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On December 7, 2003, about 12:12 a.m., central standard time, a UP switching foreman was struck and killed by two locomotives at the UP’s East Yard in San Antonio, Texas. The two locomotives were operated as a single unit under the foreman’s control. He was operating the locomotives from the ground using a remote control transmitter. He usually had a helper. However, the night the accident occurred, the helper position was not filled because of a crew dispatch problem, so the foreman worked alone. He was moving the locomotives from track 32 to train yard track 3, where he was assigned to switch 44 railroad cars. When the accident occurred, the locomotives were traveling about 11 mph and were moving back over the track they had just traversed rather than over the route leading to the destination (train yard track 3).
TO THE UNION PACIFIC RAILROAD: Issue written guidance that emphasizes the proper use of the equipment to employees who use power-assisted switch machines. Include any unique operating characteristics, such as auto-reverse, the potential undesired results of midcycle power interruption, and "lock-out" procedures, and require employees to demonstrate an understanding of the guidance.
Original recommendation transmittal letter:
Open - Acceptable Response
San Antonio, TX, United States
Railroad Switching Foreman Struck by Locomotives
Addressee(s) and Addressee Status:
Union Pacific (Open - Acceptable Response)
Safety Recommendation History
This letter concerns the 12 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the Union Pacific Railroad (UP) between 2006 and 2014. Enclosure 1 is a list of these recommendations; Enclosure 2 is a copy of the correspondence history regarding them. Based on information contained in your February 24, 2015, update, Safety Recommendations R 13 26 and R-14-56 were classified “Open—Acceptable Response,” on August 3, 2015. See Enclosures 3 and 4. We are concerned because we have not received updates regarding action either taken or planned to address the remaining 10 open recommendations for some time?in some cases, for nearly 5 years; for others, not at all. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we request an update as soon as possible regarding your plans or actions to address these 10 remaining recommendations.
The NTSB is satisfied that UP will continue to focus on (1) General Code of Operating Rules 8.19.1 "Radio Controlled Switches;" (2) biennial training and testing in Train, Engine and Yard, and Management Rules classes; (3) field training exercises, which will include discussion and demonstration of PAS operation; and (4) development of a handout addressing the unique characteristics of PAS operations for all employees who will encounter PAS in their daily work. Pending our receipt of the completed materials described above that highlight the distinct working behaviors of PAS, Safety Recommendation R-06-9 remains classified OPEN – ACCEPTABLE RESPONSE.
CC # 201000338: - From Roby B. Brown, General Manager of Safety: The UP will continue providing guidance to employees through the following: - Continued focus on Rule 8.19.1 Radio Controlled switch’s, with additional guidance. - Training and Testing in the T, E, and Y and Management Rules training classes that employees are required to attend every other year. - Training and Operational Testing Demonstration through the UP’s Field Training Exercises (FTX) which will include discussion and demonstration on the operation of the PAS for both yard and road. - Development of a Handout by the Signal Department and Operating Practices for all employees who will encounter PAS in their daily work. This handout will address the unique characteristics of the PAS and give them information in regards to their operations. - Once the handout is complete, a copy of the hand out, the rule change described earlier and a breakdown of the training and demonstration of the guidance will be forwarded to the Board for your review and the close out the Safety Recommendation.
The guidance that UP has given its employees regarding the use of PAS machines does not appear to adequately address the intent of this recommendation. The changes to the radio controlled switch operations are primarily intended for mainline operations, not yard operations. UP’s instruction that PAS will not operate if the “over switch” circuit at the PAS location is occupied is helpful; however, UP does not appear to have addressed the unique operating characteristics specified in the recommendation. These are some of the main points on which the NTSB believes employees should be instructed and tested. The general warning regarding a proper sequence and confirmation does not satisfy the intent of the recommendation. Therefore, we encourage UP to amend its instructions and test materials or to provide us additional information verifying that these points are included in its current guidance and testing. Pending our receipt of such instructions and test questions that highlight the distinct working behaviors of PAS, Safety Recommendation R-06-9 is classified OPEN – ACCEPTABLE RESPONSE.
Letter Mail Controlled 4/27/2010 10:53:00 AM MC# 2100153 - From Roby B. Brown, General Manager Safety: The Union Pacific Railroad has incorporated in the General Code of Operating Rules Rule 8.19.1 Radio Controlled Switches which addresses the issue raised in the safety board's recommendation. The demonstration by employees their understanding occurs in our Field Training Exercise Process. Rule 8.19.1 Radio Controlled Switches is copied below.
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