I want to thank my fellow Board members for their participation today. Let me
recognize the NTSB staff members who completed this accident investigation and
developed this report, in particular, the staff from the Office of Railroad,
Pipeline, and Hazardous Materials Investigations and from the Office of Research
and Engineering. Mike Flanigon, the Investigator-in-Charge, and his team did an
excellent job. I'd also like to acknowledge the work of retired investigator
Jeff Leaman, who was the initial Investigator-in-Charge for this
This thorough investigation and well-documented report highlight what we know
all too well: to err is human.
Too many accidents have demonstrated that after-arrival track authorities are
unsafe operating practices on non-signaled track. These track authorities are
flawed because they rely on flawless human performance. This is why we reiterate
â€“ again â€“ our recommendation that the Federal Railroad Administration
prohibit the use of after-arrival track warrants for train movements in
non-signaled territory not equipped with a positive train control system. And,
this is why we issued specific recommendations to the Class I freight railroads
to discontinue this practice.
Let me recognize one major Class I railroad, CSX, which discontinued its use
of after-arrival track authorities more than ten years ago.
In this investigation, we also saw two recurring issues that affect human
performance: fatigue and cell-phone distraction. We have repeatedly seen the
deadliness of fatigue and distraction in investigations across all modes of
transportation. Operating heavy machinery â€“ trains, planes, ships and more --
requires alertness and full attention. It also requires crew coordination and
Author Susan M. Dodd wrote that, "Luck is largely a matter of paying
attention." That may be true for luck, but we know that for safety there is so
much more than paying attention. Attention, vigilance, and discipline are key to
safe operations. As are practices â€“ practices that address recurring risks we
see on our railroads. It's time to prohibit after-arrival track warrants in
We stand adjourned.