June 22, 1997
NTSB Number: RAR-98-02
NTIS Number: PB98-916302
Adopted May 19, 1998
At 10:52 p.m. on June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided head-on in Devine, Texas. The trains were operating on a single main track with passing sidings in dark (nonsignalized) territory in which train movement was governed by conditional track warrant control authority through a dispatcher. The conductor from 5981 North, the engineer from 9186 South, and two unidentified individuals who may have been riding on 5981 North were killed in the derailment and subsequent fire. The engineer from 5981 North received minor injuries, and the conductor from 9186 South was seriously burned. Estimated damages exceeded $6 million.
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the third shift dispatcher to communicate the correct track warrant information to the train crew and to verify the accuracy of the read-back information because the UP management had not established and implemented workload policies and operational procedures to ensure a safe dispatching system and the Federal Railroad Administration (FRA) had failed to provide standards and oversight in all aspects of train dispatching operations. Contributing to the accident was the lack of an installed positive train separation control system that would have prevented the trains from colliding by automatically intervening in their operation because of inappropriate actions being taken.
The major safety issues discussed in this report are the train dispatcher's performance and workload, the adequacy of the UP management oversight of the dispatcher apprentice program and dispatching operations, the sufficiency of the FRA oversight of dispatching operations, the effectiveness of conditional track warrant control authority, the adequacy of disaster preparedness, the crashworthiness of locomotives and event recorders, and the merits of positive train separation control systems.
As a result of its investigation, the Safety Board makes recommendations to the UP, the FRA, and the Texas Railroad Commission. In addition, the Safety Board reiterates a safety recommendation to the FRA.
As a result of its investigation, the National Transportation Safety Board makes the following recommendations:
To the Union Pacific Railroad:
Evaluate your dispatcher training program and make necessary revisions to place greater emphasis on all safety critical activities including procedures used to issue and confirm track warrants. (R-98-18)
Conduct an audit of your train dispatching operations to identify specific factors that can lead to dispatching errors and include in the audit an assessment of dispatching errors that occur during or shortly after shift changes or because of improper radio procedures. (R-98-19)
Conduct an audit of your train dispatchers' activities to evaluate the current workload and make necessary changes to dispatcher operations to distribute workload based on the individual dispatcher's qualifications, ability, and experience. (R-98-20)
Examine the circumstances in which your policy to require a minimum 5 years of experience to qualify as an OJT dispatcher trainer was not followed and take action to ensure that your qualification policies are followed. (R-98-21)
Develop and implement a comprehensive program to select and train experienced dispatchers to serve as dispatcher trainers. (R-98-22)
Evaluate and determine the technical expertise required of corridor managers and make the necessary changes to ensure that corridor managers are qualified to provide proper dispatching assistance to the train dispatchers. (R-98-23)
Identify all distractions, evaluate their effects on dispatchers, and take action to establish a working environment conducive to safe dispatching operations. (R-98-24)
Discontinue permanently the use of after-arrival orders in dark (nonsignalized) territory. (R-98-25)
To the Federal Railroad Administration:
Revise 49 Code of Federal Regulations 220 to address track warrants and other current railroad operating practices. (R-98-26)
Require railroads to discontinue permanently the use of after-arrival orders in dark (nonsignalized) territory. (R-98-27)
Develop and establish dispatcher selection and training standards, dispatcher trainer standards, and workload limits for dispatchers by January 1, 2000. (R-98-28)
Evaluate your surveillance and enforcement activities at dispatching centers and take appropriate corrective actions to ensure that Federal oversight is adequate and effective. (R-98-29)
Working with the railroad industry, develop and implement event recorder crashworthiness standards for all new or rebuilt locomotives by January 1, 2000. (R-98-30)
To the Texas Railroad Commission:
Develop a system that would make fire suppression foam equipment readily available to emergency management agencies and local rural fire departments for the fighting of hazardous materials fires. (R-98-31)
To the Federal Railroad Administration:
Promulgate Federal standards to require the installation and operation of a train control system on main line tracks that will provide for positive separation of all trains. (R-87-16)