National Transportation Safety Board
Office of Public Affairs
Washington, D.C. - The National Transportation Safety Board today determined that the probable cause of a fatal collision between two trains was the southbound train crew's failure to adhere to an after-arrival track warrant requiring them to stay in one location until the northbound train arrived. Contributing to the accident was BNSF Railway Company's use of after-arrival track warrant authority in non-signaled territory, and the Federal Railroad Administration's failure to prohibit the use of such authority. Also contributing to the accident was the train dispatcher's informal communications regarding planned train meeting locations.
"This accident could have been prevented if the proper procedures and protocol had been followed flawed as those procedures are," said NTSB Acting Chairman Mark Rosenker. "It is imperative that crewmembers abide by the rules and regulations that are in place."
On May 19, 2004, two BNSF Railway Company freight trains collided head on near Gunter, Texas. The southbound train (BNSF 6789), was traveling about 37 mph and the northbound train (BNSF 6351) was traveling about 40 mph when the collision occurred. The collision resulted in the derailment of 5 locomotives and 28 cars. The southbound train engineer was killed, and the southbound train conductor sustained serious injuries. The crewmembers on the northbound train also sustained injuries.
The investigation revealed that there was another northbound train (BNSF 2917) that originally had main track authority to the north siding switch at Dorchester. Northbound 2917 and southbound 6789 passed each other at Dorchester; the northbound train subsequently was authorized to continue north. Because southbound 6789 did not verbally confirm the train identification of northbound 2917 by radio, the crew most likely assumed that northbound 2917 was the single train that the dispatcher had told them they would meet at Dorchester. After the trains passed, southbound 6789 was issued the track warrant authorizing it to proceed south from Dorchester after the arrival of northbound 6351.
The investigators found that at the time of the collision, northbound 6351 was proceeding at the allowed track speed with valid authority to travel north on the main track from milepost 678 to the south siding at Dorchester. The southbound 6789 train crew was required to note on their track warrant form the engine number, the time, and the location when they met northbound 6351.
Consequently, the Safety Board concluded that the southbound 6789 train crewmembers' failure to verify the engine number listed on their track warrant against the engine number of the train in the siding, combined with the expectation that they would proceed south after meeting a single train at Dorchester, resulted in the southbound 6789 train crew likely assuming that they had met northbound 6351 at Dorchester. The Board also noted that had the southbound 6789 train crew complied with their track warrant, they would not have left Dorchester and the accident would not have occurred.
Non-signaled (dark) territory presents a unique problem for rail safety, the Board stated in the final report. In dark territory there are no signals to warn trains as they approach each other, and the avoidance of collisions relies solely on dispatchers and train crews adhering to operating procedures. Issuing after-arrival track warrants under these conditions only exacerbates an already potentially tenuous and contingent work situation.
Although the Safety Board has made recommendations in this area previously, the Federal Railroad Administration (FRA) has not taken the proactive steps to address this issue. Therefore the Board concluded that had the FRA required railroads to permanently discontinue the use of after-arrival orders in dark territory as advised by the Safety Board, this accident would not have happened.
The Board also found that had the dispatcher consistently referred to all of the trains by their engine numbers- the identification mechanism required in mandatory directives- it would have reinforced the need to verify engine number when the trains met.
As a result of the accident investigation, the National Transportation Safety Board issued the following recommendations:
To the Federal Railroad Administration:
-- Prohibit the use of after-arrival track warrants for train movements in dark (non- signaled) territory not equipped with a positive train control system.
To the BNSF Railway Company:
-- Use the Gunter collision as a case study in train crew and dispatcher training and retaining to illustrate how informal communications can lead to misunderstandings and errors.
-- Discontinue the use of after-arrival track warrants for train movements in dark (non- signaled) territory not equipped with a positive train control system.
To the American Association of Railroads and the American Short Line and Regional Railroad Association:
-- Encourage your members to discontinue the use of after-arrival track warrants in dark (non-signaled) territory not equipped with a positive train control system.
NTSB Media Contact:
The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.