NTSB/RAB-06/01 

E PLURIBUS UNUM

NATIONAL TRA SPORTATIO

N

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Accident No.: DCA-05-FR-012 

Location: Shepherd, Texas 

Date: September 15, 2005 

Time: 12:07 a.m. central daylight time1

Railroad: Union Pacific Railroad 

Property Damage: $1,514,000 

Fatalities: 1 

Injuries: 2 minor 

Type of Accident: Collision 

Synopsis 

About 12:07 a.m. on September 15, 2005, Union Pacific Railroad (UP) train MPBSR 13, 

entered the siding at Shepherd, Texas, at approximately 37 mph and struck UP train LEF52 14. 

The engineer of the standing train, train LEF52 14, was killed. The lead locomotive of the 

striking train, train MPBSR 13, rolled onto its side, and the engineer and conductor sustained 

minor injuries. The temperature was approximately 78° F; and, other than darkness, visibility 

was clear. The estimated property damage was about $1,514,000. 

The collision occurred on the UP’s Lufkin Subdivision, approximately 50 miles north of 

Houston, Texas. Train movements were authorized by track warrants issued by the train 

dispatcher in Omaha, Nebraska. The maximum authorized speed was 49 mph. There were no 

wayside signals to govern the train movements or protect the train from an interruption in the 

continuity of the track, such as an open switch. Consequently, strict compliance with the 

operating rules was necessary to protect one train from another. 

Events Preceding Accident

About 10:30 p.m. on September 14 (approximately 1 hour 30 minutes before the 

accident), train LEF52 14 was waiting on the main track at Shepherd for train MPBPT 14 (a 

southbound freight train) to pass through the siding. The conductor had lined the north siding 

switch so the train could pass through the siding. Once train MPBPT 14 had passed train 

LEF52 14, the conductor re-lined the switch so that train LEF52 14 could proceed northward on 

 1

 All times in this brief are central daylight time. 
 2 NTSB/RAB-06/01 

the main track. When the rear car of train LEF52 14 passed the switch, the conductor re-lined it 

so that train LEF52 14 could back into the siding southward. 

The conductor rode the rear car of the train into the siding. When the entire train was on 

the siding and about 500 feet south of the switch, the engineer stopped the train. She and the 

conductor secured the handbrakes on three freight cars and the two engines. (The train consisted 

of 2 locomotives and 16 cars.) She returned to the cab of the lead engine and called the train 

dispatcher, as the conductor had asked her. She reported that the train was clear of the main track 

and released the track warrant authority. When she had finished, she waited for the conductor in 

the limousine that had been sent to take them to Lufkin, Texas. The conductor arrived at the 

vehicle, and they left Shepherd about 11:20 p.m. 

About 20 minutes later, when the limousine was about 20 miles from Shepherd, the 

conductor realized that he had left his keys in the switch lock. He insisted that the driver return to 

the siding. 

Meanwhile, train LEF52 14 had acquired a new crew, consisting of an engineer, a 

pilot engineer, and a conductor. Shortly after midnight, train MPBSR 13, which was southbound, 

approached Shepherd. The pilot engineer of train LEF52 14 left the cab so he could inspect the 

passing of train MPBSR 13 from the ground. The conductor was exiting the cab to do the same 

and saw that train MPBSR 13 was entering the siding. He yelled at his engineer, who was still in 

the cab, to get out. The pilot engineer and conductor escaped on the ground to the west of the 

pending collision. The engineer of train LE F52 14 was unable to exit in time and was killed. 

Right before the collision, the crewmembers on train MPBSR 13, realizing that their train 

was entering the siding, applied the brakes in emergency at approximately 37 mph. Following 

the impact, the engine rolled onto its side, and the two crewmembers sustained minor injuries. 

During the postaccident inspection, investigators found that the switch was still lined for the 

siding and that although the lock had been applied to the switch, it was still unlocked and held 

the keys belonging to the original conductor of train LEF52 14. (See figure 1.) 

Based on the position of the switch and the presence of the keys, it is likely that the 

original conductor of train LEF52 14 had not re-lined the switch, thus making it impossible for 

train MPBSR 13 to stay on the main track. 
 3 NTSB/RAB-06/01 

 Figure 1. Conductor’s key in switch lock. 

Rules Compliance 

The investigation identified a number of procedural infractions that preceded the 

accident. According to Rule 8.3,2

 “The normal position of a main track switch is for main track 

movement, and it must be lined and locked in that position.” The rule has seven exceptions; 

however, none of them applied to this situation. According to Rule 14.7, “Reporting Clear of 

Limits,” “In addition, ...a train clearing in a siding or other track must comply with requirements 

outlined in Rule 8.3 (‘Main Track Switches’) before reporting clear of the limits.” In other 

words, the switch should have been lined for main track movement before the original engineer 

of train LEF52 14 released the track warrant authority for the main track to the train dispatcher 

and reported the train clear of the limits. Instead, when she released the track warrant, she 

assumed that the conductor had either re-lined or was in the process of re-lining the switch. 

When he joined her in the limousine, she did not confirm the position of the switch. 

The UP’s operating rules3 required the conductor to comment about delays and other 

events during the tour of duty on a preprinted form, Conductor Report Form 20849 (Form 

20849). The last entry that the conductor had made was about 9:21 p.m., when the train had 

passed a defect detector at MP 48.5. He had written that no defect was found and that the 

detector announced the train’s speed as 42 mph. 

 2

 “Main Track Switches,” from the General Code of Operating Rules (Fifth Edition). 3

 Union Pacific Rules, System Special Instructions, Item 10: Rules Supplements and Amendments, Rule 1.47 

“Duties of Crew Members,” Item A. Conductor Responsibilities, 5. Conductor Report Form. 

 
 4 NTSB/RAB-06/01 

According to the operating rules, when main track switches are restored to normal in nonsignaled territory, the following items must be entered on Form 20849: 

The location and time each main track switch is returned to normal when 

operating in non-signaled track warrant control (TWC) territory, except within 

Yard Limits. However, when departing, if main track movement is made over the 

switch operated, entry is not required (i.e., following a head end set-out or pickup). 

‘Switch restored’ entries must be initialed by both the conductor and engineer.... 

During the postaccident interview, the engineer said that she had not known that she was 

supposed to initial Form 20849 when the position of a main track switch was restored to normal. 

Further, she added, “I don’t think I’ve ever signed for a switch.” 

Form 20849 was incomplete. The last entry on it should have said that the switch had 

been re-lined. The entry should have given a time and should have been initialed by both the 

conductor and the engineer. 

Oversight 

To monitor its employees’ compliance with its operating rules, the UP conducts 

compliance field audits (commonly referred to as “efficiency tests”). According to 49 Code of 

Federal Regulations Part 217, the Federal Railroad Administration (FRA) can review the 

auditing. 

In the 365 days before the accident, railroad supervisors had observed the engineer on 21 

separate occasions. The supervisors had noted 58 individual operating or safety rules that she had 

followed. They had noted three minor infractions and handled them immediately with oral 

admonishments. On three specific occasions she was observed properly following the procedures 

involved in the use of hand-thrown switches; she was never observed using a switch improperly. 

During the same period, supervisors had observed the conductor on 21 separate 

occasions. They had noted 69 individual operating or safety rules that he had followed. Of the 

69, the supervisors had orally admonished him for the following 3 minor infractions: 

• March 10, 2005: Not complying with the procedure for getting off equipment. 

• May 15, 2005: Not complying with the procedures for position of switches.4

• June 18, 2005: Not complying with the procedures for handling cars ahead of engines. 

 4

 The reference for this rule infraction was Rule 8.2 “Position of Switches.” This rule covers the use of switches 

in general and would most likely apply during switching operations. The next rule, Rule 8.3, “Main Track 

Switches,” was not referenced in the auditing and covers the proper alignment of main track switches. 
 5 NTSB/RAB-06/01 

Crew Qualifications and Rest 

The investigation determined that the crew was experienced and qualified on the 

territory. No impairing substances were found during the postaccident toxicological tests. 

When the accident happened, the conductor and the engineer were ending their third 

consecutive noon-to-midnight shift. Since Sunday (the accident happened minutes after midnight 

Wednesday), they had had three consistent cycles of sleep and work. Both said that they had not 

felt fatigued at the end of the shift and always made a point of getting enough rest during their 

off-duty time. 

Actions Taken Since The Accident 

Following this accident, the UP revised the procedures for operating a hand-operated 

switch in non-signaled territory. The new rule requires that the crewmember who is operating the 

switch immediately notify the engineer by radio or hand signal when the switch position is to be 

changed. Further, the rule now specifies that the engineer and conductor must initial Form 20849 

before releasing the track warrant for the main track authority to the dispatcher. 

The FRA had issued a Safety Advisory on January 10, 2005, about 8 months before the 

accident, warning the railroads of an increase in incidents involving hand-throw switches that 

had inadvertently been left open, allowing trains to enter side tracks unintentionally and resulting 

in collisions and injuries. The advisory said that if the number of accidents of this type did not 

decrease, the FRA would be required to take “additional action to address this situation.” 

On October 19, 2005, about a month after the collision at Shepherd, the FRA issued 

Emergency Order (EO) No. 24 to address the use of hand-operated main track switches in 

non-signaled territory. According to its preamble, the EO had been prompted by several 

accidents, including the accident in Shepherd, Texas. 

The EO has seven specific instructions about using hand-operated switches when the 

approaching train is not already prepared to slow down or when the switch is not protected by 

some form of switch-position indicator. One of the seven requirements is similar to the 

preexisting requirement connected to the Shepherd accident. The EO specifies that the conductor 

and engineer must initial a Switch Position Awareness Form when the switch is re-lined to the 

normal position. Further, the train dispatcher must be informed when the switch is in the proper 

position if the train crew is releasing authority to the main track at this location. The dispatcher is 

also required to confirm this information and make sure that the engineer and conductor have 

each initialed the Switch Position Awareness Form. 

On November 29, 2005, the Safety Board adopted the railroad accident report titled 

Collision of Norfolk Southern Freight Train 192 With Standing Norfolk Southern Local Train 
 6 NTSB/RAB-06/01 

P22 With Subsequent Hazardous Materials Release at Graniteville, South Carolina, January 6, 

2005.

5

 In the Graniteville accident, a local crew had parked its equipment on a side track in nonsignaled territory and failed to re-line the main track switch. A train had entered the side track 

and struck the unoccupied standing train. The subsequent derailment resulted in the release of 

chlorine from a tank car. Nine people were fatally injured as a result of chlorine gas inhalation. 

As a result of that accident the Safety Board recommended that the FRA: 

R-05-14

Require that, along main lines in non-signaled territory, railroads install an 

automatically activated device, independent of the switch banner that will, 

visually or electronically, compellingly capture the attention of employees 

involved with switch operations and clearly convey the status of the switch both 

in daylight and in darkness. 

R-05-15

Require railroads, in non-signaled territory and in the absence of switch position 

indicator lights or other automated systems that provide train crews with advance 

notice of switch positions, to operate those trains at speeds that will allow them to 

be safely stopped in advance of misaligned switches. 

Probable Cause 

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

September 15, 2005, collision of Union Pacific Railroad trains MPBSR 13 and LEF52 14 in 

Shepherd, Texas, was the failure of the previous crew for train LEF52 14 to return a main track 

switch to the normal position after they had secured the train on the siding and departed the area. 

Adopted: May 22, 2006 

 5

 Railroad Accident Report NTSB/RAR-05/04 (Washington, DC: NTSB, 2005).