Railroad Accident Report

Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train

Red Oak, Iowa
April 17, 2011

NTSB Number: RAR-12-02
NTIS Number: PB2012-916302
Adopted April 24, 2012
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Executive Summary

On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway coal train C-BTMCNM0-26, BNSF 9159 East, travelling about 23 mph, collided with the rear end of standing BNSF Railway maintenance-of-way equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost 448.3 on main track number two on the Creston Subdivision of the BNSF Railway Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.

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

As a result of this accident investigation, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, the Association of American Railroads, and the BNSF Railway. The National Transportation Safety Board also reiterates recommendations previously issued to the Federal Railroad Administration.

Recommendations

As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:

New Recommendations

To the Federal Railroad Administration:

Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders. (R-12-16)

Establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue. (R-12-17)

Conduct research on new and existing methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews. (R-12-18)

Require the implementation of methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews that are identified or developed in response to Safety Recommendation R-12-18. (R-12-19)

Require the use of positive train control technologies that will detect the rear of trains and prevent rear-end collisions. (R-12-20)

Revise Title 49 Code of Federal Regulations Part 229 to ensure the protection of the occupants of isolated locomotive operating cabs in the event of a collision. Make the revision applicable to all locomotives, including the existing fleet and those newly constructed, rebuilt, refurbished, and overhauled, unless the cab will never be occupied. (R-12-21)

Revise Title 49 Code of Federal Regulations Part 229 to require crashworthiness performance validation for all new locomotive designs under conditions expected in a collision. (R-12-22)

To the Association of American Railroads:

Revise Association of American Railroads Standard S-580 to provide protection for the occupants of isolated operating cabs in the event of a collision, and make the revision applicable to all locomotives, including those newly constructed, rebuilt, refurbished, and overhauled. (R-12-23)

Develop a standard that specifies the use of suitable crash-protected memory modules for all new and existing installations of onboard video and audio recorders. The memory modules should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations 229.135 Appendix D, Table 2. (R-12-24)

To the BNSF Railway:

Require all employees and managers who perform or supervise safety-critical tasks to complete fatigue training on an annual basis and document when they have received this training. (R-12-25)

Medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders. (R-12-26)

Previously Issued Recommendations

As a result of this accident investigation and four similar accidents, the National Transportation Safety Board issued the following safety recommendations on January 12, 2012:

To the Federal Railroad Administration:

Through appropriate and expeditious means, such as issuing and posting advisory bulletins on your website, advise all railroads of the occurrences of the following five recent rear-end collisions of freight trains in which crewmembers failed to operate their trains at the required restricted speed: (1) Red Oak, Iowa, on April 17, 2011, (2) Low Moor, Virginia, on May 21, 2011, (3) Mineral Springs, North Carolina, on May 24, 2011, (4) DeWitt, New York, on July 6, 2011, and (5) DeKalb, Indiana, on August 19, 2011. (R-11-6)

Through appropriate and expeditious means, inform your inspectors of the details of these accidents to ensure railroads' compliance with restricted speed requirements. (R-11-7)

To the American Short Line and Regional Railroad Association:

Through appropriate and expeditious means, such as issuing and posting advisory bulletins on your website, use the occurrences of five recent rear-end collisions of freight trains-(1) Red Oak, Iowa, on April 17, 2011, (2) Low Moor, Virginia, on May 21, 2011, (3) Mineral Springs, North Carolina, on May 24, 2011, (4) DeWitt, New York, on July 6, 2011, and (5) DeKalb, Indiana, on August 19, 2011-to urge your members to undertake a review of their operations to identify the potential for similar occurrences and to take appropriate mitigating actions. (R-11-8)

To the Association of American Railroads and the American Short Line and Regional Railroad Association

Examine the effectiveness of your member railroads' restricted speed and compliance programs. (R-11-9)

Previously Issued Recommendations Reclassified in this Report

To the Federal Railroad Administration:

Require railroads to ensure that the lead locomotives used to operate trains on tracks not equipped with a positive train control system are equipped with an alerter. (R-07-1)

Safety Recommendation R-07-01, previously classified "Open-Acceptable Action," is reclassified "Closed-Acceptable Action."

To All Class I Railroads:

Ensure that alerters are installed on all your lead locomotives used to operate trains on tracks not equipped with a positive train control system. (R-07-8)

Safety Recommendation R-07-8 issued to the Kansas City Southern Railway Company, previously classified "Open-Await Response," is reclassified "Closed-Acceptable Action."

To the Association of American Railroads:

Through appropriate and expeditious means, such as issuing and posting advisory bulletins on your website, use the occurrences of five recent rear-end collisions of freight trains-(1) Red Oak, Iowa, on April 17, 2011, (2) Low Moor, Virginia, on May 21, 2011, (3) Mineral Springs, North Carolina, on May 24, 2011, (4) DeWitt, New York, on July 6, 2011, and (5) DeKalb, Indiana, on August 19, 2011-to urge your members to undertake a review of their operations to identify the potential for similar occurrences and to take appropriate mitigating actions. (R-11-8)

Safety Recommendation R-11-8 issued to the Association of American Railroads is classified "Closed-Acceptable Action."

To the Brotherhood of Locomotive Engineers and Trainmen and the United Transportation Union:

Through appropriate and expeditious means, such as issuing and posting advisory bulletins on your website, use the occurrences of five recent rear-end collisions of freight trains-(1) Red Oak, Iowa, on April 17, 2011, (2) Low Moor, Virginia, on May 21, 2011, (3) Mineral Springs, North Carolina, on May 24, 2011, (4) DeWitt, New York, on July 6, 2011, and (5) DeKalb, Indiana, on August 19, 2011-to do the following:

Safety Recommendation R-11-10 is classified "Closed-Acceptable Action."

Recommendations Reiterated in this Report

To the Federal Railroad Administration:

Develop a standard medical examination form that includes questions regarding sleep problems and require that the form be used, pursuant to 49 CFR Part 240, to determine the medical fitness of locomotive engineers; the form should also be available for use to determine the medical fitness of other employees in safety-sensitive positions. (R-02-24)

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. (R-02-25)

Require that, when a railroad becomes aware that an employee in a safety-sensitive position has a potentially incapacitating or performance-impairing medical condition, the railroad prohibit that employee from performing any safety-sensitive duties until the railroad's designated physician determines that the employee can continue to work safely in a safety-sensitive position. (R-02-26)

Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. (R-10-1)

Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. (R-10-2)