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NTSB

Permit No. G-200
RAILROAD ACCIDENT REPORT 

NTSB/RAR-06/02 (PB2006-916302) 

COLLISION BETWEEN TWO BNSF RAILWAY COMPANY 

FREIGHT TRAINS NEAR GUNTER, TEXAS 

MAY 19, 2004

• Page 26, table 2 first row has been updated to include column head text (Fort Worth 

Conductor Extra Board*). The text did not print in the original version. (10 OCT 2006) 

 

THE CORRECTIONS BELOW ARE INCLUDED

IN THIS VERSION OF THE PUBLISHED REPORT
Railroad Accident Report

Collision Between Two BNSF Railway Company 

Freight Trains Near Gunter, Texas

May 19, 2004

NTSB/RAR-06/02

PB2006-916302 National Transportation Safety Board

Notation 7793A 490 L’Enfant Plaza, S.W.

Adopted June 13, 2006 Washington, D.C. 20594
National Transportation Safety Board. 2006. Collision Between Two BNSF Railway Company Freight 

Trains Near Gunter, Texas, May 19, 2004. Railroad Accident Report NTSB/RAR-06/02. Washington, DC.

Abstract: About 5:46 p.m., central daylight time, on May 19, 2004, two BNSF Railway Company freight 

trains collided head on near Gunter, Texas. The southbound train, BNSF 6789 South, was traveling about 

37 mph, and the northbound train, BNSF 6351 North, was traveling about 40 mph when the collision 

occurred. The trains were being operated under track warrant control rules on non-signaled single track. 

The collision resulted in the derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel 

were released from the locomotives and resulted in a fire. The southbound train engineer was killed, and 

the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The crewmembers 

on the northbound train were transported to a local hospital, where they were admitted. Estimated property 

damages exceeded $2 million.

The safety issues discussed in this report are the issuance of track warrant authority that contains an 

after-arrival stipulation and the informal communication of proposed meeting locations for trains in 

non-signaled territory.

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

the Federal Railroad Administration, the BNSF Railway Company, the Association of American 

Railroads, and the American Short Line and Regional Railroad Association.

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

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board 

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study 

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board 

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

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Records Management Division, CIO-40

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

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

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To 

purchase this publication, order report number PB2006-916302 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

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

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. 
iii Railroad Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

First Northbound Train/BNSF 2917 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Second Northbound Train/BNSF 6351 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Southbound Train/BNSF 6789 South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Collision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

BNSF 6351 North Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

BNSF 6351 North Conductor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

BNSF 6351 North Brakeman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

BNSF 6789 South Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

BNSF 6789 South Conductor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Train Dispatcher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Track and Site Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Method of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Movement of Trains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

After-Arrival Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Postaccident Changes in After-Arrival Track Warrant Volumes . . . . . . . . . . . . . . . . . 18

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Medical and Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Track and Mechanical Tests and Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Recovered Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Event Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Sight-Distance Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Use of Cellular Phones by Operating Crews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Management Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Operational Testing Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

BNSF Operational Testing of Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Testing on After-Arrival Track Warrant Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Train Crew Qualification and Familiarization Training Trips . . . . . . . . . . . . . . . . . . . 25

Additional Data/Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Use of After-Arrival Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Contents iv Railroad Accident Report

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

First Northbound Train/BNSF 2917 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Second Northbound Train/BNSF 6351 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Southbound Train/BNSF 6789 South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Dispatcher Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

After-Arrival Track Warrants in Non-Signaled Territory . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

BNSF 6789 South Engineer’s Fitness for Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Use of Cellular Phones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Positive Train Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Recommendation Reclassified in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

B: Time Line of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

C: Train Identifications Used in Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

D: Recovered Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
v Railroad Accident Report

Acronyms and Abbreviations

BNSF BNSF Railway Company

CFR Code of Federal Regulations

CPAP continuous positive airway pressure

EAP Employee Assistance Program

FRA Federal Railroad Administration

GCOR General Code of Operating Rules

MP milepost

NORAC Northeast Operating Rules Advisory Committee

PTC positive train control
vi Railroad Accident Report

Executive Summary

About 5:46 p.m., central daylight time, on May 19, 2004, two BNSF Railway 

Company freight trains collided head on near Gunter, Texas. The southbound train, BNSF 

6789 South, was traveling about 37 mph, and the northbound train, BNSF 6351 North, 

was traveling about 40 mph when the collision occurred. The trains were being operated 

under track warrant control rules on non-signaled single track. The collision resulted in the 

derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel were released 

from the locomotives and resulted in a fire. The southbound train engineer was killed, and 

the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The 

crewmembers on the northbound train were transported to a local hospital, where they 

were admitted. Estimated property damages exceeded $2 million.

The National Transportation Safety Board determines that the probable cause of 

the May 19, 2004, collision near Gunter, Texas, 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. Contributing to the 

accident was the BNSF Railway Company’s use of after-arrival track warrant authority in 

non-signaled territory, and the Federal Railroad Administration’s failure to prohibit the 

use of such authority. Also contributing to the accident was the train dispatcher’s informal 

communications regarding planned train meeting locations. 

In its investigation of this accident, the Safety Board examined the following 

safety issues: 

• The issuance of track warrant authority that contains an after-arrival stipulation 

and

• The informal communication of proposed meeting locations for trains in 

non-signaled territory.

As a result of its investigation of this accident, the National Transportation Safety 

Board makes safety recommendations to the Federal Railroad Administration, the BNSF 

Railway Company, the Association of American Railroads, and the American Short Line 

and Regional Railroad Association.
1 Railroad Accident Report

Factual Information

Accident Synopsis

About 5:46 p.m.1 on May 19, 2004, two BNSF Railway Company (BNSF) freight 

trains collided head on near Gunter, Texas. (See figure 1.) The southbound train, BNSF 

6789 South, was traveling about 37 mph, and the northbound train, BNSF 6351 North, 

was traveling about 40 mph when the collision occurred. The trains were being operated 

under track warrant control rules on non-signaled single track. The collision resulted in the 

derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel were released 

from the locomotives and resulted in a fire. The southbound train engineer was killed, and 

the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The 

crewmembers on the northbound train were transported to a local hospital, where they 

were admitted. Estimated property damages exceeded $2 million.

Figure 1. Map showing accident site.

Tulsa

Dallas

Oklahoma City

Gunter

Accident Site Madill

1 Unless otherwise noted, all times in this report are central daylight time.
Factual Information 2 Railroad Accident Report

The accident occurred at milepost (MP) 661.9 on the Madill Subdivision. (See 

figure 2.) BNSF 6351 North had 4 locomotives and 65 empty cars. BNSF 6789 South had 

3 locomotives and 65 cars loaded with rock. The dispatching plan called for the two trains 

to meet at Dorchester siding, about 3 1/2 miles north of the collision site, with BNSF 6789 

South holding the main track and BNSF 6351 North entering the siding. BNSF 6789 

South left Dorchester before BNSF 6351 North arrived. The data for both trains show an 

emergency brake application initiated from the control stand at, or just before, impact. The 

collision took place on straight track, just south of a 1 1/2°-curve with a 0.50-percent 

grade descending to the south.

Figure 2. Madill Subdivision map.

Madill

Lakeside

Barry

Sherman

CTC Denison

Hebron

Dorchester

Gunter

Celina

Prosper

Irving

TEXAS

OKLAHOMA

Accident Site

N

NOT TO SCALE BNSF Madill Subdivision

To Dallas

To Tulsa

Accident Narrative

Preaccident Events

Prior to the collision, three BNSF trains were operating on the Madill Subdivision 

between Irving and Sherman, Texas: two northbound trains and one southbound train. The 

first northbound train, BNSF 2917 North, was not involved in the collision. The second 

northbound train, BNSF 6351 North, was struck by the third train, BNSF 6789 South. In 

the time leading up to the accident,2 each train crew received track warrants and discussed 

train movements with the train dispatcher concerning potential meeting locations with the 

2 See appendix B for a complete time line of accident events.
Factual Information 3 Railroad Accident Report

other trains. According to radio transcripts and voice recordings,3 each of the three train 

crews used the radio while taking track warrants and talking with the train dispatcher. 

There were no indications that the communications systems were not working properly. 

As the trains approached each other, they were in different radio tower ranges, 

which can affect a train crew’s ability to hear all of the dispatcher’s conversations with or 

instructions to other crews. The only information available to the train crews about the 

dispatcher’s communications was either overheard on the radio or issued via track 

warrants. 

First Northbound Train/BNSF 2917 North4

The crew of the first northbound train, BNSF 2917 North, reported for duty about 

7:00 a.m. in Sherman, Texas. BNSF 2917 North had two locomotives and nine freight 

cars. This train was also sometimes referred to in transcripts as the Sherman Switcher, the 

R TEX 641, the 641 Job, the 641, or the Switcher.5 On the day of the accident, the BNSF 

2917 North crew departed from and worked in and around Sherman Yard before traveling 

south to Celina, Texas. About 4:37 p.m., after the BNSF 2917 North crew had completed 

its work at Celina, it was issued a track warrant authorizing movement from Celina6 to the 

north siding switch at Dorchester. 

About 4:40 p.m., the train dispatcher had a discussion with the BNSF 2917 North 

crew concerning possible meeting points. The train dispatcher advised the BNSF 2917 

North crew that he might hold BNSF 6789 South at Dorchester for two trains. He said the 

meeting locations depended on how the Sherman Rock Train, BNSF 6351 North, was 

running. 

Although it was authorized to proceed on the main track to the north switch at 

Dorchester, BNSF 2917 North had only a few cars, and the crew offered to head in at the 

south siding switch and release its main track authority. The dispatcher said he appreciated 

the offer because BNSF 6789 South had indicated some engine trouble and it was 

approaching the north switch on an upgrade.

About 5:12 p.m., the BNSF 2917 North crew reported that it was clear of the main 

track in Dorchester siding. The crew aligned the south siding switch behind it for the main 

track. The dispatcher then issued a track warrant to the BNSF 6789 South crew 

authorizing further movement on the main track to the south siding switch at Dorchester. 

Because BNSF 2917 North was in the siding and had released its track warrant authority, 

3 The dispatching office’s radio and phone communications are recorded. The Safety Board obtained 

all relevant transcripts pertaining to this accident. At the time of the accident, radio communications 

between trains were not being recorded.

4 The BNSF designates timetable directions on the Madill Subdivision as north and south. Timetable 

direction may vary from actual compass direction.

5 See appendix C for more information regarding the identification of the three trains discussed in this 

report.

6 Between CTC Denison and Irving, train movements are authorized through a computerized track 

warrant control system.
Factual Information 4 Railroad Accident Report

the dispatcher did not need to issue a track warrant to BNSF 6789 South to meet BNSF 

2917 North at Dorchester.

BNSF 2917 North and BNSF 6789 South passed each other at Dorchester. BNSF 

2917 North crewmembers said that both trains radioed each other that their respective rear 

markers7 were in place. The BNSF 2917 North engineer told Safety Board investigators 

that he also advised the BNSF 6789 South crew when the southbound train was clear of 

the north siding switch. During the investigation, the BNSF 2917 North engineer stated 

the following regarding the communication of engine numbers:

Investigator: In the normal process of communication, you identified yourself by 

locomotive number, BNSF 2917?

BNSF 2917 North Engineer: I don’t think so.

Investigator: Did, did he [BNSF 6789 South] ever contact you and ask specifically 

your engine number?

BNSF 2917 North Engineer: No.

About 5:18 p.m., the BNSF 2917 North crew was authorized to depart for Sherman, after 

the arrival of BNSF 6789 South. BNSF 2917 North was not involved in the collision. It 

was in Sherman when the accident occurred. 

Second Northbound Train/BNSF 6351 North 

The crew of the second northbound train, BNSF 6351 North, reported for duty 

about 7:00 a.m. in Sherman Yard, Texas. The three-person crew departed Sherman about 

8:50 a.m. Their assignment, also referred to in transcripts as the Sherman Rock Train, the 

Sherman Clark Rock Train, and the Am Rock, involved taking a loaded rock train south to 

an unloading facility near Irving, Texas, and then returning with empty cars to Sherman. 

They arrived in Irving about 11:32 a.m. The BNSF 6351 North crew began its northbound 

return trip about 4:27 p.m. with track warrant authority to the north siding switch at 

Prosper.

About 5:06 p.m., the train dispatcher radioed the BNSF 6351 North crew and 

discussed issuing a track warrant to meet BNSF 6789 South at Prosper. The dispatcher 

advised BNSF 6351 North that BNSF 6789 South was experiencing power problems at 

Dorchester and he was afraid the train might stall out. The dispatcher said: 

So, if I can make this meet at Prosper it will probably make it easier on him 

[BNSF 6789 South], over. Ya’ll go ahead and copy another one, put you in the 

hole[8] at Prosper, over.

7 Rear marker refers to a device placed on the last car indicating the end of the train. The marker 

displays a reflector during the day and a light illuminated during darkness.

8 In the hole means to clear the main track by entering a siding.
Factual Information 5 Railroad Accident Report

The BNSF 6351 North conductor advised the dispatcher that if they were held at 

Prosper, they might not have time9 to return to Sherman by 7:00 p.m. At this point, the 

dispatcher said to “hang on,” and he contacted the BNSF 6789 South crew. He asked: 

“Hey engineer on BNSF 6789 South, can you hold between the switches there at 

Dorchester, over?” The BNSF 6789 South engineer responded: “That’s correct, over.” The 

dispatcher then repeated this question, and the BNSF 6789 South engineer again 

responded: “That is correct.”

The train dispatcher then issued the BNSF 6351 North crew a track warrant 

authorizing it to proceed as far as MP 659, which was between Dorchester and Prosper. 

About 5:21 p.m., the BNSF 6351 North crew was issued another track warrant authorizing 

it to proceed to the south siding switch at Dorchester and to enter the siding to meet 

BNSF 6789 South. BNSF 6351 North continued north, passing through the town of 

Gunter, 4 miles south of the accident site about 5:40 p.m.

Southbound Train/BNSF 6789 South 

The crew of the southbound train, BNSF 6789 South, reported for duty about 

10:15 a.m. in Alliance Yard near Fort Worth, Texas. The crew traveled by taxi to Madill, 

Oklahoma, where they boarded their locomotives and departed Madill about 1:15 p.m. 

They proceeded south to the siding at Lakeside, Oklahoma, where they picked up their 

train of 65 cars loaded with rock. In transcripts, BNSF 6789 South is also referred to as the 

Doni Rock, the Doni Madill, and the Doni Train.

About 2:36 p.m., BNSF 6789 South departed Lakeside headed to Irving. Between 

Lakeside and CTC Denison, the dispatcher authorized train movements through the 

wayside signals of a centralized traffic control system. Beyond CTC Denison, train 

movements were authorized through a track warrant control system.

About 3:17 p.m., the train dispatcher issued the BNSF 6789 South crew a track 

warrant authorizing movement from CTC Denison (the end of centralized traffic control 

and the beginning of track warrant control) to the south siding switch at Sherman. The 

conductor had difficulty correctly repeating the track warrant information back to the train 

dispatcher. According to radio transcripts, the conductor made multiple attempts to copy 

and read back the track warrant to the train dispatcher. The dispatcher slowed the pace of 

his communications, and the track warrant was OK’d10 at 3:17 p.m. At that time, the 

dispatcher requested that the engineer call him on the phone.

9 Railroad operating crews are limited to 12 hours on duty by regulations at 49 Code of Federal 

Regulations Part 228.

10 The dispatcher uses the term OK as a formal confirmation that the crewmember has read back the 

track warrant instructions correctly. A track warrant is not considered in effect until the OK time is recorded.
Factual Information 6 Railroad Accident Report

About 4:02 p.m., the BNSF 6789 South engineer contacted the train dispatcher by 

cellular phone. The dispatcher said: 

Hey, do me a favor; I want you to work close with your conductor. Make sure he is 

using proper radio procedures, especially when it comes to spelling out words and 

his directions. It’s not a criticism. I can tell he’s new and I’ll certainly go slowly. 

Make sure he gets it right, if you could. Back him up, and make sure he’s doing it 

right. I sure would appreciate it.

During this cellular phone conversation, the BNSF 6789 South engineer asked the 

dispatcher if he was going to hold them at Sherman. The dispatcher replied: “No, what I’m 

going to do is roll up[11] the . . . 641 Job [641 Job was one of the names used for the BNSF 

2917 North] and have you meet them at Dorchester.” The engineer said: “Sounds good.” 

About 4:47 p.m., the dispatcher again advised the BNSF 6789 South crew that they 

would meet the 641 at Dorchester. About 4:51 p.m., a second track warrant was issued to 

the BNSF 6789 South crew authorizing movement from the south siding switch at 

Sherman to the north siding switch at Dorchester. Following the OK on this track warrant, 

the dispatcher advised the BNSF 6789 South crew that the dispatching plan was to meet 

one train at Dorchester and then proceed to Prosper to meet a second northbound train:

Dispatcher: Yes sir, that’s correct on that repeat, and ah, Sherman Switcher is 

going to clear up for you, and we’ll just take you to Prosper to meet the Sherman 

Clark Rock Train, OK, over.

BNSF 6789 South: Copy, ah, meet one at Dorchester.

About 5:05 p.m., the BNSF 6789 South engineer called the dispatcher and asked: 

“Were we going in the hole there [north siding switch at Dorchester] or what?” The 

dispatcher answered: 

No, no, no, you’re going to hold there till the Sherman Rock, excuse me, until the 

Sherman Switcher[12] clears up at Dorchester. Then I’ll take you guys on south to 

Prosper to meet the Sherman Rock Train.

The BNSF 6789 South engineer responded: “OK, we don’t have the best power, that north 

switch is right on the hill there. Anyway, we can go to the south switch?” The dispatcher 

advised the BNSF 6789 South engineer to “hang on a second.” 

About 5:06 p.m., the BNSF 2917 North crew advised the dispatcher that it was 

entering the siding at the south end of Dorchester. The dispatcher in turn advised the 

BNSF 6789 South crew to “slow up a little bit,” and he said, “they’re dragging in the 

siding right now.” Just after this, the train dispatcher gathered additional information that 

resulted in a decision to change the meeting locations from what he had just radioed the 

BNSF 6789 South crew. The dispatcher radioed the BNSF 6351 North crew to determine 

their location and what time they had to be off duty. About 5:10 p.m., after being told that 

11 As trains release portions of their authority, it is referred to as rolling up their authority. 

12 The Sherman Switcher was BNSF 2917 North. The Sherman Rock was BNSF 6351 North.
Factual Information 7 Railroad Accident Report

the BNSF 6351 North crew might exceed their maximum hours-of-service times before 

getting to Sherman if they were held at Prosper, the dispatcher issued the BNSF 6351 

North crew a track warrant authorizing movement to MP 659, which is north of Prosper. 

About 5:16 p.m., after BNSF 2917 North (the first northbound train) entered 

Dorchester siding and released its track warrant authority on the main track at Dorchester, 

the BNSF 6789 South crew was issued a track warrant authorizing movement on the main 

track to the south end of Dorchester. (See figure 3.) About 5:21 p.m., the dispatcher issued 

a track warrant to the BNSF 6351 North (the second northbound train) crew, authorizing it 

to proceed to the south siding switch at Dorchester with an instruction to clear the main 

track (enter the siding).

BNSF 6789 South was stopped at the south end of Dorchester on the main track 

about 5:39 p.m., when the dispatcher issued a track warrant (No. 3598) authorizing its 

movement from the south siding switch at Dorchester to the south siding switch at 

Hebron, after the arrival of BNSF 6351 North (the second northbound train). (See 

appendix D for a copy of the track warrant.) Prior to issuing the track warrant, the 

dispatcher checked twice with the BNSF 6789 South crew to ensure that they could “hold 

between switches at Dorchester.”

The last series of communications between the BNSF 6789 South engineer13 and 

the train dispatcher was as follows:

BNSF 6789 South Engineer: Track Warrant No. 3598, with the box 7 not in effect 

till after the arrival of BNSF 6351 at south, s-o-u-t-h, siding switch Dorchester is 

OK’d at seventeen thirty-nine, 1-7-3-9. WHM,[14] over.

Dispatcher: OK, that’s correct, hey ah, what time should I have you guys a taxi at, 

at ah, Irving back to Fort Worth for, over?

BNSF 6789 South Engineer: Ah, probably about 7:30.

Dispatcher: Nineteen thirty, OK. I’ll call you back to confirm, OK, over.

BNSF 6789 South Engineer: All right. I’ll report, ah, south siding switch Dorchester 

restored to normal.

Dispatcher: OK, ah, I can’t, I can’t, ah, normal it, ah, because ah, I can’t show it 

normal because the ah, that Rock Train,[15] the Sherman Switcher’s[16] got a box 7 

on you, OK, over.

BNSF 6789 South Engineer: OK. After we get by, we’ll let you know. 

Dispatcher: Here we go, dispatcher out. 

13 The dispatcher said that he recognized the engineer’s voice after listening to the recorded 

communications.

14 WHM are the dispatcher’s initials.

15 The Rock Train was BNSF 6351 North.

16 The Sherman Switcher was BNSF 2917 North.
Figure 3. Train operations schematic.

North 

To MadillMP 602.6

Sherman

MP 645.5

Dorchester

MP 657.7 Prosper MP 679.7 Hebron MP 692.5 

M

Collision 

Location

MP 661.9

BNSF 6789 South BNSF 6

Schematic view on

1

1

2

2

3

3

4

4

5

5

Approximate Time of Events

BNSF 2

5:12 p.m. BNSF 2917 North clears main track in Dorchester siding and releases track warrant authority.5:16 p.m. BNSF 6789 South receives track warrant authority on main track to south siding switch Dorchester.5:20 p.m. BNSF 2917 North and BNSF 6789 South pass at Dorchester. BNSF 6789 South crew does not verify en

train passing in siding using radio.

5:21 p.m. BNSF 6351 North receives track warrant authority on main track to south siding switch Dorchester.5:39 p.m. BNSF 6789 South receives track warrant authority on main track to Hebron with stipulation "after-arrival 

North" and immediately departs Dorchester.
Factual Information 9 Railroad Accident Report

This last radio exchange was made about 5:40 p.m., following the completion of the track 

warrant that required BNSF 6789 South to wait for BNSF 6351 North to enter the siding at 

the south siding switch at Dorchester before departing. However, as soon as this track 

warrant was OK’d, BNSF 6789 South departed Dorchester and accelerated to 40 mph.

The Collision

About 5:46 p.m., 7 minutes after the track warrant requiring BNSF 6789 South to 

wait at Dorchester until after the arrival of BNSF 6351 North was issued, the two trains 

collided head on about 3 1/2 miles south of the Dorchester siding. The point of collision 

occurred at MP 661.9 near the intersection of Fallon Road and State Highway 289, north 

of the town of Gunter. Most of this area was undulating agricultural land. The track was 

relatively straight with occasional curves, one of which was the 1 1/2° curve17 at the 

accident site. (See figure 4.) 

Trees restrict the view as trains round this curve, and the BNSF 6351 North 

conductor and engineer said that they first noticed the southbound train through the trees 

as they approached the curve. The conductor and engineer, who were on the leading 

locomotive, exited the cab and jumped off the train. A brakeman was riding in a trailing 

locomotive, where he remained until after the collision. According to a BNSF official, 

who arrived at the accident site shortly after the collision, the BNSF 6351 North brakeman 

told him that the BNSF 6789 South engineer had jumped out the window before the 

collision. However, the brakeman said that he could not remember this account when later 

interviewed by Safety Board investigators. The BNSF 6789 South conductor told the 

BNSF official that he had jumped out the window and that he thought the engineer had 

attempted to get out, but he was not sure how the engineer had exited the train. 

Event recorder data indicate that both trains were placed into emergency braking 

just before the collision. BNSF 6351 North was placed into emergency braking at about 

40 mph with the throttle in position 4 (of 8). BNSF 6789 South was placed into emergency 

braking as it was moving about 37 mph with the throttle in the idle, 1, or 2 position.18

17 This was a right-hand curve as viewed from the northbound train, BNSF 6351 North.

18 The event recorder does not distinguish between these three throttle positions. Also, the southbound 

train was descending a 0.50-percent grade. Throttle and braking actions just prior to the collision were 

consistent with maintaining the allowed speed of 40 mph.
Figure 4. Aerial photo of accident scene.

Factual Information 10 Railroad Accident Report
Factual Information 11 Railroad Accident Report

Emergency Response

Records indicate that about 5:49 p.m., the Grayson County Communications 

Center began receiving multiple phone calls about the accident. One of the calls was 

placed from the BNSF 6351 North brakeman’s cellular phone. The Grayson County 

Communications Center in turn notified the Gunter Volunteer Fire Department by pager. 

The Gunter Volunteer Fire Department chief told the Safety Board that he was the first 

responder to arrive on scene, about 6 minutes after receiving the page. En route to the 

scene, he said that he activated mutual aid from surrounding jurisdictions and requested 

that two medical helicopters be put on standby. As he approached the accident site, he 

observed some of the injured crewmembers and radioed a request to dispatch the 

helicopter from Sherman. The BNSF 6789 South conductor received serious burns and 

was transported by helicopter to a hospital burn center in Dallas. The other surviving 

crewmembers were transported to a local hospital in Sherman, Texas, a short time later.

A BNSF official arrived on scene about 6:00 p.m. and assisted rescue workers as 

they accounted for the crewmembers. He advised them that the BNSF 6789 South 

engineer had not been located. After searching the wreckage site, responders found the 

engineer’s body on the west side of the tracks.

Two locomotive fuel tanks ruptured, resulting in a fire immediately following the 

collision. Fire department personnel extinguished the fire. Later in the evening during 

clean up efforts, a foam truck arrived from the Grayson Airport Fire Department, located 

in Grayson, Texas, about 20 miles north of Gunter. The foam truck was placed on standby 

as a precaution. In all, seven other jurisdictions assisted the Gunter Volunteer Fire 

Department during the accident. 

At the time of the accident, the Gunter Volunteer Fire Department consisted of 21 

volunteer firefighters and 7 fire explorer scouts. The chief stated that during the year prior 

to the accident, the department had participated in training on chemical response and 

railroad operations and also had taken part in a tabletop exercise with BNSF. The chief 

stated that this previous training proved helpful when responding to the Gunter accident. 

Injuries 

The BNSF 6789 South engineer was killed. The BNSF 6789 South conductor was 

seriously burned. All three of the BNSF 6351 North crewmembers were injured and taken 

by ambulance to a hospital in Sherman. 

Damages 

During the collision, both trains were extensively damaged. A total of 28 cars were 

derailed. BNSF 6789 South had three locomotives, all of which were derailed and 
Factual Information 12 Railroad Accident Report

destroyed. BNSF 6351 North had four locomotives. The lead locomotive and the second 

locomotive were derailed and destroyed. The third and fourth locomotives also sustained 

extensive damage; however, they were not derailed. 

BNSF provided the following damage estimates: $2,039,791 for equipment 

(locomotives and cars); $50,000 for track; $52,867 for lading and environmental clean up; 

and $18,800 for wreck clearing. Total estimated property damages were $2,161,458.

Personnel Information

BNSF 6351 North Engineer

The BNSF 6351 North engineer was hired in August 1979. Prior to the accident, 

the engineer’s last annual checkride took place in April 2004. He had completed a rules 

examination in March 2003, and his engineer’s certification was current. He had regularly 

worked on the Madill and Creek Subdivisions as an engineer during the 12 months before 

the accident. When the accident occurred, he had been on duty for about 10 hours 50 

minutes. The engineer had worked the previous day, going off duty about 8:00 p.m. He 

had been off duty for 11 hours when he reported for work on May 19. 

BNSF 6351 North Conductor

The BNSF 6351 North conductor was hired in April 1998. He had completed a 

rules examination in April 2003. He had regularly worked on the Madill and Fort Worth 

Subdivisions as a conductor during the 12 months prior to the accident. The conductor had 

been on duty for about 10 hours 50 minutes when the accident occurred. He had worked 

the previous day, going off duty about 8:00 p.m. He had been off duty for 11 hours before 

reporting for work on May 19.

BNSF 6351 North Brakeman

The BNSF 6351 North brakeman was hired in July 2001. He had completed a rules 

examination in October 2003. He had regularly worked on the Madill and Fort Worth 

Subdivisions as a trainman during the 12 months before the accident. He had been on duty 

for about 10 hours 50 minutes when the accident occurred. The brakeman had worked the 

previous day, going off duty about 8:00 p.m. Prior to reporting for work on May 19, he had 

been off duty for 11 hours.

BNSF 6789 South Engineer

The BNSF 6789 South engineer was hired as a conductor in October 1994. He was 

promoted to engineer in May 1997. Prior to the accident, the engineer’s last annual 

checkride took place in July 2003. He had completed a rules examination in April 2004, and 

his engineer’s certification was current. He had regularly worked on the Madill Subdivision 

as an engineer during the 12 months before the accident. He had been on duty for about 7 

hours 35 minutes when the accident occurred. The engineer had last worked on May 17. He 

had been off duty for 50 hours 30 minutes before reporting for work on May 19.
Factual Information 13 Railroad Accident Report

The engineer’s records show he was dismissed on March 24, 2000, for being 

absent from duty without proper authority. He was reinstated on October 29, 2001, after an 

arbitrator determined that the charges against him were valid and that he had violated 

carrier rules. The ruling required him to consult with BNSF’s Employee Assistance 

Program (EAP) and follow a program on attendance devised by the EAP. 

BNSF 6789 South Conductor

The BNSF 6789 South conductor was hired in August 2001. Prior to the accident, 

he had completed a biennial rules examination in June 2003 and an annual train ride in 

September 2003. The conductor had been on duty for about 7 hours 35 minutes at the time 

of the accident. He had last worked on May 17, and he had been off duty for 50 hours 30 

minutes when he reported for work on May 19.

The conductor had recently transferred to a road service pool19 assignment 

covering the Madill Subdivision. This was his second trip. He had worked a yard 

assignment for several months before taking the pool assignment. On the yard assignment, 

he had not been required to work with a train dispatcher copying track warrants over the 

radio. The BNSF official in charge of field operations on the Madill Subdivision stated 

that the conductor was qualified to work as a conductor on the day of the accident based 

on normal qualification procedures. 

Train Dispatcher

The train dispatcher was hired in July 1999. He had completed biennial rules 

training in December 2003. He had regularly dispatched the Madill Subdivision during the 

12 months prior to the accident. The dispatcher was working a regular 3:00 p.m. to 

11:00 p.m. shift and had been on duty for about 2 hours 45 minutes at the time of the 

accident. He had gone off duty the previous evening about 11:00 p.m. He had been off 

duty about 16 hours when he reported for work on May 19.

Train Information

BNSF 6789 South consisted of 3 locomotives and 65 rock cars. The train weighed 

9,044 tons and was 2,871 feet in length (3,066 feet with locomotives). It was a unit train20

identified by BNSF with the symbol U MADDON1 19A.

BNSF 6351 North consisted of 4 locomotives and 65 empty rock cars. The train 

weighed 1,996 tons and was 2,847 feet in length (3,119 feet with locomotives). It was a 

unit train identified by BNSF with the symbol U SHTIRB1 19A.

19 A road service pool consists of personnel working on-call assignments in rotation.

20 A unit train is a set of dedicated equipment that is operated between a loading and unloading facility.
Factual Information 14 Railroad Accident Report

Track and Site Information

The collision occurred about 3 miles north of Gunter, a town about 45 miles north 

of Dallas. Track structure in the area of the collision consisted of a single main track. The 

rail was composed of 115-pound21 continuous welded rail fixed to treated timber crossties 

in crushed stone ballast. The track was designated Class 4 track22 that had a maximum 

allowable speed of 49 mph. There was a temporary speed restriction of 40 mph from 

MP 656.2 to MP 680.1 due to crosstie conditions.

Method of Operation

Movement of Trains

Train operations on the Madill Subdivision were governed by the General Code of 

Operating Rules (GCOR) dated April 2, 2002; BNSF “Texas Division Timetable Number 

5” issued on January 20, 2002; BNSF “System Special Instructions Number 8” issued on 

July 13, 2003; the BNSF Train Dispatcher, Operator, Control Operator Manual dated 

July 13, 2003; and various other bulletins and notices issued periodically.

A train dispatcher at the BNSF Network Operations Center managed and directed 

train movements on the Madill Subdivision. During a typical 24-hour period around the 

date of the accident, there were about 26 train movements on the Madill Subdivision and 7 

or 8 train movements on other territories that the Madill train dispatcher handled. The 

Madill Subdivision consisted of both centralized traffic control and track warrant control 

territory. Between Sherman and Irving, the Madill Subdivision was non-signaled single 

track with designated passing tracks (sidings). Within this dark territory,23 the dispatcher 

issued mandatory directives for trains to proceed from point to point and to make meets 

and passes of other trains via track warrants.

The BNSF official in charge of this territory described typical train movements 

between Sherman and Irving as unit rock trains and a turn-around local freight 

assignment. Loaded rock trains moved south, and empty trains moved north. He described 

train movements as “pretty much a scheduled thing,” and he stated that crews that 

regularly work the Madill Subdivision usually know which trains are running. 

21 Rail is measured in weight per linear yard.

22 Railroads determine how they will classify various segments of their track. As the class designation 

increases, the track must meet increasingly higher Federal standards for construction, maintenance, and 

inspection. Federal regulation also establishes maximum train speeds for each class of track. Class 4 track

has a maximum allowable speed of 60 mph for freight trains and 80 mph for passenger trains. The railroad 

may restrict the speed further (as was the case near Gunter).

23 Non-signaled track is often referred to as dark territory in the railroad industry.
Factual Information 15 Railroad Accident Report

Track Warrants

Track warrants are mandatory directives that convey authority for trains to occupy 

and operate on the main track between specific locations. When a track warrant is issued, 

the dispatcher also enters it into the computerized track warrant control system. The track 

warrant control system is designed to assist the train dispatcher and to identify potential 

conflicting movements. As the train dispatcher issues a track warrant by radio to the train 

crew, a crewmember writes the information on a preprinted track warrant form. 

The BNSF track warrant form has 19 items (1–17 and 21–22) that are checked off 

as needed by the train dispatcher to regulate the movement of trains. (See figure 5.) As the 

dispatcher issues the track warrant instructions, a crewmember checks off the boxes and 

enters other information as directed. Box 7 is the item that must be checked by the train 

dispatcher and the train crew when an after-arrival track warrant is issued. The train crew 

reads the track warrant back to the train dispatcher, and providing the read back is correct, 

the dispatcher advises that it is OK and issues a time. 

Track-warrant rules require that personnel identify trains by railroad initials, 

engine number, and direction in a track warrant (for example, BNSF 6789 South or BNSF 

6351 North). The BNSF made a distinction between how trains are identified in formal 

track warrant directives (railroad initials, engine number, and direction) and how they are 

referred to in less formal information exchanges (the 641 Job, the Sherman Rock, etc.). A 

senior BNSF manager explained the distinction:

Investigator: OK. Another thing is, whenever the train dispatcher is talking to a 

job, I know that when you issue a track warrant, you do it by initial, number, and 

direction, like BNSF 6125 northbound. But you also have train symbols that the 

train dispatchers are using a lot. In this Gunter case, we see where the train 

dispatcher has talked about the same train and used at least four different 

identifications in it. Is that a concern that we need to look at?

BNSF Manager: I don’t believe so. From a traffic planning standpoint, when 

meets and passes occur that have strict operational requirements regarding main 

track authority moves, I think that certainly there’s a level of communications and 

expectations that we have for those communications.

I think that outside of those, that some short identifications are actually more 

telling, I guess, for a train crew as far as who they’re meeting, such as you’re 

going to meet a Road Switcher or Rock Train or some of those type of things 

versus actually getting into alpha-numeric symbol abbreviations that the train 

crews will do a translation themselves anyway.

BNSF procedures required that employees copying track warrants state their name 

before instructions were transmitted. Before the transmittal of the last track warrant to BNSF 

6789 South, the engineer stated that the conductor was copying the track warrant. After 

listening to the tapes, the train dispatcher recognized the engineer’s voice as the person who 

had read the instructions back and OK’d the track warrant for BNSF 6789 South to wait at 

Dorchester. BNSF officials stated that they took no exception to one crewmember copying 

and a different crewmember repeating the instructions back to the dispatcher. 
Figure 5. BNSF track warrant form.

Factual Information 16 Railroad Accident Report
Factual Information 17 Railroad Accident Report

After-Arrival Track Warrants 

To comply with an after-arrival track warrant, the train crew that receives the box 7 

track warrant must wait until the train listed has arrived at the designated location before 

any movement is made. The conductor and engineer on BNSF 6789 South were jointly 

responsible for complying with these requirements.24

BNSF track warrant instructions required that the train to be met be identified by 

railroad initials, engine number, and direction. The instructions further required that the 

meeting crew know that the opposing train passed the point of restriction. Additionally, in 

non-signaled territory, the meeting train was required to make positive radio contact with 

the train to be met in order to confirm the identity of the passing train. If the crew that was 

restricted by the box 7 track warrant could not reach the train identified in box 7, then the 

train dispatcher was to be contacted to confirm the identity of the train that they met. BNSF 

procedures also included a requirement that both the engineer and the conductor of the train 

restricted by the box 7 track warrant record the time and location on their track warrant 

form, indicating that they had identified the train listed in box 7 of their track warrant. 

When the track warrant was issued requiring that the trains meet at the Dorchester 

siding (see figure 6), it was a formal directive issued by the dispatcher with a read-back by the 

crew, which provided confirmation of communication and understanding. Earlier informal 

discussions between the dispatcher and crews regarding potential meeting points were 

informational rather than directive. The BNSF viewed these informal information exchanges 

as important for operational planning to address issues, such as fuel conservation, and to 

avoid extended blocking of road crossings. A BNSF senior manager explained:

I think there’s balance in providing that information and that think aloud, you 

know, think out loud taking place may be good, and there’s other cases that it may 

set an expectation that when the plan change (sic). You know, it gets back to what 

is an obligation to go back and to what I’ll call correct that information that was 

originally transmitted because operation plans do change.

As a result of this accident, on May 28, 2004, the BNSF issued “System General 

Order Number 45,” amending the after-arrival track warrant procedures. The changes, which 

took effect on June 1, 2004, established a three-step process in non-signaled territory: 

1. Dispatcher advises the train that will receive the box 7 track warrant of the 

identification of train(s) that will be listed in box 7 (by railroad initials, engine 

number, and direction); 

2. The train that will receive the box 7 track warrant establishes the location of 

the train(s) that will be listed in box 7 (by railroad initials, engine number, and 

direction), advising the dispatcher that direct communication has been made 

and the location of the train(s) contacted; and 

3. The train crew to receive the box 7 track warrant has stopped at the meeting 

point and has notified the dispatcher that they are stopped. 

24 GCOR Rule 1.47, “Duties of Trainmen and Enginemen.”
Factual Information 18 Railroad Accident Report

An additional condition was implemented requiring that crews turn in their track warrants 

at the completion of each trip.

On May 28, 2004, the BNSF also issued “Job Briefing Number 24” to all dispatchers 

and chief dispatchers, further explaining the revised communication requirements and 

expectations regarding the after-arrival track warrant process. The briefing also stated that 

the BNSF was attempting to minimize the number of trains listed in track warrant box 7. 

Figure 6. South siding switch at Dorchester

Postaccident Changes in After-Arrival Track Warrant Volumes 

The BNSF monitored track warrant volumes, comparing the period from 

January 1 to May 20, 2004, with the period from June 6 to July 14, 2004. The comparison 

showed that the number of after-arrival track warrants issued decreased on a systemwide 

basis from a monthly average of 2,559.2 (5.88 percent of total track warrants) to 649 (1.13 

percent of total track warrants) after the accident and after the revisions to the after-arrival 

track warrant procedures. On the Madill Subdivision, the number of after-arrival track 

warrants decreased from a monthly average of 90.9 (5.03 percent of total track warrants 

issued) to 14 (0.67 percent). The BNSF has continued to monitor after-arrival track 

warrant volumes and has told the Safety Board that the monthly average remains about the 

same. During calendar year 2005, an average of about 13 after-arrival track warrants were 

issued per day in non-signaled territory on the BNSF system. BNSF representatives 

advised the Board that a number of these after-arrival track warrants were issued solely to 

monitor compliance with BNSF procedures in non-signaled territory. 
Factual Information 19 Railroad Accident Report

Meteorological Information 

The report from the Collin County Regional Airport (about 20 miles south of 

Gunter) at the time of the accident indicated that the weather was dry and clear, and the 

temperature was 86° F. There were no weather-related impediments to visibility.

Medical and Toxicological Information 

Toxicological specimens were obtained from the surviving BNSF 6789 South 

conductor, the three BNSF 6351 North crewmembers, and the BNSF dispatcher on duty at 

the time of the accident. The coroner provided specimens taken from the deceased

BNSF 6789 South engineer. All of the specimens were screened for the following 

substances: cannabinoids, cocaine, opiates, amphetamines, methamphetamines, 

phencyclidine, barbiturates, benzodiazepines, and ethyl alcohol. All of the test results 

were negative for the presence of alcohol and drugs. 

Information obtained from the medical records maintained by the personal 

physician of the deceased BNSF 6789 South engineer indicated that he had been 

diagnosed with severe obstructive sleep apnea in 1999 and he had been prescribed a 

continuous positive airway pressure (CPAP) device. The diagnosis was based on a sleep 

study that indicated the engineer had a sleep latency25 period of 2 minutes. According to 

notes in the physician’s records, the engineer began using the CPAP and reported: “More 

energy! Less fatigued/feels well.” A physician’s note from January 2002 stated that the 

engineer had discontinued using the CPAP and that he was sleeping well and had “no 

daytime somnolence.” Further notes from 2003 and 2004 exams stated that the engineer 

had not resumed use of his CPAP device.

Medical records maintained by the BNSF from July 2001 indicated that the 

deceased BNSF 6789 South engineer had been diagnosed with diabetes and hypertension 

and his condition was described as “stable.” Medications prescribed were listed in the 

records as follows: Glucophage [metformin], 1000 mg twice a day; felodipine, 10 mg a 

day; Amaryl [glimepiride], 4 mg a day; Avandia [rosiglitazone], 4 mg a day; Accupril 

[quinapril]; and Zocor [simvastatin]. His recommended work status was described as “Full 

Duty.” The engineer’s personal physician’s name and signature appeared on the form. No 

additional details were provided regarding the engineer’s diabetes and hypertension, and 

there was no mention in the BNSF’s records of a diagnosis of, or treatment for, obstructive 

sleep apnea. There is no Federal regulation that requires locomotive engineers or their 

personal physicians to report an obstructive sleep apnea diagnosis to employers.

25 Sleep latency is the amount of time it takes a person to fall asleep. The sleepier someone is, the 

shorter the person’s sleep latency will be. A person with a sleep disorder such as obstructive sleep apnea 

often has a very short sleep latency.
Factual Information 20 Railroad Accident Report

No additional requests for information regarding the engineer’s diabetes or 

hypertension had been made by the BNSF, and no other medical examinations were 

documented in the BNSF’s records.

The BNSF’s records did reflect that the engineer’s last required vision evaluation 

indicated that he had normal color vision. The evaluation also indicated distant vision of 

20/30 in the left eye and 20/20 in the right eye. His near vision was recorded as 20/30 in 

each eye. 

Medical records for the BNSF 6789 South conductor did not contain information 

about any potentially performance impairing medical conditions.

Tests and Research

Track and Mechanical Tests and Inspections

Track in the area of the collision was inspected, and no defects were noted. 

Undamaged cars on both trains were inspected. All brakes had applied on BNSF 6789 

South. One car (FURX 911139) on BNSF 6351 North had inoperative airbrakes. The 

engineer on BNSF 6351 North told investigators that the train handled as expected, and he 

took no exception to the train’s performance or braking.

Both trains were given airbrake tests prior to departing their originating locations. 

No exceptions were noted. Each locomotive from both trains was within all inspection 

parameters required by the Federal Railroad Administration (FRA).

Recovered Track Warrants

Track warrants were recovered from the locomotives involved in the accident. The 

track warrants documenting the meet between BNSF 6789 South and BNSF 6351 North 

are provided in appendix D. There is no indication on Track Warrant No. 3598, the 

after-arrival track warrant issued to BNSF 6789 South, showing that either the engineer or 

the conductor recorded the identifying information (time and location) for the train that 

was listed in box 7. 

Event Recorder Data 

Event recorder data were produced using the Safety Board’s data analysis software 

in Washington, D.C.26 The data were verified for accuracy by examining operating 

characteristics of the locomotives that had been previously recorded. The data were 

consistent and within the operating range and limitations of the locomotives. 

26 Locomotive event recorders typically record information that includes time, speed, distance, and 

throttle and brake settings.
Factual Information 21 Railroad Accident Report

Sight-Distance Observations

Sight-distance observations were conducted on May 21, 2004, to approximate the 

conditions that the crews experienced prior to the collision. The observations were 

conducted using similar locomotives to those involved in the accident. The weather at the 

time of the sight-distance observation testing was dry and cloudy, and the temperature was 

87° F, which was similar to the accident conditions.

During the testing, both locomotives stopped at the point of collision at MP 661.9 

and backed away from each other in 100-foot increments until they were 1,700 feet 

apart. Both locomotives were then moved 25 feet farther apart until the southbound 

locomotive was backed into the curve and lost sight of the northbound locomotive. At 

875 feet from the point of collision, personnel on each locomotive lost sight of the 

other locomotive. The distance between the two locomotives measured 1,750 feet. 

(See figure 7.) The sight-distance observations and the event recorder speed data 

indicate that the crewmembers in the control cabs had about 15 seconds to recognize 

the impending collision, apply the emergency brakes, and jump from the moving trains 

before impact.

Figure 7. Collision site as viewed from southbound train (BNSF 6789 South).

Use of Cellular Phones by Operating Crews

The GCOR and the BNSF “System General Order Number 37” dated March 7, 

2004, restricted the use of cellular phones and other electronic devices. Cellular phones 

were not to be used by crewmembers while the train or engine was moving. However, 
Factual Information 22 Railroad Accident Report

cellular phone use was allowed while the train or engine was stopped, providing that such

use did not interfere with required duties.

Safety Board investigators obtained records that showed the number and duration

of cellular phone calls made by crewmembers on both trains between 1:50 p.m. and the

time of the accident. (See table 1.) During this time, a total of 25 cellular phone calls were

made and/or received by the 5 crewmembers on both trains while the trains were in

motion. Three of these calls were railroad business related. The BNSF 6789 South

engineer made two of the business related calls, and the BNSF 6351 North conductor

made the third.

Table 1. Summary of crew cellular phone activity between 1:50 p.m. and collision.

The BNSF 6789 South engineer’s cellular phone record showed activity between

3:12 p.m. and 3:16 p.m. This time period coincides with the time that track warrant

authority was being received by the BNSF 6789 South conductor. (Track Warrant No.

3583 was OK’d at 3:17 p.m.) BNSF track warrant procedures required the receiver (the

BNSF 6789 South conductor in this case) to repeat back verbatim certain critical portions

of the track warrant. In this instance, the track warrant had to be repeated back to the

dispatcher several times before it was considered correct. 

Crewmember Number 

of Calls

Duration of 

Calls

Calls While 

Train in 

Motion

Calls While Track 

Warrant Authority 

Was Being Issued

BNSF Business 

Related Calls

BNSF 6789 

South 

Engineer

16 36 minutes 7 1 2

BNSF 6789 

South 

Conductor

7 16 minutes 1 0 0

BNSF 6789 

South Total

23 52 minutes 8 1 2

BNSF 6351 

North 

Engineer

20 37 minutes 12 0 0

BNSF 6351 

North 

Conductor

6 22 minutes 3 0 1

BNSF 6351 

North 

Brakeman

12 91 minutes 2 0 0

BNSF 6351 

North Total

38 150 minutes 17 0 1

Combined 

Total

61 202 minutes 25 1 3
Factual Information 23 Railroad Accident Report

Following the 3:17 p.m. OK on Track Warrant No. 3583, the dispatcher asked the 

BNSF 6789 South engineer to use his cellular phone to call him at the Network Operations 

Center. The engineer had to call the dispatcher twice because of poor 

transmission/reception during the first call. The first call to the dispatcher was made at 

3:22 p.m., and the second call was made at 4:02 p.m. Both calls were recorded. The 

dispatcher asked the engineer to provide additional assistance to the conductor in future 

track warrant communications. Event recorder data indicate that both calls were made 

while the train was in motion.

The BNSF 6351 North conductor’s cellular phone records showed a call to the 

BNSF work order reporting line27 at 5:04 p.m. Event recorder data indicate that the train 

was in motion at that time.

No cellular phone activity was recorded for either train crew during the time the 

BNSF 6789 South crew was receiving the after-arrival track warrant authority at 

Dorchester, which required them to wait for the arrival of BNSF 6351 North (OK time 

5:39 p.m.). The last cellular phone activity for the BNSF 6789 South crew was recorded at 

5:31 p.m. The call lasted about 2 minutes while the train was stopped. The last cellular 

phone activity for the BNSF 6351 North crew before the collision was recorded at 5:24 

p.m. The call lasted about 3 minutes while the train was moving. A 911 call originated 

from the BNSF 6351 North brakeman’s cellular phone at 5:48 p.m.

Management Oversight 

Operational Testing Program

Operational testing28 is one of the methods used to monitor the effectiveness of, 

and compliance with, the operating rules. The Federal Railroad Safety Act of 1970 

requires that railroads have a program of operational tests and inspections. Regulations at 

49 Code of Federal Regulations (CFR) Part 217. 9 (a) require that a railroad:

Conduct operational tests and inspections to determine the extent of compliance 

with its code of operating rules, timetables, and timetable special instructions in 

accordance with a written program retained at its system headquarters and at the 

division headquarters for each division where the tests are conducted.

The BNSF described the program as providing “an opportunity to verify that employees 

are working safely and in compliance with all company rules, policies, instructions and 

procedures.” According to managers interviewed, the BNSF established a goal of 

conducting at least 80 tests per month per manager. Operational testing statistics are 

maintained and provided to the division general manager. 

27 The BNSF has a system where crewmembers can call in information to a centralized database 

concerning work performed en route, such as railroad cars removed from or added to a train.

28 Operational testing involves management observations of employees, as well as structured scenarios, 

to verify that rules and procedures are followed.
Factual Information 24 Railroad Accident Report

Several of the tests in the BNSF program are related to track warrants, although 

the BNSF official assigned to the Madill Subdivision stated that box 7 requirements 

were difficult to test: 

I have never had a violation with a box 7 track warrant, and in fact, again, they are 

difficult to catch because, I mean, you just have to be in the right spot at the right 

time. 

BNSF operational testing records for the 12 months prior to the accident 

showed that about 1,119 operational tests were performed on the Madill Subdivision. 

Of that number, 167 were specific29 to track warrant control operations, and 5 of those 

were recorded as failures. The five failures were recorded for test 612, which covers 

the requirement that crews operating in non-signaled territory make a radio 

transmission 2 miles in advance of a siding or junction, stating the engine number, 

direction, speed, and location. 

Train dispatchers in the Network Operations Center also monitor the safe 

operations of trains. If dispatchers become aware of an operating rule violation, they 

are expected to notify the chief dispatcher. Such a notification would result in 

followup action. If the rule violation were serious (for example, a “de-certifiable”30

event, such as a train exceeding its movement authority), the dispatcher would 

typically stop the train and notify a supervisor to contact the crew.

BNSF Operational Testing of Personnel

Records indicate that the BNSF conducted 184 operational tests of the five 

crewmembers involved in the collision during the 12 months prior to the accident. 

The BNSF 6789 South engineer was tested eight times. None of the tests was related 

to track warrant authority. The engineer failed one test related to derail position, and 

he was verbally counseled. The BNSF 6789 South conductor was tested 69 times. 

He passed all of the tests; however, none of them were related to track warrant 

authority. 

The BNSF 6351 North engineer was tested 41 times. Two of the tests were 

related to track warrant authority. The engineer failed three tests, all of which were 

related to fuel conservation procedures. The BNSF 6351 North conductor was tested 

46 times. Three of the tests were related to track warrant authority. He failed two tests 

pertaining to the use of personal protective equipment. The BNSF 6351 North 

brakeman was tested 20 times. One test was related to track warrant authority. He 

passed all of the tests. 

29 These tests included 209, 608, 612, 613, and 614 in the BNSF Operations Testing Guide dated 

December 15, 2003.

30 The FRA requires railroads to certify locomotive engineers. Certain serious rule infractions can 

result in de-certification under 49 CFR 240.
Factual Information 25 Railroad Accident Report

In the 12 months prior to the accident, the BNSF tested the train dispatcher 43 

times. He failed two tests because he did not follow proper procedures when authorizing a 

train to pass a stop signal.

Testing on After-Arrival Track Warrant Rules

Prior to the Gunter collision, the BNSF did not have a specific line item test for 

compliance with box 7 track warrant requirements. However, there were line item tests for 

other aspects of track warrant control compliance, and testing officials could enter test 

results for box 7 compliance. As a result of this accident, the BNSF established a line item 

test specifically for box 7 after-arrival authorities, which required the tester to ensure 

communication and documentation requirements were being met. 

On May 28, 2004, the BNSF issued “Operations Management Instruction Number 

19” to its operations managers, detailing changes to the Operations Testing Reference 

Guide. These changes added a specific test on after-arrival track warrant compliance. The 

test procedure addressed each of the three steps required to issue a box 7 track warrant in 

non-signaled territory, as well as the requirement for crews to turn in their track warrants 

at the completion of each trip.

Train Crew Qualification and Familiarization Training Trips 

The BNSF official responsible for the Madill Subdivision described the 

familiarization process for a conductor transferring to the subdivision as making a 

minimum of one round trip.31 There were also provisions for additional training trips. He 

explained:

If the person says, yes, I made my qualifying trip, but, I don’t have a clue where I 

am at, and I don’t understand the track warrant stuff and what have you, we will, 

yeah, we will get them with somebody. And in fact, we will put them on a road 

switcher, a local out there every day so they get plenty practice at it, I will. But, 

but, as far as standard qualification trips, that is just one trip. 

As a result of this accident, the BNSF increased the number of conductor 

familiarization trips required. On June 21, 2004, the BNSF issued a general notice to 

Texas Division employees regarding changes to the policy on familiarization trips. On the 

Madill Subdivision, the policy required an increased numbered of minimum 

familiarization trips for conductors, as described in table 2. These additional trips provide 

new employees, or employees new to track warrant control territory, more practice with 

track warrants before they are qualified to work in this territory.

31 Prior to the Gunter accident, a conductor made this single trip as a working conductor. After the 

accident, the BNSF established a policy requiring that familiarization trips be made with another qualified 

conductor present.
Factual Information 26 Railroad Accident Report

Table 2. BNSF minimum number of familiarization trips for conductors working on the 

Madill Subdivision.

* These familiarization trips are also required for pool freight conductors.

Also as a result of this accident and the BNSF 6789 South conductor’s difficulties

with reading back a track warrant, the BNSF implemented a new policy limiting the

number of read-back attempts allowed before management intervention. On June 1, 2004,

the BNSF issued “System General Notice Number 515” to all operating employees and

managers explaining a new policy on repeating authorities. The notice stressed the

importance of repeating authorities precisely as transmitted and advised that if an

authority was not repeated correctly after three attempts, the dispatcher would stop the

authority and a supervisor would be contacted for followup. 

On June 3, 2004, the BNSF issued “Operations Management Instruction Number

20” to managers explaining their responsibilities under the three-strikes policy.

Additionally, the BNSF created a presentation on the policy to be used during dispatcher

training. The presentation offered the following guidance to train dispatchers:

• Use Consistency in Delivery

• Discuss Conditions and Restrictions BEFORE issuing

• Require a FULL repeat to verify clear understanding

• Issue at a SPEED at which it can be copied

• Issue in a professional manner

• Stop and START OVER any authorities in which conversation occurs

• Do not use CONFIRMATION of limits at beginning as a reason 

to STOP listening to repeat of limits later

• If necessary, STOP train and have engineer copy authority

• After 3 attempts, END issuance

Fort Worth Conductor Extra Board*

1 round trip Fort Worth to Oklahoma City

1 round trip Irving to Madill on local freight assignments

3 trips Fort Worth to Irving on Trinity Railway Express passenger trains

1 trip on U-SHTIRB (same train symbol as BNSF 6351 North)

1 trip on U-SHTCAK (Sherman, Texas, to Clark, Oklahoma)

Madill Conductor Extra Board*

1 round trip Madill to Tulsa

1 round trip Madill to Irving

1 trip on U-SHTCAK (Sherman, Texas, to Clark, Oklahoma)

1 trip on Madill Road Switcher
Factual Information 27 Railroad Accident Report

Additional Data/Information

Various aspects of BNSF operations fall under the regulatory authority of the FRA, 

as outlined in 49 CFR Parts 200-299. Texas Railroad Commission personnel also enforce 

FRA regulations in a state participation program, as outlined under 49 CFR Part 212. The 

FRA was designated as a party to this investigation, and Texas Railroad Commission 

personnel assisted the FRA.

Use of After-Arrival Track Warrants

Over a period of time, some railroads have discontinued the use of after-arrival 

movement authorities. Rules promulgated by the Northeast Operating Rules Advisory 

Committee32 (NORAC) have not allowed the use of after-arrival movement authorities for at 

least 17 years. CSX Transportation uses a proprietary rulebook that does not allow afterarrival authorities. However, rules promulgated by the GCOR Committee33 do allow the use 

of after-arrival movement authorities. Norfolk Southern Railroad uses a proprietary rulebook 

on the majority of its system, which also allows after-arrival authorities.

After the Safety Board investigated a head-on collision of two Union Pacific 

Railroad trains at Devine, Texas, in June 1997,34 the Board recommended that the Union 

Pacific Railroad:

R-98-25

Discontinue permanently the use of after-arrival orders in dark 

(nonsignalized) territory.

This recommendation was classified “Closed—Acceptable Action” on July 23, 2001, after 

Union Pacific Railroad stated that it would stop using after-arrival track warrants in nonsignaled track warrant control territory. In May 2002, Union Pacific Railroad issued 

instructions to its operating employees that again allowed the use of after-arrival track 

warrants, providing the train that was issued such instructions had already stopped to wait 

for the arrival of the opposing train. 

After the Safety Board investigated a head-on collision of two BNSF trains at 

Clarendon, Texas, in May 2002,35 the Board recommended that the FRA:

32 More than 50 railroads operate under NORAC rules, including Amtrak (North-East Corridor), 

Conrail, and portions of the Norfolk Southern.

33 More than 150 railroads operate under the GCOR, including Amtrak (Western locations); BNSF; 

Canadian National; Kansas City Southern; and Union Pacific.

34 National Transportation Safety Board, Collision and Derailment of Union Pacific Railroad Freight 

Trains 5981 North and 9186 South in Devine, Texas, June 22, 1997, Railroad Accident Report NTSB/RAR98/02 (Washington, DC: NTSB, 1998).

35 National Transportation Safety Board, Collision of Two Burlington Northern Santa Fe Freight Trains 

Near Clarendon, Texas, May 28, 2002, Railroad Accident Report NTSB/RAR-03/01 (Washington, DC: 

NTSB, 2003).
Factual Information 28 Railroad Accident Report

R-03-2

In territory not equipped with a positive train control system, restrict the 

issuance of track warrant authority that contains an after-arrival 

requirement to trains that have stopped at the location at which they will 

meet the opposing train.

The FRA declined to implement Safety Recommendation R-03-2, responding in a letter 

dated October 3, 2003, that: 

Most railroads in the Nation do have sufficient operating rules and instructions 

already in place to address the Safety Board’s concern regarding restrictions 

placed on the issuance of “after-arrival” orders without the intrusiveness of 

regulatory intervention by FRA. 

Based on this response, Safety Recommendation R-03-2 was classified “Closed—

Unacceptable Action” on August 6, 2004.

After the Clarendon accident, the BNSF changed its operating rules to allow the 

use of after-arrival track warrants in non-signaled territory only after the train that was 

issued these instructions had stopped at the point at which it was to wait for the arrival of 

the opposing train. The BNSF instructions for train dispatchers36 in effect at the time of the 

Gunter collision read:

For movement in nonsignaled territory, issue track warrant containing Box 7 (Not 

in Effect Until After the Arrival of______ at ______) only after the train to 

receive the track warrant containing Box 7 is stopped at the meeting point where 

opposing train will be met. 

After the Gunter accident, the BNSF modified its track warrant procedures by 

adding more communication requirements in non-signaled territory. The new 

requirements went into effect on June 1, 2004, and read: 

In non-signaled territory, a train may only be granted a Box 7 “Not in Effect Until 

After the Arrival of _________” track warrant, after the following requirements 

have been completed:

1. Dispatcher advises the train that will receive the Box 7 track warrant of the 

identification of train(s) that will be listed in Box 7 (by initials, engine 

number and direction).

2. The train that will receive the Box 7 track warrant establishes the location of 

the train(s) that will be listed in Box 7 (by initials, engine number and 

direction), advising the dispatcher that direct communication has been made 

and the location of the train(s) contacted.

3. The train to receive the Box 7 track warrant has stopped at the meeting point 

and has notified the dispatcher that they are stopped.

36 BNSF Train Dispatcher’s and Control Operator’s Manual issued July 13, 2003.
Factual Information 29 Railroad Accident Report

4. In nonsignaled territory after the meet has occurred, the train with Box 7 

must establish positive radio contact with the train listed in Box 7 to confirm 

the identity of the passing train. If radio communication cannot be 

established, the train dispatcher must be contacted to provide the required 

confirmation. The train identification, time passed, location passed, or 

current time and location must be written on the track warrant form by both 

the conductor and engineer of the train being so restricted.

As a result of the Devine, Texas,37 collision, the Safety Board made two 

recommendations to the FRA:

R-98-26

Revise 49 Code of Federal Regulations 220 to address track warrants and 

other current railroad operating practices.

R-98-27

Require railroads to discontinue permanently the use of after-arrival orders 

in dark (nonsignalized) territory.

In a February 4, 1999, letter in response to Safety Recommendation R-98-26, the 

FRA notified the Safety Board that it had issued a final rule, effective January 4, 1999, 

modifying 49 CFR 220 as requested. Accordingly, the Board classified Safety 

Recommendation R-98-26 “Closed—Acceptable Action” on June 29, 1999. 

In the same February 1999 letter, the FRA also stated that it had issued a safety 

directive addressing safety practices in direct train control territory. The directive 

recommended that in those instances in which a train movement instruction includes a 

train meet, the dispatcher specifically state in the movement authority, “this track warrant 

includes a requirement to meet another train.” The second recommendation in the 

directive required that railroads review their operating rules and practices pertaining to 

operations in non-signaled territory to determine what further enhancements were 

warranted to improve safety. These considerations included possibly eliminating the use 

of after-arrival orders. The letter further stated that FRA audits had determined that the 

“overwhelming majority” of railroads had eliminated the use of these orders in nonsignaled direct train control territory. Although the letter stated that the FRA would 

continue to review these safety critical procedures during future dispatcher audits, the 

FRA stopped short of prohibiting the use of after-arrival orders in non-signaled territory. 

Based on this response, the Safety Board classified Recommendation R-98-27 “Closed—

Unacceptable Action” on June 29, 1999. 

37 NTSB/RAR-98/02.
30 Railroad Accident Report

Analysis

Exclusions

The track, the locomotives, and the railcars were inspected and tested to the extent 

possible after the accident. No defects were identified. Further, both trains had received 

initial terminal airbrake inspections on the day of the accident, and no discrepancies were 

noted. Neither crew reported any problems with their respective trains. 

On the day of the accident, the weather was dry, the temperature was 86° F, and 

visibility was clear. 

The train dispatcher and the surviving crewmembers on both trains provided 

toxicological specimens that were screened for drugs and alcohol. The coroner provided 

specimens taken from the deceased engineer. All of the test results were negative for drugs 

and alcohol.

The BNSF 6789 South crewmembers had been on duty for about 7 hours 35 

minutes at the time of the accident. They had been off duty for more than 50 hours before 

beginning the trip. The train dispatcher had been on duty for about 2 hours 45 minutes, 

and he had been off duty for 16 hours before beginning his shift.

The Safety Board concludes that the following were not factors in this accident: 

the condition of the track, locomotives, or railcars; the weather; drug or alcohol use; and 

work schedules. 

First Northbound Train/BNSF 2917 North

BNSF 2917 North originally had main track authority to the north siding switch at 

Dorchester. Because BNSF 2917 North entered the Dorchester siding at the south switch 

and reported clear of its main track authority, it was not necessary for the dispatcher to 

issue a track warrant for BNSF 6789 South to meet BNSF 2917 North at Dorchester. 

BNSF 2917 North and BNSF 6789 South passed each other at Dorchester, and the BNSF 

2917 North subsequently was authorized to continue north. Because the BNSF 6789 South 

crew did not verbally confirm the train identification of BNSF 2917 North by radio when 

the trains passed, they most likely assumed that BNSF 2917 North was the single train that 

the dispatcher had told them they would meet at Dorchester. After the trains passed, BNSF 

6789 South was issued the track warrant authorizing it to proceed south from Dorchester 

after the arrival of BNSF 6351 North. The BNSF 6789 South crew likely assumed that this 

was the train they had just passed at Dorchester.
Analysis 31 Railroad Accident Report

The Safety Board concludes that the BNSF 6789 South crewmembers’ failure to 

verify the engine number listed on their track warrant against the engine number of the 

train in the siding, combined with the expectation that they would proceed south after 

meeting a single train at Dorchester, resulted in the BNSF 6789 South crewmembers 

likely assuming that they had met BNSF 6351 North at Dorchester. 

Second Northbound Train/BNSF 6351 North

At the time of the collision, BNSF 6351 North was proceeding at the allowed track 

speed with valid track warrant authority to travel north on the main track from milepost 

(MP) 678 to the south siding switch at Dorchester. 

Southbound Train/BNSF 6789 South

The BNSF Railway Company (BNSF) had a number of procedures in place to 

address the circumstances of this accident. The BNSF 6789 South crew was required to 

note on their track warrant form the engine number, the time, and the location when they 

met BNSF 6351 North. There was also a procedure requiring them to make positive radio 

contact with the train listed in the after-arrival track warrant and to verify the engine 

number. According to the BNSF 2917 North engineer, there was no radio request for 

engine number verification when the two trains passed or afterwards. Had either of the 

BNSF 6789 South crewmembers made such a call, they would have learned that they had 

not yet met BNSF 6351 North and the accident might have been averted. 

The BNSF 6789 South crew departed Dorchester immediately after receiving 

Track Warrant No. 3598 requiring them to wait for BNSF 6351 North, which had yet to 

arrive. The Safety Board concludes that had the BNSF 6789 South crew complied with 

their track warrant, they would not have left Dorchester and the accident would not have 

occurred. 

Both crewmembers were responsible for the safe operation of the train, and they 

were required to hold a job briefing to discuss the track warrant they received. The 

conductor had limited experience with track warrants and had demonstrated difficulty 

copying and repeating track warrant authorities earlier in the day. The dispatcher had 

asked the engineer to help the conductor and “make sure he’s doing it right.” Helping the 

conductor complete this task added to the engineer’s responsibilities. Although the 

engineer was experienced with track warrants on this territory, it is possible that helping 

the conductor distracted his attention from verifying which train they were to meet at 

Dorchester, particularly given the expectation that likely was established by earlier 

informal communications with the dispatcher that indicated they would meet a single train 

at Dorchester and a second train farther south. 
Analysis 32 Railroad Accident Report

Dispatcher Communications

In the hours leading up to the accident, there were two types of communication 

between the dispatcher and the BNSF 6789 South crew. Communications transmitting 

mandatory directives (track warrant authorities) consisted of a formal process in which 

trains were referred to by their operational identification (for example, BNSF 6789 

South), and an accurate read back was required to confirm the directives. Other 

communications between the dispatcher and the BNSF 6789 South crew were more 

informal as the dispatcher discussed future train movements and meeting points. Trains 

were referred to by various nicknames; sometimes several different nicknames were used 

for the same train. (See appendix C.)

Safety Board investigators listened to audio recordings of the radio 

transmissions between the dispatcher and the BNSF 6789 South crew when the 

after-arrival track warrant was issued. The dispatcher transmitted the track warrant 

word for word as entered into the dispatch center computer. The BNSF 6789 South 

engineer38 repeated the track warrant incorrectly, adding a box 139 entry that the 

dispatcher had not stated. The dispatcher caught the error, and the engineer 

acknowledged that there was no box 1 instruction on the track warrant. The rest of the 

text read back by the BNSF 6789 South crew was correct, including the repetition of 

the after-arrival stipulation. 

The track warrant form recovered from the BNSF 6789 South wreckage had a 

number of incorrect entries. Box 1 was checked, then blacked out, and “3593” was entered 

on the box 1 line, reflecting the error that was made and corrected during the read back. 

Boxes 2, 7, and 20 were marked with an “X.” The box 2 line had several words crossed 

out in the “Proceed from” space, and the entry was not legible. The entry in the box 7 line 

read, “B6351 North South SS Dorchester.” The line 20 box was marked with an “X,” and 

no switch was listed. Box 21 (permission to leave a switch in reverse) was checked, and 

“SSS DOR” was entered on that line. (See appendix D.)

The BNSF 6789 South crew was informed on four separate occasions that they 

would meet a single train at Dorchester. During the last two occasions, they were also 

informed that they would be traveling beyond Dorchester to meet a second train. When the 

plan changed, the dispatcher asked the BNSF 6789 South crew if they could fit between 

siding switches at Dorchester. He asked this question to ensure that BNSF 6789 South 

could clear the switches without blocking a road crossing. However, the dispatcher did not 

explain that he was changing the original plan and that BNSF 6789 South would then meet 

a second train at Dorchester. 

The Safety Board recognizes that some informal communication may be useful 

(for example, to avoid blocked crossings, to keep trains moving on heavy grades, or to 

38 The dispatcher said that he recognized the engineer’s voice after listening to the recorded 

communications.

39 Box 1 is used when a previously issued track warrant is made void. See figure 5 for an example of the 

BNSF track warrant form.
Analysis 33 Railroad Accident Report

pace trains for fuel conservation). However, such informal communication can 

establish expectations that may not be resolved when plans change and a mandatory 

directive is issued, as likely occurred in this accident. The use of train nicknames can 

add further confusion. On two occasions, the dispatcher first referred to BNSF 2917 

North as the Sherman Rock Train or the Rock Train before correcting himself. (BNSF 

6351 North—the train overlooked by the BNSF 6789 South crew—was the Sherman 

Rock Train, and the majority of trains on the Madill Subdivision carried rock cars.) 

Therefore, the Safety Board concludes that had the dispatcher consistently referred to 

all of the trains by their engine numbers—the identification mechanism required in 

mandatory directives—it would have reinforced the need to verify engine numbers 

when the trains met. 

In the very last radio communication that followed the dispatcher’s OK on the 

after-arrival track warrant issued to BNSF 6789 South at Dorchester, the BNSF 6789 

South crew reported the south siding switch at Dorchester as restored to normal.40 The 

dispatcher replied: “I can’t show it normal because that Rock Train, the Sherman 

Switcher’s got a box 7 on you.” This was potentially confusing because the dispatcher 

used two names to describe the northbound train; and while the Sherman Switcher 

(BNSF 2917 North) did have a box 7 track warrant naming BNSF 6789 South, that 

track warrant authorized movement from the Dorchester north siding switch, not the 

south siding switch. The other train name the dispatcher used, the Rock Train (BNSF 

6351 North, the train that never reached Dorchester), did not have a box 7 marked on 

its track warrant. However, BNSF 6351 North did have a box 21 marked, allowing it to 

leave the south siding switch at Dorchester in reverse position when it entered the 

siding. The BNSF 6789 South crew had been issued a track warrant with box 20 

checked, advising them to be prepared to stop at that switch if it was aligned for the 

siding after they met BNSF 6351 North. If the BNSF 6789 South crew believed that 

they had met BNSF 6351 North at Dorchester, it was appropriate for them to report the 

switch as normal. 

Another factor that may have resulted in confusion involved BNSF 2917 North 

reporting clear of its track warrant authority and, therefore, not being listed on any of the 

track warrants issued to BNSF 6789 South. BNSF 6789 South crewmembers were told 

(on four occasions) that they would meet one train at Dorchester. They received an 

after-arrival track warrant requiring them to meet one train at Dorchester, and they did 

pass one train at Dorchester. However, it was not the train listed on the after-arrival track 

warrant they were issued.

The after-arrival portion of the track warrant was transmitted and read back 

correctly, and the BNSF 6789 South crew should have waited at Dorchester. However, 

the BNSF 6789 South crewmembers were never specifically advised of the 

dispatcher’s change in plans. Train dispatchers should be acutely aware of how 

informal communications can create expectations that do not always correspond with 

the dispatchers’ intentions. The dispatcher involved in this accident might have 

40 Normal is aligned for movement on the main track, as opposed to reverse, which is aligned for a 

movement into or out of the siding.
Analysis 34 Railroad Accident Report

further reinforced incorrect expectations by frequently using the phrase “here we go”41

as a closing salutation, when after his last communication it was necessary for BNSF 6789 

South to remain in place. Therefore, the Safety Board concludes that informal 

communications between the dispatcher and train crews regarding authority limits, train 

names, and meeting or stopping points may lead to misunderstandings and errors. The 

Safety Board believes that the BNSF should use the Gunter collision as a case study in 

train crew and dispatcher training and retraining to illustrate how informal 

communications can lead to misunderstandings and errors. 

The Safety Board is also concerned about the use of informal communications on 

other railroads. Therefore, the Board will inform the railroad industry about the 

circumstances of this accident and will advise the industry of the importance of training 

and retraining employees to recognize how informal communications regarding authority 

limits, train names, and meeting or stopping points can lead to misunderstandings and 

errors. 

After-Arrival Track Warrants in Non-Signaled Territory

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 Federal Railroad Administration 

(FRA) sees merit in the industry’s logic,42 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.”43 Yet, the 

FRA has not taken the proactive steps to address this issue as the Safety Board has 

recommended.

The Safety Board has investigated a number of accidents involving track warrants 

in non-signaled territory. In 1996, in Smithfield, West Virginia,44 the Board investigated a 

head-on collision between two CSX Transportation freight trains. CSX Transportation 

subsequently discontinued the use of after-arrival authorities in non-signaled territory. In 

41 A review of dispatcher communication transcripts between 3:11 p.m. and the time of the collision 

showed that the dispatcher ended his conversations with BNSF 6789 South with “here we go” on six 

occasions.

42 FRA letter to the Safety Board dated October 3, 2003.

43 FRA letter to the Safety Board dated October 3, 2003.

44 National Transportation Safety Board, 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: NTSB, 1998).
Analysis 35 Railroad Accident Report

1997, the Board investigated a collision between two Union Pacific Railroad freight trains 

in Devine, Texas.45 As a result of the Devine investigation, the Board issued Safety 

Recommendation R-98-27, which advised the FRA to permanently discontinue the use of 

after-arrival orders in non-signaled territory. Safety Recommendation R-98-27 was 

classified “Closed—Unacceptable Action” on June 29, 1999. 

In 2002, the Safety Board investigated a collision between two BNSF trains in 

Clarendon, Texas.46 In its accident report, the Board issued Safety Recommendation R-03-2,

which advised the FRA to limit the use of after-arrival orders in non-signaled territory to 

trains that have stopped at the location at which they will meet the opposing train. 

Safety Recommendation R-03-2 was classified “Closed—Unacceptable Action” on 

August 6, 2004. In Safety Recommendation R-03-3, the Board also recommended that the 

General Code of Operating Rules (GCOR) Committee add language to its track warrant 

rules to ensure the same. In response to the Clarendon investigation, the BNSF established 

procedures requiring a train to stop before receiving an after-arrival track warrant and to 

make positive radio contact with the train to be met in non-signaled territory. After the 

Gunter collision, the BNSF further strengthened these procedures by requiring more 

communication between the restricted train, the train(s) to be met, and the dispatcher. 

The FRA has declined to implement either of the Safety Board’s recommendations 

(R-98-27 and R-03-2) regarding after-arrival track warrants that were developed in 

response to the Devine and Clarendon, Texas, accidents. The FRA’s final written response 

to Safety Recommendation R-03-2, dated October 3, 2003, indicated that disallowing 

after-arrival orders in non-signaled territory would reduce flexibility and hinder the 

efficient movement of trains. The FRA also stated that like the industry, it expects that 

railroad employees will adhere to all applicable operating rules. Unfortunately, expecting 

employees to always adhere to all applicable rules is more often an ideal than a reality. 

The Board has investigated too many railroad accidents in which the avoidance of a 

collision depended on the use of an operating rule or standard practice that proved to be 

insufficient to prevent accidents caused by human error.

Even though the BNSF strengthened its procedures for after-arrival track warrants 

after the Clarendon accident, the BNSF 6789 South crew still did not make positive radio 

contact to verify that the train they were passing was the train listed on their track warrant. 

In the Gunter accident, the BNSF 6789 South crew had already stopped at the location 

where they were to meet the opposing train, BNSF 6351 North. Therefore, the 

circumstances of this accident also raise concerns regarding the effectiveness of limiting 

the issuance of after-arrival orders to trains that have already stopped at the location at 

which they will meet the opposing train. Regardless of how the after-arrival order is 

implemented, this practice places full responsibility for ensuring a proper meet on the 

crew involved. When a crew does not follow procedures in non-signaled territory, as 

occurred in the Gunter accident, there are no additional warnings to either train. By 

contrast, when after-arrival track warrants are used in territory with automatic block 

45 NTSB/RAR-98/02.

46 NTSB/RAR-03/01.
Analysis 36 Railroad Accident Report

signals, both trains receive restrictive signals requiring the trains to slow and eventually 

stop short of a collision point. Although there may be some circumstances where the use 

of after-arrival orders in non-signaled territory is beneficial, the accident record has 

demonstrated that any use of these procedures increases the risk of train collisions. 

The Safety Board recognizes that unless an automated collision avoidance system 

is in place, there is no assurance that a collision will not occur. The Board remains 

convinced that the ultimate safety goal is positive train control (PTC). However, 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. Consequently, 

non-signaled territories will remain higher risk areas for collisions. The incremental steps 

taken to date by the BNSF and other railroads have not been sufficient. The Safety Board 

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

(non-signaled) territory creates an unacceptable risk of collision. 

The Safety Board is also concerned about the FRA’s failure to prohibit or limit the 

use of after-arrival track warrants in non-signaled territories as previously recommended 

by the Board. Staff from the Board and the FRA met on March 17, 2004, to discuss open 

recommendations related to railroad safety. Safety Recommendation R-03-2 was 

specifically addressed at the meeting, and FRA staff stated that although it shared the 

Board’s concerns about the problems with after-arrival orders, it was 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, it would issue an emergency order. The Gunter accident 

occurred on May 19, 2004, and the FRA has yet to take action to address this continuing 

problem. The Safety Board concludes that had the FRA required railroads to permanently 

discontinue the use of after-arrival orders in dark territory as advised in Safety 

Recommendation R-98-27, this accident would not have happened. 

The Safety Board has investigated several accidents involving after-arrival orders 

in non-signaled territory and believes that the FRA has delayed action too long. The 

Safety Board believes that the FRA should prohibit the use of after-arrival track warrants 

for train movements in dark (non-signaled) territory not equipped with a PTC system. The 

Safety Board also believes that the BNSF should discontinue the use of after-arrival track 

warrants for train movements in dark (non-signaled) territory not equipped with a PTC 

system. Further, the Safety Board believes that the Association of American Railroads and 

the American Short Line and Regional Railroad Association should encourage their 

members to discontinue the use of after-arrival track warrants for train movements in dark 

(non-signaled) territory not equipped with a PTC system.

As noted above, the Safety Board issued Safety Recommendation R-03-3 to the 

GCOR Committee as a result of the Clarendon, Texas, accident investigation.47

Specifically, the Board recommended that the committee:

47 NTSB/RAR-03/01.
Analysis 37 Railroad Accident Report

R-03-3

Add language to the track warrant rules to ensure that in territory not 

equipped with a positive train control system, track warrant authority that 

contains an after-arrival requirement is issued only to trains that have 

stopped at the location at which they will meet the opposing train.

However, as a result of its investigations, the Board now believes that the use of afterarrival track warrants in non-signaled territory not equipped with a PTC system 

should be prohibited. The Board also recognizes that the GCOR Committee was not 

the appropriate recipient for this recommendation because its rules are not mandatory. 

Accordingly, Safety Recommendation R-03-3, which was previously classified 

“Open—Unacceptable Response,” is now reclassified “Closed—Reconsidered.”

BNSF 6789 South Engineer’s Fitness for Duty

The BNSF 6789 South engineer had been diagnosed with severe obstructive 

sleep apnea through a formal sleep study almost 5 years before the accident. Obstructive 

sleep apnea is a chronic medical condition that prevents those affected by it from 

obtaining restful, uninterrupted sleep. The engineer had been prescribed and had 

successfully used a continuous positive airway pressure (CPAP) device with excellent 

results to treat the obstructive sleep apnea, but apparently he had discontinued use of the 

CPAP more than 2 years before the accident. The BNSF was unaware of his obstructive 

sleep apnea or his noncompliance with treatment. The Safety Board obtained this latter 

information from the records of his personal physician and the results of the sleep study 

he underwent. 

The engineer can be heard communicating with the dispatcher about 5:39 p.m., 

10 minutes before the collision. Event recorder data suggest that the engineer was 

actively involved in operating the train and that his manipulations of the locomotive 

controls were appropriate. Therefore, it seems likely that he, and the conductor, mistook 

BNSF 2917 North for BNSF 6351 North as the train they were supposed to meet 

according to the after-arrival track warrant. 

Neither the engineer nor his personal physician informed the BNSF of the sleep 

apnea diagnosis. They were not required to inform the railroad company. FRA guidance 

pertaining to medical certification is limited to regulations concerning medications and 

minimum vision and hearing standards. In its investigation of the collision between Union 

Pacific Railroad and BNSF freight trains in Kelso, Washington,48 the Safety Board found 

that crew medical conditions, of which the railroad was unaware, were contributing 

factors in the accident. As a result of its earlier investigation into a collision between two

48 National Transportation Safety Board, Side Collision of Burlington Northern Santa Fe Railway Train 

and Union Pacific Railroad Train near Kelso, Washington, November 15, 2003, Railroad Accident Brief

NTSB/RAB-05/03 (Washington, DC: NTSB, 2005).
Analysis 38 Railroad Accident Report

Canadian National Railroad freight trains near Clarkston, Michigan,49 the Board 

recommended that the FRA develop a standard medical examination form, requiring that 

certain conditions, including sleep apnea, be reported to the railroad and prohibiting 

safety-sensitive work until those conditions could be appropriately evaluated (R-02-24, 

-25, and -26). As a result of these previous recommendations, the FRA is currently 

reviewing the findings of a study commissioned to evaluate possible medical certification 

protocols. The status of these recommendations remains classified as “Open—Acceptable 

Response.”

Emergency Response

Emergency responders arrived on scene within 6 minutes of initial notification. 

While en route, the first responder placed two air ambulance services on standby and 

activated mutual aid from surrounding jurisdictions. It is noteworthy that the accident 

occurred in a rural area and that the Gunter Volunteer Fire Department is an all volunteer 

operation, as are most of the surrounding fire departments. The Safety Board concludes 

that the emergency response was prompt and appropriate to the accident. 

Use of Cellular Phones

As a result of its investigation into the Clarendon, Texas, collision, the 

Safety Board found that the accident was caused in part by the “engineer’s use of a cell 

phone during the time he should have been attending to the requirements of the track 

warrant his train was operating under....” Consequently, the Board made the following 

recommendation to the FRA regarding the use of cellular telephones by operating crews:

R-03-1

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. 

On October 3, 2003, the FRA advised the Safety Board that it believed that 

railroad operating and safety rules were adequate to address cell phone use by operating 

crews. Further, during a meeting on March 17, 2004, the FRA informed the Board that its 

inspectors would watch for unauthorized use of cell phones but that a regulation would be 

almost impossible to enforce. On August 19, 2004, the Board advised the FRA that it 

remained concerned that the risks of complacency and attention deficiencies associated 

49 National Transportation Safety Board, Collision of Two Canadian National/Illinois Central Railway 

Trains Near Clarkston, Michigan, November 15, 2001, Railroad Accident Report NTSB/RAR-02/04 

(Washington, DC: NTSB, 2002).
Analysis 39 Railroad Accident Report

with cell phone use are not sufficiently understood or recognized and that cell phone use 

has the potential to distract crewmembers for a considerable length of time, and is 

avoidable. Pending the FRA’s assessment of additional information to determine the 

proper direction the FRA should take, Safety Recommendation R-03-1 was classified 

“Open—Acceptable Response.”

BNSF 6789 South crewmembers were not using cellular phones at the time the last 

track warrant requiring them to wait at Dorchester was issued or at the time they departed 

Dorchester without authority. However, the BNSF 6789 South engineer received a call on 

his personal cellular phone while the conductor was having difficulty reading back Track 

Warrant No. 3583, which was only OK’d after he had made multiple read-back attempts. 

The Safety Board notes that inappropriate use of cellular phones has been a factor in other 

accidents. The frequent use by all crewmembers on the two accident trains while the trains 

were in motion indicates that BNSF rules prohibiting such use are ineffective. The Board 

remains concerned that the inappropriate use of cellular phones by crewmembers may 

pose a risk to the safety of railroad operations.

Positive Train Control

For more than 30 years, the Safety Board has investigated train collisions that 

could have been prevented through the deployment of a PTC system. Over the years, the 

Board has issued a series of relevant recommendations, and PTC has remained on the 

Board’s Most Wanted Transportation Safety Improvements list since 1990. The most 

recent safety recommendation relating to PTC, Safety Recommendation R-01-6, was 

issued to the FRA as a result of the Board’s investigation of a fatal train collision in Bryan, 

Ohio.50 Since its adoption by the Board, Safety Recommendation R-01-6 has been 

reiterated in two other reports about railroad accidents that took place in Placentia, 

California, in 200251 and Chicago, Illinois, in 2003:52

R-01-6

Facilitate actions necessary for the development and implementation of 

positive train control systems that include collision avoidance, and require 

implementation of positive train control systems on main line tracks, 

establishing priority requirements for high-risk corridors such as those 

where commuter and intercity passenger railroads operate.

50 National Transportation Safety Board, Collision Involving Three Consolidated Rail Corporation 

Freight Trains Operating in Fog at Bryan, Ohio, January 17, 1999, Railroad Accident Report NTSB/RAR01/01 (Washington, DC: NTSB, 2001). 

51 National Transportation Safety Board, Collision of Burlington Northern Santa Fe Freight Train With 

Metrolink Passenger Train, Placentia, California, April 23, 2002, Railroad Accident Report NTSB/RAR03/04 (Washington, DC: NTSB, 2003).

52 National Transportation Safety Board, Derailment of Northeast Illinois Regional Commuter Railroad 

Train 519 in Chicago, Illinois, October 12, 2003, Railroad Accident Report NTSB/RAR-05/03 

(Washington, DC: NTSB, 2005).
Analysis 40 Railroad Accident Report

Based on a March 27, 2002, letter in which the FRA outlined steps that it had taken 

toward “achieving the proper atmosphere in the rail industry to allow for the development 

and implementation of PTC,” the Safety Board classified Safety Recommendation R-01-6 

“Open—Acceptable Response.”

In answer to an April 17, 2003, letter from the Safety Board asking for an update 

on actions regarding this safety recommendation, the FRA responded, in a May 5, 2003, 

letter, that it was “moving forward across a broad front to create the conditions under 

which PTC systems can be more widely deployed on the national rail system.” In the 

letter, the FRA detailed some of the steps the agency was taking in the following areas:

• Providing a radio-navigation infrastructure and ensuring adequate 

spectrum;

• Facilitating positive train control through regulatory change;

• Supporting the demonstration and deployment of candidate 

technologies; and

• Analyzing costs and benefits.

The FRA stated that the agency was “doing everything within its power to prepare the way 

for PTC and encourage its rapid deployment.” In the meantime, the majority of railroad 

operations occur in territory without any automatic means of preventing train collisions.

The Safety Board hosted a seminar on PTC at the NTSB Academy in March 2005, 

and the Board is aware of several initiatives in the railroad industry to test PTC 

installations. The BNSF has a pilot installation on its 135-mile Beardstown Subdivision. 

The BNSF electronic train management system is described as a “safety overlay” working 

in conjunction with existing train control and signal systems to enforce speed and 

authority limits. The BNSF has applied to the FRA for an expansion of the electronic train 

management system to its line from Fort Worth, Texas, to Arkansas City, Kansas. (The 

Madill Subdivision is not on this line.) The BNSF also has submitted a product safety plan 

to the FRA that, if approved, would authorize installation of the electronic train 

management system on the entire BNSF network. 

On March 7, 2005, the FRA issued a performance standard for processor-based 

signal and train control systems, which became effective on June 6, 2005. While it is 

encouraging that the FRA has moved forward on these performance standards and that 

other PTC pilot projects are underway, the Safety Board remains concerned that it has 

taken so long for the FRA to require, and for the railroad industry to develop and 

implement, such systems.

The Safety Board concludes that had a PTC system with collision avoidance 

capabilities been in place and operational on the Madill Subdivision at the time of the 

accident, the collision would not have occurred. 
41 Railroad Accident Report

Conclusions

Findings

1. The following were not factors in this accident: the condition of the track,

locomotives, or railcars; the weather; drug or alcohol use; and work schedules.

2. The BNSF 6789 South crewmembers’ failure to verify the engine number listed on

their track warrant against the engine number of the train in the siding, combined with

the expectation that they would proceed south after meeting a single train at

Dorchester, resulted in the BNSF 6789 South crewmembers likely assuming that they

had met BNSF 6351 North at Dorchester. 

3. Had the BNSF 6789 South crew complied with their track warrant, they would not

have left Dorchester and the accident would not have occurred.

4. Had the dispatcher consistently referred to all of the trains by their engine numbers—

the identification mechanism required in mandatory directives—it would have

reinforced the need to verify engine numbers when the trains met. 

5. Informal communications between the dispatcher and train crews regarding authority

limits, train names, and meeting or stopping points may lead to misunderstandings

and errors. 

6. The use of after-arrival track warrants for train movements in dark (non-signaled)

territory creates an unacceptable risk of collision.

7. Had the Federal Railroad Administration required railroads to permanently

discontinue the use of after-arrival orders in dark territory as advised in Safety

Recommendation R-98-27, this accident would not have happened.

8. The emergency response was prompt and appropriate to the accident.

9. Had a positive train control system with collision avoidance capabilities been in place

and operational on the Madill Subdivision at the time of the accident, the collision

would not have occurred.
Conclusions 42 Railroad Accident Report

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the May 19, 2004, collision near Gunter, Texas, 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. Contributing to the

accident was the BNSF Railway Company’s use of after-arrival track warrant authority in

non-signaled territory, and the Federal Railroad Administration’s failure to prohibit the

use of such authority. Also contributing to the accident was the train dispatcher’s informal

communications regarding planned train meeting locations.
43 Railroad Accident Report

Recommendations

As a result of its investigation of the May 19, 2004, collision between two BNSF 

Railway Company freight trains near Gunter, Texas, the National Transportation Safety 

Board makes the following safety recommendations:

New 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)

To the BNSF Railway Company: 

Use the Gunter collision as a case study in train crew and dispatcher 

training and retraining to illustrate how informal communications can lead 

to misunderstandings and errors. (R-06-11)

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)

To the Association of American Railroads and 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)

Recommendation Reclassified in This Report

To the General Code of Operating Rules Committee:

R-03-3

Add language to the track warrant rules to ensure that in territory not 

equipped with a positive train control system, track warrant authority that 

contains an after-arrival requirement is issued only to trains that have 

stopped at the location at which they will meet the opposing train.
Recommendations 44 Railroad Accident Report

Safety Recommendation R-03-3, previously classified “Open—Unacceptable 

Response,” is reclassified “Closed—Reconsidered” in the “After-Arrival Track Warrants 

in Non-Signaled Territory” section of this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

Mark V. Rosenker 

Acting Chairman

Deborah A. P. Hersman

Member

Kathryn O’Leary Higgins

Member

Adopted: June 13, 2006
45 Railroad Accident Report

Appendix A

Investigation

The National Transportation Safety Board was notified about 7:47 p.m., eastern 

daylight time, on May 19, 2004, of the collision between two BNSF Railway Company 

freight trains near Gunter, Texas. The Safety Board launched an investigator-in-charge and 

other investigative team members from the Board’s Washington, D.C., headquarters and 

the Los Angeles and Atlanta regional offices. Investigative groups were formed to study 

operations, mechanical equipment, track, and human performance. No Safety Board 

Member went to the accident site. Follow-up interviews were conducted at the BNSF 

Network Operations Center in Fort Worth, Texas, on June 29, 2004.

The Federal Railroad Administration, the BNSF Railway Company, the 

Brotherhood of Locomotive Engineers and Trainmen, and the United Transportation 

Union assisted the Safety Board in this investigation.
46 Railroad Accident Report

Appendix B

Time Line of Events

7:00 a.m. Crews of BNSF 6351 North and BNSF 2917 North report on duty 

at Sherman for southbound trips.

10:15 a.m. Crew of BNSF 6789 South reports on duty at Alliance Yard, then 

travels by taxi to Madill, Oklahoma.

1:15 p.m. BNSF 6789 South begins southbound trip from Madill, Oklahoma.

3:17 p.m. BNSF 6789 South Track Warrant No. 3583 in effect to proceed on 

main track from CTC Denison to south siding switch at Sherman. 

Conductor has difficulty repeating order correctly. Dispatcher asks 

engineer to telephone him.

3:51 p.m. BNSF 6351 North begins northbound trip. Track Warrant No. 3586 

in effect from north restricted limits Irving to north siding switch at 

Prosper.

4:02 p.m. BNSF 6789 South engineer contacts dispatcher by cellular phone 

and is asked to help conductor with future track warrants. 

Dispatcher advises they will meet the 641 Job (BNSF 2917 North) 

at Dorchester.

4:37 p.m. BNSF 2917 North begins northbound trip. Track Warrant No. 3587 

in effect from milepost (MP) 675 to north siding switch at 

Dorchester.

4:47 p.m. BNSF 6789 South engineer is again told they will meet the 641 at 

Dorchester.

4:51 p.m. BNSF 6789 South Track Warrant No. 3589 in effect to proceed 

from north siding switch at Sherman to north siding switch at 

Dorchester. After track warrant is OK’d, dispatcher advises that 

BNSF 6789 South will meet the Sherman Switcher at Dorchester 

and the Sherman Clark Rock Train at Prosper.

5:05 p.m. BNSF 6789 South is again advised by dispatcher that they will 

meet the Sherman Switcher at Dorchester and the Sherman Rock 

Train at Prosper.
Appendix B 47 Railroad Accident Report

5:10 p.m. After checking with BNSF 6789 South that they can fit between 

switches at Dorchester, dispatcher issues BNSF 6351 North Track 

Warrant No. 3591 to proceed from MP 685 to MP 659.

5:12 p.m. BNSF 2917 North reports clear of main track in Dorchester siding 

and releases Track Warrant No. 3587.

5:16 p.m. BNSF 6789 South Track Warrant No. 3593 in effect to proceed 

from MP 652 to south siding switch at Dorchester.

5:18 p.m. BNSF 2917 Track Warrant No. 3594 in effect to proceed from 

north siding switch at Dorchester to south siding switch at 

Sherman, after arrival of BNSF 6789 South.

5:21 p.m. BNSF 6351 North Track Warrant No. 3593 in effect to proceed 

from MP 678 to south siding switch at Dorchester and take siding.

5:22 p.m. Lead locomotives on BNSF 6789 South and BNSF 2917 North pass 

each other at Dorchester.

5:39 p.m. BNSF 6789 South Track Warrant No. 3598 in effect to proceed 

from south siding switch at Dorchester to Hebron, after arrival of 

BNSF 6351 North. 

5:40 p.m. BNSF 6789 South departs south siding switch at Dorchester, 

accelerates to 40 mph.

5:46 p.m. BNSF 6789 South and BNSF 6351 North collide head on at 

MP 661.9.

5:49 p.m. Grayson County Communications Center receives first of many 

calls reporting collision.

5:55 p.m. First emergency responder on scene.
48 Railroad Accident Report

Appendix C

Train Identifications Used in Communications

Southbound Train/BNSF 6789 South

BNSF 6789 South Operational Identification

U MAODON1 19 BNSF Train Symbol

Doni Rock Nickname

Doni Madill Nickname

Doni Train Nickname

First Northbound Train/BNSF 2917 North

BNSF 2917 North Operational Identification

R TEX 6411 19 BNSF Train Symbol

641 Nickname

641 Job Nickname

Sherman Switcher Nickname

Road Switcher Nickname

Second Northbound Train/BNSF 6351 North

BNSF 6351 North Operational Identification

U SHTIRB1 19 BNSF Train Symbol

Sherman Rock Nickname

Sherman Rock Train Nickname

Sherman Clark Rock Train Nickname

Am Rock Nickname

Rock Train Nickname
49 Railroad Accident Report

Appendix D

Recovered Track Warrants
Appendix D 50 Railroad Accident Report