Collision of Burlington Northern

Santa Fe Freight Train With

Metrolink Passenger Train

Placentia, California

April 23, 2002

Railroad Accident Report

NTSB/RAR-03/04

PB2003-916304

Notation 7590

National 

Transportation

Safety Board

Washington, D.C.

Railroad Accident Report

Collision of Burlington Northern 

Santa Fe Freight Train With 

Metrolink Passenger Train 

Placentia, California 

April 23, 2002

NTSB/RAR-03/04

PB2003-916304 National Transportation Safety Board

Notation 7590 490 L’Enfant Plaza, S.W.

Adopted October 7, 2003 Washington, D.C. 20594
National Transportation Safety Board. 2003. Collision of Burlington Northern Santa Fe Freight

Train With Metrolink Passenger Train Placentia, California, April 23, 2002. Railroad Accident

Report NTSB/RAR-03/04. Washington, DC.

Abstract: On Tuesday, April 23, 2002, about 8:10 a.m. Pacific daylight time, eastbound Burlington

Northern Santa Fe Railway freight train PLACCLO3-22 collided head on with standing westbound

Southern California Regional Rail Authority passenger train 809 on the No. 2 track at Control Point

Atwood in Placentia, California. Emergency response agencies reported that 162 persons were transported

to local hospitals. There were two fatalities. Damage was estimated at $4.6 million.

The safety issues discussed in this report are the attentiveness of the Burlington Northern Santa Fe train

crew, the signal awareness form procedures for the Burlington Northern Santa Fe, passenger car survival

factors, and the absence of positive train control systems.

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

the Federal Railroad Administration, the Burlington Northern Santa Fe Railway Company, and the

Association of American Railroads. The Board also reiterated a previously issued safety recommendation

to the Federal Railroad Administration.

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

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

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

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

Public Inquiries Section, RE-51

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 PB2003-916304 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

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

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

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

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

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Site Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

BNSF 5340 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Metrolink 809 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

BNSF 5340 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Metrolink 809 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Metrolink Cab Car 634 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Metrolink Car 113 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Metrolink Car 167 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Metrolink Locomotive 859 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

BNSF Locomotive 5340 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Train Dispatching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Train Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Signal Awareness Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Calling Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Medical and Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Signal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Sight-Distance Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Locomotive Event Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Use of Cellular Telephones by BNSF 5340 Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

BNSF Program of Operational Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Postaccident ActionsñBNSF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Postaccident ActionsñMetrolink . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Mass Casualty Training Drill Exercise Coincident to Accident . . . . . . . . . . . . . . . . . . 26

Regulatory Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

BNSF Train Collision Avoidance System Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Crew Alertness to Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Contents iv Railroad Accident Report

Inattention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Signal Recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Enforcement of Operating Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Workstation Tables and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Emergency Access to Car End Areas Through Designated Emergency Windows. . . 32

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Positive Train Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Recommendation Reiterated in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
v Railroad Accident Report

Executive Summary

On Tuesday, April 23, 2002, about 8:10 a.m. Pacific daylight time, eastbound

Burlington Northern Santa Fe Railway freight train PLACCLO3-22 collided head on with

standing westbound Southern California Regional Rail Authority passenger train 809 on

the No. 2 track at Control Point Atwood in Placentia, California. Emergency response

agencies reported that 162 persons were transported to local hospitals. There were two

fatalities. Damage was estimated at $4.6 million.

The National Transportation Safety Board determines that the probable cause of

the April 23, 2002, collision of a Burlington Northern Santa Fe freight train and a

Metrolink commuter train in Placentia, California, was the freight train crewís

inattentiveness to the signal system and their failure to observe, recognize, and act on the

approach signal at milepost 42.31. Contributing to the accident was the absence of a

positive train control system that would have automatically stopped the freight train short

of the stop signal and thus prevented the collision.

The safety issues identified during this accident investigation are as follows:

ï Burlington Northern Santa Fe train crew attentiveness;

ï Burlington Northern Santa Fe signal awareness form procedures;

ï Passenger car survival factors;

ï The absence of positive train control systems.

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

makes safety recommendations to the Federal Railroad Administration, the Burlington

Northern Santa Fe Railway Company, and the Association of American Railroads. The

Board also reiterates a previously issued safety recommendation to the Federal Railroad

Administration.

1 Railroad Accident Report

Factual Information

Accident Synopsis

On Tuesday, April 23, 2002, about 8:10 a.m. Pacific daylight time, eastbound1

Burlington Northern Santa Fe Railway (BNSF) freight train PLACCLO3-22 collided head

on with standing westbound Southern California Regional Rail Authority (Metrolink)

passenger train 809 on the No. 2 track at Control Point (CP)2

 Atwood in Placentia,

California. Emergency response agencies reported that 162 persons were transported to

local hospitals. There were two fatalities.3 Damage was estimated at $4.6 million.

Accident Narrative

The crew (engineer and conductor) of commuter train Metrolink 809 reported for

duty at 1:30 a.m. on April 23, 2002, in Riverside, California. (See figure 1.) The crew was

scheduled to make several trips operating the same equipment but with varying train

numbers during their tour of duty. They left Riverside at 2:55 a.m. on their first trip and

arrived at Irvine sometime after 4:00 a.m. On the second trip, they departed Irvine at 4:23

a.m. and arrived at Los Angeles at 5:30 a.m. For their third trip, they departed Los Angeles

at 5:45 a.m. and arrived back at Riverside at 7:05 a.m.

Meanwhile, the crew (engineer and conductor) of freight train BNSF PLACCLO3-

22 (hereafter referred to by its operational identification, BNSF 5340) had reported on

duty at Hobart Yard (near Los Angeles) at 2:30 a.m. on April 23. Between 2:30 and 5:30

a.m., the crew took charge of the assigned locomotives, coupled them to their train, and set

out one defective car. By the time this was complete, several priority trains were ready for

departure from Hobart Yard, and these trains were permitted to leave ahead of BNSF

5340. The conductor said that while he and the engineer waited for the traffic to clear, he

took a 1 1/2 hour nap.4

 BNSF 5340 departed Hobart Yard about 7:30 a.m.

1 Both BNSF and Metrolink designate timetable directions as east and west.

2 A control point is a location where absolute signals are present and are under the control of a

dispatcher or control operator. Trains may not pass absolute signals displaying stop without authorization.

3 In order to provide standard classifications, the Safety Board applies published aviation injury

criteria (49 Code of Federal Regulations 830.2) to all modes of transportation. For statistical uniformity

only, an injury to a person that results in death within 30 days of the accident is classified a fatality. In the

Placentia accident, a third injured passenger, a 77-year-old woman, died on or about June 7, 2002, which

was about 45 days after the accident. Under the foregoing criteria, she is not classified in this report as an

accident fatality. The Safety Board's investigation did not identify any evidence that her death was directly

attributable to injuries sustained in the accident. Further, this classification does not reflect any

determination that she did not, in fact, succumb to injuries received in the accident.

4 General Code of Operating Rules Rule 1.11.1 allows napping by one of the crewmembers when the

train is waiting for departure.
Factual Information 2 Railroad Accident Report

Between Hobart Yard and CP Atwood, the BNSF railroad is multiple-track

territory with either two or three tracks. Trains may be operated in either direction on any

of the tracks. The train dispatcher requests routes, and the traffic control system5

 moves

track switches and displays signal aspects6

 to crews who operate their trains on the

designated routes. BNSF 5340 changed tracks several times between Hobart Yard and

Fullerton Junction as it negotiated the morning train traffic consisting of Metrolink and

Amtrak trains.

At 7:32 a.m., the Metrolink crew, now operating their train as Metrolink 809,

departed Riverside on their fourth trip of the day, heading for San Juan Capistrano. On this

trip, the train was configured with the locomotive on the rear and the cab car on the front.

The engineer was operating the train from a control compartment in the cab car.

Approaching CP Atwood westbound, Metrolink 809 received a diverging clear signal to

leave BNSF tracks and enter the Metrolink Olive Subdivision. (See table 1.)

Figure 1. Accident location.

5 A traffic control system (typically abbreviated ìTCSî) consists of wayside signals, powered

switches, and control points. The dispatcher issues commands to the system to route trains on the desired

tracks.

6 The signal aspect refers to the physical appearance of the signal, which usually involves the display

of colored lights, either singly or in different combinations. Although specific signal aspects vary not only

by railroad, but sometimes across territories within a single railroad system, the names given to various

signal aspects (clear, approach, stop, etc.) are generally uniform throughout the railroad industry and require

similar responses from train crews.

Los Angeles

San

Bernardino

San Juan Capistrano

Riverside

Hobart

ROUTE OF

BNSF 5340
Factual Information 3 Railroad Accident Report

Train BNSF 5340 was moving toward CP Atwood from the west. The engineer

recalled that as he approached Basta, which is at MP7 163.0 (about 7 miles from C.P.

Atwood), he received a signal that required him to slow his train to 30 mph, which he did.

He said that he then noted that the next signal displayed approach but changed to clear

before the train reached it. He then resumed normal operating speed.

The BNSF crewmembers said they were engaged in a conversation about previous

employment; they had both worked at the same oil refinery before beginning their railroad

careers. The BNSF 5340 conductor said that he called aloud the signal at MP 42.31the

signal before the signal at CP Atwoodas clear (refer to table 1) and that the engineer

repeated ìclear.î According to the transcript of an interview that BNSF officials

conducted with the conductor and engineer of BNSF 5340, the engineer acknowledged

that he heard the conductor call out ìclearî and that he ìconfirmed it.î In a Safety Board

interview, the engineer said that he did not see the signal. ìMy conductor called it before

we went under it; by the time I looked up, we were past it.î Both crewmembers said they

approached CP Atwood thinking they were operating on a clear signal and that they thus

were not required to stop or even slow the train. (According to data from signal system

data loggers, the signal at MP 42.31 was displaying approach at the time BNSF 5340

passed.)

Both BNSF 5309 crewmembers said that just before the train reached CP Atwood,

they realized that signal 4EA (MP 40.71) was showing stop.

8

 The train was traveling about

49 mph at the time. (See figure 2.) They said they noticed Metrolink train 809 on the same

track heading toward them, and the engineer placed the train brakes in emergency. The

Metrolink 809 engineer said he was slowing the train preparing to go through a switch at

25 mph when he saw the freight train coming toward his train on the same track. He also

placed his train in emergency, left the control compartment, and ran back through the

lower level of the car warning passengers to brace themselves.

Table 1. BNSF Track No. 2 signals as displayed at time of accident.

Location Name Aspect Indication Displayed to

MP 44.03 Clear Green Proceed BNSF 5340

MP 42.31 Approach Yellow Reduce to 30 MPH 

prepared to stop at next 

signal

BNSF 5340

CP Atwood 

(eastbound)

Stop Red Stop BNSF 5340

CP Atwood 

(westbound)

Diverging Clear Red over Green Proceed on diverging 

route at prescribed speed

Metrolink 809

7 BNSF milepost numbers increase from 0.0 at San Bernardino to 45.5 at Fullerton Junction. From

Fullerton Junction, numbers decrease from 165.5 to 143.4 at Harbor Jct.

8 The approach signal at MP 42.31 was intended to prepare the freight train crew to stop short of the

stop signal at CP Atwood.
Factual Information 4 Railroad Accident Report

Figure 2. Signal System Layout

SAN BERNARDINO

MP 40.71 MP 42.31

LOS ANGELES

MP 44.03

OLIVE SUBDIVISION

TO SAN DIEGO

4EA

NTSB Drawing

(not to scale)

Point

of

Impact Cab Car

Point

of

Rest

Green Signal Yellow Signal Red Signal CP Atwood

NOTE: BNSF striking freight train not shown

INTENDED

STOPPING POINT

FOR BNSF 5340

INTENDED

ROUTE OF

METROLINK 809

MP 40.39
Factual Information 5 Railroad Accident Report

As the freight train slowed, the conductor jumped clear of the locomotive at

approximately 25 to 30 mph. Soon after, the engineer also jumped clear. The train was

traveling about 23 mph when it collided head on with the standing Metrolink train about

1,630 feet past signal 4EA.

A security surveillance video camera at a commercial storage facility adjacent to

CP Atwood captured a portion of the collision on tape. The tape shows Metrolink 809

coming to a complete stop with the trailing (third) Metrolink passenger car standing in the

center of the video camera view. After being stopped for about 12 seconds, Metrolink 809

is propelled backward as BNSF 5340 makes contact. The BNSF 5340 lead locomotive

comes to rest in the center of the video image after both trains have stopped. Based on the

known length of the Metrolink passenger cars and of BNSF locomotive 5340, the easterly

movement of Metrolink 809 during impact was calculated to be about 243 feet. (See figure 3.)

Figure 3. Aerial photo of accident scene (courtesy Orange County Sheriffís Department).
Factual Information 6 Railroad Accident Report

Emergency Response

Fire and rescue emergency services for the city of Placentia are provided by the

Orange County Fire Authority under a ìjoint powers agreement,î which involves a

network of municipality-based fire departments linked by a common county-wide

emergency response dispatch system and management organization. The initial request for

emergency assistance was a telephone call that was placed to the fire authority 911

communications center at 8:10:56 a.m. This was followed by numerous additional calls.

Orange County Fire Authority Division IV/Battalion 2 was the initial responding

fire department agency9 and was the principal responding fire/rescue emergency services

agency in the accident. Other emergency services resources of Orange County

simultaneously responded to the accident. Emergency response support was also provided

by a large number of mutual aid response agencies as well as municipal and private

ambulance services.

Ultimately, at least a dozen emergency response organizations and municipal

support agencies were represented at the scene, including five fire department agencies

and seven police agencies. A total of about 60 emergency response vehicles, 45

ambulances supplied by seven ambulance companies, and several motor coaches10

responded to the scene. An estimated 120 emergency personnel, about 40 of whom were

paramedics, responded to the scene. Also, medical trauma personnel (a physician and

eight nurses) responded to the scene.

An Orange County Fire Authority chief served as the incident commander11 during

the emergency response and coordinated the combined activities of the various responding

organizations.

The Metrolink cab car,. 634, sustained substantial crush damage and debris in and

around the aft stairwell, which rendered the stairwell impassable. (See figure 4.) The

stairwell provides access between the upper-level deck, the intermediate level, and the

lower-level deck of the railcar (where the main doors are located). There is an

intermediate level at each end of the railcar where an end door allows passage to an

adjacent coach car. When the cab car came to rest, the aft end door was misaligned relative

to the adjacent coach car. (See figure 5.) Emergency responders reported that those

passengers on the intermediate level were able to remove the emergency exit windows

without external assistance and were readily able to exit through the emergency exit

windows and climb to the ground on ladders.

9 Division IV/Battalion 2 is the fire brigade resident to the city of Placentia.

10 The motor coaches provided transportation to local hospitals for those identified during triage to have

suffered minor injuries. Other buses were used, upon request, to transport uninjured passengers back to their

initiating stations.

11 The incident command system provides for the coordination of personnel, resources, and

communication during the response to an emergency.
Factual Information 7 Railroad Accident Report

Figure 4. Damaged stairway in Metrolink cab car.

Figure 5. Damaged exterior of Metrolink cab car.
Factual Information 8 Railroad Accident Report

Emergency responders indicated that while passengers in the aft intermediate level

of the coach were slightly delayed in exiting the railcar because of the damaged door, the

passengers told responders that they were not injured or entrapped in any way. These

passengers were also reported to have instructed the emergency responders to attend to the

more seriously injured persons on the train until resources were available to assist them in

exiting the car.

Emergency responders found two passengers who were showing minimal or no

signs of life lying in the aisle of the upper deck of the lead Metrolink railcar. After a

medical triage assessment was performed, one of these injured passengers, a 48-year-old

male, was immediately transported by ambulance. The passenger expired in route and was

pronounced dead upon arrival at the hospital. The other passenger, a 59-year-old male,

was later pronounced dead at the scene.

Emergency response agency and medical facility records indicated that 264

persons on board the two trains were medically triaged at the scene. A total of 102 persons

in the medical triage count were identified as ìuninjured.î In addition, one firefighter

experienced dehydration at the scene and was transported to a local medical facility, which

raised the medical triage count to 265 persons (which included the on-scene fatality). Of

the 265 persons in the medical triage count, 162 persons received emergency

transportation for medical assessment and/or treatment at local hospitals. This included

157 Metrolink passengers, 2 Metrolink crewmembers, 2 BNSF crewmembers, and the 1

injured firefighter. (See figure 6.)

Figure 6. Emergency responders treating accident victims.
Factual Information 9 Railroad Accident Report

Site Description

The BNSF San Bernardino Subdivision is part of the larger Southern California

Division and runs in a timetable east-west direction between San Bernardino at MP 0.0

and Harbor Junction at MP 143.4. The San Bernardino Subdivision consists of multiple

main track territory with sidings and crossovers. The maximum timetable12 speed for

trains operating through CP Atwood in the vicinity of the accident is 50 mph for freight

trains and 60 mph for passenger trains. About 40 to 50 freight trains pass through CP

Atwood each weekday, along with more than a dozen passenger trains.

The collision occurred on track No. 2 at BNSF milepost 40.39 on tangent track at

CP Atwood. The point of collision was east of signal 4EA that governs eastbound

movements on track 2 through CP Atwood. CP Atwood also controls movements to and

from the Metrolink Olive Subdivision that connects Metrolink stations on the BNSF San

Bernardino Subdivision tracks to stations along the Metrolink San Diego and Orange

Subdivision tracks. In addition to the Olive Subdivision connector, there are two main

tracks at CP Atwood, and trains can run in either direction on any track.

The general track construction at CP Atwood is a mixture of 119-, 131-, and 136-

pound continuously welded rail fastened through tie plates to standard timber crossties

supported by granite ballast.

Injuries

A review of hospital records for those Metrolink passengers transported from the

scene indicated that the passengers stated to the medical staff that their injuries were

sustained principally as a result of being thrown forward and striking some hard or

unyielding surface or object such as a workstation table or seatback structure. (See table 2.)

12 BNSF, Southern California Division Timetable No. 6, effective January 20, 2002.
Factual Information 10 Railroad Accident Report

Table 2. Injuries

Notations in several passengersí medical records indicated that they had informed

the medical staff that one of the Metrolink train crewmembers in the cab car attempted to

warn passengers of the impending collision just before the impact. The notations also

indicated that several of those passengers were able to place themselves in positions or

locations that they felt might have helped to reduce their injuries.

A review of the pathology reports on the two fatalities indicated that both persons

received severe blunt impact trauma injuries to the chest and upper abdomen. These two

fatally injured persons were found near seats 58 and 61 and 66 and 70, respectively, on the

upper level of the lead railcar. They were apparently sitting next to each other on the right

side of the aisle (relative to the direction of travel) in seats numbered 60 and 61, with both

persons facing the direction of travel. (See figures 7 and 8.) These seats are about in the

middle of the railcar and are a paired seating set arranged in an opposing (face-to-face)

layout with another paired seating set (seat numbers 56 and 57), with a workstation table

between them. The workstation table was found to have been pushed forward relative to

its normal service location and was partially resting against the seatback of the opposite

seat pair set. Although the table pedestal had not fully separated from its attachment to the

floor, its attachment joint with the floor was bent and partially separated.13 No one was

identified as having been occupying seats 56 or 57 at the time of the collision.

Injury Typea Employees Passengers Others Total

Fatal 0 2 0 2

Serious 0 22 0 22

Minor 4 114 1b 119

None 0 122c 0 122

Total 4 260 1 265

a 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as ìany injury which results in death within 30 days of 

the accidentî and serious injury as ìan injury which: (1) requires hospitalization for more than 48 hours, commencing 

within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of 

fingers, toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or 

(5) involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface.î b Responding firefighter treated for dehydration.

c Includes 102 persons who were medically triaged at the scene and identified as ìuninjuredî and released from the 

scene, plus 20 persons who were transported in the ìminorî injury category to a local medical facility for which no 

medical records could be located (these persons apparently did not receive medical assessment or treatment and are 

thus not listed as injured).

13 Emergency medical services personnel later needed to detach the table from the floor and wall in

order to access the emergency exit window at that location.
Factual Information 11 Railroad Accident Report

Figure 7. Seating layout of the upper-deck level of the 

Metrolink cab car. (Fatally injured passengers were seated 

in seats 60 and 61 at workstation table.) DIRECTION OF TRAVEL

Table

Table

Table

Table

61

60

65

64

69

68

73

72

63

62

67

66

71

70

75

74

59

58

55

54

51

50

47

46

43

42

39

38

35

34

37

36

41

40

45

44

49

48

53

52

57

56

33

32
Factual Information 12 Railroad Accident Report

Damage

Metrolink cars 634 and 113 derailed and sustained substantial crush damage.

Metrolink estimated monetary damage at $4.6 million. BNSF locomotive unit 5340

sustained damage to the front end. BNSF estimated monetary damage to be $25,000.

Switch No. 3 on BNSF track No. 2 was damaged as a result of being run through

(subjected to train movement that conflicted with the route for which the switch was lined)

by the freight train. BNSF engineering personnel estimated the total track, structures, and

signal equipment damages at $6,400.00. This figure included costs for the installation of a

new switch point and stock rail.

Category Damages

BNSF Equipment $25,000

Metrolink Equipment 4,600,000

Track-Structures-Signals 6,400

Total $4,631,400

Figure 8. Photograph depicting a simulation of the positions of the two fatally injured 

passengers relative to an exemplar workstation table. (The passengers were facing the 

direction of travel.)
Factual Information 13 Railroad Accident Report

Personnel Information

BNSF 5340

The engineer of BNSF 5340 was hired as a switchman in 1997. He was promoted

to locomotive engineer on July 30, 1999. He had operated over the accident territory

(Hobart to Barstow) for 1 1/2 years as a conductor and about 1 year as an engineer. He was

due for engineer recertification training on July 30, 2002. His disciplinary record indicated

that he received a formal reprimand for failing to stop short of cars on a yard track while

working as a switchman in 1997. Otherwise, his record was clear.

The BNSF 5340 engineer was assigned to an extra board.14 The day before the

accident (Monday, April 22) he completed a 12-hour shift that began on Sunday at 4:00

p.m. and ended the next morning at 4:00 a.m. He said he then drove for an hour to his

home, where he fell asleep about 5:30 a.m. and slept for about 10 hours. After waking, he

remained at home, did some chores, and ate dinner. Afterwards, he said he took a nap for 2

1/2 hours until he was awakened by a phone call from the railroad at 11:30 p.m., during

which he was told to report for duty at 2:30 a.m. He said he departed his house at 1:30 a.m.

on April 23 and drove to the terminal. He told investigators that he felt ìpretty goodî when

he departed Hobart Yard on the accident trip.

The BNSF 5340 conductor was hired as a switchman in 1998. He was promoted to

conductor 3 months after being hired. His disciplinary record indicates he received a 30-

day suspension in 2000 for failing to properly secure railcars, resulting in a collision with

a motor vehicle. Otherwise, his record was clear.

The conductor was also assigned to an extra board. On the day before the accident

(Monday, April 22), the conductor, after completing an assignment that had taken him to

an away-from-home terminal, arrived at his hotel about 12:30 a.m. and slept until 7:45

a.m., when he was called by the BNSF to go on duty at 9:15 a.m. on April 22. He worked

until 4:10 p.m. He said he spent time with his wife that evening, ate dinner, and slept from

9:00 p.m. until 11:30 p.m., when he was called to go on duty at Hobart Yard at 2:30 a.m.

He said that after this call, he slept for another hour, then awoke and traveled to the

terminal. He arrived at the terminal at 2:25 a.m. and went on duty at 2:30. The conductor

said that although he felt tired when he reported for work, he felt ìwide awakeî when

BNSF 5340 departed Hobart Yard.

Metrolink 809

The Metrolink 809 engineer was hired on August 24, 1992. He began operating

Metrolink trains in September 1999. He received a favorable evaluation during his last

locomotive engineer evaluation on January 18, 2002.

14 An extra-board employee does not have an assigned job but is called as necessary either to substitute

for a regular employee who is unavailable for duty or to serve as a crewmember on an unscheduled

assignment.
Factual Information 14 Railroad Accident Report

The Metrolink 809 conductor began working in the railroad industry with the

Atchison Topeka and Santa Fe Railroad in 1973 as a switchman/brakeman, and worked

there until he was hired by Amtrak in March 1989. He began working on Metrolink15

trains in September 1999.

Train Information

BNSF 5340

BNSF 5340 consisted of three locomotives and 27 loaded multi-platform

intermodal freight cars (67 platforms total). The train weight was 5,755 tons. Records

indicate that a mechanical inspection and an initial terminal air brake test were performed

before the train departed Hobart Yard on the day of the accident. No exceptions were

noted during this inspection and testing.

Metrolink 809

Metrolink 809 consisted of one locomotive and three passenger cars. At the time of

the accident, the locomotive was at the rear of the train being controlled from the cab car

at the front. This configuration, referred to as ìpushñpullî operation, eliminates the need

to turn or switch equipment at the end of each run and allows quicker turnaround time at

terminals.

Records indicate the Metrolink 809 was mechanically inspected and received an

initial terminal air brake test before its departure from Riverside. No exceptions were

noted during the inspection and testing.

The passenger cars on Metrolink 809 were bi-level coach cars manufactured by

Bombardier Transportation, a division of Bombardier Corporation. The Metrolink railcar

coach fleet comprises three groups16 of Bombardier bi-level coach railcars identified by

delivery series, number, and delivery dates, with the delivery of the individual groups

occurring several years apart.

With regard to the design of interior features, the three groups of bi-level coach

railcars are similar, with minor variants occurring between the delivery series. The design

incorporates two full decks (an upper and lower) in the center of the railcar, with an

intermediate-level deck situated over the truck assemblies at each end of the car. All three

decks provide passenger seating. The bi-level coaches are all configured to the same basic

passenger seating arrangement. The only significant difference between the coach/cab car

and the coach/trailer is that an operatorís cab compartment is provided at the leading end

of the coach/cab car. The Metrolink bi-level cab car and coach/trailer units have seating to

15 Amtrak supplies the crews to operate Metrolink trains.

16 These ìgroupsî are also referred to (by both Metrolink and Bombardier) as ìgenerations,î or

ìseries.î
Factual Information 15 Railroad Accident Report

accommodate 142 and 149 passengers, respectively. Both coach railcar designs have a

crush load17 capacity of about 360 passengers.

Two stairwells in each Metrolink bi-level coach18 provide access between the

lower-level deck, the intermediate level at each opposite end of the railcar, and the upperlevel deck of the railcar. Four main passenger ingress/egress side pneumatically operated

pocket door sets19 are on the lower-level deck of each railcar, with two sets of doors on

each side. A vestibule area is provided between the main side-exit doors at each end of the

lower-level deck. An emergency release handle adjacent to each main side-exit door may

be used to release one of the sliding pocket door panels at each door location. A restroom

is at one end of the lower-level deck. A door at each end bulkhead on the intermediate

level provides passage to adjacent railcars.

Passenger seating accommodations on board the Metrolink bi-level railcars consist

of a combination of transverse and longitudinal-mounted fixed seat assemblies,20 with the

seat assemblies installed on both sides of a longitudinally oriented center aisle passageway

on all three deck levels. Almost all of the transverse mounted fixed seat assemblies in the

Metrolink bi-level coach railcar fleet are arranged in a ì2 + 2,î paired/side-by-side

configuration (also referred to as a ìpaired seating setsî arrangement). Many of the paired

seating sets are arranged in an opposing face-to-face layout with the balance of the paired

seating sets arranged so that the paired seating sets are all facing in the same direction.

Each Metrolink bi-level railcar is fitted with eight workstation tables, four on the

upper level and two at each end of the intermediate level. These tables are fitted between

paired seating sets of opposing passenger seats. The tables are a basic design consisting of

a one-piece tabletop assembly that is cantilevered from and secured to the carbody

sidewall. A single pedestal support leg is attached to the tabletop underside and is secured

to the floor. The tabletops are trapezoidal in shape, approximately of a uniform size, and

manufactured of a resilient plastic material.

Bombardier representatives said all of the bi-level railcars delivered to its

customers have been fitted with the workstation tables and that the company had not

conducted any biomechanical engineering analysis, testing, or injury causation assessment

of occupant impact against the workstation tables.

Metrolink delivery series 200 and 207 railcars21 have three exterior sidewall

emergency access windows on each side of the upper-level deck. The lower-level deck has

two emergency access windows on each side. A retro-reflective decal on the car exterior

17 The crush load is the maximum number of passengers that can possibly be riding in the railcar

(standing and sitting).

18 The stairwells are at approximately the 1/4 point and the 3/4 point along the length of the carbody.

19 A pocket door is a door that opens by sliding horizontally into a narrow compartment within the wall

adjacent to the doorway.

20 A fixed seat is a passenger seat that is permanently configured in a given location such that it cannot

otherwise be readily reconfigured (by operational or maintenance personnel) to face any other direction.

21 These delivery series include railcars 113, 167, and 634, all involved in this accident.
Factual Information 16 Railroad Accident Report

near each upper- and lower-level emergency access window describes the emergency

window removal procedure. The instructions are to use a screwdriver to pry out the seal

(grommet) surrounding the windowpane. The decal also includes a grommet-removal

pictorial and additional step-by-step instructions.

On the intermediate-level deck, all of the exterior sidewall windows could be

removed by using an axe, a sledgehammer, or a similar impact tool to break the window

glazing. Although emergency exit windows on the intermediate level had instructional

signage and pull rings on the inside of the railcar, no instructional signage describing the

window removal procedure was provided on the exterior sidewall near the intermediatelevel deck windows, and such signage was not specifically required by regulations.

The upper- and lower-level decks of Metrolink delivery series 214 railcars22 are

fitted with the same exterior sidewall emergency access window configurations and

exterior instructional signage as the series 200 and 207 cars described above. The

intermediate-level deck windows can be removed without breaking the window glazing.

Although not specifically required by regulation, intermediate-level exterior instructional

signage was installed on this series of cars before the accident. The signage consists of a

retro-reflective decal stating: ìUSE SCREWDRIVER TO PRY OUT SEAL

SURROUNDING THE WINDOW PANE,î along with additional step-by-step

instructions.

Wreckage

The derailed Metrolink equipment came to rest substantially upright and

somewhat in alignment with the track, although the aft end of the lead Metrolink railcar

had skewed onto the adjacent track. The leading end of the Metrolink cab car,. 634, came

to rest about 131 feet east of the Richfield Road grade crossing (centerline of the

pavement). The lead BNSF locomotive 5340 came to rest lodged against the front

bulkhead fascia of the Metrolink cab car.

Metrolink Cab Car 634

Metrolink cab car 634 had both its truck assemblies derailed, and the aft end of the

railcar had skewed about 11 feet to the north. The carbody received relatively moderate

impact damage to the front exterior and operatorís cab. The aft end of the carbody

structure was substantially damaged. The carbody in the vicinity of the aft stairwell was

bent to the left (relative to the direction of travel) and displayed a 30° bend from its linear

configuration. The aft end of the carbody was laterally displaced about 89 inches relative

to its linear configuration, with the displacement point occurring about 178 inches from

the aft bulkhead exterior fascia. Debris and crush damage rendered the aft stairwell

impassable. There were no occupants reported in the stairwell area at the time of the

accident. A section of the roof panel above the aft stairwell of the car had separated from

22 None of which were involved in this accident.
Factual Information 17 Railroad Accident Report

its attachment and was buckled upward about 35 inches. A segment of the left sidewall

panel near the aft stairwell of the car had been longitudinally displaced from its structural

attachment. This resulted in a localized partial telescoping of the carbody sidewall panel

structure in that area.23 On the underside, severe damage was apparent on the structural

steel center sill assembly.

On the interior, a number of the passenger seats and workstation tables throughout

the railcar had shifted from their normal positions. Most of the emergency pull-windows

had been removed.

Metrolink Car 113

The leading end of the second Metrolink car, 113, was lodged against the aft end of

the lead cab car with its lead truck assembly derailed. A preliminary visual inspection

indicated that the carbody received relatively little structural damage, with the damage

principally confined to the exterior fascia panel of the front bulkhead, which had fractured

in several places. A later, more extensive examination by Metrolink identified that the

center sill (under-frame) structure at the A-end of the railcar was substantially damaged.

In the interior, many of the seat cushions were dislodged from their attachments to the

seats. There was no significant interior crush damage or a loss of occupant survival space

in this car.

Metrolink Car 167

The leading end of the third Metrolink car, 167, was lodged against the aft end of

the second railcar, and the aft end was coupled to the locomotive. This railcar had not

derailed and was relatively undamaged during the accident.

Metrolink Locomotive 859

Inspection of Metrolink locomotive 859, indicated that the shank of the coupler at

the leading end of the unit was bent. The locomotive was otherwise undamaged, and it did

not derail.

BNSF Locomotive 5340

The lead locomotive of the freight train received minimal damage and did not

derail, nor did the two other locomotives or any of the railcars in the BNSF train.

23 The sidewall panel had separated from the structural framing and then was displaced (aft) when the

carbody structure (aft of that location) pivoted to the left such that the sidewall panel came to rest

overlapping the adjacent sidewall panel.
Factual Information 18 Railroad Accident Report

Operations Information

Train Dispatching

Train movements on the BNSF San Bernardino Subdivision and the Metrolink

Olive Subdivision are governed by the General Code of Operating Rules, effective April

2, 2000, and by timetable instructions and the signal indications of a traffic control signal

system. The train dispatcher at the BNSF control center in San Bernardino coordinates

train movements with the signal system on the BNSF San Bernardino Subdivision. The

BNSF train dispatcher controls CP Atwood and any diverging train movements between

BNSF tracks and Metrolink tracks on the Olive Subdivision.

The BNSF traffic control system between CP Fullerton and CP Atwood

(approximately 4.5 miles) consisted of three-aspect searchlight-type signals. With threeaspect signals, the aspect sequence encountered by a train approaching a red signal is

green, followed by yellow, then red. A red signal is displayed to approaching trains when

a track signal circuit is occupied by another train or under certain other conditions. Signals

are arranged for train movements in either direction, are continuously lit, and are

controlled by electronic coded track circuits.

Train Control

On the nearby Metrolink Orange and San Diego Subdivisions, an intermittent

automatic train stop system has been in operation since the 1960s. This system was

installed by the predecessor railroad (the ATSF) to allow 90-mph passenger train

operations. (Without an intermittent automatic train stop or similar system in place,

Federal regulations restrict passenger train speeds to a maximum of 79 mph.) In an

intermittent automatic train stop system, wayside inductors transmit signal information to

receiving equipment on Amtrak or Metrolink locomotives. Any signal indication other

than clear requires an acknowledgement from the locomotive engineer. If the engineer

does not acknowledge the signal indication within 7 to 8 seconds, the trainís brakes will

automatically apply.

The intermittent automatic train stop system does not enforce speeds; that is, as

long as the engineer acknowledges a more restrictive signal, the system takes no other

action, even if the requirements of the signal are ignored. Nor is the system fail safe: if an

inductor is removed or inoperative, the system no longer requires an acknowledgement of

a restrictive indication, and the wayside signal system does not automatically restrict train

movement.

When Metrolink went into operation in the early 1990s, the signal system was

renovated and spaced for cab signals.24 Pole lines were replaced with coded track circuits,

but locomotives were not equipped for cab signals, nor was any field equipment installed

24 A cab signal system displays the governing signal aspect inside the cab of a locomotive so long as

the locomotive is equipped to receive and display the signals and it is operating in territory equipped with a

working cab signal system.
Factual Information 19 Railroad Accident Report

for cab signals. The Metrolink Orange/San Diego Subdivision intermittent automatic train

stop system is the only such equipment on Metrolink tracks, and no cab signal systems are

operative on the Metrolink system or on the BNSF San Bernardino Subdivision. The

BNSF freight trains that operate over Metrolink tracks under trackage rights agreements

are not equiped with automatic train stop receiving equipment and are limited by

Metrolink to a maximum speed of 55 mph.

Signal Awareness Form

BNSF procedures required the BNSF 5340 conductor to enter the name/aspect of

each signal encountered during the trip on a signal awareness form.25 This form was

recovered from BNSF locomotive 5340 after the accident. The first page of the form

included the signals from MP 144.00 to MP 157.91. The train entered the territory at an

intermediate point on the form, and the first signal encountered was at MP 146.98. The

entry for this signal was ìDA,î meaning diverging approach.

26 This entry showed the

speed and time (10 mph and 7:20 a.m.) as required by BNSF procedures. Some entries on

the first page showed ìA,î indicating that the signals displayed approach. Several entries

were ìAM,î or approach medium.

27 Most remaining entries had a ìC,î which the

conductor explained meant clear. The second page contained the list of signals involved

with the accident, from MP 159.48 to MP 40.71, the location of the stop signal.

The conductor explained that he always entered a ìCî in this column as shown on

the first page of the signal awareness form. Furthermore, the conductor explained that he

did not always make an entry each time he observed a clear signal; he said he often waited

either until an approach signal was encountered or until it was time to turn to the next

page of the awareness form and then backfilled the entries for the clear signals up to that

point.

The BNSF procedure requires that:

All block signal names or aspects and yellow or yellow/red flags must be

recorded. With the exception of CLEAR signals, which only require the name or

aspect to be recorded, information must include the location of each flag, the train

speed, time the signal or flag is passed and the name or aspect of the signal that

was called. When speed indicator is not visible to the conductor, the engineer

must call out the speed, in addition to the signal name or aspect, if other than

CLEAR. Should the conductor be unable to record a signal aspect due to other

activities, this fact must be noted on the form, including the reason.

25 The investigation determined that the Union Pacific Railroad also requires conductors to annotate

signals on a special form, and the Norfolk Southern Railroad is considering such a requirement.

26 Upon receiving a diverging approach signal, a train must ìProceed on diverging route not exceeding

prescribed speed through turnout; approach next signal preparing to stop, if exceeding 30 mph immediately

reduce to that speed.î

27 Upon receiving an approach medium signal, a train must ìProceed prepared to pass next signal not

exceeding 40 mph and be prepared to enter diverging route at prescribed speed.î
Factual Information 20 Railroad Accident Report

Calling Signals

The General Code of Operating Rules has a requirement for crew members to call

signals. 

The rule specifies the following:

Rule 5.16 Observe and Call Signals. Crew members in the engine control

compartment must be alert for signals. As soon as signals become visible or

audible, crew members must communicate clearly to each other the name or

aspect of signals affecting their train. They must continue to observe signals and

announce any change of aspect until the train passes the signal.

If the signal is not complied with promptly, other crew members must remind the

engineer and/or conductor of the rule requirement. If the crew members receive

no response or if the engineer is unable to respond, they must immediately take

action to ensure safety, using the emergency brake valve to stop the train, if

necessary.

During the investigation, the conductor described the signal at MP 44.03 (two

signals in advance of Atwood) as the ìfirst approach to Atwoodî and said that this signal

displayed green (clear).

The conductor said that he next called out the signal at MP 42.31 (one signal in

advance of the stop signal at CP Atwood) as clear. The engineer stated that he

remembered the conductorís calling this signal clear, but that he did not look at the signal

himself.

Because of the location of Metrolink 809 and the settings in the train dispatcherís

computer, the signal just before CP Atwood was displaying approach. Both the engineer

and the conductor stated that the CP Atwood signal displayed stop.

Meteorological Information

At the time of the accident, the weather at Fullerton Airport (about 8 miles from

CP Atwood) was reported as haze with a temperature of 58° F. The BNSF 5340 engineer

stated that the weather at the time of the accident was clear and dry, with no smog or

precipitation. Sunrise was at 6:11 a.m., and the altitude and azimuth of the sun at the time

of the accident were reported to be 23.6° and 90.3°, respectively.28

Medical and Toxicological Information

The BNSF 5340 engineerís last company medical examination for vision and

hearing was in the spring of 2002 as part of a required locomotive engineer recertification.

28 Source: U.S. Naval Observatory <http://mach.usno.navy.mil/cgi-bin/aa_altazw>.
Factual Information 21 Railroad Accident Report

The examining physician indicated that he could operate in his current assignment with no

restrictions. The engineer wore bifocals and said he was wearing them during the accident

trip. The engineer indicated that he had not taken any medications during the 3 weeks

leading up to the accident.

The BNSF 5340 conductorís last company medical examination was in 1998. The

examining physician indicated that he could operate in his current assignment with no

restrictions. He wore glasses for reading only. His most recent hearing test was on May 18,

1998; no operating restrictions were noted. The conductor indicated that he had not taken

any medications before the accident.

The Metrolink 809 engineerís last company physical was on June 14, 2001. No

operating restrictions were indicated.

The Metrolink 809 conductorís last physical examination was conducted on

November 1, 1999. No operating restrictions were indicated.

Pursuant to Federal Railroad Administration (FRA) postaccident toxicological test

requirements as found at 49 Code of Federal Regulations (CFR) 219 Subpart C, each

crewmember on the BNSF and Metrolink trains involved in the accident provided

specimens that were tested for the presence of alcohol and drugs.29 All of the

crewmembers on both trains tested negative for all tested substances.

Tests and Research

Signal System

On April 23, 2002, investigators from the BNSF, Metrolink, Amtrak, the FRA, the

Brotherhood of Railroad Signalmen, the California Public Utilities Commission, and the

Safety Board began a field inspection of the railroad signal system. The postaccident

inspection found all signal units, switches, and the signal cases at the intermediate signals

and at CP Atwood locked and secured with no indications of tampering or vandalism.

All relay positions were found to be in accordance with the physical location of the

accident trains and with the displayed signal aspects. Ground tests were performed, signal

searchlight mechanisms were inspected, and lamp operating voltages were verified.

Movements of the spectacle arm30 were smooth with no binding. All mechanisms were

found to be operating properly with no exceptions noted. Track connections and insulated

joints were inspected, and no exceptions were noted. Information developed from signal

system data loggers and dispatch center records during the investigation indicated that this

signal at MP 42.31 was displaying approach at the time BNSF 5340 passed the signal.

29 Specimens were tested for cannabinoids, cocaine, opiates, amphetamines, methamphetamines,

phencyclidine, barbiturates, and benzodiazapines.

30 A spectacle arm holds different color lenses that it positions in front of a single lamp to display the

proper signal color.
Factual Information 22 Railroad Accident Report

Sight-Distance Tests

On April 25, 2002, Safety Board investigators conducted sight-distance tests by

riding a locomotive of similar design to BNSF 5340 over the route the freight train

traversed before striking the Metrolink train and observing the distances at which signal

aspects could be seen and identified. The time of day and weather were similar to those on

the day of the accident. Three trips were made, each starting at Fullerton and ending near

the collision point. Investigators noted and recorded the visibility of the wayside signals at

MP 44.03 (which showed clear when BNSF 5340 passed), MP 42.31 (which showed

approach), and MP 40.71 (which showed stop). The distances recorded for the three runs

were used to develop an average sight distance for each signal.

On the first run, the signals were set (from west to east) at clear, approach, and

stop, which duplicated their aspects during the passage of BNSF 5340. On the second run,

all signals were set at clear. On the third run, signals were again set at clear, approach,

and stop.

The signal with the shortest average sight distance was the first one, at MP 44.03,

which could be identified at about 1,960 feet. The next signal, at MP 42.31, could be seen

and identified at approximately 3,010 feet. This was the signal that, on the day of the

accident, was showing approach but that was called out as clear by the conductor.

According to the locomotive event recorder, the accident train went by this location at 42

to 43 mph. With 3,010 feet of visibility and with the train moving at 42 mph, the signal

would have been visible for about 48 seconds. The last signal before the collision point,

signal 4EA at MP 40.71, could be seen and identified at an average distance of about

2,375 feet. Because of its weight and speed, train BNSF 5340 could not stop short of the

signal.

Placentia Police Department records indicate that shortly after the accident, the

BNSF 5340 engineer told an officer that he could not see the approach signal, that the sun

was very bright behind the signal, and that he could not distinguish the color. When the

engineer was interviewed by Safety Board investigators on April 24, he said that he did

not ìcatchî the signal but that the conductor told him it was clear.

Locomotive Event Recorder Data

Event recorder data were recovered from Metrolink locomotive unit 859,

Metrolink cab car 634, and the three BNSF locomotive units. The data were reviewed by

Safety Board staff. The data from the various recorders on each train were found to be in

reasonable correlation. Metrolink cab car 634 (the lead car on Metrolink 809) experienced

significant damage in the collision. The recorder installed on that car was removed and reinstalled on cab car 636 in order to retrieve the data. The data from the Metrolink cab car

634 event recorder show that the train was placed into emergency braking, coming to a

full stop at recorder time31 08:06:27 and was standing when it was struck by BNSF 5340.

31 Each event recorder records time independently from an internal clock. Typically, these clocks vary

somewhat from actual time and from one other.
Factual Information 23 Railroad Accident Report

The data from the recorder on BNSF 5340 (the lead locomotive on the freight

train) show locomotive engineer activity, including a throttle movement and dozens of

whistle activations as the train approached and traversed grade crossings in the 10 minutes

before the accident. The data indicate that at recorder time 08:15:12 and at a train speed of

49 mph, an emergency brake application was initiated by the engineer. Between recorder

time 08:15:13 and 08:16:00, train speed decreased from 49 to 0 mph. At recorder time

08:15:45, train speed was 23 mph. One second later, at 08:15:46, the trainís speed dropped

to 17 mph. The recorder data indicate that the distance to a stop traveled by BNSF 5430

from the point where the speed rapidly decreased from 23 to 17 mph was 233 feet.

Other Information

Use of Cellular Telephones by BNSF 5340 Crew

The BNSF 5340 conductor told Safety Board investigators that both he and the

engineer had used their cellular telephones during the accident trip. The conductor stated

that soon after they departed the yard, he had a brief conversation with his wife, after

which the engineer made a personal call using his own cell phone. According to the

conductor, the last conversation ended before the train reached Fullerton. The conductor

said he was not aware of any BNSF rule prohibiting the use of a cellphone while operating

a train.

The BNSF 5340 engineer told investigators that he called his wife sometime

before reaching Fullerton and that he did not use his cell phone again until after the

collision, when he used it to contact BNSF officials. A review of cell telephone records for

both the conductorís and engineerís numbers confirmed these accounts.

Federal regulations do not prohibit a locomotive engineer from using a cell phone

while at the controls of a moving train. Since April 10, 1994, the General Code of

Operating Rules (which BNSF has followed since about 1985) has had the following rule

(Rule 1.10, ìGames, Reading, or Electronic Devicesî) about the use of equipment not

related to train operations:

Unless permitted by the railroad, employees on duty must not: Play games, read

magazines, newspapers, or other literature not related to their duties or use

electronic devices not related to their duties.

Additional guidance on cell phone use is provided by the BNSF published Safety

Briefing on September 20, 2001 (SB-2001-04):

Under no circumstances should a train crew on the head-end involve themselves

in personal cell phone conversations while the train is moving. Inbound callers

will understand that the employee will call back when the opportunity presents

itself (usually while stopped in a siding - - and NOT while inspecting a passing

train.) Refer to GCOR 1.10, which covers restriction in the use of non-authorized

electronic devices not related to railroad duties.
Factual Information 24 Railroad Accident Report

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

in Clarendon, Texas,32 the Safety Board found that use of a cell phone by the engineer of

one of the trains may have distracted him to the extent that he was unaware of the

dispatcherís instructions that he stop his train at a designated point. As a result of that

accident, the Board. on June 13, 2003, recommended that the FRA:

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.

After the Placentia and Clarendon accidents and as a result of a collision on a

different BNSF subdivision,33 the BNSF, on June 18, 2002, issued instructions to

operating employees that specifically prohibited the use of cell phones and laptop

computers while on duty, with certain exceptions. Per these instructions, locomotive

engineers ìare prohibited from using cell phones/laptop computers while operating the

controls of a locomotive.î

BNSF Program of Operational Tests

Under regulations at 49 CFR Part 217, the BNSF is required to periodically

conduct operational tests and inspections34 to determine the extent of operating employee

compliance with the code of operating rules, timetables, and timetables special

instructions.

To comply with the regulations, the BNSF program must:

ï Provide for operational testing and inspection under the various operating

conditions on the railroad;

ï Describe each type of operational test and inspection adopted, including the

means and procedures used to carry it out;

ï State the purpose of each type of operational test and inspection;

ï State, according to operating divisions where applicable, the frequency with

which each type of operational test and inspection is conducted; and

ï Provide for a record-keeping system meeting the requirements of the

regulation.

32 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, D.C.:

NTSB, 2003).

33 This collision was not investigated by the Safety Board.

34 Typically referred to as ìefficiency tests.î
Factual Information 25 Railroad Accident Report

The BNSF provided the Safety Board with a copy of its program, entitled

Operations Testing Reference Guide.

35 At the time of the accident, the FRA had not taken

any exceptions to the program submitted by the BNSF. After the accident, the Consumer

Protection and Safety Division of the California Public Utilities Commission issued an

investigation report concerning the Placentia collision. One portion covered the

postaccident inspections performed by the commission and the FRA. Following is an

excerpt from that report:

Öaudit results indicated that BNSF managers were not conducting quality

operational efficiency tests.[36] As a result, [California Public Utilities

Commission] inspectors[37] filed 10 federal operating practice violations against

the BNSF as well as 85 Railroad Operating Rule (ROR) defects (CFR Part ß

217.9).

FRA representatives confirmed that these alleged violations were filed as five

separate cases. Two of the cases involve alleged falsification of efficiency tests. As of this

writing, one of the two cases has been dropped because of insufficient evidence, and the

second case is expected to be dropped or settled by the end of FY '04. The other three

cases, which did not involve allegations of falsification, were settled with the railroad at

the end of FY '03.

Postaccident ActionsñBNSF

After the Placentia accident, the BNSF revised its Operations Testing Reference

Guide, adding a specific test entitled ìBlock SignalñApproach Aspects.î The test involves

confirming that crews reduce train speed and handle trains appropriately when an

approach signal is encountered.

Also since the Placentia accident, the BNSF has developed a pilot program of

signal rules compliance testing that is conducted remotely from the dispatching center.

When remote testing is conducted, the dispatcher sets up a stop signal for a train. The train

crewís actions in response to the signal are captured by the locomotive event recorder.

Through the use of wayside radio communication links, this event recorder data can then

be downloaded remotely and evaluated for compliance by company officials. This system

allows crew compliance with approach and stop signal indications to be evaluated on an

almost real-time basis.

The pilot program also involves querying historical computerized dispatching

records to identify locations, such as CP Atwood, where trains have encountered stop

signals infrequently. Those locations can then be highlighted for testing, either through

local ìon-the-groundî testing operations or through remote testing from the dispatch

center.

35 Last update: April 8, 2002.

36 Efficiency tests involve setting up a scenario, such as a restrictive signal, and documenting the

operating crewís actions to verify that they comply with applicable rules.

37 The California Public Utilities Commission employs inspectors certified by the FRA to conduct

oversight as part of a State participation program.
Factual Information 26 Railroad Accident Report

Postaccident ActionsñMetrolink

Emergency Window Exterior Signage. After the on-scene investigation,

Metrolink installed exterior instructional signage at the intermediate-level emergency

windows on its delivery series 200 and 207 railcars. With this application, intermediatelevel exterior window removal signage is in place on the entire railcar fleet.

Emergency Window Grommet Design. Metrolink management informed Safety

Board investigators that they are currently testing an intermediate deck-level emergency

exit window grommet design that will allow the emergency exit/access windows to be

removed without having to break the window. This grommet design uses removable ìzipî

or ìfillerî strips on both the interior and exterior at the four intermediate deck-level

emergency windows. If the window grommet testing is successful, the new window

grommet type will be installed on the emergency access windows of the 200 and 207

delivery series railcars of the Metrolink fleet. This would result in all of the emergency

access windows in the Metrolink railcar fleet being removable from the railcar without the

need to break the window glazing.

Mass Casualty Training Drill Exercise Coincident to Accident

On the morning of the accident, the Brea Fire Department38 was hosting a

scheduled mass casualty training drill exercise39 to begin at 9:15 a.m. The Orange County

Fire Authority and local fire and police agencies were to participate as mutual aid in this

exercise, which was conducted in conjunction with the Orange County Hospital System

annual accreditation drill. The training drill was in the final stages of preparation at the

time of the accident and was to involve a request for 30 ambulances and almost 100

personal trauma transports (to 16 local hospitals). Upon learning of the actual train

collision, officials suspended the training drill and immediately directed the emergency

services resources to the Placentia accident. Local hospitals, as well as the local chapter of

the American Red Cross (the hospitals and the Red Cross were participating in the drill),

were also notified of the train collision and diverted their resources accordingly.

Regulatory Framework

Various aspects of BNSF and Metrolink operations fall under the regulatory

authority of the FRA as outlined in CFR 49 Parts 200-299. California Public Utilities

Commission personnel enforce FRA regulations in a State participation program outlined

under CFR 49 Part 212.

The FRA has contracted with the Volpe National Transportation Systems Center40

to perform research on passenger railcar crashworthiness. According to a Volpe Center

representative, the research includes field studies of actual collision damage, and a

contractor to the Volpe Center has gathered data on the Placentia accident. Also, the Volpe

38 Brea is a neighboring municipality to the northwest of Placentia.

39 The activity was organized by the Orange County Fire Operations Chiefs (a subgroup of the Orange

County Fire Chiefís Association).

40 The Volpe Center is a Federal fee-for-service organization within the Department of Transportation.
Factual Information 27 Railroad Accident Report

Center is currently performing finite element computer simulation modeling of carbody

structural deformation and of occupant kinematics (as occurred in the Placentia collision)

in order to identify an improved table design, possibly by incorporating exposed edge

cushioning and a provision for no detachment from the wall. Volpe Center staff also

anticipate conducting, in December 2003, a full-scale two-car passenger railcar crash test

using crash test dummies and seats with a table similar to those that were in place in the

Placentia accident.

BNSF Train Collision Avoidance System Testing

The BNSF is testing a global positioning system-based radio telemetry collision

avoidance system. The system, designated ETMS for ìelectronic train management

system,î involves a track system database, global positioning system units on

locomotives, and train-to-wayside communications. A locomotive cab display tells the

engineer the current authorized speed, the next signal aspect, upcoming speed restrictions,

the distance to the next signal, and other information related to safety of operations.

Allowable and actual speed are displayed; and as the train approaches a speed restriction,

restricting signal, or misaligned switch, allowable speed decreases along a safe braking

profile based on train tonnage and braking capability. The engineer must stay at or under

the allowable speed or a warning sounds, followed by an automatic brake application that

brings the train to a stop. Such stops are annunciated to the dispatcher as well.

A beta test of the system was successful, and the BNSF plans a pilot installation on

135 miles of track between Beardstown and Centralia, Illinois, in 2004. The location was

chosen because it offers a mix of operating conditions. About 50 locomotives will be

equipped with the system and will be kept captive between the two points.

If pilot tests are successful, some potential issues for future full implementation of

such a system include cost (the BNSF has more than 4,000 locomotives and 33,500 route

miles of track), mixing non-equipped foreign locomotives (Amtrak, Metrolink, etc.) on

BNSF track, and interoperability with other railroads that use other communications

technology. Testing of the BNSF system is partially funded by the FRAís Office of

Railroad Development.
28 Railroad Accident Report

Analysis

General

The accident occurred during daylight hours and in clear weather. Inspection

records and testing of the signal and train braking systems revealed no defects that would

explain the failure of the BNSF 5340 crew to slow their train and stop short of signal 4EA

at CP Atwood, which was displaying stop. Postaccident sight-distance tests revealed that

the approach signal in advance of signal 4EA was clearly visible from more than 3,000

feet away. Federally mandated drug and alcohol test results were negative for all

crewmembers involved in the accident.

The Safety Board considered whether the BNSF crewís performance was affected

by fatigue. The engineer told Safety Board investigators he felt ìpretty goodî when his

train departed Hobart Yard. Similarly, the conductor, who acknowledged that he felt tired

when he reported for duty, said that he was ìwide awakeî after taking a 1 1/2 hour nap

while waiting for clearance to depart Hobart Yard. During the early part of the accident

trip, the crewmembers were conversing, which would have contributed to their being alert

and awake. Data from locomotive event recorders also showed that as the train

approached the misidentified signal, the engineerís control inputs were appropriate and

timely. Finally, the accident occurred at 8:16 a.m., a time when the average person has

passed the period of circadian41 low and is typically experiencing a heightened level of

alertness.

The Safety Board therefore concludes that there was no evidence of fatigue

impairment or alcohol or drug use in this accident, and the following factors were neither

causal nor contributory to the accident: weather, signal visibility, and signal or train

braking system malfunction.

Accident Discussion

At the time of the accident, that portion of the BNSF signal system governing

eastbound trains, such as BNSF 5340, on track No. 2 approaching CP Atwood involved

three signals. All three signals were capable of displaying clear, approach, or stop, and the

signals changed automatically, depending on train traffic in the vicinity of the control

point.

41 Circadian rhythms describe the regular recurrence, in cycles of about 24 hours, of biological

processes or activities such as sensitivity to drugs and stimuli, hormone secretion, sleeping, and eating.

Performance degradation is most likely to occur during the natural circadian low points that occur for most

people between 2:00 a.m. and 6:00 a.m.
Analysis 29 Railroad Accident Report

At the time of the accident, the signal governing eastbound movement at

CP Atwood, signal 4EA at MP 40.71, was showing stop because of the presence of

Metrolink 809. Information developed from signal system data loggers and dispatch

center records during the investigation indicated that the signal in advance of signal 4EA,

the signal at MP 42.31, was displaying approach and that the next signal to the west of this

signal, at MP 44.03, was displaying clear. As BNSF 5340 proceeded toward CP Atwood,

the first signal it encountered was the clear signal at MP 44.03. This signal required no

special action on the part of the crew, and the train continued at track speed. The next

signal was the approach signal at MP 42.31. Encountering this signal, the crew of BNSF

5340 should have slowed their trainís speed to 30 mph or less and been prepared to stop at

the next signal.

But when train BNSF 5340 approached the approach signal at MP 42.31, the

crewmembers were engaged in a conversation, and the engineer said he was not watching

the signal. The conductor called the signal, incorrectly, as clear. Although the engineer

told BNSF investigators that he ìconfirmedî the conductorís call out of the signal as

ìclear,î he indicated to Safety Board investigators that he did not, as required by BNSF

operating rules, personally observe the signal and identify its aspect. He stated that when

he did look toward the signal, his train had already passed it. In this case, the engineer took

the word of the conductor that the signal was clear and continued to operate the train

accordingly. The Safety Board therefore concludes that the BNSF 5340 train crew were

insufficiently attentive to the operation of their train, with the result that they failed to see,

identify, and respond appropriately to the approach signal indication at MP 42.31. By the

time the engineer and conductor saw that the next signal, signal 4EA, was displaying stop

and the engineer placed the train brakes in emergency, the train was traveling too fast

(about 49 mph) to be brought to a stop before striking Metrolink 809. Ample distance

existed between the approach and stop signals to allow the train to slow sufficiently to

stop short of the stop signal and avoid the collision if the engineer had begun braking as

required. The Safety Board therefore concludes that had the BNSF 5340 crew operated

their train in accordance with the signal indications, the accident would not have occurred.

Crew Alertness to Signals

Inattention

The General Code of Operating Rules required both crewmembers to remain alert

for the signal, to call out the signal, and to continue observing the signal until the train

passed. Investigators found that the approach signal was visible from more than 3,000 feet

away, or for 48 seconds given the speed of BNSF 5340 at that time. As evidenced from

their statements to investigators, the BNSF 5340 crewmembers were focusing attention on

their conversation rather than on the signals governing the operation of their train.
Analysis 30 Railroad Accident Report

Signal Recording

Besides calling signals, one of the mechanisms the BNSF uses to encourage

heightened crew alertness to signal indications is the signal awareness form. BNSF

procedures require that conductors enter the time and train speed whenever a restrictive

(less-than-clear) signal is encountered. A clear signal requires only that a check mark be

made in a column on the form, and the procedures do not clearly specify that the entry

must be made at the time the clear signal is observed. The BNSF 5340 conductor told

Safety Board investigators that he routinely did not enter clear signals on the form when

he observed them. Rather, he would wait until he encountered a restrictive signal and

would then backfill the form in the clear column. This meant that the conductor did not

need to take any action other than calling out the signal when clear signals were

encountered.

For efficiency, trains are generally operated such that the majority of signals

encountered by an operating crew will be clear. Thus, conductors may inadvertently

become passive in their observance of signals. In that case, the additional effort required

by conductors to complete the signal awareness form when the signal displays either stop

or approach (that is, the additional requirement to record the speed and time the signal

was passed, as well as the aspect name) may prompt the crew to be more actively involved

in observing the signals.

In the view of the Safety Board, if conductors were also required to record speed

and time information for clear signals, they would, of necessity, take a more active role in

observing all signals. In this accident, for example, the BNSF 5340 conductor stated that

he made an effort to observe the misidentified approach signal only when the train was

close to the signal. That action was limited to making a single observation and calling out

ìclearî for the engineer to confirm. If the conductor had been required to complete the

signal awareness form for a clear signal in a similar manner to other signals, he may have

felt compelled to observe all signals earlier (even those expected to be clear) in order to

have more time to accurately observe and record the signal-related information. This

earlier observation of signals would also provide conductors with additional time to make

repeated signal observations if necessary. At the same time, the added requirement would

not in any way interfere with the conductorís other duties.

The Safety Board therefore concludes that had the BNSF 5340 conductor been

more actively involved by entering clear signals on his signal awareness form at the time

he observed them, his awareness of signal indications may have been increased, and he

may not have misidentified an approach signal as clear.

The BNSF conductorís practice of not entering clear signals on his signal

awareness form at the time he observed them was not specifically prohibited by BNSF

rules, as those rules required different actions for clear signals than for more restrictive

signals. The Safety Board therefore believes that the BNSF should revise its signal

awareness form procedure to require recording of time, speed, and aspect name for all

signals encountered at the time they are encountered.
Analysis 31 Railroad Accident Report

Enforcement of Operating Rules

FRA regulations in 49 CFR 217.9 specifically address a program of operational

tests, inspections, and record-keeping on railroads subject to FRA jurisdiction. Such rules

compliance programs typically include check rides, efficiency tests, and event recorder

reviews to confirm that engineers are following the rules.

After the accident, the BNSF revised its program, adding an approach signal test.

Additionally, the BNSF reviewed dispatching and testing records on its system to identify

locations, such as CP Atwood, where stopping trains was uncommon. Local railroad

officials are now advised of these locations, and additional testing is conducted. The

BNSF has also developed a remote testing program that allows stop signal testing to be

conducted from the dispatch center. This is particularly useful for remote field locations,

where access for testing by local railroad officials is difficult.

While rules compliance enforcement programs can be effective accident

prevention tools, such programs cannot be completely relied upon to eliminate humanerror accidents. This is one of the reasons that the Safety Board has long recommended the

installation of redundant systems to automatically take action and stop a train when a crew

does not comply with signal indications.

Survival Factors

Workstation Tables and Injuries

The workstation tables fitted to Metrolink bi-level railcars are rigid, unyielding

structures that are attached to the railcar sidewall, thus affording little impact energy

attenuation upon being struck by a train occupant. The initial collision speed was about 23

mph, and the distance the Metrolink train was shoved back was about 243 feet. There is

minimal crush attenuation provided to the cab car, and no crush attenuation provided to

the freight locomotive. The two individuals who sustained fatal injuries in this accident

were seated at a workstation table in the lead Metrolink bi-level railcar, facing the

direction of travel. The pathology reports of those two individuals indicated that both

received severe blunt impact trauma injuries to the chest and upper abdomen.

The deceleration forces of the accident would have been expected to thrust those

forward-facing persons seated at workstation tables directly toward the exposed edge of

the workstation table. The degree and types of injuries sustained by the forward-facing

railcar occupants seated at several of the workstation tables in this accident are consistent

with such a mechanism of injury. Therefore, the Safety Board concludes that the two fatal

injuries and many of the serious abdominal injuries to passengers throughout the

Metrolink train likely resulted from impact with the workstation table edges.

Similar workstation tables have been installed in the entire Bombardier bi-level

railcar fleet consisting of about 700 cars now in North American service. Bombardier did
Analysis 32 Railroad Accident Report

not conduct any biomechanical injury causation assessment in the design and installation

of these workstation tables. Further, there are no FRA standards that specifically address

provisions for workstation tables in passenger railcars.

The identification of crash injury causation hazards of workstation tables is

accomplished only through a detailed biomechanical assessment using finite element

simulation modeling or physical testing. The Volpe Center is currently performing finite

element computer simulation modeling of carbody structural deformation and of occupant

kinematics in order to identify an improved table design. The Safety Board has also been

informed that the Volpe Center, in conjunction with the FRA, plans to conduct a full-scale

two-car passenger railcar crash test in December 2003. The test will involve the use of

crash test dummies and seats with tables similar to those that were in place in the Placentia

accident. Data obtained from this test could form the basis for new standards or

regulations regarding workstation tables in passenger railcars.

Emergency Access to Car End Areas Through Designated Emergency 

Windows.

Exterior instructional signage for first responders was not present at the

intermediate-level deck emergency access windows in the Metrolink delivery series 200-

207 railcars. Impact forces in this accident resulted in blockage of the stairway and the end

bulkhead door of Metrolink cab car 634, essentially isolating passengers in one end of the

car. Fortunately, the passengers were not incapacitated, and they were able to remove

these emergency windows that, at the time of the accident, had instructional signage and

pull rings on the inside (but not on the outside) of the windows. Removal of the windows

from the outside would have been more difficult than from the inside. While wellequipped and trained emergency responders may be able to break or remove emergency

exit windows to gain access to incapacitated passengers inside, the first people on the

scene of railroad accidents are often nearby residents or passersby. Emergency access

instructions on all emergency windows could aid such ìgood Samaritansî in providing

assistance. The Safety Board concludes that the absence of exterior instructional signage

on emergency exit windows of the Metrolink cars could hinder emergency response in

future accidents, particularly in a scenario in which first responders might be untrained

and ill-equipped civilian ìgood Samaritans.î

FRA regulations do not specifically require exterior instructional signage for

emergency responders on exterior intermediate-level deck emergency windows.

Regulatory requirements for emergency window exits in passenger railcars are under

49 CFR 238.113, which states ìIf the passenger car has multiple levels, each main level

shall have a minimum of four emergency window exits, Ö.î Regulatory requirements

under 49 CFR 223.9(d)(1), and 49 CFR 223.9(d)(2), respectively, require that instructional

signage describing emergency removal procedures be provided at the emergency window

locations on both the inside and the outside of the railcar. Metrolink representatives told

investigators that the intermediate level of the railcars is not considered a ìmainî level;

hence, the exterior emergency windows at that level of the railcars were not required to

have instructional signage.
Analysis 33 Railroad Accident Report

Since the accident, Metrolink has taken steps to install such instructional signage

on this series of railcar (a later delivery series had such signage installed) and is testing an

emergency window design that will allow responders to remove intermediate-level

windows from the outside without breaking them.

The Safety Board is encouraged that Metrolink is taking prompt action to improve

emergency access to its railcars but is concerned that passengers and crew riding on other

railroads in the intermediate level of this type of railcar,42 may not be afforded the same

degree of emergency access protection that is afforded to persons riding in the main level

of that same railcar. The Safety Board therefore believes that the FRA should revise the

language of 49 CFR 238.113(a)(1) to reflect that appropriate exterior instructional signage

describing the emergency removal procedure be required at emergency windows on all

levels of a multiple-level passenger railcar.

Emergency Response

The initial notification to local emergency response resources occurred within 1

minute, and personnel were dispatched and en route almost immediately. Arrival of

responders on scene occurred within about 3 minutes of dispatch. A mass casualty

incident command system was established, and additional mutual aid resources were

diverted to the scene from a scheduled training drill as support. Records indicate that all

immediate transport priority injured persons were extricated, triaged, stabilized, and

transported from the scene within about 1 hour of the initial response. All remaining

injured were transported from the scene within about 2 hours. The Safety Board therefore

concludes that the emergency response to this incident was timely, effective, and

appropriate to the incident.

Positive Train Control

The Safety Board is concerned about the safety of railroad operations when

backup systems are not available to intervene if a train crew operates a train improperly or

fails to comply with wayside signals. Safety Board railroad accident investigations over

the past 30 years have shown conclusively that the most effective way to avoid train-totrain collisions is through the use of positive train control systems that will automatically

assume some control of a train when the train crew does not comply with the requirements

of a signal indication. In fact, positive train control has been on the Safety Boardís list of

ìMost Wantedî transportation safety improvements since the list was developed in 1990.43

42 Approximately 300 railcars.

43 The Safety Board developed the ìMost Wantedî list, drawn up from previously issued safety

recommendations, to bring special emphasis to the safety issues the Board deems most critical. The Most

Wanted list is reviewed, revised, and reissued as needed, or at least annually.
Analysis 34 Railroad Accident Report

Most recently, in its investigation of the previously referenced May 28, 2002,

collision of two BNSF freight trains near Clarendon, Texas, the Safety Board determined

that the accident would have been prevented if an operational positive train control system

had been in place on that section of track. Similarly, had such a system been in place and

operational on the territory where the Placentia accident occurred, it would have

intervened when the engineer failed to slow his train in response to the approach signal

and would have stopped the train short of the stop signal. The Safety Board concludes that

had a fully implemented positive train control system been in place on the BNSF San

Bernardino Subdivision at the time of the accident, the system would have intervened to

stop the freight train before it could enter the track area occupied by Metrolink 809, and

the collision would not have occurred.

Since 1969, the Safety Board has issued a number of safety recommendations

related to positive train control. The most recent safety recommendation was issued as a

result of the Safety Boardís investigation of a train collision involving three freight trains

in Bryan, Ohio.44 That recommendation, issued to the FRA, was as follows:

R-01-6

Facilitate actions necessary for 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.

In a response to the Safety Boardís request for an update on the status of this

recommendation, which is currently classified ìOpenñAcceptable Response,î the FRA

administrator, in a May 5, 2003, letter to the Safety Board, stated:

FRA is doing everything within its power to prepare the way for PTC [positive

train control] and encourage its rapid deployment. FRA shares the Boardís

disappointment that certain aspects of this work have not proceeded as rapidly as

projected. For instance, the Association of American Railroads has yet to provide

standards for interoperability of PTC systems. Nevertheless, we remain convinced

that the momentum achieved to date, together with the strong potential for PTC

technology to support other business needs, will result in the safety advances that

we both seek.

In the letter, the FRA stated that it was ìmoving forward across a broad front to

create the conditions under which [positive train control] systems can be more widely

deployed on the national rail system.î The FRA provided the following examples of its

support for the demonstration and deployment of candidate positive train control

technologies:

On the Northeast Corridor (NEC), FRA has issued an order requiring installation

44 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, D.C.: NTSB, 2001).
Analysis 35 Railroad Accident Report

and use of the Advanced Civil Speed Enforcement System (ACSES) where

Amtrak has sought to increase speeds in order to reduce trip times. ACSES,

working in concert with existing Automatic Train Control system[s], provides

PTC core functions. New Jersey Transit has responded by developing a similar,

interoperable system it is presently deploying. These new train control systems

are now in service and are being rolled out progressively to larger territories

within the NEC. Amtrakís ownership and dispatching role over much of the

corridor has made this process feasible.

On Amtrakís Michigan line, FRA has joined with Amtrak and the State of

Michigan to develop and install the Incremental Train Control System (ITCS),

which currently supports train speeds to 90 mph.

Working with the State of Illinois, the Union Pacific Railroad, Amtrak, and the

Association of American Railroads, FRA is a funding partner in the North

American Joint PTC program. FRAís Office of Safety is presently reviewing the

first of the final safety documents constituting the Product Safety Plan for this

systemin effect, making the first use of the proposed regulatory structure

described above even before a final rule is issued. This system is the most

technically ambitious of the PTC projects to date and will play a key role in

convincing a skeptical railroad industry that a central-office PTC architecture can

succeed by meeting the dual tests of safety and availability (reliability)Ö.

FRA is working with the CSX [Railroad], Burlington Northern Santa Fe Railway,

and the Alaska Railroad on additional ëoverlayí systems that show potential for

significant safety gains at reduced cost. According to the railroads, each intends to

pursue the possibility of broad application of the technology. FRAís role is to

provide needed regulatory relief, technical assistance, and encouragement, as well

as to raise appropriate safety issuesparticularly with respect to human factors.

FRA has also provided funding towards both the BNSF and the Alaska Railroad

projects.

While the Safety Board understands that positive train control development is

complex and expensive, the Board remains convinced that these systems provide the best

approach to reduce human-error collisions. While the Safety Board is aware of the BNSF

program to develop a train collision avoidance system, 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. Therefore, the Safety Board reiterates Safety

Recommendation R-01-6 to the FRA.

As noted in the FRA letter, one of the issues hindering development and

deployment of positive train control systems is the lack of standards for interoperability.

Such standards are necessary to ensure that the effectiveness of positive train control

systems is not compromised by the sharing of locomotive units that is common among

railroads. The Association of American Railroads is working with railroad industry

representatives to formulate the interoperability standards, but progress thus far has been

slow. The Safety Board is vitally interested in this issue and therefore believes that the

Association of American Railroads should report to the Safety Board the milestones and

activities needed for completion of the interoperability standards for positive train control

systems and its priorities for completion of this effort.
36 Railroad Accident Report

Conclusions

Findings

1. There was no evidence of fatigue impairment or alcohol or drug use in this accident,

and the following factors were neither causal nor contributory to the accident:

weather, signal visibility, and signal or train braking system malfunction.

2. The BNSF 5340 train crew were insufficiently attentive to the operation of their train,

with the result that they failed to see, identify, and respond appropriately to the

approach signal indication at MP 42.31.

3. Had the BNSF 5340 crew operated their train in accordance with the signal

indications, the accident would not have occurred.

4. Had a fully implemented positive train control system been in place on the Burlington

Northern Santa Feís San Bernardino Subdivision at the time of the accident, the

system would have intervened to stop the freight train before it could enter into the

track area occupied by Metrolink 809, and the collision would not have occurred.

5. Had the BNSF 5340 conductor been more actively involved by entering clear signals

on his signal awareness form at the time he observed them, his awareness of signal

indications may have been increased, and he may not have misidentified an approach

signal as clear.

6. The two fatal injuries and many of the serious abdominal injuries to passengers

throughout the Metrolink train likely resulted from impact with the workstation table

edges.

7. The absence of exterior instructional signage on emergency exit windows of the

Metrolink cars could hinder emergency response in future accidents, particularly in a

scenario in which first responders might be untrained and ill-equipped civilian ìgood

Samaritans.î

8. The emergency response to this incident was timely, effective, and appropriate to the

incident.
Conclusions 37 Railroad Accident Report

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the April 23, 2002, collision of a Burlington Northern Santa Fe freight train and a

Metrolink commuter train in Placentia, California, was the freight train crewís

inattentiveness to the signal system and their failure to observe, recognize, and act on the

approach signal at milepost 42.31. Contributing to the accident was the absence of a

positive train control system that would have automatically stopped the freight train short

of the stop signal and thus prevented the collision.
38 Railroad Accident Report

Recommendations

As a result of its investigation of the April 23, 2002, collision of a Burlington

Northern Santa Fe freight train and a Metrolink commuter train in Placentia, California,

the National Transportation Safety Board makes the following safety recommendations:

New Recommendations

To the Federal Railroad Administration:

Revise the language of 49 Code of Federal Regulations 238.113(a)(1) to

reflect that appropriate exterior instructional signage describing the

emergency removal procedure be required at emergency windows on all

levels of a multiple-level passenger railcar. (R-03-21)

To the Burlington Northern Santa Fe Railway Company:

Revise your signal awareness form procedure to require recording of time,

speed, and aspect name for all signals encountered at the time they are

encountered. (R-03-22)

To the Association of American Railroads:

Report to the National Transportation Safety Board the milestones and

activities needed for completion of the interoperability standards for

positive train control systems and your priorities for completion of this

effort. (R-03-23)

Recommendation Reiterated in This Report

The National Transportation Safety Board reiterates the following safety

recommendation to the Federal Railroad Administration:

R-01-6

Facilitate actions necessary for 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.
Recommendations 39 Railroad Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

Ellen G. Engleman Mark V. Rosenker

Chairman Vice Chairman

John J. Goglia

Member

Carol J. Carmody

Member

Richard F. Healing

Member

Adopted: October 7, 2003

41 Railroad Accident Report

Appendix A

Investigation

The National Transportation Safety Board was notified of the Placentia,

California, accident about 11:39 a.m., eastern standard time, on April 23, 2002, and

dispatched a major railroad accident investigation team to the accident scene.

Investigative groups examined the operation, track, signals, communications, mechanical,

survival factors, human performance, and event recorder aspects of the accident. ThenChairman Marion Blakey was on the scene during the on-site investigation.

Parties to the investigation were the Federal Railroad Administration, the

California Public Utilities Commission, Amtrak, Bombardier Transportation Company,

the Burlington Northern Santa Fe Railway, Metrolink, the Brotherhood of Locomotive

Engineers, the Brotherhood of Railroad Signalmen, the United Transportation Union,

Orange County Fire Authority, and the Placentia Police Department.

No public hearings or depositions were held in connection with this accident.