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National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Accident No.: DCA-03-FR-003 

Location: Scottsbluff, Nebraska 

Date of Accident: February 13, 2003 

Time: 12:25 p.m. mountain standard time

1

Railroad: Burlington Northern Santa Fe Railway 

Fatalities: 1 

Injuries: 2 

Property Damage: $2.4 million 

Type of Accident: Collision 

Synopsis 

On February 13, 2003, about 12:25 p.m., an eastbound Burlington Northern Santa 

Fe Railway (BNSF) unit coal train collided with a BNSF yard train on the main track in 

Scottsbluff, Nebraska. The coal train consisted of 2 locomotives and 124 loaded cars; the 

yard train2 consisted of 1 locomotive and 16 freight cars. Both locomotives of the coal 

train and 28 cars of coal derailed; the locomotive and 3 cars of the yard train derailed. 

The crew of the coal train consisted of an engineer and a conductor. The engineer 

received minor injuries, and the conductor sustained fatal injuries. The crew of the yard 

train consisted of an engineer, a conductor, and a brakeman. The yard train engineer 

received minor injuries. 

The Accident 

The yard train crew went on duty at the Scottsbluff yard at 6:00 a.m. on 

February 13, 2003. After obtaining the information for their day’s switching assignments, 

the crewmembers held a job safety briefing and then boarded the locomotive. Initially, 

they switched cars within the Scottsbluff yard. Later in the morning, they obtained the 

proper authority from the BNSF dispatcher to occupy the main track and went via the 

main track to Mitchell, Nebraska, where they performed switching activities. After 

returning to Scottsbluff from Mitchell, they contacted the train dispatcher, reported their 

train clear of the main track, and resumed switching in the Scottsbluff yard. 

 1

 All times used in this brief are mountain standard time. 

2

 The yard train was a “road switcher,” which switched cars in the yard and traveled on the main track 

to service industries. The symbol for the yard train was R-PWR8941-13A. The symbol for the coal train 

was C-NRMCNMO-01A. 

NTSB/RAB-04/02 
About 12:25 p.m., the yard train crew was performing a switching maneuver that 

involved the brakeman’s positioning himself at various locations within the yard to 

couple the cars, the conductor lining the switches at the east end of the yard, and the 

engineer operating the locomotive. The conductor was in control of the movement and 

was relaying signals by radio. According to the General Code of Operating Rules

(GCOR), the person handling the switches must make sure that the switches are properly 

lined for the intended route. 

The conductor instructed the engineer to move the locomotive eastward. The 

planned movement was for the yard train to move eastward down the straight track, 

referred to as the “lead track,” which was parallel and adjacent to the main track. The 

conductor said that he planned to tell the engineer to stop once the rear car of the yard 

train had cleared the appropriate switch. He then planned, once the switches were lined 

for the appropriate track, to tell the engineer to shove the cars in the reverse direction 

back into another yard track. 

The locomotive of the yard train was “backing up” as it pulled the cars out of one 

yard track in order to switch them to another. As the locomotive backed eastward, the 

front of the locomotive, which had the cab windows affording the best visibility, was 

facing west. While moving eastward, the engineer in the locomotive had limited visibility 

due to the engine’s configuration.3

 The engineer was responsible for operating the train at 

a speed that would allow stopping within one-half the range of vision, short of an 

improperly lined switch or obstruction on the track. 

The engineer said that he could see the switch banners4

 but not the switch points.5

According to the engineer, the switch banners were “all green” as he proceeded eastward. 

He mistakenly thought that this indicated that the route was lined for a straight movement 

in the direction of the lead track. Although the display indicated that the yard switches 

were lined for movement down the lead track, the green switch banner on the inside 

switch indicated that this switch was lined for a diverging movement onto the main track. 

Had this switch been lined for movement on the lead track, as the engineer intended, its 

switch banner would have been yellow.6

 The inside switch was equipped with a lock that 

should have been used to lock the switch in a position lined for the lead track. After the 

collision, the switch was found unlocked, and the lock was found lying on the ground. 

The engineer said that the first indication he had that the yard train was diverging 

from his intended route was when he felt the lateral motion associated with a locomotive 

 3

 In railroad vernacular, this is known as having the “long hood forward.” 

4

 A switch banner, sometimes termed a switch indicator or switch target, is typically a reflectorized

metal flag-like device connected to the switch stand. It consists of one or two flags of different colors that

indicate the position of the switch to the crew of an approaching train. 

5

 A switch point is the end of a switch rail formed into a sharp point for diverting the wheels of rolling 

stock and equipment from one track to another. The entire switch rail is often called the switch point. 

6

 The yard train engineer had 23 years of railroad operating experience but was relatively unfamiliar 

with practices at the Scottsbluff yard. His understanding, based on experience at other locations, was that

“all green” aspects indicated the route was lined for a straight movement in the direction of the lead track. 

2

NTSB/RAB-04/02 
going through a crossover or turnout. Event recorder data indicated the locomotive was 

moving about 5 mph at the time. The engineer initiated an emergency brake application 

and unsuccessfully attempted to reverse direction. 

Meanwhile, a coal train was proceeding eastward on the BNSF main track 

through Scottsbluff at a recorded speed of 50 mph on a clear signal indication (green 

aspect, indicating that the train should proceed at normal speed). The coal train conductor 

and engineer noticed another train entering the main track ahead of them from an 

adjacent track. They shouted warnings to each other, and the coal train engineer 

immediately applied the train brakes. A wayside signal was visible to the coal train crew 

at that time, and the signal indication changed from clear to stop (due to the yard train’s 

locomotive fouling the main track circuit). The coal train engineer remained in the 

locomotive control compartment; the conductor jumped from the moving train. Moments 

later, a collision occurred while the coal train was moving about 43 mph. 

Nomenclature Consistency

The BNSF operating, signal, and engineering departments each used different 

terms to identify the system of track and switches through which the yard train 

locomotive had unintentionally passed. Each of the three BNSF departments fulfilled its 

maintenance, inspection, and operational duties in accordance with the requirements of 

its own terminology. Sometimes these requirements conflicted with those being used by 

the other departments. 

According to the BNSF operating department, the system was termed a 

“crossover.” At the time of the accident, the GCOR defined a crossover as “A section of 

track that connects two adjoining tracks.” The GCOR has rules that address proper 

crossover operation. According to BNSF requirements for main tracks, the inside switch 

of a crossover must be electronically connected to the main track signal system. The 

inside switch through which the yard train locomotive passed onto the main track was not 

electronically connected to the main track signal system. 

The BNSF signal department considered the track system a “turnout.” According 

to the signal department, the inside switch of a turnout is not required to be electronically 

connected to the main track signal system. 

The BNSF engineering department called the track system a “yard turnout.” 

Under BNSF procedures, the inside switch of a yard turnout would require a monthly 

inspection. The inside switch of a main track crossover would require a weekly 

inspection. 

Switch Banner Display

The switch banners at most BNSF locations display an aspect more restrictive 

than green when the switch is lined for movement onto the main track. However, the 

banner on the inside switch involved in this accident displayed a green aspect when the 

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NTSB/RAB-04/02 
switch was lined for movement from the yard onto the main track and a yellow aspect 

when the switch was lined for movement away from the main track. Train crews had 

raised the issue of the possibly misleading nature of this display to BNSF supervisors 

prior to the accident. Based on these concerns, BNSF had reviewed the switch banner 

display procedure at this location before the accident but had decided to keep the display 

as it was. This display arrangement had been in effect for at least 5 years on the 

Scottsbluff inside switch. 

Entering the Main Track 

Nothing prevented a yard train crew from inadvertently entering the main track 

from the Scottsbluff yard. The single switch displaying a green banner allowed access. At 

the time, there was no electronic interconnection or electric lock, there was no derail,7

and there was no outstanding operational requirement to stop nor was a stop indication 

displayed on the inside switch. As has been noted, this switch was not electrically 

connected to the main track signal system. 

Under these conditions, the crew of a main track train would have had no 

indication that the inside switch was lined in a position that would allow another train to 

diverge toward the main track. Because this switch was not connected to the signal 

system, the crew of a main track train would have had no warning that a conflicting 

movement was occurring until the main track was actually obstructed. 

Regulatory Requirements for Switches 

There are no Federal regulations providing specific requirements for switch 

banners. Regulations governing periodic switch inspection and electronic 

interconnections of the signal system are dependent on the definition of a particular 

switch and its function. 

Actions Taken Since the Accident 

The inside switch at the east end of the Scottsbluff yard was replaced following 

the accident. The switch banner for the new switch now displays a red aspect when the 

switch is lined for movement to the main track and has no display when the switch is 

lined for movement to the lead track. Additionally, the switch is now electronically 

connected to the main track signal system so that a red signal is displayed in both 

directions when the switch is lined for movement between the yard and the main track. 

BNSF officials conducted an audit of their entire system to identify other 

locations where track systems similar to the configuration at the Scottsbluff yard existed. 

BNSF subsequently identified 48 locations that had a similar switch at the inside of a 

 7

 A derail is a safety device attached to one side of a siding or storage track that will cause a car to be

derailed if it rolls free toward a main track. 

4

NTSB/RAB-04/02 
crossover. In all these locations, the switch banner display practice was the same as it had 

been at the Scottsbluff yard, and the inside switch was not electrically connected to the 

main track signal system. Since the review, the inside switch banners have been adjusted 

at all these locations, and all these switches have been connected to the signal system that 

governs the use of the main track. 

Since the accident, at a meeting of the GCOR Committee, BNSF proposed new 

language for defining a “crossover” such that the switches as well as the connecting track 

are included in the definition. The proposed language was adopted, and the GCOR 

definition of a crossover now reads: “A combination of two switches that connect two 

adjacent tracks.” BNSF has modified its Maintenance of Way rules to include the revised 

definition of a crossover. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of 

the February 13, 2003, collision between a Burlington Northern Santa Fe Railway coal 

train and yard train near the Scottsbluff, Nebraska, yard was the failure of the yard train’s 

conductor to properly line and lock the switches for the yard train’s intended route. 

Contributing to the cause of the accident was the lack of an electronic connection 

between the inner switch and main track signal system. 

Adopted: February 13, 2004 

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NTSB/RAB-04/02