NTSB/RAB-05/03 

 

E PLURIBUS UNUM

NATIONAL TRA SPORTATION

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Accident No.: DCA-04-MR-003 

Location: Kelso, Washington 

Date: November 15, 2003 

Time: 7:40 a.m. Pacific standard time1

Railroads: Burlington Northern Santa Fe Railway Company and 

Union Pacific Railroad 

Property Damage: $2.7 million 

Injuries: 2 

Fatalities: None 

Type of Accident: Side collision 

Synopsis 

About 7:40 a.m. on Saturday, November 15, 2003, Union Pacific Railroad (UP) 

northbound train UGLSE-14, consisting of 3 locomotives and 90 empty cars, struck 

southbound Burlington Northern Santa Fe Railway Company (BNSF) train UINBR001-14, 

consisting of 3 locomotives and 32 loaded cars. The BNSF train was struck about seven 

container platforms behind the locomotives, resulting in five derailed cars. The striking UP 

train had all 3 locomotives and 15 of its cars derail as a result of the collision. Both members 

of the UP crew were seriously injured. The two BNSF crewmembers did not sustain any 

injuries. The railroad in the area of the accident is owned by BNSF and is used jointly by 

BNSF and UP. The accident occurred at milepost (MP) 102.7 at the interlocking of Longview 

Junction South, near Kelso, Washington. About 2,800 gallons of fuel were released from the 

ruptured fuel tanks of the UP locomotives. A nearby train crew extinguished a minor fire. 

Weather conditions were overcast with light rain and a temperature of 44° Fahrenheit. 

Estimated damages were $2.7 million. 

The Accident 

This accident occurred on BNSFís Northwest Division, Seattle Subdivision, at MP 

102.7, Longview Junction South. The track is owned and operated by BNSF. 

The maximum timetable speed for trains operating in the vicinity of the accident was 

60 mph for freight trains and 79 mph for passenger trains. Train movements on the main 

tracks were governed by wayside signal indications as part of a centralized traffic control 

 1

 All times in this brief are Pacific standard time. 
 NTSB/RA 2 B-05/03 

system controlled by the BNSF train dispatcher located at the Network Operations Center in 

Fort Worth, Texas. 

The UP train and engine crewmembers involved in the accident boarded their train in 

Champ, Oregon, after having gone on duty at Albina yard in Portland, Oregon, at 1:00 a.m. on 

November 15, 2003. UP train UGLSE-14 departed Champ at 6:15 a.m. en route to Argo, 

Washington, a distance of 141 miles. BNSF train UINBR001-14 departed Interbay yard in 

Seattle, Washington, at 11:40 p.m. on November 14, 2003, en route to Roosevelt, 

Washington, a distance of approximately 181 miles. Before departure, both trains were given 

a Class I air brake test and predeparture equipment inspections. Both train crews were 

qualified on the territory and had the required time off duty as specified by the hours-ofservice regulations. Neither the BNSF nor the UP train crews had reported any operating 

difficulties or physical problems prior to the accident. At the time of the collision, the weather 

was cold with light rain. Visibility was clear. 

The UP train entered the BNSF territory at North Portland Junction in the Vancouver 

Terminal dispatching district and remained in that district until transferred to the Centralia 

South dispatcher. The Centralia South train dispatcher told investigators that he never had any 

radio conversation with the crew on UGLSE-14. He explained that the Vancouver dispatcher 

had issued the UP crew its trainís paperwork and operating authorities, and that he did not 

need to talk to the crew before the accident occurred. 

The northbound UP train passed the approach signal for the interlocking at Longview 

Junction South about 7:38 a.m., moving at 46 mph. The event recorder indicated that the train 

gained speed to 49 mph at the point of collision at Longview Junction South. The collision 

occurred as the BNSF train was proceeding through the crossover from the No. 1 main track 

to the No. 2 main track. After the accident, the event recorders on the BNSF locomotives 

confirmed that the train was moving about 31 mph as indicated by the crew. 

The BNSF engineer told investigators that after the head-end of his train had passed 

through the crossover, he noticed the opposing UP train was traveling fast on the No. 2 main 

track. Initially, he thought that the UP train was only lite power2

 or a short consist of 

locomotives with a few cars. When he saw it was a train, he told investigators that he knew 

that the UP train was going too fast to stop clear of the interlocking. The BNSF conductor told 

investigators that when the two trains were about to pass each other, he turned around and 

looked at the interlocking signal for the No. 2 main track behind him. He saw that the signal 

was displaying a stop indication and knew the UP train was not going to stop. The conductor 

stated that he did not detect motion in the cab of the opposing train. 

According to the UP engineer, he activated the emergency brake and applied the 

independent brake just prior to impact. The UP conductor stated that he did not remember 

seeing the signal at Longview Junction South, but remembers jumping to the floor of the 

locomotive just before impact. 

 2 Lite power is one or more locomotives without cars. 
 NTSB/RA 3 B-05/03 

During National Transportation Safety Board interviews, the UP engineer told 

investigators that he thought that the approach signal before Longview Junction South was 

displaying a clear3

 indication when he passed it, and he did not observe the stop signal at 

Longview Junction South when it was first visible because he was working with his radio. 

The second time the signal was visible, he did not observe the stop indication until he was 

passing the BNSF train just before impact. According to signal event recorder information, 

the signal at Longview Junction South displayed a stop aspect from 6:38 a.m. until the time of 

the collision, which occurred more than an hour later. The UP conductor did not remember 

seeing or calling the approach signal at MP 104.6 and did not see the stop signal at Longview 

Junction South. His signal log did not show an entry for the approach or the stop signals. The 

UP conductor told investigators that the BNSF train was moving northbound (it was actually 

southbound) and that he did not see a headlight on the BNSF train for that reason. He stated 

that he did not remember seeing the BNSF train until the collision occurred. 

The distance from the approach signal at MP 104.6 to the interlocking at Longview 

Junction South was 10,873 feet. An examination of the signal system began immediately after 

the accident. The signal case at Longview Junction South was locked when Safety Board 

investigators arrived, and there was no evidence of tampering with or vandalism to any of the 

signal equipment. A time stamp was verified and the data recorder log was downloaded. The 

signal system operated as designed during testing4 and inspection. 

Sight-distance tests indicated that the engineer on the UP train would have had a clear 

sight of the approach signal at MP 104.6 for 1,519 feet before the train reached the signal. The 

sight-distance tests also indicated that the UP engineer would have been able to view the stop 

signal at the Longview Junction South interlocking signal on two separate occasions. The 

engineer could have observed the stop signal from a distance of 2,618 feet and again from 

1,609 feet before reaching the stopping point. (See figure 1.) 

 3

 A clear indication is the most favorable signal that can be conveyed. A crew that receives a clear signal 

may proceed at track speed. 

4

 The following tests were performed: grounds check, insulation resistance, searchlight mechanisms, relays, 

indication locking, approach locking, bulb voltages, and visual inspection. No exceptions were taken to any of 

the test results or inspections. 
 NTSB/RA 4 B-05/03 

Figure 1. The signal at Longview Junction South facing north.

UP Train Crew Performance 

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

the territory. Weather conditions did not limit visibility. No impairing substances were found 

during the Federal Railroad Administration (FRA) postaccident toxicological tests, and 

examination of the signal system indicated that all signals were properly displayed. 

Event recorder data for the UP train indicate that there were no control inputs as the 

train traveled for about 2 1/2 minutes toward the impending collision. In the seconds before 

the collision, at a recorded speed of 49 mph, an emergency application of the brakes occurred. 
 NTSB/RA 5 B-05/03 

UP Crew Health 

Investigators examined medical records obtained from the UP engineerís personal 

physician. These records revealed that the engineer had been diagnosed as having moderate to 

severe obstructive sleep apnea 2 years before the accident.5 Records showed that the engineer 

had to be desensitized for a phobic reaction to the facemask used in conjunction with the 

continuous positive airway pressure (CPAP)6

 device prescribed as therapy for the disorder, 

and the device was never properly adjusted through titration to establish a therapeutic air 

pressure level. Furthermore, documentation provided showed that the prescribed CPAP 

treatment was not well tolerated and that there was no indication the device was providing 

adequate relief from the disorder. The UP engineer told investigators that he did not have the 

CPAP device with him for the layover on the day before the accident. 

If the engineerís sleep disorder was not effectively treated, he would have 

accumulated a long-term sleep debt resulting from deficient proportions of sleep staging and 

from poor sleep quality, both of which are consequences of this disorder. This sleep debt 

would be expected to result in a higher than normal tendency to fall asleep.7

The UP conductorís physician noted that the conductor had complained several times 

about fatigue and was having difficulty sleeping. He also described the conductor as 

significantly obese.8

Based on the train crewís actions, it is likely that neither employee was alert when 

passing the approach signal at MP 104.6 nor during the period when the stop signal at MP 

102.5 could have been observed in time to initiate control inputs that would have slowed the 

train before the collision. The crewmembersí failure to recognize the impending collision 

suggests that they were most likely asleep. 

 5

 The engineer also had a history of hypoglycemic (low blood sugar) episodes with one episode occurring as 

recently as 5 months before the accident. Although there was no evidence that he suffered an episode 

immediately before the collision, impairment from low blood sugar could include incapacitation caused by a loss 

of consciousness. 

6

 (a) J. Hausfeld, Donít Snore Anymore (New York: Three Rivers Press, 1999) 147ñ151. CPAP refers to a 

mechanical device used to force air into a patientís upper nasal passages to prevent the throat from collapsing 

and obstructing breath. The device consists of an adjustable pressure air pump, a hose, and a mask worn over the 

nose (or nasal plugs in the nose). The device supplies air under prescribed pressure, usually based on oxygen 

levels in the patientís blood during sleep. (b) R. Grunstein and C. Sullivan, ìContinuous Positive Airway 

Pressure for Sleep Breathing Disorders,î eds. M.H. Kryger and others, Principles and Practice of Sleep 

Medicine (Philadelphia, PA: W.B. Saunders Co., 2000) 894ñ912. See chapter for an elaboration on CPAP. 

7

 National Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts in the 

1990s to Address Operator Fatigue, Safety Report NTSB/SR-99/01 (Washington, DC: NTSB, 2001) 68ñ72. 

Sleep debt refers to sleep loss that accumulates when a person is deprived of all needed sleep time for recovery 

over an extended period of time. This type of sleep loss will significantly degrade performance, alertness, and 

mood. 

8

 Although there is no conclusive evidence that obesity by itself causes obstructive sleep apnea, the Safety 

Boardís medical officer continues to monitor the literature for the development of a screening tool for sleep 

disorders based on weight and height. Certain weight and height calculations provide a body mass index (BMI) 

that can distinguish between weight problem conditions (for example, a BMI greater than 29 typically refers to 

an obesity problem versus a severely overweight condition). There is evidence that higher BMIs are associated 

with sleep disorders and as a result may have potential along with other criteria for screening employees in 

safety-sensitive jobs for sleep disorder conditions. 
 NTSB/RA 6 B-05/03 

UP Crew Work and Rest Cycles 

The UP engineerís work records indicate that he had worked 6 days in the 14-day 

period preceding the accident trip. He worked on the day before the accident trip after 4 

consecutive days off. During those 4 days off, he slept nighttime hours. Prior to this break in 

service, his work schedule for the reviewed period included days, evenings, and one early 

morning start time. The trip to Portland the night before the accident required the UP engineer 

to work through the evening and change his sleep pattern from nighttime to daytime in 

preparation for the return trip to Seattle (the accident trip). This inversion of the sleep wake 

cycle degrades the quality of sleep, as well as desynchronizes the circadian system, causing 

sleepiness with severe effects on performance.9

 The UP engineerís work schedule requiring 

this inverted cycle likely contributed to an increased propensity for unintended sleep on the 

morning of the collision. 

In the 14 days before the accident, the UP conductor had worked 8 days. On 6 of those 

days, he worked consecutive trips starting in the morning. The last 2 days he worked before 

the accident trip, he reported for duty in the late afternoon and early evening. However, he did 

not work the day before the accident trip and slept nighttime hours on November 13 and 14, 

2003. The UP conductor told investigators that he was sleeping prior to receiving the call to 

report for duty at 1:00 a.m. on November 15, 2003. On the morning of the accident, he was 

working when his circadian system was accustomed to nighttime sleep. As a result, he may 

have been at increased risk for unintended sleep because of inverted work and off-duty times. 

Railroad Fatigue Management of Train Crews 

The Safety Board's investigators found important sleep health information for both 

train crewmembers that was documented by their personal physicians. These medical 

problems, if known to UP medical officials, should have led to a careful evaluation. Enough is 

known from sleep science about the risks of compromised rest from sleep disorders, circadian 

systems that are in continuous readjustment, and accumulated sleep debt from insufficient 

recovery sleep to predict risk for assigning any employees to schedules with inverted sleep 

and work times. 

Investigators reviewed UP records for the train crew and found no medical 

information pertaining to the engineerís sleep disorder. UP medical records were in 

compliance with FRA requirements for vision and hearing for the engineerís certification. His 

examination records showed notations for ìtraceî sugar in urine specimens collected in 1980, 

1984, and 1988, and ìborderline diabetesî in 1988. No references were found assuring the 

disease was controlled. Company records also showed that the conductor had high blood 

pressure controlled by medication and made reference to an obesity condition. There was no 

reference to his complaints of difficulty sleeping or fatigue. 

 9

 National Transportation Safety Board, Uncontrolled Collision With Terrain, American International 

Airways Flight 808 Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 

1993, Aircraft Accident Report NTSB/AAR-94/04 (Washington, DC: NTSB, 1994) 135ñ136. 
 NTSB/RA 7 B-05/03 

The Safety Board has previously addressed the issue of inadequate medical 

information available to a railroad. On November 15, 2001, two Canadian National Railroad 

trains collided near Clarkston, Michigan, killing two crewmembers and seriously injuring two 

others.10 The investigation determined that the engineer and conductor were incapacitated by 

fatigue, and both crewmembers were found to be suffering from obstructive sleep apnea. 

These findings prompted the Safety Board to recommend Federal requirements for reporting 

and evaluating potentially incapacitating or impairing medical conditions for train crews.11 

Use of an Alerter 

The lead locomotive involved in this accident, UP 6164, was not equipped with an 

alerter. UP reported there are 7,232 road locomotives in its fleet; 4,892 of those locomotives 

(67.6 percent) are equipped with an alerter. Additionally, UP representatives informed 

investigators that all new UP locomotives are purchased with an alerter. 

The lead BNSF locomotive on the train involved in this accident was equipped with an 

alerter. BNSF reported there are 5,500 road locomotives in its fleet; 4,925 of those 

locomotives (89.5 percent) are equipped with an alerter. 

Positive Train Control 

The Safety Board has long been a proponent of systems that prevent train collisions by 

automatically interceding in the operation of a train when the crew fails to control its train in 

response to signal indications. Had a positive train control system been in place in this area, 

such a system could have intervened to slow and stop the train before it passed the stop signal 

at Longview Junction South.12 Similar findings were reported by the Safety Board in a report 

that detailed the investigation of a head-on collision and derailment, which occurred on 

November 11, 1993, between BNSF and UP trains in the same Longview Junction South 

(Kelso) area and resulted in five fatalities.13 

 10 National Transportation Safety Board, Collision of Two Canadian National/Illinois Central Railway 

Trains Near Clarkston, Michigan, November 15, 2001, Railroad Accident Report NTSB/RAR-02/04 

(Washington, DC: NTSB, 2002). 

11 NTSB/RAR-02/04, 28. Safety Recommendation R-02-25 issued as a result of the Clarkston, Michigan, 

accident reads: Require that any medical condition that could incapacitate, or seriously impair the performance 

of, an employee in a safety-sensitive position be reported to the railroad in a timely manner. 

12 National Transportation Safety Board, Collision Involving Three Consolidated Rail Corporation Freight 

Trains Operating in Fog on a Double Main Track Near Bryan, Ohio, January 17, 1999, Railroad Accident 

Report NTSB/RAR-01/01 (Washington, DC: NTSB, 2001) 49. Safety Recommendation R-01-6 issued to the 

FRA reads: 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. 

13 National Transportation Safety Board, Head-on Collision and Derailment of Burlington Northern Freight 

Train with Union Pacific Freight Train, Kelso, Washington, November 11, 1993, Railroad Accident Report 

NTSB/RAR-94/02 (Washington, DC: NTSB, 1994). 
 NTSB/RA 8 B-05/03 

Probable Cause 

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

November 15, 2003, Union Pacific Railroad collision with a Burlington Northern Santa Fe 

Railway Company train near Kelso, Washington, was the Union Pacific Railroad 

crewmembersí neglect of the information conveyed by the wayside signal system because 

they were asleep. The engineerís and conductorís respective health conditions in combination 

with irregular work schedules contributed to the accident. The lack of a positive train control 

system was also a contributing factor. 

Adopted: June 6, 2005