Railroad Accident Report

Head-On Collision of Two Union Pacific Railroad Freight Trains

Near Goodwell, Oklahoma
June 24, 2012

NTSB Number: RAR-13-02
NTIS Number: PB2013-107679
Adopted: June 18, 2013
PDF

Executive Summary

On Sunday, June 24, 2012, at 10:02 a.m. central daylight time, eastbound Union Pacific Railroad (UP) freight train ZLAAH-22 and westbound UP freight train AAMMLX-22 collided head-on while operating on straight track on the UP Pratt subdivision near Goodwell, Oklahoma. Skies were clear, the temperature was 89°F, and visibility was 10 miles. The collision derailed 3 locomotives and 24 cars of the eastbound train and 2 locomotives and 8 cars of the westbound train. The engineer and the conductor of the eastbound train and the engineer of the westbound train were killed. The conductor of the westbound train jumped to safety. During the collision and derailment, several fuel tanks from the derailed locomotives ruptured, releasing diesel fuel that ignited and burned. Damage was estimated at $14.8 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the eastbound Union Pacific Railroad train crew’s lack of response to wayside signals because of the engineer’s inability to see and correctly interpret the signals; the conductor’s disengagement from his duties; and the lack of positive train control, which would have stopped the train and prevented the collision regardless of the crew’s inaction. Contributing to the accident was a medical examination process that failed to decertify the engineer before his deteriorating vision adversely affected his ability to operate a train safely.

 

Recommendations

New Recommendations

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

To the Federal Railroad Administration:

Determine what constitutes a valid, reliable, and comparable field test procedure for assessing the color discrimination capabilities of employees in safety-sensitive positions. (R-13-18)

When you have made the determination in Safety Recommendation R-13-18, require railroads to use a valid, reliable, and comparable field test procedure for assessing the color discrimination capabilities of employees in safety-sensitive positions. (R-13-19)

Require more frequent medical certification exams for employees in safety-sensitive positions who have chronic conditions with the potential to deteriorate sufficiently to impair safe job performance. (R-13-20)

Develop medical certification regulations for employees in safety-sensitive positions that include, at a minimum, (1) a complete medical history that includes specific screening for sleep disorders, a review of current medications, and a thorough physical examination; (2) standardization of testing protocols across the industry; and (3) centralized oversight of certification decisions for employees who fail initial testing; and consider requiring that medical examinations be performed by those with specific training and certification in evaluating medication use and health issues related to occupational safety on railroads. (R-13-21)

Require all information captured by any required recorder to also be recorded in another location remote from the lead locomotive(s) to minimize the likelihood of the information’s being unrecoverable as a result of an accident. (R-13-22)

Publish the positive train control implementation update reports submitted by all railroads subject to the positive train control provisions of the Rail Safety Improvement Act of 2008 and make the reports available on your website within 30 days of report receipt. (R-13-23)

To the Brotherhood of Locomotive Engineers and Trainmen:

Work with the Union Pacific Railroad and the United Transportation Union to develop and implement a nonpunitive peer audit program focused on rule compliance and operational safety for the Union Pacific Railroad. (R-13-24)

To the United Transportation Union:

Work with the Union Pacific Railroad and the Brotherhood of Locomotive Engineers and Trainmen to develop and implement a nonpunitive peer audit program focused on rule compliance and operational safety for the Union Pacific Railroad. (R-13-25)

To All Class I Railroads:

Install in all controlling locomotive cabs and cab car operating compartments crash- and fire-protected inward- and outward-facing audio and image recorders. The devices should have a minimum 12-hour continuous recording capability. (R-13-26)

To All Railroads Subject to the Positive Train Control Provisions of the Rail Safety Improvement Act of 2008:

Provide positive train control implementation update reports to the Federal Railroad Administration every 6 months until positive train control implementation is complete. The update reports should consist of two sections: components and training. The components section should include a description of the positive train control component to be implemented, the number of components, the number of components completed on the report date, the number of components that remain to be completed, the overall completion percentage, and the estimated completion date. Components are defined as locomotives, wayside units, switches, base station radios, wayside radios, locomotive radios, and any new and novel technologies that are part of a positive train control system. The training section should include the number of safety-related employees and equivalent railroad carrier contractors and subcontractors that need to be trained, by class and craft; minimum training standards for those employees and contractors, meaning the knowledge of and ability to comply with federal railroad safety laws and regulations and carrier rules and procedures to implement positive train control; the percentage of employees who have completed training; the percentage of employees who remain to be trained; and the estimated date that training will be completed. (R-13-27)

To Union Pacific Railroad:

Work with the Brotherhood of Locomotive Engineers and Trainmen and the United Transportation Union to develop and implement a nonpunitive peer audit program focused on rule compliance and operational safety. (R-13-28)

Develop and implement a plan to establish a safety management system, which incorporates crew resource management. (R-13-29)

Audit your medical records to ensure that all personnel in safety-sensitive positions have adequate documentation of appropriate medical testing. (R-13-30)

Replace your color vision field test with a test that has established and acceptable levels of validity, reliability, and comparability to ensure that certified employees in safety-sensitive positions have sufficient color discrimination to perform safely. (R-13-31)

Until you have implemented a validated, reliable, and comparable color vision field test, perform a safety analysis and undertake measures to manage the risk created by the use of an inadequate test. Such measures might include, but are not limited to, restricting crewmembers who have failed primary color vision testing to yard assignments or unsignaled territory. (R-13-32)

Once your replacement color vision field test is implemented, retest all certified Union Pacific Railroad employees in safety-sensitive positions who failed the primary color vision testing on their last medical certification exam using the new procedure. (R-13-33)

Previously Issued Recommendations Reiterated in this Report

As a result of this accident investigation, the National Transportation Safety Board reiterates the following previously issued safety recommendations:

To the Federal Railroad Administration:

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 classified “Open―Unacceptable Response”)

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 classified “Open―Unacceptable Response")

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 classified “Open―Unacceptable Response”)

To the Association of American Railroads:

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 Section 229.135, Appendix D, Table 2.

(R-12-24 classified “Open—Initial Response Received”)

Previously Issued Recommendations Reclassified in this Report

As a result of this accident investigation, the National Transportation Safety Board reclassifies from “Open—Acceptable Response” to “Closed―Unacceptable Action/Superseded,” by Safety Recommendation R-13-21, the following safety recommendations to the Federal Railroad Administration:

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 Title 49 Code of Federal Regulations 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)