Opening Statement by the Investigator-in-Charge
Good Morning Member Healing and members of the Board of Inquiry.
After notification of the accident, the Safety Board launched a team of investigators from Headquarters and our Los Angeles Field Office. Investigative groups were formed in Railroad Operations, Hazardous Materials, Survival Factors, Human Performance, Mechanical, Signals, Event Recorders and Track.
At onscene our organizational meeting, parties joining the investigation were the:
I will begin with the BNSF train first:
The crew consisted of an engineer and a conductor, both were employees of BNSF.
This crew reported for duty in San Antonio at 8:15 p.m., on June 27, after 10 hours and ½ hours off duty. They were transported by crew van to Hondo Texas, to operate an eastbound train into San Antonio --- a distance of 42 miles. Once they arrived in San Antonio, the crew was then transported by crew van to Seco, Texas, where they took control of the train in this accident, the eastbound MEAPTUL1-26D. Their movement to Macdona was uneventful.
At 5:01 a.m., the BNSF train's head-end started to enter the west end of Macdona siding track, moving at 27 mph in compliance with signal indications.
UP Train
The Union Pacific crew reported for duty at 2:45 a.m. at the UP's Kirby yard in San Antonio. The engineer had been duty 14 hours and 15 minutes. The conductor had been off duty nearly 26 hours. Once on duty, the crew was transported by a crew van to UP's East yard where they boarded the westbound MHOTU-23 --- destination Del Rio, Texas -- a distance of 154 miles. The train departed at 4:03 a.m.
Nearing Macdona --- At milepost 222 --, the train received an Advance Approach signal indication requiring the UP train to:
Event recorders from the UP train document the throttle being increased from 1 to 5 eventually increasing the train's speed to approximately 45 miles per hour.
One and ½ miles later at the next signal, at milepost 223.6, the UP train received an Approach Signal indication at the east end of Macdona.
The time was 5:01 a.m.
The approach signal indication required the UP train to:
Throttle setting remained at level 5, increasing the train's speed to 46 miles per hour, before the throttle was decreased level 4.
The trains were now approaching from opposite directions - the BNSF train was entering the siding preparing to stop at in the siding and UP train was on the main moving at approximately 45 miles per hour
At 5:02 a.m., the UP train began a series of three short unexplained intermittent whistles, shortly before the leading ends of the two trains passed. The BNSF crew stated that they dimmed their headlight as the westbound UP train approached, but the UP train's headlight remained on bright.
The train's lead locomotives passed, 2015 feet from the west end of the siding. The BNSF crew stated that they were unable see anyone in the UP locomotive but did take note that the UP train seemed to be going too fast.
Five seconds after the head-ends passed, the Union Pacific train's throttle was reduced from run 4 to 3, now moving at a speed of 45 miles per hour.
Twenty seven seconds later the UP train struck the 63rd car behind the locomotives of the advancing BNSF train as it was entered the siding track.
The UP locomotive event recorders do not show any braking or other reaction to either the stop signal or the BNSF train in its path. The Union Pacific train's throttle remained in notch at position 3 --- no braking attempt was recorded.
After the collision, the BNSF crew remained with their train summoning emergency responders.
The UP crew survived the collision, receiving relatively minor crash injuries. They exited their overturned lead locomotive as the escaping chlorine from the breached tank car was filling the derailment area with the poisonous chlorine gas.
They walked to the west along a road on the north side of the tracks. During the escape, the conductor was overcome by the gas -- unable to continue.
The engineer eventually retraced his route, walking to the east, until found by emergency responders.
Two local residents living in a house to the southwest of the tracks and the UP train conductor were fatally injured from exposure to the chlorine.
To date :
Our investigations of the signals, track and equipment have not identified any factual information to indicate a problem with these systems.
We have fully documented the hazardous materials incident and the docket will contains the release mechanisms and the emergency response activities by the end of this month.
Unfortunately, there is no positive train control or automatic train stop system installed on this line capable of enforcing signal indications. We intend to revisit the need for PTC in our final report.
In March of 2004, the Safety Board hosted a symposium on the status of PTC technology and gathered the latest information available. Please visit the Board's website for the results of the symposium.
This completes my statement.
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