Collision of Two Canadian National Railway Freight Trains 

near Two Harbors, Minnesota 

September 30, 2010 

Accident Summary Report

NTSB/RAR-13/01/SUM

PB2013-104865 National 

Transportation 

Safety Board

NTSB/RAR-13/01

PB2013-104865

Notation 8464

Adopted February 12, 2013

Railroad Accident Report

Collision of Two Canadian National Railway Freight Trains

near Two Harbors, Minnesota

September 30, 2010

National 

Transportation 

Safety Board

490 L’Enfant Plaza, SW

Washington, DC 20594
National Transportation Safety Board. 2013. Collision of Two Canadian National Railway Freight 

Trains near Two Harbors, Minnesota, September 30, 2010. Railroad Summary Report

NTSB/RAR-13/01. Washington, DC.

Abstract: On September 30, 2010, about 4:05 p.m. central daylight time, a southbound 

Canadian National Railway freight train collided head on with a northbound Canadian National Railway 

freight train near Two Harbors, Minnesota. The collision occurred near milepost 13.5 on Canadian 

National Railway’s Iron Range Subdivision. The trains were operating in nonsignaled territory. The 

northbound train had 118 empty iron ore railcars and had authority to operate on the single main track. 

The southbound train had 116 railcars loaded with iron ore and did not have authority to operate on the 

single main track. The crew of the southbound train entered the main track after failing to properly 

execute an after-arrival track authority. A total of three locomotives and 14 railcars derailed. All five 

crewmembers on the two trains were injured and transported to hospitals. Four crewmembers were treated 

and released; one crewmember remained hospitalized for further treatment. Canadian National Railway 

estimated damages at $8.1 million.

As a result of its investigation of this accident, the National Transportation Safety Board (NTSB) makes 

recommendations to the Federal Railroad Administration, Canadian National Railway, the Brotherhood of 

Locomotive Engineers and Trainmen, the United Transportation Union, Canadian Pacific Railway 

Limited, Kansas City Southern Railway Company, Norfolk Southern Railroad, and Union Pacific 

Railroad. The NTSB also reiterates previous recommendations to the Federal Railroad Administration, 

BNSF Railway, and the American Short Line and Regional Railroad Association. The NTSB also 

reiterates and reclassifies recommendations to the Federal Railroad Administration.

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 NTSB makes public its actions and 

decisions through accident reports, safety studies, special investigation reports, safety recommendations, and 

statistical reviews.

Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about 

available publications also may be obtained from the website or by contacting:

National Transportation Safety Board

Records Management Division, CIO-40

490 L’Enfant Plaza, SW

Washington, DC 20594

(800) 877-6799 or (202) 314-6551

NTSB publications may be purchased by individual copy from the National Technical Information Service. To 

purchase this publication, order report number PB2013-104865 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

http://www.ntis.gov

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence 

or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter 

mentioned in the report.
NTSB Railroad Summary Report

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Contents

Figures........................................................................................................................................... iii

Tables............................................................................................................................................ iii

Abbreviations and Acronyms ..................................................................................................... iv

Executive Summary.......................................................................................................................v

1 Investigation and Analysis ......................................................................................................1

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

1.2 Events Preceding the Accident.................................................................................................2

1.3 Factors Not Contributing to This Accident ..............................................................................7

1.4 After-Arrival Track Authorities on Nonsignaled Tracks .........................................................7

1.4.1 Human Error and After-Arrival Track Authorities........................................................8

1.4.2 Risks of After-Arrival Authorities on Nonsignaled Track ............................................9

1.4.3 Previous NTSB Investigations Involving After-Arrival Track Authorities.................10

1.4.4 Class I Railroad Actions to Improve After-Arrival Authority Processes....................13

1.4.5 NTSB Position on After-Arrival Track Authorities in Nonsignaled Territory............14

1.5 Fatigue ....................................................................................................................................16

1.5.1 Physiological Fatigue...................................................................................................16

1.5.2 Disruption of Circadian Rhythms................................................................................17

1.5.3 Continuous Hours of Wakefulness ..............................................................................17

1.5.4 Lack of Crew Coordination and Communication........................................................18

1.6 Use of Portable Electronic Devices........................................................................................20

1.7 Communication and Coordination of Southbound Train Crew .............................................25

1.8 Crew Resource Management..................................................................................................28

2 Management and Regulatory Oversight..............................................................................32

2.1 CN Management Oversight....................................................................................................32

2.2 FRA Regulatory Oversight.....................................................................................................36

2.3 Actions Taken Since the Accident .........................................................................................37

3 Conclusions.............................................................................................................................38

3.1 Findings..................................................................................................................................38

3.2 Probable Cause .......................................................................................................................39

4 Recommendations..................................................................................................................40

4.1 New Recommendations..........................................................................................................40

4.2 Previously Issued Recommendations Reiterated in this Report.............................................41

4.3 Previously Issued Recommendations Reiterated and Reclassified in this Report .................42

Board Member Statements .........................................................................................................44
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5 Appendixes..............................................................................................................................46

5.1 Appendix A: Investigation .....................................................................................................46

5.2 Appendix B: Comparative Table of BNSF and CN Rule Requirements for After-Arrival 

Track Authorities in Nonsignaled Territory ..................................................................................47

5.3 Appendix C: Canadian National Rule on PED Use ...............................................................48

5.4 Appendix D: Southbound Train After-Arrival Track Authority, Conductor Copy ...............50

5.5 Appendix E: Southbound Train After-Arrival Track Authority, Engineer Copy ..................51
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Figures

Figure 1. This is an aerial photograph of the train collision. ......................................................... 2

Figure 2. This is a map of the CN rail line between Two Harbors and the Minntac mine. ........... 4

Figure 3. This map depicts the point of collision........................................................................... 6

Figure 4. This graphic shows cell phone use by the southbound and northbound train crews 

during the accident trip. ................................................................................................................ 21

Tables

Table 1. Train information. ............................................................................................................ 1

Table 2. Approximate timeline of southbound train at the Highland siding.................................. 6

Table 3. Approximate numbers of after-arrival track authorities issued........................................ 8

Table 4. NTSB investigations involving after-arrival track authority. ........................................ 11

Table 5. Crew work history.......................................................................................................... 16

Table 6. CN rules compliance testing of crewmembers of the accident trains. ........................... 32

Table 7. CN rules compliance testing on four CN subdivisions. ................................................. 32

Table 8. Summary of five CN tests conducted in 2009, 2010, and 2011, on four CN 

subdivisions................................................................................................................................... 33
NTSB Railroad Summary Report

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Abbreviations and Acronyms

BRM bridge resource management

CFR Code of Federal Regulations

CN Canadian National Railway

CP Canadian Pacific Railway Limited

CRM crew resource management

DM&IR Duluth, Missabe and Iron Range Railway Company

FRA Federal Railroad Administration

KCS Kansas City Southern Railway Company

NS Norfolk Southern Railroad

NTSB National Transportation Safety Board

PED portable electronic device

PTC positive train control

RSAC Railroad Safety Advisory Committee

RSIA Rail Safety Improvement Act

RTC rail traffic controller

SMS safety management system

UP Union Pacific Railroad

WCL Wisconsin Central Ltd.
NTSB Railroad Summary Report

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Executive Summary

On September 30, 2010, about 4:05 p.m. central daylight time, a southbound 

Canadian National Railway freight train collided head on with a northbound Canadian National

Railway freight train near Two Harbors, Minnesota. The collision occurred near milepost 13.5 on 

Canadian National Railway’s Iron Range Subdivision. The trains were operating in nonsignaled 

territory. The northbound train had 118 empty iron ore railcars and had authority to operate on 

the single main track. The southbound train had 116 railcars loaded with iron ore and did not 

have authority to operate on the single main track. The crew of the southbound train entered the 

main track after failing to properly execute an after-arrival track authority. A total of 

three locomotives and 14 railcars derailed. All five crewmembers on the two trains were injured 

and transported to hospitals. Four crewmembers were treated and released; one crewmember 

remained hospitalized for further treatment. Canadian National Railway estimated damages at 

$8.1 million. The weather was clear and the temperature was 72°F.

The National Transportation Safety Board determines that the probable cause of the 

accident was the southbound train crew’s error in departing the Highland siding before the 

northbound train had passed. Contributing to the accident was the Canadian National Railway’s

use of after-arrival track authorities in nonsignaled territory, a procedure that is vulnerable to 

human error and lacks inherent safety redundancies necessary to ensure consistent, safe 

operation. Also contributing to the accident was crew fatigue and inadequate crew resource 

management.

This report discusses the following safety issues:

use of after-arrival track authorities for train movement on nonsignaled tracks

prohibited use of portable electronic devices

fatigue

crew resource management

management and regulatory oversight
NTSB Railroad Summary Report

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1 Investigation and Analysis

1.1 Accident Narrative

On September 30, 2010, about 4:05 p.m. central daylight time,1 Canadian National 

Railway (CN)2freight train U78982-30 (southbound train), consisting of three locomotives and 

116 railcars loaded with iron ore, collided head on with CN freight train U78983-30 (northbound 

train), consisting of three locomotives and 118 empty iron ore railcars. Prior to the collision, the 

southbound train was traveling about 15 mph and the northbound train was traveling about 

39 mph. Three locomotives and 14 railcars derailed. The five crewmembers on both trains were 

injured and transported to hospitals. Four crewmembers were treated and released, while the 

fifth crewmember required additional treatment in the hospital.

The collision occurred near milepost 13.5 on the Iron Range subdivision of the CN 

North division near Two Harbors, Minnesota (see figure 1). The estimated property damage was 

$8.1 million. At the time of the accident, the sky was clear, and the temperature was about 72°F.

The accident occurred on a single main track where the northbound train had track 

authority3to operate. The southbound train entered and operated on the single main track without 

authority. Table 1 provides information on the two trains.

Table 1. Train information.

Data type Southbound train Northbound train

Train designation U78982-30 U78983-30

Operational IDaIC 6258 South IC 6265 North

Railcars 116 loaded ore railcars 118 empty ore railcars

Train length 2,982 feet 3,035 feet

Train weight 11,974 tons 2,596 tons

a Operational IDs use one locomotive unit number (typically the lead locomotive) and direction of travel. Trains are referred to by 

their operational IDs on track authorities. The initials “IC” refer to Illinois Central, a railroad previously acquired by CN.

 

1 All times in this report are central daylight time.

2 The track upon which the accident occurred was owned by the Duluth, Missabe and Iron Range Railway 

Company (DM&IR), which was a subsidiary of CN. After the accident, DM&IR was merged into CN subsidiary 

Wisconsin Central Ltd. (WCL). DM&IR, WCL, and all of the other railroads indirectly or wholly owned by CN are 

collectively referred throughout this report as CN.

3

Track authority is a movement instruction issued by some railroad dispatchers/rail traffic controllers, 

including those at CN for a train to proceed on a designated segment of track. Some railroads use the term 

track warrants instead.
NTSB Railroad Summary Report

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Figure 1. This is an aerial photograph of the train collision.

1.2Events Preceding the Accident

The northbound train crew consisted of an engineer and a conductor. They reported for 

duty at Two Harbors Yard at 2:30 p.m. on the day of the accident. The northbound train crew 

departed Two Harbors at about 3:20 p.m. The crew initially received a track authority at 

3:23 p.m. to operate on the single main track to the north end of the Highland siding. They then

received a second track authority at 4:00 p.m. to operate on the single main track beyond the 

Highland siding to Allen Junction. These track authorities allowed the northbound crew to 

operate the train at the maximum authorized speed of 40 mph on the single main track as it 

approached the south end of the Highland siding. The engineer told investigators that as he was 

coming out of a curve just south of the Highland siding, he saw the headlight of the southbound 

train and applied emergency braking.

The southbound train crew consisted of an engineer, a conductor, and a student engineer. 

They are referred to as such throughout this report. They reported for duty at Two Harbors Yard 

at 4:30 a.m. on the day of the accident. The southbound train departed Two Harbors at 6:40 a.m. 

The student engineer was operating4the train and the engineer was with him in the cab of the 

controlling locomotive. The conductor elected to ride in the second locomotive during most of 

 

4 CN allows a qualified student engineer to operate a train while under the direct supervision of a qualified 

engineer.
NTSB Railroad Summary Report

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the trip. There were two seats on the left side of the lead locomotive, but the conductor said that, 

in his view, seating was inadequate for two people. One of the two seats on the left side of the 

leading locomotive was well padded and was equipped with armrests. The second seat had less 

padding and did not have armrests. Neither the engineer nor the student engineer objected to his 

decision to ride on the second locomotive. The second locomotive was located immediately 

behind the controlling (lead) locomotive and was facing in the same direction.

The southbound train initially proceeded north about 77 miles to US Steel’s Minntac 

Mine, at Mt. Iron, Minnesota, to be loaded with iron ore. The train arrived at Minntac Mine 

about 9:52 a.m. During loading operations, the conductor contacted the Two Harbors yardmaster 

to let him know the train was unlikely to be able to return to Two Harbors Yard before the

crewmembers reached their 12-hour time limit5at 4:30 p.m. The yardmaster advised the

conductor that they would be relieved by another train crew at the Highland siding. Around 

1:14 p.m., after the 116 railcars were loaded, the crew began the southward return trip along the 

same route toward Two Harbors (see figure 2).

During the southbound return trip, the student engineer operated the train from the mine 

to Allen Junction (a distance of about 31 miles) by the signal indications of a traffic control 

system that was controlled by a rail traffic controller (RTC)6at Homewood, Illinois. Between 

Allen Junction and Two Harbors (a distance of about 46 miles), the track was in nonsignaled 

territory and the train movement was controlled with track authorities issued to trains via radio 

by the RTC. The conductor copied7a track authority from the RTC authorizing movement from 

Allen Junction to South Fairbanks and, later, another authority to South Brimson8authorizing 

movement to the north end of Highland with an instruction to enter the siding. The conductor 

moved to the lead locomotive before reaching South Brimson to align a track switch. The 

conductor told investigators: “I gave it (the track authority form) to the engineer.” He also said 

that he had written out a second copy9for himself before returning to the second locomotive, 

where he stayed for the duration of the trip.

Upon arriving at the Highland siding, the student engineer stopped the train on the main 

track and the conductor aligned the hand-operated switch for the siding. As the train entered the 

siding at about 3:38 p.m., the conductor returned to the second locomotive. The student engineer 

operated the train into the Highland siding where he stopped north of the Highland Road grade 

crossing at about 3:42 p.m. From the second locomotive, the conductor informed the RTC by 

radio that the train was clear of the main track. The conductor released the track authority back to 

the RTC. The RTC informed the conductor that, instead of being relieved in the siding as 

originally planned, the Two Harbors yardmaster wanted the crew to bring the train as far as 

possible toward Two Harbors Yard (about 14 miles from Highland). Hearing this conversation 

on the radio, the locomotive engineer told the student engineer to start moving the train south in 

 

5

Federal regulations limit train crews to 12 hours on duty per shift.

6 CN refers to train dispatchers as RTCs.

7 Copying occurs when a train crewmember dictates information from the RTC onto a form and successfully 

repeats the information verbatim back to the RTC.

8 Brimson and Fairbanks are sidings. Authorities are issued for movement to one end of a siding; in this case, 

the south end.

9 CN provides pads of blank track authority forms and carbon paper to the conductors. The conductor of the 

southbound train stated he did not use carbon paper on this trip.
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the siding because they did not have much work time left and they needed to weigh10 the train 

before departing the Highland siding.

Figure 2. This is a map of the CN rail line between Two Harbors and the Minntac mine.

The student engineer moved the train south and changed the locomotive cab radio to the 

scale’s channel. The scale had an automated radio system to announce if the speed was too high 

for the weighing mechanism. Even though the radio was on the scale’s channel, the radio system 

was designed so that transmissions from the RTC would override the scale channel.

 

10 The Highland siding had a weigh-in-motion scale that required the train to move at about 3 mph until the 

entire train had cleared the scales.
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While the student engineer moved the train toward the scale, the RTC transmitted a new 

track authority to the conductor authorizing train movement south from Highland on the single 

main track to Two Harbors. This track authority was conditional, containing an after-arrival 

restriction. The southbound train was not to act on this authority until the northbound train had 

arrived.

11 The conductor was on the second locomotive when he copied this authority. On his 

first read-back attempt, the conductor made an error in the repeat process. The RTC caught the 

error and the conductor repeated the track authority correctly on his second attempt. The 

conductor completed the track authority form at 3:47 p.m. The southbound locomotive engineer, 

who was located in the lead locomotive, heard the RTC’s message and copied it onto a second 

track authority form.

Although the conductor was close by in the second locomotive, he did not walk up to the 

lead locomotive to deliver the engineer a copy of the track authority form and to ensure that the 

engineer and student engineer understood it, as required by CN rules and Federal Railroad 

Administration (FRA) regulations. Instead, the conductor said that he asked the engineer over the 

radio, “did you copy?” and that the engineer responded affirmatively. The engineer had copied 

the information onto a track authority form but had not read it back to the RTC. The 

crewmembers said that they never discussed this track authority among themselves. The engineer 

did not give the track authority to the student engineer to read and the student engineer did not 

ask him about it.

The student engineer told National Transportation Safety Board (NTSB) investigators

that when he had completed weighing the southbound train, the locomotive engineer instructed 

him to depart the Highland siding while making no mention of the after-arrival requirement 

contained in the track authority. The southbound train departed the Highland siding and entered 

the single main track at the Highland south siding switch without waiting for the arrival of the 

northbound train. Meanwhile, the northbound train crew had already received a track authority 

authorizing them to proceed at the maximum track speed of 40 mph past the Highland south 

siding switch on the main track. The southbound engineer said that he first saw the oncoming 

northbound train as it rounded a curve and that he told the student to apply the emergency 

brakes. Figure 3 shows the Highland siding and the point of collision.

NTSB investigators downloaded the event recorders from the lead locomotives of both 

accident trains and sent the files to the NTSB’s Vehicle Recorder division for evaluation and 

analysis. Both locomotive event recorders recorded 13 parameters, including throttle and braking 

information.

According to the event recorders, the southbound train was traveling at about 15 mph 

when, about 12 seconds before the collision, the pneumatic control switch was opened and the 

automatic brake pressure began to decrease. The southbound train’s speed decreased slightly, to 

about 13 mph, at the time of collision. The northbound train was traveling at about 39 mph prior 

to a reduction in its automatic brake pressure, about 10 seconds before the collision. The 

northbound train’s speed decreased to about 29 mph at the time of the collision. Sight distance 

 

11 In this case, the northbound train is not considered to have “arrived” at the Highland siding until the entire 

train had passed the south switch and the main track was clear for the southbound train to enter.
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observations conducted after the accident indicated that the crews of the two trains would have 

first been able to see the other train when they were about 1,295 feet apart.

Figure 3. This map depicts the point of collision.

Table 2 provides a timeline—based on event recorder data and crew interviews—of the 

southbound train’s movement and its crew’s actions upon reaching the Highland siding.

Table 2. Approximate timeline of southbound train at the Highland siding.

Time Events

3:37 p.m. Train stops short of the Highland north siding switch. Conductor aligns the switch for the 

siding and boards the second locomotive.

3:38 p.m. Train begins moving into the Highland siding.

3:42 p.m. Train stops in the siding north of the Highland Road grade crossing.

3:45 p.m. Train begins moving toward the scale after the RTC advises the conductor to get ready to 

copy another movement authority.

3:47 p.m. RTC issues complete (OK) timeafor track authority with an after-arrival track authority 

condition.

3:48 p.m. Train speed reduced to a steady 3 mph (scale speed).

4:01 p.m. Train speed and throttle increase after the last railcar is weighed.

4:05 p.m. Student engineer applies train emergency brakes.

a

The time the train crewmember successfully repeats the track authority information back verbatim to the RTC.
NTSB Railroad Summary Report

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1.3Factors Not Contributing to This Accident

The locomotives and the train railcars passed postaccident mechanical inspections. A 

review of preaccident testing and maintenance records for both trains did not reveal any 

problems. The weather at the time of the accident was clear, with no visual impairments. The 

postaccident toxicological tests for crewmembers of the two trains were negative for drugs or 

alcohol. Finally, the northbound train was where it was authorized to be and operating at the 

allowable speed. The NTSB concludes that the mechanical condition of the trains, the weather, 

drug or alcohol impairments, and the actions of the northbound train crew were not factors in this 

accident. 

1.4 After-Arrival Track Authorities on Nonsignaled Tracks

Track authorities are movement instructions issued by a train dispatcher or RTC. The 

FRA classifies track authorities as mandatory directives and, when issued by radio, they fall 

under regulations found at Title 49 Code of Federal Regulations (CFR) section 220.61. Track 

authorities authorize a train to move from one designated point to another designated point. 

Railroads use track authorities on both nonsignaled tracks and on tracks equipped with automatic 

block signals.12 When trains are enroute, track authorities typically are issued to crews by radio. 

On CN and most other railroads, a crewmember (usually the conductor) receives the radio 

transmission from the RTC, makes entries on a preprinted form, and then repeats the information 

back to the RTC verbatim. This is known as a read back. The read back step allows the RTC to 

verify that the information was copied correctly. If the read back is correct, the RTC 

acknowledges by issuing a complete (OK) time13 and then states his or her name. The employee 

copying the authority must repeat the complete time and the name of person issuing it.

One condition that an RTC may attach to a track authority is as an “after arrival.” With an 

after-arrival track authority, the permission to occupy a designated portion of single main track 

does not become effective until after the arrival of one or more opposing trains. In the 

Two Harbors accident, the last track authority received by the southbound train contained an 

after-arrival condition. This meant that the southbound train was not authorized to enter the 

single main track until after the arrival of the northbound train. In the Two Harbors case, this 

meant that the crew of the southbound train would have visually identified the northbound train 

by locomotive number (IC 6265) and then confirmed by radio contact with the passing train that 

it was the correct train, as listed on the track authority form.

The use of after-arrival track authorities allows RTCs to preestablish meeting points14 in 

advance of actual train arrivals at those locations. Reasons frequently cited for the use of 

after-arrival track authorities are that they allow better movement planning, save fuel, improve 

efficiency, minimize train delays, and reduce the time that road crossings are blocked.

 

12 Automatic block signals provide information to trains about the occupancy of the signal block (track segment) 

ahead. They do not authorize train movement.

13 Complete (OK) time is the time the train crewmember successfully repeats the track authority information 

back verbatim to the RTC.

14 Meeting points are locations where trains will pass.
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NTSB investigators asked all Class I railroads about the number of after-arrival track 

authorities issued during a typical 12-month period. The findings are shown in table 3.

Table 3. Approximate numbers of after-arrival track authorities issued.

Railroad After-arrival track authorities 

issued in signaled territory

After-arrival track authorities 

issued in nonsignaled territory

BNSF Railwaya118,353 35

CN 1,249 2,755

Canadian Pacific Railway 

Limited (CP)

675 23,250

CSX Transportationb0 0

Kansas City Southern Railway 

Company (KCS)

number not provided number not provided

Norfolk Southern Railroad (NS) 106,723 14,594

Union Pacific Railroad (UP) 80,069 11,680

a As a result of a head-on collision near Gunter, Texas, BNSF made a policy decision to reduce the number of after-arrival track 

authorities in nonsignaled territory to only those needed to (1) avoid blocking grade crossings or (2) set up meets during a 

dispatcher turnover.

b As a result of a head-on collision near Smithfield, West Virginia, CSX made a policy decision to discontinue the use of after-arrival 

track authorities.

1.4.1 Human Error and After-Arrival Track Authorities

Human performance literature describes many principles related to the nature of human 

errors.15 Many of these principles apply to the execution of after-arrival track authorities by train 

crews.

For example, when people must complete multiple steps to accomplish a task, they are 

more likely to miss the later steps in the sequence, rather than the earlier steps.16 Two of the most 

critical steps of the after-arrival track authority process are toward the end of the sequence: 

waiting until after the arrival of one or more opposing trains listed in the authority and then 

verifying that the train being met is the correct train.

When people encounter unexpected task interruptions during a sequential process, the 

procedural steps that follow are more prone to errors.17 This occurs because a person can lose his 

or her place in the required sequence and then restart the task actions at a point further along than 

appropriate. In the Two Harbors accident, the southbound train crew had expected to complete 

the trip at the Highland siding. After plans changed, they were required to copy another track 

authority, weigh the train, await the arrival of the northbound train, verbally confirm the train ID 

and, then, proceed. There was about a 15-minute period between the time the southbound train 

 

15 David D. Woods, Sidney Dekker, Richard Cook, Leila Johannesen, Nadine Sarter, Behind Human Error, 2nd ed. 

(Burlington: Ashgate, 2010); (b) J. Reason, “Combating Omission Errors Through Task Analysis and Good 

Reminders,” Quality and Safety in Health Care 11 (2002): 40–44, 2002.

16 Woods, Dekker, Cook, Johannesen, Sarter, Behind Human Error; (b) Reason, “Combating Omission Errors,” 

40–44.

17 Reason, “Combating Omission Errors,” 40–44.
NTSB Railroad Summary Report

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crew received the track authority and the time when the train reached the end of the 

Highland siding, where it should have stopped. During this time the crew needed to move the 

train to the scale, weigh the cars, and then move to the south end of the siding. This provided the 

opportunity for the crewmembers to lose their place in the process and neglect actions in the 

sequence, such as the after-arrival track authority.

The communication involved in issuing and executing an after-arrival track authority 

occurs in several stages: verbally from the RTC to the conductor, in writing when the conductor 

completes the form, verbally by the conductor reading the contents of the form back to the RTC, 

in writing when the conductor hands the engineer a copy of the form, and verbally among the 

conductor and crewmembers, preferably in person, during the briefing. Timeliness, accuracy, and 

comprehension must be accomplished without error by all participants at each stage of the 

communication process. If one or more participants fail to understand or properly execute the 

requirements, the after-arrival element of the track authority risks being misunderstood or 

overlooked.

Leading up to the Two Harbors accident, there were multiple communication errors and 

omissions. At the Highland siding, the conductor misstated the northbound train engine number 

during the first read-back dialogue. The RTC caught and corrected his error. When copying an 

earlier authority at Brimson, the conductor was on the lead locomotive with the engineer and 

student engineer as he copied, which facilitated face-to-face communication. However, at the 

Highland siding, the conductor did not walk to the lead locomotive for a briefing with the rest of 

the crew. The engineer did not discuss the track authority with the student engineer who was 

operating the train nor did he provide him with a copy. The student engineer did not ask to see a 

copy of the track authority or ask for a briefing on the contents.

In addition to potential communication failures in issuing or receiving after-arrival track 

authorities, there is also the risk of improper execution of these authorities. Execution of the 

track authority occurs through several stages. The crew must wait at the location named in the 

track authority. The crew must maintain a vigilant lookout for the train listed on the track 

authority. The crewmembers must visually identify the train being met as the one they are

waiting for and verbally contact that train, confirming it is the correct train. Only after these steps 

are complete can the crew begin the movement. These stages of behavior require sustained 

vigilance, accurate visual detection, effective verbal communication, and correct cognitive 

decision making to execute the track authority properly. Throughout these steps, the 

crewmembers may be involved in other work tasks that demand their attention and/or physical 

capabilities, such as operating the train slowly over a scale to weigh the cars. If fatigue, 

distraction, or work demands compete for the crew’s cognitive resources, there is a risk that the 

after-arrival track authority will be executed improperly. In the Two Harbors accident, all of 

these factors may have been at play. The potential for error increased when none of the 

crewmembers took steps to hold a briefing to discuss the track authority.

1.4.2 Risks of After-Arrival Authorities on Nonsignaled Track

The use of after-arrival track authorities in nonsignaled territory involves greater risk than 

in signaled territory. This is because automatic block signals provide redundancy by displaying 

indications about the track segment beyond the signal. Had there been a signal system in this 
NTSB Railroad Summary Report

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accident, the southbound train would have seen a red signal aspect at the south end of the 

Highland siding because the northbound train was approaching. This would have served as a 

reminder to the crewmembers that they had to meet a northbound train. In the absence of a signal 

system, there is nothing to remind a crew that there may be a train approaching and there is no 

restricted speed requirement. Although head-on collisions following train crew errors in 

executing after-arrival track authorities are uncommon, when they occur, they have catastrophic 

consequences.

The NTSB has previously expressed concerns regarding after-arrival track authorities in 

nonsignaled territory:18

Non-signaled (dark) territory presents a unique problem for rail safety. In dark 

territory, there are no signals to warn trains as they approach each other, and the 

avoidance of collisions relies solely on dispatchers and train crews adhering to 

operating procedures. Issuing after-arrival track warrants under these conditions 

only exacerbates an already potentially tenuous and contingent work situation. 

While the railroad industry contends that after-arrival track warrants facilitate the 

expedient and efficient movement of trains and reduce the amount of wasted 

resources, and the FRA sees merit in the industry’s logic, ultimately, the role of 

human error and the cost of human casualties also must be considered in this 

equation. The FRA acknowledges that, “until positive train control can be fully 

achieved, we need to take those steps that will decrease the risk of collisions that 

may occur as a result of employee error.”19 Yet, the FRA has not taken the 

proactive steps to address this issue as the Safety Board has recommended.

CSX Transportation, a large Class I railroad, discontinued the use of after-arrival track 

authorities in nonsignaled territory following an accident that occurred in 1996. CSX has been 

operating successfully without using after-arrival authorities in nonsignaled territory for well 

over 10 years. BNSF Railway, another large Class I railroad, discontinued the use of after-arrival 

authorities in nonsignaled territory in 2004 in all but a small handful of cases.20 The NTSB 

concludes that the use of after-arrival track authorities in nonsignaled territory presents 

unacceptable and unnecessary safety risks. CSX discontinued the use of after-arrival track 

authorities with no reported decrements to operational efficiency. As a result, CSX has not 

experienced an accident similar to the Smithfield, West Virginia, collision.

1.4.3 Previous NTSB Investigations Involving After-Arrival Track Authorities

This is not the first accident the NTSB has investigated in which a train crew did not 

adhere to the provisions of an after-arrival track authority in nonsignaled territory. Since 1996, 

the NTSB has investigated five high-consequence accidents that occurred due to human errors in 

executing after-arrival track authorities (see table 4).

 

18 Collision of Two Burlington Northern Santa Fe Freight Trains Near Clarendon, Texas, May 28, 2002, 

Railroad Accident Report NTSB/RAR-03/01 (Washington, DC: National Transportation Safety Board, 2003).

19 FRA letter to the NTSB dated October 3, 2003.

20 There have been 36 after-arrival track authorities issued in nonsignaled territory by BNSF during a recent 

12-month period.
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In 1996, in Smithfield, West Virginia,21 the NTSB investigated a head-on collision 

between two CSX Transportation freight trains. As a result of this accident, CSX Transportation 

discontinued the use of after-arrival track authorities in nonsignaled territory. There were no 

recommendations resulting from this investigation.

Table 4. NTSB investigations involving after-arrival track authority.

Accident Date Injuries Damages Human performance factors 

involved

Smithfield, WV

CSX

8/20/96 2 fatal, 1 injured $4.8 million Inadequate Crew Resource 

Management (CRM)

Devine, TX

UP

6/22/97 4 fatal > $6 million Dispatcher – Crew Communication

Clarendon, TX

BNSF

5/28/02 1 fatal, 3 injured > $8 million PED Use, Inadequate CRM

Gunter, TX

BNSF

5/19/04 1 fatal, 4 injured > $2 million PED Use, Dispatcher – Crew 

Communication, Inadequate CRM

Two Harbors, MN

CN

9/30/10 5 injured > $8 million PED Use, Potential Fatigue, Crew 

Communication, Inadequate CRM

Total 8 fatal, 12 injured > $28.8 million

In 1997, the NTSB investigated a collision between two UP freight trains in 

Devine, Texas.22 Because of this investigation, the NTSB issued Safety Recommendation 

R-98-27 to the FRA to require that railroads permanently discontinue the use of after-arrival 

track authorities in nonsignaled territory. The FRA responded by issuing a recommendation that 

railroads add a statement that the track authority contains a requirement to meet another train 

when a track authority contains an after-arrival condition. The FRA also recommended that 

railroads review their practices with a goal of reducing the number of after-arrival authorities 

issued. The NTSB responded that it was “disappointed with FRA’s decision not to prohibit the 

use of after-arrival orders.” Safety Recommendation R-98-27 was classified 

“Closed―Unacceptable Action” on June 29, 1999.

In 2002, the NTSB investigated a collision between two BNSF freight trains in 

Clarendon, Texas.23 From this investigation, the NTSB recommended that the FRA limit the use 

of after-arrival orders in nonsignaled territory to trains that have stopped at the location at which 

they will meet the opposing train (Safety Recommendation R-03-2). The FRA did not implement 

Safety Recommendation R-03-2 and the FRA advised the NTSB that it found merit in the 

industry’s assertion that requiring a train to be stopped at the meeting point before issuing an 

after-arrival track authority would reduce dispatcher (or RTC) flexibility and potentially increase 

the amount of time grade crossings were blocked; delay trains; and increase fuel usage, air and 

noise pollution, brake shoe wear, and crew fatigue. The NTSB responded on August 6, 2004: 

 

21 Head-On Collision, Trains Q317-19 and Q316-18, CSXT Railroad, Smithfield, West Virginia, 

August 20, 1996, Railroad Accident Brief NTSB/RAB-98/13 (Washington, DC: National Transportation Safety 

Board, 1998).

22 Collision and Derailment of Union Pacific Railroad Freight Trains 5981 North and 9186 South in 

Devine, Texas on June 22, 1997, Railroad Accident Report NTSB/RAR-98/02 (Washington, DC: National 

Transportation Safety Board, 1998).

23 NTSB/RAR-03/01.
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“FRA staff indicated that the agency was planning no further action in response to this 

recommendation. Given the FRA's position and the Safety Board's continued belief in the 

recommendation's merit, the Board has no alternative but to classify Safety Recommendation 

R-03-2 “Closed―Unacceptable Action.” The NTSB notes that several Class I railroads have 

voluntarily adopted this practice.

In 2004, the NTSB investigated a collision between two BNSF freight trains near 

Gunter, Texas.24 The NTSB determined that the probable cause of the accident was the 

southbound train (BNSF 6789 South) crew’s failure to adhere to an after-arrival track warrant 

requiring them to stay at Dorchester until the northbound train (BNSF 6351 North) arrived. From 

this accident investigation, the NTSB made the following safety recommendation to the FRA:

Prohibit the use of after-arrival track warrants for train movements in dark 

(non-signaled) territory not equipped with a positive train control system. 

(R-06-10) (Open—Unacceptable Response)

In the Gunter, Texas, report, the NTSB noted:

The FRA has declined to implement the NTSB’s safety recommendations to 

prohibit the use of after-arrival track warrants. The FRA has indicated that 

disallowing after-arrival authorities in non-signaled territory would reduce 

flexibility and hinder the efficient movement of trains. The FRA also has stated 

that it expects that railroad employees will adhere to all applicable operating 

rules. The NTSB has investigated too many accidents in which the avoidance of 

the accident depended on the use of an operating rule or standard practice that 

proved to be insufficient to prevent accidents caused by human error. The NTSB 

is concerned about the FRA’s failure to prohibit the use of after-arrival track 

warrants in non-signaled territories, as previously recommended.

In the Gunter, Texas, report, the NTSB expressed concern about the FRA’s failure to act 

and cited a meeting of NTSB and FRA staff that occurred before the Gunter, Texas, collision, on 

March 17, 2004. During discussions of Safety Recommendation R-03-2, staff from the FRA 

stated that although they shared concerns about the risks of after-arrival orders, they were 

reluctant to prohibit their use at that time. However, the FRA staff did state that if another 

accident occurred because of an after-arrival order, the FRA would issue an emergency order. 

Two months later, on May 19, 2004, the Gunter, Texas, accident occurred. Now, after nine years, 

the FRA still has not taken any specific action to require railroads to discontinue the use of 

after-arrival track authorities.

The CN rule on issuing track authorities that was in effect at the time of the Two Harbors 

accident met all FRA regulatory requirements except for the specific requirement that the 

conductor and engineer ensure that all crewmembers have read and understand the directive. CN 

had Operating Rule 104 in effect at the time of the accident, which required engineers and 

conductors to “ensure their subordinates were familiar with their duties.” CN officials stated that 

they felt this addressed the regulatory requirement. After the accident and on the advice of 

 

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

Accident Report NTSB/RAR-06/02 (Washington, DC: National Transportation Safety Board, 2006).
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the FRA, CN added language to the rule explicitly requiring the conductor and engineer to 

ensure that all crewmembers read and understand the track authority.

1.4.4 Class I Railroad Actions to Improve After-Arrival Authority Processes

Several Class I railroads have implemented procedural safeguards on the use of 

after-arrival track authorities, above FRA minimum requirements. For example, NS requires the 

engineer on a train restricted by an after-arrival track authority to contact the engineer on the 

other train to determine that they are, or will be, clear one mile in advance of approaching the 

meeting point. NS also requires the conductor to remind the engineer of the meeting point 

two miles before reaching it. Both BNSF and NS require dispatchers to advise crews that they 

will be receiving an after-arrival track authority and to provide the identification of the train 

being met. Both BNSF and UP require that the restricted train be stopped at the meeting location 

before the after-arrival track authority can be issued.25

BNSF has significantly reduced the use of after-arrival track authorities in nonsignaled 

territory. It has also added several additional levels of safety redundancy on the use of 

after-arrival track authorities in nonsignaled territory. The following are key elements of this 

process for issuing after-arrival track authorities in nonsignaled territory:

The issuance of after-arrival track authorities in nonsignaled territory is restricted to 

(1) locations where public grade crossings would otherwise be blocked for extended 

periods of time and (2) train meets that would occur during the train dispatcher shift 

change.

The crew of the train that would be receiving the after-arrival track authority must 

make radio contact with the crew of the train it will meet and advise the train dispatcher 

that the contact was made.

The crew of the train to receive the after-arrival track authority must notify the 

dispatcher when it has stopped at the meeting point.

The dispatcher may issue the after-arrival track authority only after the previous steps 

have been completed.

The crew of the train that is to receive the after-arrival track authority must make radio 

contact for the second time with the crew of the train it has been waiting for to confirm 

that it has actually passed the meeting point.

Following that confirmation, the train crew must document the met train’s ID, the 

meeting point, and the meeting time on the form.

 

25 NTSB recommended that the FRA require that trains be stopped at the meeting point before an after-arrival 

track authority was issued. The FRA did not act on this recommendation and it is classified “Closed―Unacceptable 

Action.”
NTSB Railroad Summary Report

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BNSF also installed recording equipment in radio towers covering nonsignaled territory 

to allow auditing of compliance with the more stringent radio communication protocols. BNSF 

advised NTSB investigators that every after-arrival authority used for nonsignaled track is 

reviewed against the recorded audio to verify communication requirements were completed

successfully. Appendix B contains a comparative summary of the BNSF and CN railroad 

after-arrival track authority processes.

1.4.5 NTSB Position on After-Arrival Track Authorities in Nonsignaled Territory

Errors in communication, judgment, and action resulted in noncompliance with the 

after-arrival track authority procedures. The limits of human cognition and behavior provide a 

basis to expect continued errors with after-arrival track authorities unless additional safeguards 

are implemented. Successful execution of after-arrival track authorities depend on error-free 

human performance, which is unlikely without additional safeguards since fatigue, distraction, 

and competing tasks may interfere with the after-arrival track authority communication and 

execution process. The NTSB concludes that the use of the after-arrival track authorities in 

nonsignaled territory presents unacceptable and unnecessary safety risks to railroad operational 

safety, because the procedure is vulnerable to human error and lacks inherent safety 

redundancies ensuring consistent safe operation.

The NTSB recognizes that a positive train control (PTC) system provides the most 

effective means to avoid train collisions. However, as the NTSB recognized in the investigation 

of the Gunter, Texas, collision:

26

...even if PTC becomes more widely adopted, the current non-signaled areas of 

the U.S. railroad network will probably be among the last to be outfitted with PTC 

for the same reasons they remain non-signaled now―train volume and type of 

traffic.

The NTSB is disappointed that the FRA has not implemented Safety Recommendation 

R-06-10. However, the NTSB is encouraged that CSX Transportation recognized the significant 

risk of after-arrival track authorities in nonsignaled territory and voluntarily discontinued their 

use. BNSF has also recognized the higher risk of after-arrival track authorities on nonsignaled 

track and has implemented policies that substantially limit their use in nonsignaled territory. The 

NTSB concludes that, in the absence of a PTC system, discontinuing the use of after-arrival track 

authorities in nonsignaled territory will mitigate future accidents involving authority overruns.

Many miles of the US railroad network will not fall under FRA PTC mandates, and CN 

officials verified that PTC would not be installed in the Two Harbors accident area when PTC 

requirements take effect. Therefore, the NTSB reiterates Safety Recommendation R-06-10 to the 

FRA and encourages the FRA to take immediate and appropriate action. The NTSB also 

recommends that CN discontinue the use of after-arrival track authorities in nonsignaled territory 

not equipped with PTC.

 

26 NTSB/RAR-06/02.
NTSB Railroad Summary Report

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As a result of the Gunter, Texas, accident, the NTSB made the following safety 

recommendation to BNSF Railroad:

Discontinue the use of after-arrival track warrants for train movements in dark 

(non-signaled) territory not equipped with a positive train control system. 

(R-06-12)

BNSF responded that the railroad had implemented procedures to significantly reduce the 

number of after-arrival track authorities used in nonsignaled territory and implemented 

additional procedural safeguards. NTSB classified safety recommendation R-06-12 

“Open―Unacceptable Response” on September 7, 2007. NTSB appreciates that BNSF has 

recognized the risks of using after-arrival track authorities in nonsignaled territory and has taken 

steps to reduce the frequency of their use on BNSF, as well as clarified and tightened 

communication protocols. However, NTSB remains convinced that the use of after-arrival track 

authorities in nonsignaled territory is a flawed process with inherent risks that will inevitably 

result in future accidents. Therefore, NTSB reiterates safety recommendation R-06-12 to BNSF.

As a result of the Devine, Texas, collision, NTSB made the following safety 

recommendation to UP:

Discontinue permanently the use of after-arrival orders in dark (nonsignalized) 

territory. (R-98-25)

UP advised NTSB that the railroad had discontinued the use of after-arrival track 

authorities in nonsignaled territory shortly after the Devine, Texas, accident and that they had no 

intention of reestablishing the practice. Based on this assurance, Safety Recommendation 

R-98-25 was classified “Closed―Acceptable Action” on July 23, 2001. However, at some point 

later, UP did, in fact, reestablish the use of after-arrival track authorities in nonsignaled territory. 

The NTSB is disappointed that UP made the choice to resume the use after-arrival track 

authorities in nonsignaled territory and that, other than CSX, no Class I railroads have 

discontinued their use. Therefore, NTSB recommends that UP, CP, KCS, and NS discontinue the 

use of after-arrival track authorities for train movements in nonsignaled territory not equipped 

with a PTC system.

While the Class I railroads account for the bulk of train movements in the United States, 

various short line and regional railroads may also use after-arrival track authorities in their 

operations; however, these roads are too numerous to address individually. As a result of the 

Gunter, Texas, accident, the NTSB made the following safety recommendation to the American 

Short Line and Regional Railroad Association.

Encourage your members to discontinue the use of after-arrival track warrants for 

train movements in dark (non-signaled) territory not equipped with a positive 

train control system. (R-06-13)

Because Safety Recommendation R-06-13 is over six years old, and the NTSB has 

received no indication that the American Short Line and Regional Railroad Association has 

taken action on it, the recommendation was recently classified “Open―Unacceptable Action.” 

The NTSB reiterates Safety Recommendation R-06-13 to the American Short Line and Regional 
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Railroad Association to inform its members of the circumstances of this accident and urge them 

to discontinue the use of after-arrival track authorities for train movements in nonsignaled 

territory not equipped with a PTC system.

1.5Fatigue

The NTSB investigation reviewed CN work records for the five crewmembers involved 

in the accident. Table 5 presents the work histories for the five crewmembers, based on CN 

records. For the crewmembers of the southbound train, the accident occurred in the final hour of 

their 12-hour work shift; whereas, for the northbound train crewmembers, the accident occurred 

about 2 hours after the start of their work shift.

Table 5. Crew work history.

Crewmember Monday 9/27 Tuesday 9/28 Wednesday 9/29 Thursday 9/30

Southbound 

engineer 

On duty: 6:20 a.m.

Off duty: 9:10 a.m.

On duty: 10:00 p.m.

Off duty: 

8:45 a.m.

On duty: 3:30 a.m.

Off duty: 3:30 p.m.

On duty: 4:30 a.m.

Off duty: accident

Southbound 

conductor 

Did not work Did not work On duty: 3:30 a.m.

Off duty: 3:30 p.m.

On duty: 4:30 a.m.

Off duty: accident

Southbound 

student engineer 

On duty: 8:50 p.m. Off duty: 

8:45 a.m.

On duty: 3:30 a.m.

Off duty: 3:30 p.m.

On duty: 4:30 a.m.

Off duty: accident

Northbound 

engineer 

Did not work Did not work On duty: 11:30 a.m.

Off duty: 11:10 p.m.

On duty: 2:00 p.m.

Off duty: accident

Northbound 

conductor 

On duty: 10:45 a.m.

Off duty: 10:41 p.m.

Did not work On duty: 8:00 a.m.

Off duty: 6:20 p.m.

On duty: 2:00 p.m.

Off duty: accident

All crewmembers had received at least the minimum amount of time off duty as required 

by federal regulations. However, the NTSB recognizes that simply meeting regulatory 

requirements for time off duty does not ensure that crewmembers arrive and remain alert 

throughout their on-duty work shifts. The causes, symptoms, and consequences of fatigue are 

varied. As discussed below, the human factors of physiological fatigue, disruption to circadian 

rhythms, and continuous hours of wakefulness affected the alertness of crewmembers.

1.5.1 Physiological Fatigue

The length of sleep that an individual needs each night varies with genetics, circadian 

timing, sleep debt, and other factors.27 The National Sleep Foundation believes that adults need 

7 to 9 hours of sleep each night.28 On the day before the accident, the southbound train conductor 

had the opportunity to obtain about 3 hours, 45 minutes of sleep; on the prior day, he had the 

opportunity to obtain just over 6 hours of sleep. Likewise, the southbound train student engineer 

had the opportunity to obtain about 4 hours, 45 minutes of sleep the day before the accident, and 

 

27 M. Carskadon and W. Dement, “Normal Human Sleep: An Overview,” in Principles and Practice of Sleep 

Medicine, 4th Edition, ed. M. Kryger, T. Roth, and W. Dement (Philadelphia: Elsevier-Sanders, 2005).

28 "How Much Sleep Do We Really Need?" National Sleep Foundation, accessed November 23, 2010, 

http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need.
NTSB Railroad Summary Report

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about 8 hours, 30 minutes of sleep over two separate periods on the prior day. Their actual 

amount of sleep was less than their sleep opportunity time.

While one night of reduced sleep opportunity time may not significantly degrade 

performance, the southbound train’s conductor and student engineer had reduced sleep 

opportunity time for at least two nights prior to the accident. Chronic partial sleep restriction 

results from a repeated reduction in the amount of sleep a person gets. Scientific literature has 

shown that as little as two hours less sleep than normal is associated with impairment of 

performance and alertness.29

1.5.2 Disruption of Circadian Rhythms

Human physiology fluctuates over the 24 hours of a day; that is known as circadian 

rhythm. Examples of human physiological processes showing circadian rhythms include: body 

temperature, heart rate, blood pressure, and “sleepiness” or alertness.30 For alertness, subjective 

sleepiness and performance degradation are most pronounced during the low phases of the 

circadian cycle,31occurring between midnight and 6:00 a.m., and, again, between 2:00 p.m. and 

5:00 p.m.

The review of CN work records also indicated that the southbound train engineer had 

started his work shifts at different times on several days preceding the accident (i.e., 4:30 a.m. on 

September 30; 3:30 a.m. on September 29; 8:45 a.m. on September 28; and 6:20 a.m. on 

September 27). People often require several days to adjust, both physically and psychologically, 

to shifts in their sleep schedules. Moreover, shifting on-duty and off-duty times can lead to sleep 

difficulties; that is, irregular work schedules disrupt circadian rhythms and sleep patterns, leading 

to fatigue. The southbound train engineer was affected by circadian disruptions; and, 

consequently, likely suffered from fatigue-induced performance impairments. However, the 

investigation did not reveal detailed information on the southbound train engineer’s sleep 

patterns or off-duty activities, because he was unable to provide any information about his 

sleep/awakening in the days prior to the accident.

1.5.3 Continuous Hours of Wakefulness

The length of time a person has been awake and their total time-on-task have been 

associated with increased risk of fatigue. Continuous hours of wakefulness exceeding 16 hours 

has been found to result in deficits equivalent to those seen in individuals with blood alcohol 

 

29 M.A. Carskadon, “Sleep Restriction,” Sleep, Sleepiness and Performance, ed. T.H. Monk, 

(Chichester, England: John Wiley & Sons, 1991) 155–167. For comparison, evidence exists showing that a two-hour 

sleep debt produces performance decrements comparable to those produced by a blood alcohol level of 

0.045 percent and that a four-hour sleep debt produces performance decrements comparable to a blood alcohol level 

of 0.095 percent. T. Roehrs, E. Burduvali, A. Bonahoom and others, “Ethanol and Sleep Loss: A ‘Dose’ Comparison 

of Impairing Effects,” Sleep, 26, no. 8 (2003): 981-985.

30 Kroemer, K.H.E.; Kroemer, H.J.; and Kroemer-Elbert, K.E., Engineering Physiology: Bases of Human 

Factors/Ergonomics, 2nd ed., (New York: Van Nostrand Reinhold, 1990) 176.

31 H.P.A. Van Dongen and D. Dinges, “Circadian Rhythms in Sleepiness, Alertness, and Performance,” in 

Principles and Practice of Sleep Medicine, 4th Edition, ed. M. H. Kryger, T. Roth, and W.C. Dement (March 2005).
NTSB Railroad Summary Report

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content values between 0.05 percent and 0.1 percent.

32 With respect to time-on-task, studies have 

shown that the risk of accidents increases exponentially beyond the eighth or ninth hour at 

work.33

Twelve-hour work shifts have been associated with fatigue-related performance 

decrements. One study found “decreased performance (187 percent more errors) and increased 

sleepiness (66 percent) for workers of a 12-hour shift during their last 4 hours on shift.”34 Thus, 

the southbound train crew was at a high risk of fatigue-induced performance problems.

The three southbound train crewmembers had been awake for between 13 and 14 hours at 

the time of the accident. The accident occurred during the final hour of a 12-hour shift for the 

crew. Their potential continuous hours of wakefulness ranged from over 13 hours in the case of 

the student engineer to almost 14 hours in the case of the engineer and conductor at the time of 

the accident. Since the accident occurred at 4:05 p.m., which corresponds to a low phase in the 

circadian rhythm, the crew likely experienced reduced alertness and cognitive functioning in the 

time period leading up to the accident. The consequences of these fatigue-induced performance 

problems in one’s work environment usually results in a reduction in safety, efficiency, and 

productivity. Specific signs of fatigue-related performance problems include: reduced

decision-making ability, reduced ability to perform complex planning, reduced communications

skills, reduced reaction time, increased forgetfulness, and increased manual and cognitive errors.

These signs of fatigue were identified in the NTSB investigation of this accident. Therefore, 

based on physiological fatigue, disruption to circadian rhythms, and extended continuous hours 

of wakefulness, the southbound train crew was fatigued.

1.5.4 Lack of Crew Coordination and Communication

The circumstances of this accident suggest that fatigue played a role in the events leading 

up to the accident. The conductor elected to remove himself from the lead locomotive and 

remain on the second locomotive unit for much of the trip, thereby physically isolating himself 

from the engineer and student engineer. Being located in the second unit by himself would have 

provided him an opportunity to nap or sleep. When the final track authority before the accident 

was issued by the RTC, the conductor incorrectly repeated the engine number of the northbound 

train his train was scheduled to meet, an error that was detected by the RTC. Such an error could 

be attributed to reduced cognitive functioning associated with fatigue. Furthermore, he did not 

walk to the first locomotive unit and discuss the contents of the track authority with the engineer 

and student engineer, as was required by CN rules and FRA regulations. The willful lack of 

effective communications and coordination among the crewmembers most likely was due to their 

 

32 (a) D. Dawson and K. Reid. “Fatigue, Alcohol, and Performance Impairment,” Nature 388, (1997): 235; 

(b) A.M. Williamson and A.M. Feyer, “Moderate Sleep Deprivation Produces Impairments in Cognitive and Motor 

Performance Equivalent to Legally Prescribed Levels of Alcohol Intoxication,” Occupational and Environmental 

Medicine 57, (2000) 649-655.

33 K. Hanecke, S. Tiedemann, F. Nachreiner, and H. Crzech-Sukalo, “Accident Risk as a Function of Hours at 

Work and Time of Day as determined from Accident Data and Exposure Models for the German Working 

Population,” Scandinavian Journal of Work, Environment, and Health, 24 no. 3 (1998): 43-48.

34 R.R. Rosa, M.J. Colligan, and P. Lewis, “Extended Workdays: Effects of 8-Hour and 12-Hour Rotating Shift 

Schedules on Performance, Subjective Alertness, Sleep Patterns, and Psychosocial Variables,” Work and Stress 3 

no. 2 (1989): 21-32.
NTSB Railroad Summary Report

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fatigue. Therefore, the NTSB concludes that fatigue-induced performance errors contributed to 

the accident.

The NTSB has identified fatigue as a factor in numerous transportation accidents, the 

most recent railroad accident investigation involving fatigue was a rear-end collision that 

occurred near Red Oak, Iowa, on April 17, 2011, that resulted in fatalities to both crewmembers 

on the striking train and over $8.7 million in damage. The NTSB’s investigation determined that 

both crewmembers on the striking train had fallen asleep due to fatigue. The NTSB noted that 

the Rail Safety Improvement Act (RSIA) passed by Congress in 2008 mandated that railroads 

develop fatigue management plans. The Red Oak, Iowa, accident report described the RSIA 

requirements and FRA’s implementation as follows:

The RSIA gives railroads 4 years after enactment of the law in which to develop 

these plans, which must include methods to manage and reduce fatigue 

experienced by railroad employees in safety-related positions and to reduce the 

likelihood of accidents, incidents, injuries, and fatalities caused by fatigue. There 

are several elements to the RSIA‘s fatigue management plan requirements, many 

of which are relevant to this accident. Three of these elements are listed here and 

discussed below:

Employee education and training on the physiological and human factors 

that affect fatigue, as well as strategies to reduce or mitigate the effects of 

fatigue, based on the most current scientific and medical research and 

literature.

Opportunities for identification, diagnosis, and treatment of any medical 

condition that may affect alertness or fatigue, including sleep disorders.

Scheduling practices for employees, including innovative scheduling 

practices, on-duty call practices, work and rest cycles, increased 

consecutive days off for employees, changes in shift patterns, appropriate 

scheduling practices for varying types of work, and other aspects of 

employee scheduling that would reduce employee fatigue and cumulative 

sleep loss.

In a December 19, 2011, letter, the FRA advised the NTSB that it is currently in the 

process of drafting guidance for railroads to develop fatigue management plans as part of a larger 

railroad risk-reduction program. The guidance is expected to be issued in early 2013. The FRA 

also has recently formed a Railroad Safety Advisory Committee (RSAC) working group to 

provide advice on developing fatigue management plans.

On June 11, 2012, in coordination with the Volpe Center; Harvard Medical School, 

Division of Sleep Medicine; and the WGBH Educational Foundation; the FRA launched a 

Railroader Guide to Health Sleep website (http://www.railroadersleep.org). The website provides 

information to train crewmembers about fatigue and its countermeasures. This is an initial step 

by the FRA and other stakeholders to implement a fatigue guidance resource. Discussions with 

the FRA disclosed that the FRA is drafting rule text, which it will present to the RSAC in 
NTSB Railroad Summary Report

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April 2013. Task teams from the RSAC are working on additional fatigue guidance information. 

The development and implementation of fatigue management plans will be an important step in 

improving railroad safety. In the Red Oak, Iowa, investigation, the NTSB recommended that the 

FRA:

Establish an ongoing program to monitor, evaluate, report on, and 

continuously improve fatigue management systems implemented by 

operating railroads to identify, mitigate, and continuously reduce 

fatigue-related risks for personnel performing safety-critical tasks, 

with particular emphasis on biomathematical models of fatigue. 

(R-12-17)

The FRA responded in a letter dated July 31, 2012, stating that it was working with an

RSAC working group to develop a regulation document responsive to RSIA requirements. The 

letter also advised NTSB that FRA had developed a fatigue risk management systems guidance 

document. Safety Recommendation R-12-17 is classified “Open―Acceptable Response.” The 

NTSB appreciates that FRA is taking these steps and takes this opportunity to reiterate Safety 

Recommendation R-12-17 to the FRA.

1.6 Use of Portable Electronic Devices

NTSB investigators obtained cell phone records for the five crewmembers involved in the 

accident. The records indicated that four of the five crewmembers had used their cell phones 

while on duty on the day of the accident.

CN operating rules and FRA regulations prohibit the use of cell phones and other 

portable electronic devices (PED) while on duty when (1) the train is in motion or (2) when a 

crewmember is on the ground (off the locomotive). CN operating rules prohibit text messaging at 

any time when on duty. Figure 4 shows the cell phone usage for the southbound and northbound 

train crews; most of the unauthorized cell phone use involved text messaging or occurred while 

the trains were moving or while the southbound train conductor was on the ground. In addition, 

one 33-second call made by the northbound train engineer at 3:39 p.m. occurred while the train 

was moving and he was at the controls. The records indicate that the northbound train conductor 

did not engage in any cell phone activity.

The NTSB concludes that the use of cell phones by crewmembers on the southbound 

train and by the engineer on the northbound train was a distraction to the safe operation of both 

trains and an indication of a clear disregard for CN rules and FRA regulations.

The NTSB recognizes that PED usage is a significant factor underlying many forms of 

transportation accidents. Moreover, the NTSB has advocated for the prohibition of unauthorized 

use of PEDs in railroad operations.
NTSB Railroad Summary Report

21

Figure 4. This graphic shows cell phone use by the southbound and northbound train crews 

during the accident trip.

In its investigation of a May 28, 2002, collision of two BNSF freight trains near 

Clarendon, Texas,35 the NTSB determined the probable cause of the accident was, “the coal train 

engineer’s use of a cell phone during the time he should have been attending to the requirements 

of the track warrant for his train.” As a result of that investigation, the NTSB made the following 

safety recommendation to the FRA:

Promulgate new or amended regulations that will control the use of cellular 

telephones and similar wireless communication devices by railroad operating 

employees while on duty so that such use does not affect operational safety. 

(R-03-1)

Following the Chatsworth, California, collision, the FRA published Emergency Order 26 

restricting PED use by on-duty operations personnel. As a result of this action, the NTSB 

classified Safety Recommendation R-03-1 “Closed―Acceptable Alternate Action.”

During the investigation of the May 19, 2004, Gunter, Texas, collision,36 the NTSB noted 

that the engineer of the train that overran its authority had been on his cell phone at the time that 

 

35 NTSB/RAR-03/01.

36 NTSB/RAR-06/02.
NTSB Railroad Summary Report

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the conductor had experienced difficulty in copying an earlier track authority. The 

Gunter, Texas, investigation found that rules did not deter “frequent use [of cell phones] by all 

crew members of the two accident trains while the trains were in motion.”

On September 12, 2008, a westbound Southern California Regional Rail Authority 

Metrolink train collided head on with an eastbound UP Railroad freight train near 

Chatsworth, California.37 The accident resulted in 25 fatalities, including the engineer of the 

Metrolink train, and 102 injured passengers. The NTSB noted as part of the probable cause, the 

locomotive engineer “...was engaged in prohibited use of a wireless device, specifically text 

messaging that distracted him from his duties.” As a result of this investigation, the NTSB made 

two safety recommendations to the FRA:

Require the installation, in all controlling locomotive cabs and cab car operating 

compartments, of crash- and fire-protected inward- and outward-facing audio and 

image recorders capable of providing recordings to verify that train crew actions 

are in accordance with rules and procedures that are essential to safety as well as 

train operating conditions. The devices should have a minimum 12-hour 

continuous recording capability with recordings that are easily accessible for 

review, with appropriate limitations on public release, for the investigation of 

accidents or for use by management in carrying out efficiency testing and 

systemwide performance monitoring programs. (R-10-1)

Require that railroads regularly review and use in-cab audio and image recordings 

(with appropriate limitations on public release), in conjunction with other 

performance data, to verify that train crew actions are in accordance with rules 

and procedures that are essential to safety. (R-10-2)

Both safety recommendations were originally classified “Open―Acceptable Response.” 

While the FRA has indicated that it is favorable to the concept of using audio and imaging

technology in locomotives and cab cars, it has yet to directly address the implementation of these 

specific safety recommendations. Pending a concrete action by the FRA to require that all 

locomotives and cab cars operated under 49 CFR Part 229 be equipped with a crash- and 

fire-protected inward- and outward-facing audio and image recorders, Safety Recommendations 

R-10-1 and -2 are classified “Open―Unacceptable Response.”

The NTSB urges the FRA to promptly initiate rulemaking activity for the audio and 

imaging requirements outlined in Safety Recommendations R-10-1 and -2 and reiterates these 

two recommendations. By taking action now on the NTSB cab audio and image recorder 

recommendations, the FRA will require locomotive manufacturers to implement important safety 

improvements. NTSB accident investigations conducted since the issuance of these 

recommendations further demonstrate how cab audio and image recorders can play a key role in 

identifying and deterring unsafe acts as well as by providing critical human performance and cab 

environment information for accident investigations that would otherwise be unavailable. The 

 

37 Collision of Metrolink Train 111 with Union Pacific Train LOF65-12, Chatsworth, California, 

September 12, 2008, Railroad Accident Report NTSB/RAR-10/01 (Washington, DC: National Transportation Safety 

Board, 2010).
NTSB Railroad Summary Report

23

NTSB, therefore, encourages the FRA to move quickly to implement the NTSB’s audio and 

imaging recommendations.

In its most recent response to the NTSB on July 31, 2012, the FRA advised that it 

recognized the value of cameras and voice recordings for accident investigations. It also 

indicated awareness of “significant privacy concerns” and the belief that implementing the 

recommendations would erode employee morale and might result in selective enforcement and 

retaliation. The NTSB is disappointed that more than four years after the deadliest passenger 

train accident in decades, the FRA has not acted on two recommendations that would protect 

railroad employees, as well as the public. Therefore, the NTSB reiterates Safety 

Recommendations R-10-1 and -2 to the FRA.

Following the Chatsworth, California, accident and the many others preceding it that 

involved improper PED usage, the FRA issued Emergency Order 26 on October 7, 2008.38 In the 

findings supporting the issuance of the emergency order, the FRA highlighted the need to 

“eliminate this source of extremely dangerous distraction in the railroad operating environment.”

FRA Emergency Order 2639 contained three major components and included the 

following requirements:

(1) Each personal electronic or electrical device must be turned off with any 

earpieces removed from the ear while on a moving train, except that, when 

radio failure occurs, a wireless communication device may be used in 

accordance with railroad rules and instructions.

(2) Each personal electronic or electrical device must be turned off with any 

earpieces removed from the ear when a duty requires any railroad 

operating employee to be on the ground or to ride rolling equipment 

during a switching operation and during any period when another 

employee of the railroad is assisting in preparation of the train 

(e.g., during an air brake test).

(3) Use of a personal electronic or electrical device to perform any function 

other than voice communication while on duty is prohibited. In no 

instance may a personal electronic or electrical device interfere with the 

railroad operating employee’s performance of safety-related duties.

On September 27, 2010, the FRA published a final rule codifying the requirements of 

Emergency Order 26, prohibiting the unauthorized use of cell phones and other electronic 

devices by on-duty railroad operating employees at 49 CFR Part 220 Subpart C. The final rule 

became effective on March 28, 2011. At the time of the accident, CN’s operating rules were 

consistent with the restrictions in Emergency Order 26, with the added restriction that text 

 

38 Federal Railroad Administration, “Emergency Order To Restrict On-Duty Railroad Operating Employees’ 

Use of Cellular Telephones and Other Distracting Electronic and Electrical Devices,” Title 73

Federal Register 58702 (October 7, 2008) was in effect at the time of this accident. The FRA has since promulgated 

a regulation.

39 Title 73 Federal Register 58702 (October 7, 2008).
NTSB Railroad Summary Report

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messaging was not permitted at any time. The CN rules on PED use that were in effect at the 

time of the accident are shown in appendix C.

On May 8, 2009, Massachusetts Bay Transportation Authority Green Line Train 3612 

struck the rear end of a standing train. Sixty-eight passengers and crewmembers were injured, 

and damages exceeded $9 million. The NTSB again found that PED usage was part of the 

probable cause, remarking that the train operator was “...engaged in [the] prohibited use of a 

wireless device, specifically text messaging that distracted him from his duties.”40

The circumstances of PED misuse in the Two Harbors accident, as well as the series of 

previous accidents discussed earlier in this report, highlight a persistent and pervasive safety 

hazard in the rail industry; that is, the unauthorized use of PEDs by on-duty crewmembers is too 

difficult to prevent by rules, policies, and punitive consequences. The use of PEDs has become, 

and likely will continue to be, engrained in our daily lifestyles. Consequently, procedural 

guidelines and enforcement offer little, if any, assurance that all on-duty train crewmembers will 

refrain from PED misuse. Therefore, additional measures that prevent unauthorized PED use by 

on-duty train crewmembers are needed. The NTSB concludes that additional measures to prevent 

unauthorized PED use by train crewmembers is necessary because of the continuing use of these 

devices by some railroad crewmembers, and the resulting risks to safety caused by distraction.

Commercial technology to detect the presence of cell phone signals is available and 

suitable for use in locomotive cabs. This technology only detects the presence of electronic 

signals. It does not record the contents and destination of communications or infringe on 

personal privacy. This technology could be used to alert railroad management about the presence 

of an active cell phone or other PED producing a signal in a locomotive cab, allowing railroad 

management to intervene with the train crew in a timely manner. The NTSB concludes that 

electronic signal detection technologies in locomotive cabs would enhance safety by deterring 

inappropriate PED use without affecting crewmember privacy. Therefore, the NTSB 

recommends that the FRA identify, and require railroads to use in locomotive cabs, 

technology-based solutions that detect the presence of signal-emitting PEDs and that inform the 

railroad management about the detected devices in real time.

There are also commercially available and relatively inexpensive handheld cell 

phone-signal detectors that can be used by railroad management and FRA inspectors to detect the 

presence of cell phones that are in use or turned on, which could potentially create an unsafe 

distraction. Such handheld detectors can be put into use quickly and have the advantage of 

detecting the unauthorized use of PEDs, both on trains in switching operations and at other 

railroad locations where unauthorized use presents a safety hazard. The NTSB concludes that 

handheld cell phone-signal detectors can serve as an effective tool for personnel performing 

inspections and test to deter the unauthorized use of PEDs by railroad personnel. Therefore, the 

NTSB recommends that the FRA incorporate the use of handheld signal detection devices to aid 

in the enforcement of 49 CFR Part 220 Subpart C.

 

40 Collision of Two Massachusetts Bay Transportation Authority Light Rail Passenger Trains, 

Boston, Massachusetts, May 8, 2009, Railroad Accident Brief NTSB/RAB-11/06 (Washington, DC: National 

Transportation Safety Board, 2011).
NTSB Railroad Summary Report

25

1.7 Communication and Coordination of Southbound Train Crew

Before reaching the Highland siding, the conductor of the southbound train had two radio 

conversations concerning the amount of time that the crew had remaining to work. In the first 

conversation, the conductor asked the RTC to call the Two Harbors yardmaster and advise him 

that the crew would not be able to complete the return trip before the expiration of the 

12 hours-of-service limitation and would need to be relieved enroute.

The conductor said he received a radio call from the Two Harbors yardmaster after the 

conversation with the RTC. In an interview with NTSB investigators, the conductor said, “I told 

him we’ll make it to Highland and probably get it [the train] weighed.” According to the 

conductor, the yardmaster’s response was, “Yeah, that’s fine. There’s going to be a van and a 

crew for you.”

The conductor told NTSB investigators that when the train reached the Highland siding, 

he understood that the train needed to stop before it blocked the Highland Road grade crossing 

and, then, he and the crew needed to wait for a relief crew to arrive in a van. Once the train 

stopped and was clear of the single main track in the Highland siding, the conductor radioed the 

RTC and released the train’s track authority. The conductor said that the RTC told him, 

“...I talked to the yard [Two Harbors yardmaster]. They want you to take it further south, try to 

get to Waldo.”41

The conductor told the RTC that his understanding was that the crew would be relieved at 

the Highland siding. The conductor said that the RTC responded, “No, you have to keep it 

moving.” The RTC added, “Are you ready to copy? Get ready to copy.”42 The conductor 

responded, “Okay.”

The locomotive engineer overheard this conversation between the RTC and the conductor 

and instructed the student engineer to start moving the train south on the siding to begin the 

weighing process. While the train was moving toward the scale, the RTC transmitted an 

after-arrival track authority to the conductor, who was still in the cab of the second locomotive. 43

This after-arrival track authority allowed the southbound train to proceed south toward 

Two Harbors after the arrival of the northbound train.

CN operating rules in place at the time of the accident required the conductor to copy the 

authority on a track authority form, using carbon paper to make a second copy; read the form

back to the RTC to confirm its accuracy; ensure that the engineer had a copy of the track 

authority; and ensure that every crewmember had a complete understanding of the track 

authority’s requirements. The conductor told NTSB investigators that when he rode in the cab of 

the lead locomotive, he would often make a carbon copy while writing the original track 

authority, and then physically hand the carbon copy to the engineer. On this trip, he rode in the 

 

41 Waldo station was 10.4 miles south of the Highland siding and was closer to Two Harbors.

42 This comment meant that the RTC wanted to issue a new track authority to the conductor for movement 

beyond the Highland siding.

43 The conductor chose to ride in the second locomotive and was not in the lead locomotive during most of the 

trip. The conductor told NTSB investigators that he did so because he did not believe the third seat in the cab of the 

lead locomotive unit was suitable for him because of his size.
NTSB Railroad Summary Report

26

second locomotive and so did not make a carbon copy of the authorities. In copying an earlier 

authority, he described how he handed the written authority to the engineer and then wrote out a 

second copy for himself before returning to the second locomotive.

A review of recordings of radio communications revealed that the conductor had initially 

repeated to the RTC the wrong locomotive number of the train they were supposed to wait for at 

the Highland siding. The RTC caught the error and had the conductor correct the train ID on the 

after-arrival portion of the track authority. At 3:47 p.m., the RTC confirmed that the conductor 

had correctly repeated the after-arrival track authority and issued the complete (OK) time. Then, 

the conductor asked the locomotive engineer over the radio, “Did you copy?” During interviews

with NTSB investigators, the conductor stated that the locomotive engineer responded, “Yes.”

The locomotive engineer told NTSB investigators that he did not recall if he had a 

conversation with the conductor, but claimed he could hear the conductor receiving the track 

authority from the RTC and said, “I believe it was clear enough for me to copy.” He also recalled 

that the track authority included an after-arrival authority instruction and acknowledged that they 

should not have left the Highland siding until after the northbound train had passed. Copies of 

these two after-arrival track authority forms are in appendixes D and E. The engineer copied this 

track authority but did not read it back. CN rules require that when an employee copies a 

track authority, he or she reads it back to the RTC to ensure accuracy. CN rules also required a 

job briefing on the new authority among all employees. The job briefing was never held.

The student engineer told NTSB investigators that while the locomotive engineer was 

copying the track authority, he was operating the train with his attention focused on achieving a 

controlled, slow train speed.44 The student engineer said he knew that the engineer was copying a 

track authority because the engineer had the radio handset against his ear and was writing. 

However, he added that he was not aware of the contents of the communication between the 

conductor and the RTC or between the locomotive engineer and the conductor. He did not ask 

the engineer about the contents of the track authority and he did not ask to see it. When the scale 

automated radio system announced that the train had cleared the scales (at about 4:01 p.m.),45 the 

student engineer told investigators that the locomotive engineer said, “We’ve got one for 

Two Harbors.”46 The student engineer said that the locomotive engineer added, “We don’t have 

much time, we’re not going to get very far. We need to get rolling; you need to be doing 

10 (mph) when we get over that switch.”47 According to the student engineer, the locomotive 

engineer did not explain to him that the track authority contained an after-arrival requirement and 

he did not ask.

 

44 In order for the scales to be able to weigh the train, the train speed must be maintained at 3 mph.

45 The collision was at 4:05 p.m., about one-half mile from the Highland south siding switch. If the train was 

operating at 10 mph (traveling one mile every six minutes) over the switch, the train would have departed the 

Highland siding at approximately 4:02 p.m.

46 This statement would have meant that the train had track authority to leave the Highland siding and proceed 

toward Two Harbors on the single main track.

47 The engineer was saying the student engineer needed to accelerate the train up to 10 mph (the speed limit 

through the switch) from 3 mph. The reference to the switch would have been the Highland south siding switch 

where the train would reenter the main track.
NTSB Railroad Summary Report

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The student engineer said that he felt a sense of being rushed because of the short amount 

of time remaining to work. According to the event recorder, once the rear of the train had cleared 

the scales, the student engineer increased the throttle to position seven.48 The train accelerated to 

10 mph while still on the Highland siding. As the train reached 12 mph, the student engineer then 

lowered the throttle setting to idle and then applied the dynamic braking. Although the speed 

limit while moving through the spring switch was 10 mph, the student engineer allowed the train 

to reach 15 mph. When the crew saw the northbound train, the engineer said “shoot ’em”49 and 

the student engineer applied emergency braking. The student engineer said he expressed surprise 

and he remembered hearing the locomotive engineer respond, “...we had an after.”

Leading up to and during the accident sequence, the southbound train crew exhibited a 

degree of disengagement and a lack of professionalism that fatigue alone would not explain. 

When the conductor abandoned an available seat in the operating cab because it did not look 

suitable to him at the beginning of the trip, he chose to take a seat on the left side of the second 

locomotive. Had the conductor sat on the right side of the locomotive, in the engineer’s seat on 

that unit, he would have been in a better position to observe the signals governing the train’s 

movement when the train was in signal territory. He also would have been able to observe the 

speedometer and air gauges and better monitor, and be engaged in, the train’s operation. When 

the conductor copied the final track authority, he did not use the provided carbon paper to make 

copies of track authorities for the engineer, as required. Finally, although there is an easily 

accessible walkway between the locomotives that does not require getting off the locomotive, the 

conductor did not walk up to the cab of the lead locomotive to give the engineer a copy of the 

track authority and/or make sure the engineer and the student engineer understood the 

requirement to wait for the northbound train.

The southbound engineer’s decision not to discuss the track authority with the student 

engineer (who he was supposed to have under “close supervision”)50 or to give a copy of the 

document to the student engineer to read was a dereliction of his responsibilities. These actions

displayed a lack of professionalism and engagement.

The student engineer, who was qualified and familiar with CN operating rules, did not 

ask to see the track authority nor did he question its content, thereby demonstrating, similar to his 

crewmates, a lack of engagement that resulted in the unsafe operation of the train. One element 

of effective CRM is to encourage subordinates to effectively and appropriately challenge 

authority in situations deemed by them to be unsafe, or that have the potential for unsafe actions. 

This element helps overcome problems associated with “authority gradients” within crews, 

where members of lower position or rank hesitate to voice their concerns and perspectives to 

members of higher rank or position within the command hierarchy, thereby limiting the quality 

of teamwork and group decision making.

 

48 The throttle positions run from one through eight, plus idle. Idle is no power, one is the lowest amount of 

power, and eight is the highest amount of power.

49 This is a slang term and the command meant to apply the emergency brakes.

50 Both CN and the FRA told NTSB investigators that “close supervision” required the engineer to be in the 

operating cab with the student engineer and to be in a position to intervene, if necessary, to ensure safety.
NTSB Railroad Summary Report

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1.8 Crew Resource Management

Many accidents and dangerous situations occur in transportation systems because of poor 

human decision making,51 as opposed to technical failures. Consequently, approaches to 

minimize and avoid these occurrences have received considerable attention over the past 

two decades across several transportation industries: aviation,

52 maritime,53 pipeline,54 and 

railroad55 transportation. One of the more successful approaches is CRM, which makes use of 

equipment, procedures, and people to achieve greater levels of safety and efficiency in system 

operations. The main principle of CRM is that crewmembers will work together safely when 

their work climate fosters effective communication, improved situational awareness, and quality 

leadership. One study found that while the impact of CRM training on learning and behavioral 

changes suggested mixed results across and within domains, CRM training generally produced a 

positive reaction from trainees.56 The behavioral findings of these studies included increases in 

team relationships, maintaining workload levels, mission information exchange, 

cross-monitoring performance, managing mission-threatening errors, and completion of mission 

segments. In the aviation industry, the organizational impact resulted in a decrease in the number 

of aircraft accidents.

The purpose of CRM is to assure that all crewmembers understand their roles and 

responsibilities in relation to the tasks being performed. Teamwork and active engagement are 

important elements of CRM. CRM becomes even more important when one or more members of 

a crew potentially becomes fatigued or distracted, therefore at higher risk of making errors. 

Using CRM principles of effective communication, situational awareness, and teamwork can 

mitigate the adverse effects of fatigue and serve as a countermeasure.

In August 2012, NTSB investigators met with the FRA to discuss some of the issues 

involved in the Two Harbors accident, including CRM. During the meeting, the FRA provided 

information on efforts to develop and implement CRM in the rail industry. FRA representatives 

told NTSB investigators that they will continue to monitor progress regarding CRM with both 

the Long Island Railroad and UP. NTSB staff will request periodic updates from the FRA in 

 

51 G.E. Cooper, M.D. White, and J.K. Lauber, “Resource Management on the Flightdeck: Proceedings of a 

NASA/Industry Workshop,” NASA CP-2120 (Moffett Field, California: NASA-Ames Research Center, 1980).

52 R.L. Helmreich, A.C. Merritt, and J.A. Wilhelm, “The Evolution of Crew Resource Management Training in 

Commercial Aviation,” International Journal of Aviation Psychology 9, no. 1 (1999): 19-32.

53 C. Hetherington, R. Flin, and K. Mearns, “Safety in Shipping: The Human Elements,” Journal of Safety 

Research 37 (2006): 401–411.

54 Enbridge Incorporated Hazardous Liquid Pipeline Rupture and Release, Marshall, Michigan, July 25, 2010, 

Pipeline Accident Report NTSB/PAR-12/01 (Washington, DC: National Transportation Safety Board, 2012).

55 Collision of Norfolk Southern Corporation Train 255L5 With Consolidated Rail Corporation Train TV 220, 

Butler, Indiana, March 25, 1998, Railroad Accident Report NTSB/RAR-99-02 (Washington, DC: National 

Transportation Safety Board, 1999).

56 G. Grubb, N. Crossland, and L. Katz, “Evaluating and Delivering the U.S. Army Aircrew Coordination 

Training Enhancement (ACTE) Program” Proceedings of the Interservice/Industry Training, Simulation and 

Education Conference (Arlington, Virginia: National Training Systems Association, 2002) 1143-1149; G. Grubb 

and J.C. Morey, “Enhancement of the U.S. Army Aircrew Coordination Training (ACT) Program,” Proceedings of 

the 12th International Symposium on Aviation Psychology, ed. R.S. Jensen (Columbus, Ohio: Ohio State University, 

2003) 446-452.
NTSB Railroad Summary Report

29

relation to these pilot programs. One FRA-sponsored research study,57 published in 2007 by the 

Texas A&M Transportation Institute, developed CRM training curricula for transportation, 

mechanical, and engineering employees. Another FRA-sponsored research study,58 also 

published in 2007, presented the business case for CRM in the rail industry. Additionally, FRA 

awarded grants to the Long Island Railroad and UP railroad for CRM pilot programs.

Staff reviews of CRM literature support the conclusion that CRM participants have 

favorable reactions to the training.59 Specifically, one study60 found that CRM training produced 

positive reactions, enhanced learning, as measured through attitude and behavioral changes in the 

cockpit. While the study could not determine with certainty the effect CRM training had on 

aviation safety, the authors concluded, “...it may be argued that the current evidence for the 

effectiveness of CRM training program, as impressive, albeit imperfect.”61

The Federal Aviation Administration in an Advisory Circular62 discussed a Fatigue Risk 

Management System. Page 6 of the document noted that, “Implementing error detection and 

corrective processes can prevent operational consequences of fatigue. Crew Resource 

Management (CRM) is a recognized and widely used process to encourage crewmembers to 

work together to detect and prevent operational errors. From a practical standpoint, CRM 

programs typically include educating crews about the limitations of human performance, 

including an understanding of cognitive errors, and how stressors (such as fatigue, emergencies, 

and work overload) contribute to the occurrence of errors.

The circumstances of the Two Harbors accident draw attention to the importance of 

CRM―particularly, the need for effective crew coordination and communication. The NTSB is 

concerned that each member of the southbound train crew was responsible for the safe operation 

of the train and adhering to CN rules, but did not do so. The southbound train’s engineer and 

conductor did not discuss the specific elements of the track authority issued to them at 3:47 p.m. 

The engineer, in turn, did not discuss that same track authority with the student engineer. 

Moreover, the student engineer did not inquire about the track authority before moving the train. 

Regarding the performance and supervision of the student engineer, an important element of 

CRM is developing techniques and confidence among junior crewmembers, and encouraging 

them to challenge their more senior colleagues regarding proper procedures. Further, the 

engineer and conductor did not speak up or take action when the student engineer entered the 

single main track without authority. Likewise, they took no action to slow the train when the 

student engineer exceeded the maximum allowable speed through the Highland south siding 

 

57 Federal Railroad Administration, Rail Crew Resource Management (CRM): Pilot Rail CRM Training 

Development and Implementation (Springfield, Virginia: National Technical Information Service, 2007).

58 Federal Railroad Administration, Rail Crew Resource Management (CRM): The Business Case for CRM 

Training in the Railroad Industry (Springfield, Virginia: National Technical Information Service, 2007).

59 O’Connor et al., 2002; Salas et al., 2001; Salas, Wilson, Burke & Wightman, 2006 as cited in O’Connor, 

Campbell, Newton, Melton, Salas, and Wilson, “Crew Resource Management Training Effectiveness: A 

Meta-Analysis and Some Critical Needs,” International Journal of Aviation Psychology 18 no. 4 (2008): 353-368.

60 Salas, E., Wilson, K.A., and Burke, C.S., “Does Crew Resource Management Training Work? An Update, an 

Extension and Some Critical Needs,” Human Factors 48 no. 2 (Summer 2006): 392-412.

61 Salas, E., Wilson, K.A., and Burke, C.S., “Does Crew Resource Management Training Work? An Update, an 

Extension and Some Critical Needs,” Human Factors 48 no. 2 (Summer 2006): 410.

62 Federal Aviation Administration, Fatigue Risk Management Systems for Aviation Safety, AC No: 120-103, 

August 3, 2010.
NTSB Railroad Summary Report

30

switch. These events illustrate that effective crew communication and coordination are 

imperative, especially when a crewmember is receiving on-the-job training. The NTSB 

concludes that the southbound train crew displayed poor coordination of activities and 

inadequate communication, which are indicative of poor CRM.

One method of improving crew coordination and communication is through CRM 

training. The NTSB identified inadequate or nonexistent CRM training as a safety issue in the 

Marshall, Michigan, pipeline accident,63 as well as several aviation64 and marine accidents.65

In 1999, the NTSB addressed the lack of railroad CRM in an investigation of the collision 

between two trains in Butler, Indiana.66 The NTSB concluded that the accident, as well as other 

accidents, demonstrated that if crewmembers receive CRM training, railroad safety can be 

improved.67 As a result of the Butler, Indiana, accident, the NTSB issued Safety 

Recommendation R-99-13, as well as other recommendations for the FRA, all Class I railroads, 

the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive 

Engineers and Trainmen, and the United Transportation Union to work together to develop and 

implement CRM training for train crewmembers.

With regard to R-99-13, the NTSB noted that the FRA had engaged in direct 

communication with the Association of American Railroads and many of the Class I railroads 

about CRM training. Furthermore, the NTSB indicated that since that accident, the railroad 

industry had made great strides to embrace the concept of CRM training. Therefore, based on the 

industry’s voluntary development and implementation of CRM training, on May 6, 2003, the 

NTSB classified this safety recommendation “Closed―Acceptable Alternate Action.”

NTSB investigators requested copies of any CRM training materials used by CN at the 

time of the accident. CN responded that while it did not have stand-alone formal CRM training, 

several elements of CRM training, including crewmember proficiency and effective 

communication, situational awareness, and challenging and questioning authority were in place 

and addressed Safety Recommendation R-99-13 that resulted from the Butler, Indiana, 

investigation.

 

63 NTSB/PAR-12/01.

64 Loss of Control and Impact With Terrain Aviation Charter, Inc., Raytheon (Beechcraft) King Air A100, 

N41BE, Eveleth, Minnesota, October 25, 2002, Aviation Accident Report NTSB/AAR-03/03 (Washington, DC: 

National Transportation Safety Board, 2003); Air Florida, Inc., Boeing 737-222, N62AF, Collision with 14th Street 

Bridge near Washington National Airport, Washington, DC, January 13, 1982, Aviation Accident Report 

NTSB/AAR-82-08 (Washington, DC: National Transportation Safety Board, 1982); Runway Overrun During 

Rejected Takeoff Global Exec Aviation Bombardier Learjet 60, N999LJ, Columbia, South Carolina, 

September 19, 2008, Aviation Accident Report NTSB/AAR-10/02 (Washington, DC: National Transportation 

Safety Board, 2010).

65 Grounding of the United Kingdom Passenger Vessel RMS Queen Elizabeth 2, near Cuttyhunk Island, 

Vineyard Sound, Massachusetts, August 7, 1992, Marine Accident Report NTSB/MAR-93/01 (Washington, DC: 

National Transportation Safety Board, 1993); Grounding of the U.S. Tankship Star Connecticut, Pacific Ocean, near 

Barbers Point, Hawaii, November 6, 1990, Marine Accident Report NTSB/MAR-92/01 (Washington, DC: National 

Transportation Safety Board, 1992); Collision between the Greek Tankship Shinoussa and the U.S. Towboat 

Chandy N and Tow near Red Fish Island, Galveston Bay, Texas, July 28, 1990, Marine Accident Report 

NTSB/MAR-91/03 (Washington, DC: National Transportation Safety Board, 1991).

66 NTSB/RAR-99-02.

67 The investigation revealed that no crewmember in this accident had received formal CRM training. 
NTSB Railroad Summary Report

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While the NTSB is encouraged that CN has attempted to address some of the elements 

that are contained in CRM training, it believes the current CN efforts do not go far enough in 

developing and implementing a comprehensive and effective CRM training program. For 

example, CN indicated it did not have specific training that addressed situational awareness, but 

instead, taught employees why situational awareness was important. Furthermore, the 

information CN provided that discussed effective peer-to-peer communication consisted of one 

slide of a presentation that did not specifically explain the principles and dynamics of 

interpersonal communications. Finally, with respect to challenging and questioning authority, 

CN cited its rule Z that notes federal law permits an employee “...the right to challenge a 

directive from a supervisor that the employee feels would violate a railroad operating rule 

regarding shoving movements, leaving unattended equipment foul of an adjacent track, or 

handling switches or derails.” Rule Z does not specifically address operating personnel, such as 

engineers or conductors, who function in an operational environment, nor does it delineate how 

an employee would effectively exercise strategies that would appropriately challenge authority in 

dynamic situations, such as in the locomotive cab of a train.

The NTSB concludes that had the crewmembers on the southbound train received 

training in, and practiced the principles of, CRM, they may have demonstrated better 

coordination and communication. Based on the response and materials received from CN 

regarding its CRM training, the NTSB believes that CN should develop and implement specific 

training that will result in operating personnel acquiring and using strategies and skills based on 

the principles of CRM.

Federal regulations require CRM training for aviation cockpit crews and bridge resource 

management (BRM) training for mariners. FRA studies show that CRM training can be effective 

on railroads. The NTSB recommends that FRA require railroads to implement initial and 

recurrent CRM training for train crews.
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2 Management and Regulatory Oversight

2.1 CN Management Oversight

FRA regulations require railroads to establish a program of operational tests and 

inspections. The CN testing program involves establishing goals for managers based on the 

number and type of tests they should be administering each quarter. Goals are modified each 

quarter based on CN management reviews of accidents, incidents, rules violations, and failures 

from the previous quarter. The manual68 states that CN’s philosophy on rules compliance testing 

provides:

....an opportunity to verify that employees are working safely and in compliance 

with all company rules, policies, instructions and procedures. Quality Efficiency 

Testing is one of the most valuable services (managers) can perform to ensure 

safe, efficient rail operations.

CN provided operational testing data for the accident crews during the 12 months prior to 

the accident. Table 6 summarizes these data:

Table 6. CN rules compliance testing of crewmembers of the accident trains.

Crewmember Number of tests Noncompliant tests Noncompliant test items

SB Engineer 16 1 Test #43: Inspection of Trains

SB Conductor 26 3 Test #22: Radio Use

Test #62: Special - Tardiness

Test #62: Special - Tardiness

SB Student Engineer 31 0 n/a

NB Engineer 4 0 n/a

NB Conductor 7 0 n/a

CN also provided rules compliance test data for the Iron Range, Keenan, Minntac, and 

Two Harbors subdivisions69 covering calendar years 2009, 2010, and 2011. Table 7 summarizes 

all operational tests conducted on these four subdivisions:

Table 7. CN rules compliance testing on four CN subdivisions.

Year Noncompliant tests Tests passed Total tests

2009 34 424 458

2010 32 694 726

2011 49 863 912

 

68 Canadian National Railway, CN Southern Region Efficiency Tests and Inspections (Montreal, Canada: 

Canadian National Railway, 2009).

69 Ore trains to the Minntac mine operate on these four subdivisions.
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Several specific CN operational tests are particularly relevant to this accident. These tests 

relate to the authority to occupy and move on the main track and the use of PEDs. Table 8 shows 

the number of tests conducted by CN both before and after the accident. All of these tests were 

recorded as passed.

Table 8. Summary of five CN tests conducted in 2009, 2010, and 2011, on four CN subdivisions.

CN test 2009 2010 2011 Three-year total

Test 11 – Authority to Occupy Main Track (all passed) 1 1 5 7

Test 17 – Communicating Restrictions (all passed) 3 1 10 14

Test 18 – Copy Manditory Directives (all passed) 6 3 21 30

Test 51 – RTC Issuing Authorities (all passed) 2 8 3 13

Test 56 - Proper Use of PEDs (all passed) 0 0 1 1

Yearly total of all five tests 12 13 40 65

CN describes the purpose of test 11 as follows: “to determine the train or engine has 

received authority to occupy the main track...” There were several observations listed in CN data 

for this test for the four subdivisions during the time period between 2009 and 2011; all were 

recorded as passed.

CN describes the purpose of test 17 as follows: “determines employees practice proper 

procedures for communicating restrictions and signals affecting train movement.” There were 

14 observations listed in CN data for this test in the four subdivisions during the time period 

between 2009 and 2011; all were recorded as passed.

CN describes the purpose of test 18 as follows: “to determine that the employee has 

copied and/or repeated mandatory directives correctly.” There were 30 observations listed in CN 

data for this test in the four subdivisions during the time period between 2009 and 2011; all were 

recorded as passed.

In this accident, the southbound train crew would have failed tests 11, 17, and 18. They 

would have failed test 11 because the train departed from the Highland siding and entered the 

main track without authority. They would have failed test 17 because no one on the crew 

communicated the restriction (waiting for the northbound train) to the student engineer who was 

operating the train. Lastly, they would have failed test 18 because the conductor did not provide 

a copy of the authority to the engineer, the engineer copied the authority without reading it back 

to the RTC, and the crew did not hold a job briefing.

CN describes the purpose of test 51 as follows: “Observe the RTC/control operator 

verbally issuing an instruction or authority, or listen to historical tapes to verify that the 

RTC/control operator listened to the repetition correctly.” There were 13 observations listed in 

CN data for this test in the four subdivisions during the time period between 2009 and 2011; all 
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were recorded as passed. The RTC issuing the last authority to the southbound train would have 

passed this test.

CN describes the purpose of test 56 as follows: “determines that employee knows how

and when they may use railroad-supplied and personal electronic devices, other than railroad 

radios.” There was only one observation recorded in the CN data for this test in the 

four subdivisions during the time period between 2009 and 2011, and it was recorded as passed. 

Had CN managers been able to overcome the challenges of detecting unauthorized personal PED 

use, as exhibited by the crewmembers involved in this accident, all three members of the 

southbound train crew, as well as the northbound train engineer, would have failed this test.

CN conducted limited operational testing of the rules that were not complied with in this 

accident, prior to this collision. With the exception of the testing of RTCs on issuing authorities, 

CN’s testing before the accident on these important operational safety areas that were factors in 

this accident increased after the accident. The unauthorized use of PEDs by four of five 

crewmembers indicates a serious disregard for CN rules and FRA regulations, yet CN managers 

recorded only one test observation of PED use on these subdivisions during the time period 

between 2009 and 2011. CN’s efficiency testing manual describes the purpose of operational 

testing as:

...assuring employees an opportunity to demonstrate their command of rules and 

instructions, while giving supervisors the chance to praise a job well done or to 

correct operating deficiencies.

The NTSB concludes that given CN’s limited management oversight of track authorities 

and particularly the infrequent test observations of PED use, CN’s program before the accident 

was ineffective in ensuring compliance with these operating rules.

The limited observations on PED usage again point out the challenges of detecting 

unauthorized use. As noted earlier in this report, commercially available handheld cell 

phone-signal detection devices can be used by managers to better identify and correct improper 

PED use. The NTSB concludes that CN’s oversight of crew PED use can be improved by 

equipping managers with cell phone-signal detection technology. Therefore, the NTSB 

recommends that CN incorporate the use of handheld signal detection devices into its operational 

efficiency program on the use of PEDs.

The NTSB is a strong advocate for the use of safety management systems (SMS) to 

improve the safety of transportation operations in all modes. In its report on the derailment of a 

CN freight train at Cherry Valley, Illinois, on June 19, 2009,70 the NTSB noted that:

had an effective SMS been implemented at the CN, the inadequacies and risks 

that led to the accident would have been identified and corrected...

An effective SMS should at a minimum:

 

70 Derailment of CN Freight Train U70691-18 With Subsequent Hazardous Materials Release and Fire, 

Cherry Valley, Illinois, June 19, 2009, Railroad Accident Report NTSB/RAR-12/01 (Washington, DC: National 

Transportation Safety Board, 2012).
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Define how the organization is set up to manage risk

Identify workplace risk and implement suitable controls

Implement effective communication across all levels of the organization

Implement a process to identify and correct nonconformities

Implement a continual improvement process

CN operates in both Canada and the United States. In Canada, CN operations fall under 

the regulatory authority of Transport Canada. Effective since 2001, regulations from Transport 

Canada required CN develop and implement a SMS. CN officials told investigators that (1) CN 

introduced SMS to its US operations around October 2010, and (2) the first system audit in the 

Two Harbors area occurred in April 2011. The NTSB recognizes that implementation of SMS is 

a long--term effort that requires a strong management commitment to changing and improving 

the prevailing work culture. The NTSB is encouraged that CN’s US operations has started the 

implementation of SMS.

The 2011 CN audit report included a review of transportation efficiency testing. The 

report found that managers were “actively” performing efficiency testing. The report noted that 

historical testing compliance rates were at 96 percent while the audit found a lower compliance 

rate of 71 percent. The report listed “need to drive efficiency test quality” as an area of 

opportunity for improvement. CN’s internal audit and the NTSB’s investigation both found 

weakness in CN’s operational testing program. Moreover, the NTSB notes that four of the five 

crewmembers involved in this accident demonstrated open and repeated disregard for rules on 

use of PEDs and that the southbound train crew failed to comply with several safety-critical 

operating rules and practices. The NTSB is concerned that theses safety issues are not isolated 

incidents; rather they may be indicators of a larger systemic problem. Similar concerns were 

expressed in the NTSB investigation of a 2009 CN railroad accident in Cherry Valley, Illinois.71

The NTSB recommends that CN improve its operational testing program and verify that the 

testing of track authority procedures and unauthorized PED use is adequate to ensure consistent, 

safe operation.

Risk identification and mitigation is a key element of SMS. Operational testing is one 

method of gathering data to help identify risks. The use of peer observers in a nonpunitive 

program to assess operational safety, perform peer-to-peer counseling and to generate data on 

trends of risky behaviors that can be used to develop mitigation strategies is an approach with 

merit. The aviation industry has found success in the Line Operations Safety Audit (LOSA),

72 a 

voluntary safety program in which trained observers (usually line pilots from the airline) ride on 

a jump seat during regularly scheduled flights to collect safety-related data on environmental 

conditions, operational complexity, training efficacy, and flight crew performance. The data 

collected remains confidential, and pilots are assured of nonpunitive use of those data.

The LOSA program provides a unique and proactive opportunity to study the flight 

management process―both successful and unsuccessful―by noting the problems crews 

encounter on the line and how they manage these problems. Such a program would prove equally 

 

71 NTSB RAR-12/01.

72 For more information on LOSA, see the Federal Aviation Administration’s Advisory Circular 120-90.
NTSB Railroad Summary Report

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valuable to the rail industry, as suggested by the circumstances of the Two Harbors accident. The 

NTSB is aware that some railroads have begun the implementation of LOSA-like programs. The 

NTSB concludes that a nonpunitive peer audit program is an important element of effective SMS 

and would provide CN with the opportunity to better address operational safety issues.

At the time of the Two Harbors collision, CN did not have an active peer audit program 

in place in the area where the accident occurred. While CN did introduce a Safety For 

Everyone (SaFE) peer audit program on portions of the North Division before the accident, it 

was not fully successful and was discontinued. CN advised NTSB investigators that the program 

continues in successful operation on the Southern portion of CN’s US lines (former Illinois 

Central). The NTSB is encouraged that CN has implemented a LOSA-like program called SaFE 

on portions of its US lines, but is disappointed that it was not fully successful on the North 

Division.

The NTSB concludes that a nonpunitive peer audit program would provide CN with the 

necessary data to address operational safety issues on the North Division and would be consistent 

with and support CN’s implementation of SMS. Therefore, the NTSB recommends that CN work 

with the Brotherhood of Locomotive Engineers and Trainmen and the United Transportation 

Union to develop and implement a nonpunitive peer audit program for the North Division, 

focused on rule compliance and operational safety. Also, the NTSB recommends that the 

Brotherhood of Locomotive Engineers and Trainmen work with CN and the United 

Transportation Union to develop and implement a nonpunitive peer audit program for CN’s 

North Division. Further, the NTSB recommends that the United Transportation Union work with 

CN and the Brotherhood of Locomotive Engineers and Trainmen to develop and implement a 

nonpunitive peer audit program for the North Division.

2.2FRA Regulatory Oversight

CN’s US operations fall under the safety regulatory authority of the FRA. Regulations 

found at 49 CFR Part 217 require that CN have in place a program of operational tests and 

inspections to confirm that crews are operating trains in accordance with CN rules. The FRA also 

issued Emergency Order 26 restricting the use of PEDs.

FRA operating practices require that inspectors periodically visit all US railroads and 

make inspections for compliance with specific FRA regulations. In some instances, a small 

group of inspectors will perform a much more comprehensive in-depth audit of a railroad’s 

operational testing program over a period of several days and will provide the railroad with a 

written report that summarizes the audit findings and which may contain recommendations for 

improvement to the railroad’s program.

NTSB investigators asked the FRA for any inspection reports related to CN’s operations 

testing program on the North Division. The FRA provided copies of all operating practice reports 

relating to 49 CFR Part 217 filed for inspections conducted on the CN North Division during 

2009, 2010, and 2011. During the 21 months before the collision, FRA inspectors filed nine 

inspection reports on CN operational rules compliance. These inspection reports noted seven 

observations for compliance with PED use requirements with one instance of improper use.
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37

During the 14 months following the collision, FRA inspectors filed 23 inspection reports. 

These reports noted three observations for compliance with PED use requirements, with no 

improper use observed. The FRA inspection reports also recorded seven observations on the 

proper execution of mandatory directives (three before the accident and four after).

NTSB investigators also asked the FRA to provide reports on any Part 217 audits 

performed on the CN North Division either before or after the accident. FRA representatives 

explained that they analyze accidents, injuries, employee complaints, and railroad operational 

testing data in order to select locations for in-depth Part 217 audits. Based on an evaluation of 

these factors, FRA did not conduct a Part 217 audit on the subdivision where this accident 

occurred. FRA did supply NTSB with four reports on audits performed on CN operations during 

2006 and 2007. The last FRA audit on the CN North Division prior to the accident was

conducted in Wisconsin in 2007. However, an FRA representative advised that, based on FRA’s 

review of CN safety data, a Part 217 audit was determined not to be needed, and therefore was 

not conducted on the portions of the CN North Division where the accident crew operated.

The NTSB concludes that railroad safety on the CN North Division would benefit from a 

FRA audit on CN’s program of operational tests and inspections. Therefore, NTSB recommends 

that the FRA conduct an audit of the CN North Division program of operational tests and 

inspections to determine if the program is effective in promoting knowledge and compliance 

with rules on executing track authorities and the appropriate use of PEDs.

2.3 Actions Taken Since the Accident

Representatives from CN told NTSB investigators that they have taken several steps 

since the accident. These include:

CN issued Superintendent’s Notice L-10-LZ, dated October 5, 2010, mandating that 

all members of an operating train crew occupy the lead locomotive unless there are no

seats available to accommodate them.

CN retrofitted all locomotives having only two seats with a third seat.

CN modified Rule 1000 to include the following language: “...before being acted 

upon, conductor and engineer must each have a copy of all mandatory directives 

issued for their train, and they must be read and understood by all members of the 

crew who are responsible for the operation of the train. They will be retained for the 

duration of the train crew’s work assignment.”

CN instituted a policy where it conducts safety awareness meetings73 for three days 

immediately following an accident.

CN increased operational testing of train crews using supervisors of locomotive 

engineers from other divisions as test administrators.

 

73 Safety awareness meetings are also known as a “safety blitz” and require that managers contact all affected 

employees, discuss the circumstances of the accident, and reinforce applicable rules and procedures.
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3 Conclusions

3.1Findings 

1. The mechanical condition of the trains, the weather, drug or alcohol impairments, and the 

actions of the northbound train crew were not factors in this accident.

2. The use of after-arrival track authorities in nonsignaled territory presents unacceptable and 

unnecessary safety risks to railroad operational safety, because the procedure is vulnerable to 

human error and lacks inherent safety redundancies to ensure consistent, safe operation.

3. In the absence of a positive train control system, discontinuing the use of after-arrival track 

authorities in nonsignaled territory will mitigate future accidents involving authority 

overruns.

4. Fatigue-induced performance errors contributed to the accident.

5. The use of cell phones by crewmembers on the southbound train and by the engineer on the 

northbound train was a distraction to the safe operation of both trains and an indication of a 

clear disregard for Canadian National Railway rules and Federal Railroad Administration 

regulations.

6. Additional measures to prevent unauthorized portable electronic device use by train 

crewmembers is necessary because of the continuing use of these devices by some railroad 

crewmembers, and the resulting risks to safety caused by distraction.

7. Electronic signal detection technologies in locomotive cabs would enhance safety by 

deterring inappropriate portable electronic device use without affecting crewmember 

privacy.

8. Handheld cell phone-signal detectors can serve as an effective tool for personnel performing 

inspections and tests to deter the unauthorized use of portable electronic devices by railroad 

personnel.

9. The southbound train crew displayed poor coordination of activities and inadequate 

communication, which are indicative of poor crew resource management.

10. Had the crewmembers on the southbound train received training in, and practiced the 

principles of, crew resource management, they may have demonstrated better coordination 

and communication.

11. Given Canadian National Railway’s limited management oversight of track authorities and 

particularly the infrequent test observations of portable electronic device use, Canadian 

National Railway’s program was ineffective in ensuring compliance with these operating 

rules.
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12. Canadian National Railway’s oversight of crew portable electronic device use can be 

improved by equipping managers with cell phone-signal detection technology.

13. A nonpunitive peer audit program is an important element of an effective safety management 

system and will provide Canadian National Railway management with the necessary data to 

better address operational safety issues.

14. Railroad safety on the Canadian National Railway North Division would benefit from a 

Federal Railroad Administration audit on Canadian National Railway’s program of 

operational tests and inspections.

3.2Probable Cause

The National Transportation Safety Board determines that the probable cause of the 

accident was the southbound train crew’s error in departing the Highland siding before the 

northbound train had passed. Contributing to the accident was the Canadian National Railway’s

use of after-arrival track authorities in nonsignaled territory, a procedure that is vulnerable to 

human error and lacks inherent safety redundancies to ensure consistent, safe operation. Also 

contributing to the accident was crew fatigue and inadequate crew resource management.
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4 Recommendations

4.1 New Recommendations

As a result of this investigation, the National Transportation Safety Board makes the 

following new safety recommendations:

To the Federal Railroad Administration:

Identify, and require railroads to use in locomotive cabs, technology-based 

solutions that detect the presence of signal-emitting portable electronic devices 

and that inform the railroad management about the detected devices in real time. 

(R-13-5)

Incorporate the use of handheld signal detection devices to aid in the enforcement 

of Title 49 Code of Federal Regulations Part 220 Subpart C. (R-13-6)

Require railroads to implement initial and recurrent crew resource management 

training for train crews. (R-13-7)

Conduct an audit of the Canadian National Railway’s North Division program of 

operational tests and inspections to evaluate their effectiveness for promoting 

knowledge and compliance with rules regarding the execution of track authorities 

and the appropriate use of portable electronic devices. (R-13-8)

To Canadian National Railway:

Discontinue the use of after-arrival track authorities in nonsignaled territory not 

equipped with positive train control. (R-13-9)

Develop and implement specific training that will result in operating personnel 

acquiring and using strategies and skills based on the principles of crew resource 

management. (R-13-10)

Incorporate the use of handheld signal detection devices into your operational 

efficiency program on the use of portable electronic devices. (R-13-11)

Evaluate your operational testing program, and verify that the testing of track 

authority procedures and unauthorized use of portable electronic devices is 

adequate to ensure consistent, safe operation. (R-13-12)

Work with the Brotherhood of Locomotive Engineers and Trainmen and the 

United Transportation Union, to develop and implement a nonpunitive peer audit 

program for the North Division, focused on rule compliance and operational 

safety. (R-13-13)
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To the Brotherhood of Locomotive Engineers and Trainmen:

Work with the Canadian National Railway and the United Transportation Union, 

to develop and implement a nonpunitive peer audit program for the Canadian 

National Railway’s North Division, focused on rule compliance and operational 

safety. (R-13-14)

To the United Transportation Union:

Work with the Canadian National Railway and the Brotherhood of Locomotive 

Engineers and Trainmen, to develop and implement a nonpunitive peer audit 

program for the Canadian National Railway’s North Division, focused on rule 

compliance and operational safety. (R-13-15)

To Canadian Pacific Railway Limited, Kansas City Southern Railway Company, 

and Norfolk Southern Railroad, and Union Pacific Railroad

Discontinue the use of after-arrival track authorities for train movements in 

nonsignaled territory not equipped with a positive train control system. (R-13-16)

4.2Previously Issued Recommendations Reiterated in this Report

As a result of this accident investigation, the National Transportation Safety Board 

reiterates the following previously issued safety recommendations:

To the Federal Railroad Administration:

Prohibit the use of after-arrival track warrants for train movements in 

dark (non-signaled) territory not equipped with a positive train control 

system. (R-06-10)

Safety Recommendation R-06-10 is classified “Open―Unacceptable Response”.

Establish an ongoing program to monitor, evaluate, report on, and 

continuously improve fatigue management systems implemented by 

operating railroads to identify, mitigate, and continuously reduce 

fatigue-related risks for personnel performing safety-critical tasks, 

with particular emphasis on biomathematical models of fatigue. 

(R-12-17)

Safety Recommendation R-12-17 is classified “Open―Acceptable Response”.
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To BNSF Railway:

Discontinue the use of after-arrival track warrants for train movements 

in dark (non-signaled) territory not equipped with a positive train 

control system. (R-06-12)

Safety Recommendation R-06-12 is classified “Open-Unacceptable Response”.

To the American Short Line and Regional Railroad Association:

Encourage your members to discontinue the use of after-arrival track 

warrants for train movements in dark (non-signaled) territory not 

equipped with a positive train control system. (R-06-13)

Safety Recommendation R-06-13 is classified “Open―Unacceptable Response”.

4.3Previously Issued Recommendations Reiterated and Reclassified 

in this Report

As a result of this accident investigation, the National Transportation Safety Board 

reclassifies the following previously issued safety recommendations:

To the Federal Railroad Administration:

Require the installation, in all controlling locomotive cabs and cab car 

operating compartments, of crash- and fire-protected inward- and 

outward-facing audio and image recorders capable of providing 

recordings to verify that train crew actions are in accordance with rules 

and procedures that are essential to safety as well as train operating 

conditions. The devices should have a minimum 12-hour continuous 

recording capability with recordings that are easily accessible for 

review, with appropriate limitations on public release, for the 

investigation of accidents or for use by management in carrying out 

efficiency testing and systemwide performance monitoring programs. 

(R-10-1)

Safety Recommendation R-10-1, previously classified “Open—Acceptable Response” is 

classified “Open―Unacceptable Response” in this report.
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Require that railroads regularly review and use in-cab audio and image 

recordings (with appropriate limitations on public release), in 

conjunction with other performance data, to verify that train crew 

actions are in accordance with rules and procedures that are essential 

to safety. (R-10-2)

Safety Recommendation R-10-2, previously classified “Open—Acceptable Response” is 

classified “Open―Unacceptable Response” in this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

DEBORAH A.P. HERSMAN ROBERT L. SUMWALT 

Chairman Member 

CHRISTOPHER A. HART MARK R. ROSEKIND

Vice Chairman Member 

EARL F. WEENER

Member 

Adopted: February 12, 2013
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Board Member Statements

Vice Chairman Christopher A. Hart, concurring:

I concur with the findings, probable cause, and recommendations in this report, but I 

believe that we would have been warranted in going further with three of the recommendations, 

and perhaps also recommending that the Federal Railroad Administration (FRA) take an active 

role in implementing the recommended audit programs.

The Three Recommendations. The report contains recommendations to each of three 

entities, the Canadian National Railway (CN), the Brotherhood of Locomotive Engineers and 

Trainmen, and the United Transportation Union:

... to develop and implement a nonpunitive peer audit program for the North 

Division, focused on rule compliance and operational safety.

Given what this investigation revealed about the inadequate safety culture at CN, query 

whether this recommendation should have applied to CN’s entire operation rather than being 

limited to the North Division.

For example, the frequency of the use of cell phones by the train crew while operating the 

train, in violation of both CN and FRA regulations, indicates inadequate concern by the train 

crews about the potential safety implications of cell phone use while underway. Unfortunately 

we have seen far too many fatalities, in all modes of transportation, that resulted from the use of 

cell phones by people who were not paying adequate attention to their primary operating 

responsibilities.

Similarly, the openness by the train crews of their cell phone use, in clear view of other 

crewmembers, shows that the practice is widely ignored and tolerated; and given the amount of 

cell phone use that was discovered in this investigation of just one accident, it is difficult to 

conceive that management is not aware of that cell phones are being used inappropriately.

Complicating the issue is that management permits cell phone use for certain 

work-related reasons. Query what safeguards CN has employed to assure that any permitted use 

does not unduly distract an operator from his or her primary responsibilities. Given the limited 

management oversight of cell phone use discussed in the report, this is a critical item for CN to 

address.

Another example of CN’s inadequate safety culture relates to the fact that when the 

Canadian Government imposed a requirement for the implementation of a safety management 

system (SMS), CN complied with that requirement for its Canadian operations, but did not 

systematically extend the SMS program to its US operations until many years later. This clearly 

suggests a lack of urgency to implement this safety measure.
NTSB Railroad Summary Report

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Notwithstanding these examples, I hope that CN will decide to implement nonpunitive 

peer audit programs throughout its system, even though our recommendation refers only to its 

North Division.

FRA Involvement. Also not included in our report is a recommendation to the FRA to 

play a role in the implementation of the audit program. Aviation industry experience has 

demonstrated that one of the key issues in the implementation of an audit program is what 

protections will be applied to the data from the audits, and the ultimate decision on that issue 

rests with the regulator.

Given that the FRA has attempted to be proactive regarding safety by, for example, 

establishing a near-miss reporting program for the railroad industry, it seems unlikely that the 

FRA would do anything that undercuts a proactive audit program, such as attempting to use any 

of the audit data for enforcement purposes. That said, however, in order for the parties to be 

willing to participate in an audit program, the FRA will probably need to establish guidelines 

regarding the protection of audit data, much as the Federal Aviation Administration has done in 

FAA Advisory Circular 120-90 with respect to the Line Operations Safety Audit (LOSA) 

program in aviation.

Members Sumwalt and Weener concurred with this statement.
NTSB Railroad Summary Report

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5 Appendixes

5.1 Appendix A: Investigation

The National Transportation Safety Board was notified on September 30, 2010, of the 

collision of two Canadian National Railway trains near Two Harbors, Minnesota. The National 

Transportation Safety Board launched an investigator-in-charge and two other investigative team 

members from its headquarters and from the Los Angeles and Chicago regional offices. The 

Federal Railroad Administration, the Canadian National Railway, the Brotherhood of 

Locomotive Engineers and Trainmen, and the United Transportation Union assisted the National 

Transportation Safety Board in this investigation.
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5.2 Appendix B: Comparative Table of BNSF and CN Rule 

Requirements for After-Arrival Track Authorities in Nonsignaled 

Territory

Comparative table of BNSF and CN rule requirements for after-arrival

track authorities in nonsignaled territory BNSF CN

Use of after-arrival track authority in nonsignaled territory is restricted to preventing 

extended road crossing blockage and train meets during dispatcher shift turnover.

X

Before transmittal, the dispatcher/RTC advises the train receiving after-arrival 

track authority that the authority will require a meet with another train.

X X

Before transmittal, the dispatcher/RTC advises the train receiving the after-arrival 

track authority that the authority will require a meet with another train and advises the 

crew of the ID of the train to be met.

X

The restricted train must make contact with the other train, establish its location, and 

inform the dispatcher/RTC before the after-arrival track authority is transmitted.

X

The train receiving the after-arrival track authority must be stopped at the meeting 

point and advise the dispatcher/RTC of the fact before the after-arrival track authority 

is transmitted.

X

The after-hours track authority is transmitted, read back, and okayed. X X

The crew must note on the track authority form and read back, "This authority requires 

a meet with another train at _________."

X

All train crews must announce their train ID, location, speed, and direction 

approximately two miles in advance of approaching a junction or siding.

X

When the train arrives, the restricted train must again communicate via radio to 

confirm its train ID before proceeding.

X X

The crew of the restricted train must note on the track authority form the train ID of the 

train met, the time met, and the location met.

X

Every after-arrival track authority used for nonsignaled track is reviewed against 

recorded audio to verify the communication requirements were met.

X
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5.3 Appendix C: Canadian National Rule on PED Use

L. COMMUNICATION AND ELECTRONIC DEVICES. The use of railroad 

supplied or personal electronic devices must not interfere with operating 

employees covered by the Federal Hours of Service law during performance of 

safety related duties. This rule does not apply to railroad radios.

Personal or railroad supplied electronic devices may be used to respond to an

emergency involving railroad operations. They also may be used in place of the

radio, when radio failure occurs, however all radio rules will apply to electronic

devices.

When operating company vehicles or off-track equipment, hands-free technology

must be utilized unless vehicle is stopped.

Railroad Supplied Electronic Devices

The use of railroad supplied electronic devices by Engineers is prohibited:

• On a moving train, or

• When any crew member is working on the ground, or riding equipment during a 

switching operation, or

• During any time when another employee of the railroad is assisting in

preparation of the train, i.e. utility employee.

The use of railroad supplied electronic devices by other employees is prohibited:

• On a moving train or on-track equipment, unless authorized for company

business, and:

1. A safety briefing is conducted, and all agree it is safe to do so, or

2. Within the body of a passenger train or business car.

• Outside the locomotive cab or on-track equipment, unless:

1. Not fouling the track,

2. No switching is being performed,

3. No other safety related duties are being performed, and

4. All employees have been briefed that operations have been stopped.
NTSB Railroad Summary Report

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Personal Electronic Devices

While on duty, the use of personal electronic devices for other than voice 

communication is prohibited.

All operating employees must have personal electronic devices TURNED OFF, 

and if equipped, earpiece removed when:

• On a moving train.

• When duty requires any crew member to be on the ground.

• When a crew member is riding rolling equipment during a switching operation.

• During any time when another employee of the railroad is assisting in

preparation of the train.
NTSB Railroad Summary Report

50

5.4 Appendix D: Southbound Train After-Arrival Track Authority, 

Conductor Copy
NTSB Railroad Summary Report

51

5.5 Appendix E: Southbound Train After-Arrival Track Authority, 

Engineer Copy