NTSB Press Release

National Transportation Safety Board
Office of Public Affairs

Train Collision in Oklahoma Caused by Vision Problems, Inattentiveness, and Lack of Positive Train Control

June 18

The National Transportation Safety Board today determined that the probable cause of a June 24, 2012 head-on collision of two Union Pacific Railroad freight trains was the eastbound train crew's failure to respond to wayside signals. Specifically, the NTSB cited the eastbound train 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.

As a result of the collision near Goodwell, Oklahoma, 3 locomotives and 24 cars of the eastbound train, and 2 locomotives and 8 cars of the westbound train, derailed. 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 resulitng derailment, several fuel tanks from the derailed locomotives were ruptured, releasing diesel fuel that ignited and burned. Damage was estimated at $14.8 million.

During the investigation, the NTSB learned that the engineer had a history of vision problems and, at the time of the crash, impaired visual acuity and defective color vision. Additionally, Union Pacific did not comply with internal company policy when it medically recertified the eastbound train engineer. The NTSB has recommended that the Federal Railroad Administration improve their medical certification procedures for employees in safety-sensitive positions.

"This engineer had a restricted driver's license due to his poor vision, yet, he had no similar restrictions on his ability to operate a mile long freight train," said Chairman Deborah A.P. Hersman. “This accident highlights a significant safety gap in the rail industry, which must be quickly remedied."

The event recorder data from the eastbound train showed throttle and brake activity as the crew passed two approach signals, without a reduction in speed as required. The eastbound train also passed a stop signal while travelling at 65 miles per hour. Neither the eastbound train's engineer nor conductor took action to slow or stop the train until seconds before the collision, when emergency braking was initiated.

"While the debate continues regarding delaying implementation of the provisions of the Rail Safety Improvement Act, today we deliberated on yet another PTC preventable accident," said Hersman. "As a result, we recommended that FRA provide more accountability and transparency about the progress towards PTC. The discussion should not be focused on when PTC won't be implemented, but when it WILL be implemented."

As a result of this investigation, the NTSB made recommendations to the Federal Railroad Administration, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, all Class I Railroads, Union Pacific and all railroads subject to the positive train control provision of the Rail Safety Improvement Act of 2008. To view the summary of this accident including findings, probable cause and recommendations, click on the following link: www.ntsb.gov/news/events/2013/goodwell_ok_board/Goodwell_Synopsis.pdf

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Terry Williams



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.