Railroad Accident Report

Collision of Burlington Northern Santa Fe Freight Train With Metrolink Passenger Train

Placentia, California
April 23, 2002

NTSB Number: RAR-03-04
NTIS Number: PB2003-916304
Adopted: October 7, 2003
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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.

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 crew's 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:

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.

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.