylinder pressure (psi). The parameter

values were recorded whenever a parameter

changed. The magnitude of the change

necessary to trigger a parameter recording is

preprogrammed into the recording system. The

manufacturer of the Q-Tron recorder indicated

that the maximum recording resolution of the

recorder was 1/10 second, with the exception of

speed, which was recorded at 1-second

intervals.

The collision log report from the

locomotive UP5084 Q-Tron recorder read-out at

the Safety Board laboratory follows:

 Recorder Train

 Time Speed Action

10:49:44 p.m. 43.6 mph Throttle position

changed from 8 to 4. Traction motor

current decreased steadily from 416

to 205 amps during the following 6

seconds.

10:49:50 p.m. 42.5 mph Throttle position

changed from 4 to 0 and remained at

0 thereafter. Traction motor current

decreased from 205 to 99 amps about

1 second later and gradually

decreased to 0 amps during the

following 4 seconds.

 

16Pulse Electronics, Incorporated, Rockville,

Maryland.
19

10:49:52 p.m. 42.2 mph Brake cylinder

pressure changed from 0 to 6 psi and

increased to 76 psi during the

following 10 seconds.

10:49:53 p.m. 41.7 mph Brake pipe

pressure changed from 89 to 59 psi

and decreased to 0 psi within 1

second.

10:50:23 p.m. 18.7 mph Brake cylinder

pressure changed from 77 to 7 psi

and decreased to 0 psi during the

following 3 seconds.

10:50:25p.m.17 0 mph

The type of event recorder equipment from

locomotive UP4211 of train 5981 North and

from locomotives UP9186 and UP6143 of train

9186 South was customarily carried in the nose

section of the controlling end of the locomotive.

The event recorder equipment from locomotive

units UP5981 and UP5084 of train 5981 North

was most likely located in the locomotive alcove

either immediately on the right, attached to the

sidewall, or on the left, attached to the bulkhead

wall. No standards have been developed for the

location of event recorder equipment.

The event recorder from locomotive

UP5981 of train 5981 North was destroyed by

crushing force, and the event recorders on

locomotives UP9186 and UP6143 of train 9186

South were destroyed by the fire. The Safety

Board is working with the FRA, class 1

railroads, railroad employee union

representatives, and locomotive event recorder

and locomotive manufacturers to develop and

implement an FRA rule detailing specific

survivability standards that locomotive event

recorders must adhere to. The Safety Board has

encouraged the FRA to address the survivability

of event recorders in all known or anticipated

accident scenarios, considering the experience

with other modal standards of event recorder

crashworthiness. At the time of this report, the

FRA had no anticipated date of issuance for the

standards.

 

17The railroad recording time was not synchronized

with the time of the police report.

Other Information

Nonsignalized Territory Accident Risk --

The Safety Board investigated an earlier

accident having similar circumstances as those

that occurred in the June 1997 Devine accident.

On August 30, 1991, near Ledger, Montana,18 a

Burlington Northern Railroad Company

(BNSF)19 train was operating in dark

(nonsignalized) territory, and the radio

transmission for authority to the main track was

improperly delivered. The train dispatcher failed

to detect an improper read-back from the crew

in the field. In the Ledger accident, the train

dispatcher did not detect the crew’s misreading

of a train station when the crew read the track

warrant back to the train dispatcher. Thus, two

trains had authority to proceed to the same block

of track from opposite directions at the same

time. The trains collided head-on and three

crewmembers were fatally injured.

After the Ledger collision, the BNSF

determined that if the train dispatcher had to

perform a physical or mechanical task during

the repeat process, the failure to detect an

incorrect read-back would be less likely to

occur. The computerized system that BNSF uses

was reprogrammed, and, during the read-back

by the crews, the dispatcher must now perform

specific tasks. The track warrant that the

dispatcher originally issued is displayed on the

computer screen, but the variable fields that are

unique to this track warrant are not filled. As the

crew reads the original track warrant to the train

dispatcher, the train dispatcher follows along on

the computer screen and a pull-down selection

menu appears at each variable field. Within the

pull-down menu are randomly generated

numbers or station names. Only one of the

choices corresponds to that in the original track

warrant. The train dispatcher must select the

correct “fill-in,” hit the enter key before the

cursor will move on the screen, and fill all the

 

18For more information, see Railroad Accident

Report--Head-On Collision between Burlington Northern

Railroad Freight Trains 602 and 603 near Ledger,

Montana, on August 30, 1991 (NTSB/RAR-93/01).

19The Burlington Northern Railroad Company and the

Atchison, Topeka and Santa Fe Railway Company merged

on October 1, 1995, and formed the Burlington Northern

and Santa Fe Railway Company. The carrier is referred to

as the BNSF throughout this report.
20

fields correctly before the screen will clear and

allow the next task to be performed on the

computer. In addition, the BNSF traincrews in

the field are required to identify a specific train

before using authority to the main track and

must write the train ID, time passed, location

passed, or current time and location on the track

warrant form; they can be disciplined for not

performing this activity.

After the accident at Devine on June 22,

1997, the BNSF further modified its track

warrant system to include a “total number of

lines issued” statement at the end of the track

warrant. If a train dispatcher is issuing a track

warrant that has a box 7 after-arrival restriction,

a total of nine lines for the track warrant may be

created. If the train dispatcher fails to transmit

the box 7 after-arrival restriction, yet informs

the crew that they have been given a total of

nine lines, the crew in the field should challenge

the train dispatcher’s original transmission.

Federal Railroad Administration -- The

FRA began a review of the UP operations on

August 23, 1997. Following this 14-day

comprehensive safety inspection of the UP by

Federal and State inspectors, the FRA

announced on September 10, 1997, that the

“findings of widespread safety deficiencies in

the areas of training, dispatching, and employee

fatigue are of great concern to the FRA, and we

strongly encourage that our recommendations be

implemented.” Based on the findings by the

inspection team, the FRA recommended

mandatory classes and job briefings for

dispatchers, dispatcher supervisors, and other

operating officials; management identification

of the safety officer on duty; adequate training

for all employees on all equipment they use; and

adequate crew transportation for traincrews

whose hours-of-service have expired.

Between November 3 and 7, 1997, the FRA

conducted another safety audit of the HDC and

reported that it “observed inefficient and unsafe

practices by supervisors and dispatchers at the

HDC, which can be attributed to lack of training

and extreme work overload.”

Union Pacific Railroad Postaccident

Actions -- According to the UP, since the

Devine accident on June 22, 1977, it has

developed a safety action plan for the HDC

covering communication, dispatching training

and staffing, and track warrant control. The plan

is reviewed regularly within the HDC and with

the FRA.

A dispatching safety hot line has been

established for employees to express their

concerns and make suggestions regarding

dispatching safety and rules issues. The UP is

setting up focus teams of managers and

dispatchers to develop policies and procedures

for rules compliance, two-way communications,

and dispatcher skill levels.

The UP identified several corridor managers

who had no experience as train dispatchers and

has scheduled training for them in dispatching

system procedures. An annual dispatcher

retraining program has been initiated to include

a complete review of safety rules. A mentor

program has been established in which

dispatchers with more than 5 years of

experience coach one or more train dispatchers

with less experience. The UP has also modified

the train dispatcher selection, training, and

qualification program. It has revised the

dispatcher track warrant training module to

include current process changes and suggestions

from the FRA February 1998 Safety Assurance

and Compliance Report and also revised its

training manual. The UP has a staff of 15

dispatcher training personnel, in addition to the

8 positions that continue to support and develop

train dispatching systems, and has hired 9

former train dispatchers and 39 apprentice train

dispatchers during the 6 months since the

Devine accident. In September 1997, the UP

added to its staff a director of efficiency testing

for the HDC and all UP centers with dispatching

operations. Finally, the Austin subdivision was

split in January 1998 to reduce the dispatcher

workload.

The UP stated that the visibility of the box 7

after-arrival instruction on the track warrant

control and track warrant form has been

enhanced and heightened on its computers.

Dispatcher acknowledgment procedures have

been implemented for box 7, as well as an

interactive read-back feature. The UP has

instituted an oral summary requirement for the

box numbers and the total boxes checked in the
21

sending and receiving of every track warrant.

According to the UP, it has discontinued the use

of box 7 after-arrival authority in nonsignalized

track warrant control territory and is signalizing

the Austin subdivision from San Antonio to

Laredo, which should be completed by

December 31, 1998. Also, the UP is upgrading

its digital dispatcher recording system to allow

both sides of the train dispatcher conversation to

be monitored.

Safety Board Public Hearing -- In March

1998, the Safety Board conducted a 3-day public

hearing in Springfield, Virginia, that concerned

the safety oversight of the UP. The results of

this hearing, “The Special Investigation of the

Effectiveness of Safety Oversight on the Union

Pacific Railroad,” will be addressed in future

Safety Board reports.
22

General Factors

The weather at the time of the collision was

reported to be clear, with visibility of 10 miles,

and did not adversely affect train operations. No

mechanical problems or equipment failure were

noted. During the pre- and postaccident

inspections, no defects or deviations were found

in the track or equipment.

No evidence of dispatching computer

equipment malfunction was found. A print-out

of the track warrant information from the

dispatcher’s computer confirmed the accuracy

of track warrant 8289 for train 9186 South as

presented on the computer screen. The previous

and subsequent issuance of track warrants

contained accurate information for other

traincrews.

A review of the UP records indicated that all

crewmembers met the requirements as

prescribed in the Hours-of-Service Act.

Information obtained during the postaccident

interview with the dispatcher did not indicate

that he was fatigued. The data retrieved from the

event recorders confirm that train 5981 North

was handled in accordance with accepted train

handling practices while operating on a track

warrant as prescribed by the UP operating rules.

Because event recorder data from train 9186

South were destroyed in the fire and no

testimony could be obtained from the traincrew,

the Safety Board could not retrieve information

about the train’s functions and operations.

Postaccident toxicological tests were

negative for drugs and alcohol for the train

dispatcher and the engineers of trains 5981

North and 9186 South. In the case of the

deceased conductor of 5981 North, the alcohol

levels detected were consistent with expected

postmortem microbial production of ethanol. No

evidence was found that alcohol had been

consumed by the 5981 North conductor

immediately before or during the trip, and his

medical and personnel records contained no

information relating to alcohol-related incidents

or problems. The level of drugs found in the

blood and urine specimens of the conductor of

9186 South was apparently due to drug

administration after the accident.

The Safety Board therefore concludes that

neither the weather nor the train equipment or

track caused or contributed to the collision. The

computer-generated track warrant 8289

information was correct. Both operating

traincrews were in compliance with the

requirements specified in the Hours-of-Service

Act and were qualified to perform their duties;

no crewmember or dispatcher fatigue was

indicated. Neither alcohol nor drug use appears

to have been a factor in the accident.

Accident Narrative

During the issuance of track warrant 8289 to

train 9186 South, the third-shift dispatcher

failed to accurately communicate the track

warrant information in its entirety to the

traincrew from his computer screen as it was

apparently displayed. He omitted the afterarrival instructions (hold the main track at

Gessner until the arrival of train 5981 North)

when formally issuing authorization to train

9186 South to proceed from Gessner to Melon.

The recorded radio transcripts of the

transmission between the dispatcher and the

9186 South traincrew substantiated that the

dispatcher did not include the after-arrival

instructions of track warrant 8289 to the crew.

When the train 9186 South conductor repeated

the track warrant back to the dispatcher, the

third-shift dispatcher failed to confirm the

accuracy of the read-back information from the

crew with the display on the computer screen.

Had the third-shift dispatcher done so, he would

have noted the discrepancy between the track

warrant that was displayed on his computer

screen and the read-back information and could

have corrected the inconsistency and provided

the after-arrival instruction (hold the main track

at Gessner until the northbound train had

ANALYSIS
23

passed). Because train 9186 South was not

notified to wait for the northbound train to pass

at Gessner, it proceeded from Gessner toward

the northbound train, which was earlier

authorized to proceed and occupy the block of

track from Melon to Gessner. Therefore, the

Safety Board concludes that the third-shift

dispatcher’s failure to accurately issue track

warrant 8289 to train 9186 South and his failure

to detect and correct the 9186 South conductor’s

repeat of the track warrant authority limit

resulted in the crew receiving an incorrect track

warrant that allowed the opposing trains 5981

North and 9186 South to operate on the same

track in opposite directions through Devine on

June 22, 1997.

Dispatcher Performance and Workload

The third-shift dispatcher had been

operating as a qualified dispatcher since August

1996. Most of his experience had been

dispatching trains in dark (nonsignalized)

territories, such as the one in which this accident

occurred. He had no previous dispatching

violations before June 22, 1997. During the 10

months before the Devine accident, the thirdshift dispatcher had demonstrated sufficient

knowledge of dispatching duties. He had

accurately communicated track warrant

information to other traincrews during previous

and subsequent issuance of track warrants.

However, he failed to accurately communicate

the track warrant 8289 information to train 9186

South and to validate the line repeat-back from

the conductor of that train.

At the time of the Devine accident, the UP

verification process of track warrants relied on

the train dispatcher to detect an inaccurate readback message and to ensure that a complete and

accurate transmission was received from the

traincrew. This verification process, in which

the train dispatcher just followed the oral repeatback received from the crew, did not provide a

redundancy feature that would confirm whether

an accurate repeat-back of the original

transmission had registered with and been noted

by the train dispatcher.

On the day of the accident at Devine, the

third-shift dispatcher understood that when

communicating a track warrant to a traincrew,

his primary tasks were to read the information

as presented on the screen and verify its

accuracy, comparing the oral read-back from the

traincrew with the information on the screen; he

believed that he had been following the

established UP track warrant communication

procedures. Track warrants have not been

addressed in the CFR and, therefore, their use as

a method of operation for train movement has

not been federally directed. The Safety Board

concludes that the third-shift dispatcher did not

communicate the accurate information in track

warrant 8289 to the crew of train 9186 South.

Therefore, the Safety Board believes that the UP

should evaluate its dispatcher training program

and make necessary revisions to place greater

emphasis on all safety critical activities

including procedures used to issue and confirm

track warrants. In addition, the Safety Board

believes that the FRA should revise 49 CFR 220

to address track warrants and other current

railroad operating practices.

The third-shift dispatcher stated that on the

night of the accident, his workload was

“probably an average night for that position”

and that from the start of his shift, he had

received several radio calls and “it was busy.”

Immediately after the shift changeover, he had

to process the information just received from the

departing dispatcher and prioritize the tasks that

he was to perform during the shift. That night

the dispatcher’s first task was the radio

transmission with the delayed Amtrak train still

on his territory, which was a rare occurrence for

the beginning of this shift. Immediately after

this, he turned his attention toward dispatching

the UP trains and spent the majority of his initial

time on the radio.

The third-shift dispatcher issued the

incomplete track warrant information to the

crew of train 9186 South within the first 10

minutes of his shift. Veteran dispatchers at the

HDC reported that the most difficult time of a

shift is the first 30 minutes, when a dispatcher is

“trying to assimilate everything” and mentally

planning the operation of the territory. The

Safety Board examined the UP dispatcher rule

violations data and found that approximately 30

percent of the violations occurred within the

first hour after the start of a new, 8-hour shift,

particularly on territories of high-operating

demands. The Safety Board concludes that the

UP dispatchers’ elevated workload at the
24

beginning of shifts may contribute to the

disproportionately greater number of

dispatching violations occurring during this

time. Therefore, the Safety Board believes that

the UP should conduct an audit of its train

dispatching operations to identify specific

factors that can lead to dispatching errors and

include in the audit an assessment of

dispatching errors that occur during or shortly

after shift changes or because of improper radio

procedures.

The Safety Board is concerned that an error

similar to the one committed by the third-shift

dispatcher was also committed by two other

dispatchers, all of whom were trained in the year

before the June 22, 1997, accident. The thirdshift dispatcher, although reporting that he

believed his training was adequate, stated, “How

can training be equal to . . . a dozen radios going

off and ten people yelling at you at the same

time. . . . Having to deal with that sort of thing is

hard.” The Safety Board therefore examined the

challenges faced by less experienced dispatchers

operating in territories of high-operating

demands.

Many of the territories to which less

experienced dispatchers are initially assigned,

such as the Austin subdivision, have nearly

doubled in train volume since the early 1990s,

when they may have been more easily

dispatched because of the fewer trains

operating. Such territories often pose

operational challenges to even the most

experienced dispatchers. Veteran dispatchers

reported that under conditions of high-operating

demands, less experienced dispatchers may

issue track warrants while mentally or

physically attending to their next task and not

concentrating on the read-back communication

from the train crewmembers. The FRA noted

during its safety audit of the HDC that

dispatchers working under high-workload

conditions were not consistently monitoring the

computer screens during read-backs of track

warrants because of other task demands, which

included answering the telephone,

communicating with other dispatchers, and

reading lineups and performing transfers with

their relief shift dispatchers. Some dispatchers,

as a result, may forgo safe dispatching practices

in an attempt to manage the high-operating

demands.

The Safety Board is concerned that newly

qualified dispatchers initially assigned to

territories of high-operating demands may not

have the opportunity to refine their skills to

increase their dispatching efficiency.

Rudimentary skills taught to apprentice

dispatchers in the initial training program can be

further developed as they operate in territories

of moderate-operating demands. Those assigned

to territories of high-operating demands who

have not developed critical skills and strategies

to operate efficiently may relinquish safe

procedures to manage the high-operating

demands. The box 7 after-arrival errors

committed by the newly qualified dispatchers

were the result of their omitting track warrant

verification procedures, perhaps as a means to

manage their dispatching duties. The Safety

Board concludes that some UP apprentice

dispatchers may not have been adequately

prepared to be placed and operate safely in

territories of high-operating demands

immediately after completing the training

program.

The majority of all HDC dispatching errors

for dispatchers occur in territories of highoperating demands. As train volume increases,

the workload demands on the dispatcher

likewise increase. The Safety Board is thus

concerned that for both veteran and newly

qualified dispatchers, the need to manage the

steady increase in train traffic may jeopardize

their ability to attend to all critical tasks and to

dispatch trains safely.

The UP has a study under way to determine

which territories on its system pose the highest

operating demands on its dispatchers. Several

operational factors are being assessed, including

the train volume, the number of track warrants

issued, and the amount of time spent issuing

track warrants. The Safety Board notes that this

assessment is a critical step in determining

where the greatest challenges are for the UP

dispatchers but advises that a comprehensive

evaluation of operational demands in a given

territory needs to consider both the task and the

knowledge, skill, and ability of the dispatchers,

including the level of task demands, the

operator’s mental and physical capacity, the
25

work strategy, and the skill level.20 For instance,

one UP dispatcher with many years of

experience indicated that handling 18 trains on

his territory was not difficult for him; however,

a less-experienced dispatcher working the same

territory felt overloaded by the dispatching

demands. The Devine accident demonstrates

that not all qualified dispatchers are equally

prepared to manage similar operating demands.

The errors committed by qualified, but less

experienced, dispatchers strongly indicate a

need for careful consideration of the placement

of dispatchers in territories of high-operating

demands. The Safety Board believes that the UP

should conduct an audit of its train dispatchers’

activities to evaluate the current workload and

should make necessary changes to dispatcher

operations to distribute workload based on the

individual dispatcher’s qualifications, ability,

and experience.

Management Oversight

Dispatcher Apprentice Program --

Although the UP had a policy that an apprentice

dispatcher became a qualified dispatcher only

with the full agreement of several officials

involved in the training process and would be

provided training until ready to work the

position, the Safety Board found some instances

in which these standards were not being upheld

by management. Dispatchers indicated that

management has qualified apprentice

dispatchers despite opposition from some OJT

dispatcher trainers involved in the training

process, and dispatchers believed that the

qualifying process has been compromised to

expedite the placement of new dispatchers in the

dispatching operations. The Safety Board

concludes that the UP may have jeopardized

safe dispatching operations by qualifying

unprepared apprentice dispatchers and assigning

less experienced dispatchers to territories of

high-operating demands.

Another area in which the UP did not adhere

to its policies was in upholding the experience

level of OJT dispatcher trainers for apprentice

dispatchers. The UP management reported that

 

20Welford, A.T., “Mental Workload as a Function of

Demand, Capacity, and Skill,” Ergonomics, 21, 1978, pp.

151-167.

qualified dispatchers responsible for conducting

the OJT for apprentice dispatchers must have at

least 5 years of dispatching experience.

According to UP dispatchers, however,

dispatchers with less than 5 years of experience

were training apprentice dispatchers. Some

veteran dispatchers believed that 5 years should

be the minimum experience level for an OJT

dispatcher trainer. Since the accident at Devine,

the UP has increased to 10 years the minimum

experience level for the OJT dispatcher trainers.

The Safety Board has learned from the UP

dispatcher data that fewer than half of the UP

dispatchers have attained this experience level

and concludes that because the UP did not meet

its 5-year experience standard for OJT

dispatcher trainers, complying with the higher

standard of a minimum 10-year experience level

for OJT dispatcher trainers may not be achieved.

Therefore, the Safety Board believes that the UP

should examine the circumstances in which its

policy to require a minimum 5 years of

experience to qualify as an OJT dispatcher

trainer was not followed and take action to

ensure that the UP qualification policies are

followed.

Like many other railroads, the UP had no

formal training or procedures for the dispatcher

trainers who oversee the apprentice dispatchers

during OJT. The FRA reported that in many

railroads the OJT had been delegated to

subordinates without adequate direction,

control, or evaluation methods, which led to

unstructured and inconsistent training. Although

the FRA found no evidence during its reviews

that inadequate dispatcher training directly

resulted in train accidents, it noted that training

directly impacts train dispatcher efficiency and

productivity, which can impact safety.

Additionally, the lack of well-defined training

may contribute to train dispatcher stress and

fatigue, as well as work overload. The Safety

Board concurs with the FRA’s position.

Therefore, the Safety Board believes that the UP

should develop and implement a comprehensive

program to select and train experienced

dispatchers to serve as dispatcher trainers.

The FRA report in 1995 stated that the FRA

would publish in 1998 an ANPRM proposing

minimum training standards for train dispatchers

that include initial, periodic, refresher, and

physical characteristic training and minimum
26

operating rule training and testing standards.

The Safety Board urges the FRA to encourage

the timely adoption and implementation of these

standards.

Dispatching Operations -- The safety of

the system is directly dependent on the

appropriate actions of those operating in safetysensitive areas. Management has a responsibility

to establish an operating environment most

conducive to safe operations. The Safety Board

examined the UP management efforts to ensure

a safe and efficient operating environment for

the dispatchers. Although the UP policies do

address many critical safety-sensitive areas, the

Safety Board has identified areas in which

actual company practice has fallen short of

company standards. The Safety Board

understands that apprentice dispatchers have

become qualified dispatchers without the

concurrence of OJT dispatcher trainers or the

apprentice dispatcher trainee. Newly qualified

dispatchers have been placed in territories of

high-operating demands without the benefit of

developing skills through experience. By failing

to accommodate the needs of less experienced

dispatchers and by not adhering to its own

standards, the UP failed to create an

environment conducive to safe dispatching

operations. Consequently, the Safety Board

concludes that the third-shift dispatcher’s failure

to communicate the information in track warrant

8289 accurately to the 9186 South traincrew and

to verify the accuracy of the read-back

information resulted from operational

shortcomings at the HDC.

The UP company policy did not require that

corridor managers have previous dispatching

experience, and some did not. Although during

normal operations this typically does not pose a

problem, dispatchers expressed frustration with

what they perceived as poor decisions by some

corridor managers during more complex

operating situations. Dispatchers reported that

during the daily safety and production meetings,

some corridor managers lent support to the

dispatchers’ workload challenges on their

territories, and other corridor managers were not

interested in discussing the problems

experienced by the dispatchers. As a result,

dispatchers sought advice from other sources,

such as upper management officials, when

confronting certain complex situations. The

Safety Board concludes that some UP corridor

managers did not consistently provide

appropriate technical support to the train

dispatchers. Therefore, the Safety Board

believes that the UP should evaluate and

determine the technical expertise required of

corridor managers and make the necessary

changes to ensure that corridor managers are

qualified to provide proper dispatching

assistance to the train dispatchers.

The UP train dispatchers also expressed

concern about the noise level originating from

adjacent dispatching stations at the HDC. The

noise level is highest during the shift

changeover when the dispatchers brief their

replacements about the status of their territories.

Waist-high barriers separate dispatchers from

each other, but do not block out distracting

conversations. Higher partitions, used at some

dispatch centers, serve better as sound barriers

and provide a quieter working environment. The

Safety Board has investigated accidents in

which distractions hindered the performance of

a safety-critical operator. The Safety Board

concludes that although no evidence was found

that adjacent noises in the dispatching area

contributed to the third-shift dispatcher’s

inattention to the track warrant 8289

information in the Devine accident, a

dispatcher’s performance may be affected by

unnecessary, avoidable sound distractions.

Therefore, the Safety Board believes that the UP

should identify all distractions, evaluate their

effects on dispatchers, and take action to

establish a working environment conducive to

safe dispatching operations.

After-Arrival Conditional Authority -- The

use of after-arrival instructions creates an

inherent danger by giving a traincrew

conditional authority, under which, if a

condition is met, their train is allowed to

proceed into a block of track even though that

track is occupied by an opposing train. (In the

Devine accident, the condition was the physical

passing of another train.) Should a failure occur

in the transmission or comprehension of a track

warrant that results in the omission or inaccurate

communication of the condition, two opposing

trains may occupy the same block of track at the

same time, as they did in the Devine accident.

Once an error has occurred in dark
27

(nonsignalized) territory and two trains are on

the same track at the same time, no wayside

signals are available to warn one train of the

presence of the other.

After the 1991 Ledger train collision, the

BNSF dispatching system was reprogrammed to

add another protection barrier against the

occurrence of a train dispatcher error. If the

train dispatcher does not correctly apply the

read-back information from the traincrew, the

computer screen does not clear, and the next

computer screen display will not appear. This

redundancy feature increases protection against

dispatcher error in the BNSF dispatching

system. The UP attempted to mitigate the risk of

a dispatcher error by adding a warning system

that required the train dispatcher to

acknowledge a message on the computer screen.

In the UP dispatching system, the UP elected to

display its track warrant box 7 (“not in effect

until after arrival of”) on the computer screen to

reduce the risk of a dispatcher error and a train

collision.

The Safety Board has investigated other

railroad accidents in which the avoidance of a

collision depended on the use of a rule or

standard operating practice that proved to be

insufficient to prevent an accident. In the

Devine accident, the third-shift dispatcher failed

to adhere to procedural policy and to follow

verbatim the read-back message from the

traincrew. The system employed by the UP at

the time of the Devine accident allowed for such

a failure to occur and permitted the third-shift

dispatcher to overlook a critical element during

the issuance of track warrant 8289. Hence, the

UP method used for dark (nonsignalized)

territory operations needs to be revised to ensure

that an oversight by a dispatcher cannot occur.

The Safety Board concludes that had the UP

after-arrival system in dark (nonsignalized)

territory operations not been used in the Devine

accident area, the opposing trains 5981 North

and 9186 South would not have been occupying

the same block of track. Therefore, the Safety

Board believes that the UP should discontinue

permanently the use of after-arrival orders in

dark (nonsignalized) territory The Safety Board

also believes that the FRA should require

railroads to discontinue permanently the use of

after-arrival orders in dark (nonsignalized)

territory.

Federal Railroad Administration Train

Dispatching Oversight

The Safety Board has previously examined

the FRA oversight of train dispatching. After the

Safety Board investigated the derailment of an

Amtrak train at Fall River, Wisconsin,21 in

October 1986, it urged the FRA to:

Conduct a thorough study of the

selection process, training, duties, and

responsibilities of train dispatchers to

determine whether the workload is

beyond the normal job stress level and

to determine what selection and

training standards are used for train

dispatchers. Establish selection and

training standards and limits of

workload for dispatchers. (Safety

Recommendation R-87-66)

In 1990, the FRA reported to the U.S.

Congress that the imposition of Federal training

standards for train dispatchers was not

necessary. The FRA based its judgment on a

number of factors that it found during the FRA

nationwide review of train dispatching.

In a September 1991 letter to the Safety

Board, the FRA wrote of its intent to implement

a formal research and development study of

dispatcher training programs, workload

measurement models, occupational stresses, and

fatigue effects. The FRA stated in January 1995

that it had found that train dispatchers continue

to provide safe, efficient service to the industry;

however, it believed that several dispatching

areas, particularly training and testing, had

shortcomings. In February 1995, the Safety

Board advised the FRA that it was disappointed

that many of the study’s findings and concerns

were not adequately addressed in the published

recommendations for action. For example, the

study identified several major safety-related

problems in the occupational stress, workload,

and environmental policies affecting

dispatchers, but the FRA still has not completed

satisfactory regulatory activity to establish

 

21For more information, see Railroad Accident

Report--Derailment of Amtrak Passenger Train 8

Operating on the Soo Line Railroad, Fall River,

Wisconsin, on October 9, 1986 (NTSB/RAR-87/06).
28

dispatcher standards. Therefore, the Safety

Board concludes that the FRA has failed to

develop dispatcher standards and needs to

accelerate the establishment of regulatory

standards for train dispatchers.

Because the FRA has only partially met the

intent of Safety Recommendation R-87-66 by

conducting a study of the selection process,

training, duties, and responsibilities of train

dispatchers, the Safety Board is classifying

Safety Recommendation R-87-66 “Closed--

Unacceptable Action/Superseded” and issuing a

new safety recommendation to the FRA. The

Safety Board believes that the FRA should

develop and establish dispatcher selection and

training standards, dispatcher trainer standards,

and workload limits for dispatchers by

January 1, 2000.

During its investigation of a train collision

that occurred on July 30, 1988, near Altoona,

Iowa,22 the Safety Board examined the FRA’s

surveillance and enforcement of compliance

with Federal regulations. The Safety Board cited

the FRA as contributing to the cause of the

Altoona accident because of the inadequate

FRA surveillance and enforcement of

compliance with Federal regulations.

After its investigation of the August 1991

Ledger head-on collision between two BNSF

freight trains, the Safety Board found that

several procedural dispatching errors occurred

during the train radio transmissions that

precipitated the accident. Three years before the

Ledger accident, the FRA, in its National Train

Dispatcher Safety Assessment of 1987-88, had

recommended that the BNSF immediately

implement a program for dispatchers to teach

and enforce radio procedures that comply with

all applicable Federal and carrier radio rules.

The Safety Board found that had either the FRA

or the BNSF adequately followed up on the

recommendations to the BNSF, the Ledger

accident would not have happened.

 

22For more information, see Railroad Accident

Report -- Head-On Collision between Iowa Interstate

Railroad Extra 470 West and Extra 406 East with Release

of Hazardous Materials near Altoona, Iowa, July 30, 1988

(NTSB/RAR-89/04).

Following the Devine accident in June

1997, the FRA documented significant

dispatcher procedural deficiencies at the HDC

that had preexisted that accident. Although the

FRA had in place a routine operating practices

oversight program for the HDC, the FRA has no

record that its previous routine inspections had

cited these dispatcher procedural deficiencies.

The Safety Board concludes that the FRA

surveillance and enforcement of compliance

with Federal regulations at the HDC before the

Devine accident were inadequate and

ineffective. Therefore, the Safety Board believes

that the FRA should evaluate its surveillance

and enforcement activities at dispatching centers

and take appropriate corrective actions to ensure

that Federal oversight is adequate and effective.

Emergency Response and Disaster

Preparedness

Within minutes of the collision, a DPD

officer, as well as the first fire, rescue, and EMS

personnel, had arrived on scene. The chief of the

DVFD activated the Incident Command System

and assumed control as incident commander. He

acted effectively and managed the incident

successfully to completion without serious

injury to responders, local residents, or officials

at the accident site. However, the DVFD did not

have access to an adequate amount of fire

suppression foam equipment that would have

further aided its efforts to mitigate the massive

fire that ensued after the collision. Such

equipment is not readily available for rural fire

departments, although hazardous materials are

routinely transported through their jurisdictions.

The increase in rail traffic on the San Antonio to

Laredo railroad corridor indicates a need for

such readily available firefighting equipment to

mitigate a fire event such as the one that

occurred in the Devine accident. Therefore, the

Safety Board concludes that although the local

emergency response was timely and adequate,

the lack of readily available fire suppression

foam equipment shows a need for additional

firefighting equipment to mitigate significant

fire events. Consequently, the Safety Board

believes that the Texas Railroad Commission

should develop a system that would make fire

suppression foam equipment readily available to

emergency management agencies and local rural

fire departments for the fighting of hazardous

materials fires.
29

Crashworthiness

Locomotives -- The operating cab of the

lead locomotive of train 5981 North had

separated from the unit, was found crushed

beneath the pile of wreckage debris, and was

fully consumed by the fire. Based upon the

engineer’s statement, he was able to

successfully jump from the unit several hundred

feet before impact and landed on the ground

immediately adjacent to the railroad right-ofway. The body of the conductor was found

adjacent to the track beneath wreckage debris

north of the north bridge abutment. Given the

injuries sustained, massive crush, and severe

burn trauma, his death resulted from being

crushed near the POI beneath wreckage debris,

which was further engulfed in the fire. Based on

the available evidence, the conductor may not

have jumped before impact but may have been

on or near the left front corner of the locomotive

at the time of impact. Upon collision, the impact

momentum may have resulted in his body being

thrown and then crushed by wreckage debris of

the derailing equipment, which then caught

afire. Fragments of two unidentified, severely

traumatized and burned bodies, suspected to be

transients, were found beneath wreckage debris

near the POI. The likely location of the two

people before the collision was either in the cab

of the second locomotive, which was crushed

and overridden by wreckage, or beneath the

floorboards of the lead locomotive, which was

fully crushed by wreckage.

The operating cab of the lead locomotive of

train 9186 South was not significantly crushed

on impact, but the unit derailed and was then

fully consumed by the massive fire. Based on

the evidence, the two crewmembers apparently

exited the locomotive with the intention of

jumping clear before impact. The body of the

engineer was found adjacent to the track. Given

the location of the body and the injuries

sustained, he died as a result of his impact with

the ground. The conductor was found standing

on the road beneath the bridge near the burning

wreckage. Given his severe burn injuries and the

lack of ground-impact type injuries, he probably

was subjected to the heat of the massive fire

after jumping clear of the locomotive very close

to the POI.

Based upon the estimated speeds of the

locomotives at impact, the loss of survival space

in the locomotives, and the severity of the

massive fire, the Safety Board concludes that

the collision in Devine was not survivable for

crewmembers or anyone occupying the

locomotive equipment at the time of the impact.

Event Recorders -- In its investigations, the

Safety Board relies on data recovered from the

event recorders to determine train speed,

direction of travel, distance, throttle position,

brake application, and cab signal aspects, when

applicable, before and during an accident. As

was demonstrated in the Safety Board’s

investigation of the February 1996 freight train

derailment near Cajon Junction, California,23

certain critical data are retrieved only in the

event recorder of the lead locomotive unit and

not in the event recorders of the trailing units. In

the Devine accident, the event recorder data for

train 9186 South and the lead locomotive of

train 5981 North were destroyed by impact

forces or fire, or both, and critical event

recorder data were lost that could not be

retrieved from the other event recorders.

The Safety Board has investigated other

accidents in which the event recorder data were

compromised due to impact forces or water or

fire exposure. In its Corona, California,24 Knox,

Indiana,25 and Mobile, Alabama,26 accident

investigations, the Safety Board found that

critical operational data were lost because the

 

23For more information, see Railroad Accident

Report--Derailment of Freight Train H-BALT1-31

Atchison, Topeka and Santa Fe Railway Company near

Cajon Junction, California, on February 1, 1996

(NTSB/RAR-96/05).

24For more information, see Railroad Accident

Report--Atchison, Topeka and Santa Fe Railway Company

(ATSF) Freight Trains ATSF 818 and ATSF 891 on the

ASTF Railway in Corona, California, on November 7,

1990 (NTSB/RAR-91/03).

25For more information, see Railroad

Accident/Incident Summary Report -- Knox, Indiana --

September 17, 1991 (NTSB/RAR-92/02/SUM).

26For more information, see Railroad Accident

Report--Derailment of Amtrak Train No. 2 on the CSXT

Big Bayou Canot Bridge near Mobile, Alabama, on

September 22, 1993 (NTSB/RAR-94/01).
30

event recorders were not crashworthy. Since

1993, when the FRA required the use of

locomotive event recorders, the Safety Board

has advocated the development of standards for

the crashworthiness of these devices.

Three of the five event recorders in the

Devine accident were destroyed either from

crash forces or fire exposure. The event recorder

on the lead locomotive of 5981 North was

destroyed by damage incurred in the accident.

Data were recovered from the event recorders

on the two trailing locomotives of 5981 North.

The event recorders on the lead locomotive and

the trailing locomotive of 9186 South were

destroyed in the postaccident fire. From a fire

resistance standpoint, the type of encasement

employed by the manufacturer did not protect

the event recorders from thermal destruction.

None of the event recorders on the locomotives

were designed to meet crash forces or fire

exposure standards. The Safety Board concludes

that had the event recorders been designed to

withstand crash forces and fire exposure, the

three destroyed event recorders would have

survived and could have provided data for the

investigation.

The Safety Board is familiar with the

crashworthiness standards in the aviation

industry that require the ability to withstand

impact shock forces of 3,500 g27 and fire

exposure at 1,100° F for 1 hour, which allow the

retrieval of event recorder data after a

catastrophic event occurs to the aircraft. Similar

standards are not available in the railroad

industry. Although the FRA assured the Safety

Board in August 1997 that actions have been

taken to develop standards for crashworthiness,

no standards have been established. Therefore,

the Safety Board believes that the FRA, working

with the railroad industry, should develop and

implement event recorder crashworthiness

standards for all new or rebuilt locomotives by

January 1, 2000.

 

27An acceleration equal to the acceleration of gravity,

about 32 feet per second per second.

Positive Train Separation Control

Systems

A positive train separation (PTS) control

system can prevent trains from colliding by

automatically intervening in the operation of a

train when an engineer does not comply with the

requirements of a signal indication or operating

rules. The Safety Board has long advocated a

PTS control system and since 197028 has issued

safety recommendations calling for this

prevention measure. Since most train collisions

result from human error, a highly effective train

control system is needed as a preventive

measure. Greater security is provided by a train

control system capable of intervening should a

failure to observe signals and operating rules

occur for whatever reason.

Following its investigation of the head-on

collision between two BNSF freight trains near

Ledger, the Safety Board urged the FRA in July

1993 to:

Establish a firm timetable that

includes at a minimum, dates for final

development of required advanced

train control system hardware, dates

for an implementation of a fully

developed advanced train control

system, and a commitment to a date

for having the advanced train control

system ready for installation on the

general railroad system. (R-93-12)

The Safety Board classified Safety

Recommendation R-93-12 “Open--Acceptable

Response” on July 8, 1994, after the FRA took

action to seek the “final system definition,

migration path, and timetable” for a PTS control

system by December 1994.

The Safety Board has investigated numerous

train collisions in which the probable cause or

contributing cause was the inattention of the

traincrew to wayside signals. After its

investigation of the Thedford, Nebraska,29

 

28For more information, see Railroad Accident

Report--Head-on Collision Between Penn Central Trains

N-48 and N-49 at Darien, Connecticut, August 20, 1969

(NTSB/RAR-70/03).

29For more information, see Railroad Accident

Report--Collision and Derailment Involving Three
31

accident, the Safety Board stated that had a PTS

control system been in place, it could have

detected that the engineer was not responding

appropriately to the signal indications and could

have slowed and stopped the train, thus

preventing the collision.

The Silver Spring, Maryland, accident30 in

February 1996 was the latest in a series of

collisions that could have been prevented if a

PTS control system had been in place. The

Safety Board determined that the probable cause

of the accident was the apparent failure of the

engineer and the traincrew because of multiple

distractions to operate their train according to

signal indications and the failure of the FRA,

the Federal Transit Administration, the

Maryland Mass Transit Administration, and the

CSX Transportation Inc. . . . to provide a

redundant safety system that could compensate

for human error. As a result of the Silver Spring

accident investigation, the Safety Board

reiterated Safety Recommendation R-87-16,

which asked the FRA to promulgate Federal

standards to require the installation and

operation of a train control system on main line

tracks that will provide for positive separation

of all trains,31 and Safety Recommendation

R-93-12.

The FRA and the railroad industry share

responsibility for the development and

implementation of a PTS control system. Under

its regulatory authority, the FRA can order a

railroad to install a PTS control system. In the

Devine accident, a PTS control system could

have detected that the 9186 South engineer was

not responding appropriately to the track

warrant and then have slowed and stopped the

train, thus preventing the head-on collision. The

Safety Board concludes that had a PTS control

 

Burlington Northern Freight Trains near Thedford,

Nebraska, on June 8, 1994 (NTSB/RAR-95/03).

30For more information, see Railroad Accident

Report--Collision and Derailment of Maryland Rail

Commuter MARC Train 286 and National Railroad

Passenger Corporation Amtrak Train 29 near Silver

Spring, Maryland, on February 16, 1996 (NTSB/RAR97/02).

31Issued to the FRA in May 1987 after the review of

accident investigations since 1967 in which the accidents

could have been prevented had a mandated train separation

system been in effect.

system been installed and working in the Devine

accident area, the two trains would not have

been allowed to enter the same block of track

traveling in opposite directions and, as a result,

the head-on collision on June 22, 1997, would

not have occurred. Therefore, the Safety Board

reiterates Safety Recommendation R-87-16 to

the FRA.
32

Findings

1. Neither the weather nor the train equipment

or track caused or contributed to the

collision. The computer-generated track

warrant 8289 information was correct. Both

operating traincrews were in compliance

with the requirements specified in the

Hours-of-Service Act and were qualified to

perform their duties; no crewmember or

dispatcher fatigue was indicated. Neither

alcohol nor drug use appears to have been a

factor in the accident.

2. The third-shift dispatcher’s failure to

accurately issue track warrant 8289 to train

9186 South and his failure to detect and

correct the 9186 South conductor’s repeat of

the track warrant authority limit resulted in

the crew receiving an incorrect track

warrant that allowed the opposing trains

5981 North and 9186 South to operate on

the same track in opposite directions

through Devine on June 22, 1997.

3. The third-shift dispatcher did not

communicate the accurate information in

track warrant 8289 to the crew of train 9186

South.

4. The Union Pacific Railroad dispatchers’

elevated workload at the beginning of shifts

may contribute to the disproportionately

greater number of dispatching violations

occurring during this time.

5. Some Union Pacific Railroad apprentice

dispatchers may not have been adequately

prepared to be placed and operate safely in

territories of high-operating demands

immediately after completing the training

program.

6. The Union Pacific Railroad may have

jeopardized safe dispatching operations by

qualifying unprepared apprentice

dispatchers and assigning less experienced

dispatchers to territories of high-operating

demands.

7. Because the Union Pacific Railroad did not

meet its 5-year experience standard for OJT

dispatcher trainers, complying with the

higher standard of a minimum 10-year

experience level for OJT dispatcher trainers

may not be achieved.

8. The third-shift dispatcher’s failure to

communicate the information in track

warrant 8289 accurately to the 9186 South

traincrew and to verify the accuracy of the

read-back information resulted from

operational shortcomings at the Harriman

Dispatch Center.

9. Some Union Pacific Railroad corridor

managers did not consistently provide

appropriate technical support to the train

dispatchers.

10. Although no evidence was found that

adjacent noises in the dispatching area

contributed to the third-shift dispatcher’s

inattention to the track warrant 8289

information in the Devine accident, a

dispatcher’s performance may be affected

by unnecessary, avoidable sound

distractions.

11. Had the Union Pacific Railroad after-arrival

system in dark (nonsignalized) territory

operations not been used in the Devine

accident area, the opposing trains 5981

North and 9186 South would not have been

occupying the same block of track.

12. The Federal Railroad Administration has

failed to develop dispatcher standards and

needs to accelerate the establishment of

regulatory standards for train dispatchers.

CONCLUSIONS
33

13. The Federal Railroad Administration

surveillance and enforcement of compliance

with Federal regulations at the Harriman

Dispatch Center before the Devine accident

were inadequate and ineffective.

14. Although the local emergency response was

timely and adequate, the lack of readily

available fire suppression foam equipment

shows a need for additional firefighting

equipment to mitigate such significant fire

events.

15. Based upon the estimated speeds of the

locomotives at impact, the loss of survival

space in the locomotives, and the severity of

the massive fire, the collision in Devine was

not survivable for crewmembers or anyone

occupying the locomotive equipment at the

time of the impact.

16. Had the event recorders been designed to

withstand crash forces and fire exposure, the

three destroyed event recorders would have

survived and could have provided data for

the investigation.

17. Had a positive train separation control

system been installed and working in the

Devine accident area, the two trains would

not have been allowed to enter the same

block of track traveling in opposite

directions and, as a result, the head-on

collision on June 22, 1997, would not have

occurred.

Probable Cause

The National Transportation Safety Board

determines that the probable cause of this

accident was the failure of the third-shift

dispatcher to communicate the correct track

warrant information to the traincrew and to

verify the accuracy of the read-back information

because the Union Pacific Railroad management

had not established and implemented workload

policies and operational procedures to ensure a

safe dispatching system and the Federal

Railroad Administration had failed to provide

standards and oversight in all aspects of train

dispatching operations. Contributing to the

accident was the lack of an installed positive

train separation control system that would have

prevented the trains from colliding by

automatically intervening in their operation

because of inappropriate actions being taken.
34

As a result of its investigation, the National

Transportation Safety Board makes the

following recommendations:

-- to the Union Pacific Railroad:

Evaluate your dispatcher training

program and make necessary revisions

to place greater emphasis on all safety

critical activities including procedures

used to issue and confirm track

warrants. (R-98-18)

Conduct an audit of your train

dispatching operations to identify

specific factors that can lead to

dispatching errors and include in the

audit an assessment of dispatching

errors that occur during or shortly after

shift changes or because of improper

radio procedures. (R-98-19)

Conduct an audit of your train

dispatchers’ activities to evaluate the

current workload and make necessary

changes to dispatcher operations to

distribute workload based on the

individual dispatcher’s qualifications,

ability, and experience. (R-98-20)

Examine the circumstances in which

your policy to require a minimum 5

years of experience to qualify as an OJT

dispatcher trainer was not followed and

take action to ensure that your

qualification policies are followed.

(R-98-21)

Develop and implement a

comprehensive program to select and

train experienced dispatchers to serve as

dispatcher trainers. (R-98-22)

Evaluate and determine the technical

expertise required of corridor managers

and make the necessary changes to

ensure that corridor managers are

qualified to provide proper dispatching

assistance to the train dispatchers.

(R-98-23)

Identify all distractions, evaluate their

effects on dispatchers, and take action to

establish a working environment

conducive to safe dispatching

operations. (R-98-24)

Discontinue permanently the use of

after-arrival orders in dark

(nonsignalized) territory. (R-98-25)

--to the Federal Railroad Administration:

Revise 49 Code of Federal Regulations

220 to address track warrants and other

current railroad operating practices.

(R-98-26)

Require railroads to discontinue

permanently the use of after-arrival

orders in dark (nonsignalized) territory.

(R-98-27)

Develop and establish dispatcher

selection and training standards,

dispatcher trainer standards, and

workload limits for dispatchers by

January 1, 2000. (R-98-28)

Evaluate your surveillance and

enforcement activities at dispatching

centers and take appropriate corrective

actions to ensure that Federal oversight

is adequate and effective. (R-98-29)

RECOMMENDATIONS
35

Working with the railroad industry,

develop and implement event recorder

crashworthiness standards for all new or

rebuilt locomotives by January 1, 2000.

(R-98-30)

--to the Texas Railroad Commission:

Develop a system that would make fire

suppression foam equipment readily

available to emergency management

agencies and local rural fire departments

for the fighting of hazardous materials

fires. (R-98-31)

Also, as a result of its investigation, the

National Transportation Safety Board reiterates

the following recommendation:

--to the Federal Railroad Administration:

Promulgate Federal standards to require

the installation and operation of a train

control system on main line tracks that

will provide for positive separation of

all trains. (R-87-16)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

May 19, 1998