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Safety Recommendation Details

Safety Recommendation R-03-022
Details
Synopsis: On Tuesday, April 23, 2002, about 8:10 a.m. Pacific daylight time, eastbound BNSF freight train PLACCLO3-22 collided head on with standing westbound Southern California Regional Rail Authority (Metrolink) passenger train 809 on the No. 2 track at Control Point (CP) Atwood in Placentia, California. Emergency response agencies reported that 162 persons were transported to local hospitals. There were two fatalities. Damage was estimated at $4.6 million.
Recommendation: TO THE BURLINGTON NORTHERN AND SANTA FE RAILWAY: Revise your signal awareness form procedure to require recording of time, speed, and aspect name for all signals encountered at the time they are encountered.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: Placentia, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA02MR004
Accident Reports: Collision of Burlington Northern Santa Fe Freight Train With Metrolink Passenger Train
Report #: RAR-03-04
Accident Date: 4/23/2002
Issue Date: 11/6/2003
Date Closed: 5/23/2013
Addressee(s) and Addressee Status: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 5/23/2013
Response: The NTSB is pleased that the BNSF now requires crews to record the time, speed, and signal aspect of all signals, other than Clear signals, at the time they are encountered, and that crewmembers must communicate clearly to each other the name of all signals affecting their train movement as soon as signals become visible or audible, including Clear signals. These actions constitute an acceptable alternative to revising the form procedure, as they promote good communication and awareness of signals as they are encountered. Consequently, Safety Recommendation R-03-22 is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 1/31/2013
Response: -From Mark A. Schulze, Vice President, Safety, Training, and Operations Support: With regard to the NTSB's recommendation addressing signal awareness form procedures in R-03-22, Signal Awareness and Switch Position Forms are a component of safe train operations and have been utilized at BNSF both before and since the publication of the recommendation. The Signal Awareness Form contains a requirement that crews record the name or aspect of all signals, and also to record the train's speed and time the train passes a signal for all signals other than Clear. BNSF also has subdivision specific Signal Awareness Forms which require crews to document when the train passes wayside defect detectors and track flags, if such flags are used in conjunction with speed restrictions. BNSF operating rules also require train crew members to communicate signal information to each other while in the controlling compartment of a locomotive to promote good communication and awareness of signals as they are encountered. The crew is therefore jointly accountable for controlling the train movement to maintain compliance with signal requirements. After careful review of the Board's recommendation in this area, BNSF continues to recognize that logging train speed and time may be a useful tool to promote employee engagement when a crew is operating in conditions that vary from maximum authorized speed, such as on restrictive signals and at reduced train speed. However, BNSF believes that logging such information when a crew is operating at maximum authorized speed, through a clear signal that does not alter a train crew's operating directives, would not enhance safe train operations. BNSF therefore respectfully requests that the Board close this recommendation as "Closed: Acceptable Action."

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 12/18/2012
Response: This recommendation is now more than 9 years old. The NTSB has received no update regarding progress to address this recommendation since BNSF’s June 30, 2006, e-mail. Accordingly, this recommendation is classified OPEN—UNACCEPTABLE RESPONSE, because of the lack of action to address the recommendation in a timely manner. We urge you to provide an update concerning any actions you have taken to address Safety Recommendation R-03-22. A copy of the letter in which we issued the recommendation is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2003/R_03_22.pdf. The full report of the Placentia, California, accident investigation (Report Number NTSB/RAR-03/04) is available on our website at http://www.ntsb.gov/doclib/reports/2003/RAR0304.pdf.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 6/30/2006
Response: Thank you for meeting with me last week on this issue. We had an internal meeting this morning to discuss next steps. We have asked our Manager, Human Factors to begin a literature search to see if we can determine the impact of routine tasks, such as the signal awareness from, on alertness. More specifically is there a point where engagement in the primary task actually begins to decrease rather than increase. We should be able to review the literature, prepare a response, and discuss it with you by late July or early August. I will keep you updated on our progress. If you have any questions please contact me.