Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation R-06-010
Details
Synopsis: About 5:46 p.m., central daylight time, on May 19, 2004, two BNSF Railway Company (BNSF) freight trains collided head on near Gunter, Texas. The southbound train, BNSF 6789 South, was traveling about 37 mph, and the northbound train, BNSF 6351 North, was traveling about 40 mph when the collision occurred. The trains were being operated under track warrant control rules on non-signaled single track. The collision resulted in the derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel were released from the locomotives and resulted in a fire. The southbound train engineer was killed, and the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The crewmembers on the northbound train were transported to a local hospital, where they were admitted. Estimated property damages exceeded $2 million.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Prohibit the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Gunter, TX, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA04FR009
Accident Reports: Collision Between Two BNSF Railway Company Freight Trains
Report #: RAR-06-02
Accident Date: 5/19/2004
Issue Date: 6/29/2006
Date Closed: 9/23/2013
Addressee(s) and Addressee Status: FRA (Closed - Unacceptable Action)
Keyword(s): Positive Train Control,

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/23/2013
Response: We are disappointed that the FRA continues to believe that an overall prohibition on the use of after-arrival orders would present operational challenges in certain instances, as we believe that the use of such orders presents unacceptable and unnecessary safety risks. Although we are somewhat encouraged that the FRA shares our interest in improving railroad safety in non signaled territory, we remain convinced that the use of after-arrival track authorities in non signaled territory will continue to result in accidents. After arrival track authorities are very vulnerable to human error, such as the behavioral distractions that contributed to the crew’s disregard of the orders, the inadequate crew resource management, and the crew communication problems that occurred in the Gunter accident. Our recent investigation report on the Two Harbors, Minnesota, accident describes our concerns in detail. Despite our continued belief in the recommendation’s merit, given the FRA’s position, Safety Recommendation R-06-10 is classified CLOSED—UNACCEPTABLE ACTION.

From: FRA
To: NTSB
Date: 6/13/2013
Response: -From Joseph C. Szabo, Administrator: Thank you for your March 8, 2013, letter to the Federal Railroad Administration (FRA) concerning the National Transportation Safety Board (NTSB) Safety Recommendations R-13-05 through R-13-08, R-06-10, R-12-17, R-10-01, and R-10-02. These recommendations were issued (or, in the case of previously issued recommendations, reiterated) as a result ofthe report on the September 30,2010, accident, in which two Canadian National Railway (CN) freight trains collided near Two Harbors, Minnesota. The enclosure outlines FRA's response to each recommendation (except R-10-01 and R-1 0-02, which NTSB reclassified in its March 8, 2013, letter) and the safety systems and regulations in place to address them. Based upon the information provided below, FRA respectfully requests that NTSB classify Safety Recommendations R-13-05, R-13-06, and R-06-10 as "Closed-Reconsidered" and R-13-07 as "Closed-Acceptable Alternate Action." Additionally, FRA requests that NTSB classify Safety Recommendation R-13-08 as "OpenAcceptable Response" and R-12-17 remain "Open-Acceptable Response." We look forward to continuing to work with you to address these important rail safety matters. FRA believes that an overall prohibition on the use of after-arrival orders in all circumstances would present operational challenges in certain instances. In addition, several recent accidents involving the issuance of after-arrival orders also involved other factors, such as behavioral distractions that contributed to the crew's disregard of the orders, inadequate crew resource management, and crew communication problems. NTSB has noted these same issues as a result of investigating accidents involving after-arrival orders.

From: NTSB
To: FRA
Date: 3/8/2013
Response: From the report Collision of Two Canadian National Railway Freight Trains near Two Harbors, Minnesota, September 30, 2010, adopted Feb. 12, 2013, issued on March 8, 2013: Errors in communication, judgment, and action resulted in noncompliance with the after-arrival track authority procedures. The limits of human cognition and behavior provide a basis to expect continued errors with after-arrival track authorities unless additional safeguards are implemented. Successful execution of after-arrival track authorities depend on error-free human performance, which is unlikely without additional safeguards since fatigue, distraction, and competing tasks may interfere with the after-arrival track authority communication and execution process. The NTSB concludes that the use of the after-arrival track authorities in nonsignaled territory presents unacceptable and unnecessary safety risks to railroad operational safety, because the procedure is vulnerable to human error and lacks inherent safety redundancies ensuring consistent safe operation. The NTSB recognizes that a positive train control (PTC) system provides the most effective means to avoid train collisions. However, as the NTSB recognized in the investigation of the Gunter, Texas, collision: …even if PTC becomes more widely adopted, the current non-signaled areas of the U.S. railroad network will probably be among the last to be outfitted with PTC for the same reasons they remain non-signaled now?train volume and type of traffic. The NTSB is disappointed that the FRA has not implemented Safety Recommendation R-06-10. However, the NTSB is encouraged that CSX Transportation recognized the significant risk of after-arrival track authorities in nonsignaled territory and voluntarily discontinued their use. BNSF has also recognized the higher risk of after-arrival track authorities on nonsignaled track and has implemented policies that substantially limit their use in nonsignaled territory. The NTSB concludes that, in the absence of a PTC system, discontinuing the use of after-arrival track authorities in nonsignaled territory will mitigate future accidents involving authority overruns. Many miles of the US railroad network will not fall under FRA PTC mandates, and CN officials verified that PTC would not be installed in the Two Harbors accident area when PTC requirements take effect. Therefore, the NTSB reiterates Safety Recommendation R-06-10 to the FRA and encourages the FRA to take immediate and appropriate action. The NTSB also recommends that CN discontinue the use of after-arrival track authorities in nonsignaled territory not equipped with PTC.

From: NTSB
To: FRA
Date: 12/1/2011
Response: CC# 201100449 was closed administratively; no response was written or mailed.

From: FRA
To: NTSB
Date: 4/12/2011
Response: -From Ray LaHood, Secretary of the United States Department of Transportation: NTSB Classification and Actions Taken by FRA: Open – Unacceptable Response. FRA’s RSAC Operating Rules Working Group met with NTSB staff while studying after-arrival track warrants. FRA prepared a draft rule that would strictly limit use of after-arrival track warrants and discussed it extensively with the working group. Since the working group was not able to reach a resolution, FRA intends to proceed with an NPRM as soon as practicable, given the competing requirements of the RSIA. Nevertheless, FRA’s final rule on PTC provides that PTC systems will enforce contingencies in mandatory directives issued in non-signaled territory, eliminating the hazard in PTC territory. See 75 Fed. Reg. 2598, 2701. Actions Needed to Be Taken by FRA: Issue regulations.

From: NTSB
To: FRA
Date: 6/2/2010
Response: The NTSB notes that the FRA’s RSAC Operating Rules Working Group was unable to reach a resolution regarding the use of after-arrival track warrants for train movements in dark (non-signaled) territory. The FRA prepared a draft rule that would strictly limit the use of after-arrival track warrants, discussed it extensively with the working group, and intends to proceed with an NPRM as soon as practical, given the competing priorities of the RSIA. The NTSB is disappointed that the FRA has once again delayed the implementation of this recommendation. Pending our review of an NPRM that prohibits the use of after-arrival track warrants for train movements in dark territory without PTC, Safety Recommendation R-06-10 remains classified OPEN -- UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 9/2/2009
Response: Letter Mail Controlled 9/14/2009 10:35:09 AM MC# 2090581: - From Joseph C. Szabo, Administrator: The FRA's RSAC Operating Rules Working Group met with NTSB staff while studying after-arrival track warrants. FRA prepared a draft rule that would strictly limit use of after arrival track warrants and discussed it extensively with the Working Group. Since the Working Group was not able to reach a resolution, FRA intends to proceed with an NPRM as soon as practicable, given the competing requirements of the RSIA. The FRA respectfully requests that NTSB classify this Safety Recommendation as Open-Acceptable Response, until such time as FRA has published its NPRM.

From: NTSB
To: FRA
Date: 5/18/2007
Response: The Safety Board notes the Federal Railroad Administration’s (FRA’s) statement that the use of after-arrival orders merits further study and that the FRA will refer this recommendation to the Railroad Safety Advisory Committee’s (RSAC’s) Railroad Operating Rules Working Group in early 2007. The Board appreciates the FRA’s request for Board staff to participate in the discussion of this working group. Mr. Bob Chipkevich, Director, Office of Railroad, Pipeline, and Hazardous Materials Investigations, attends the RSAC meetings and will coordinate with you on Board participation in the working group. Although the Safety Board understands the benefits of the RSAC process, we are concerned that, in this particular case, it may result in undue delay. This is not a new issue; for more than a decade, the Board has investigated accidents involving the issuance of track warrants in non-signaled, or dark, territory and has issued recommendations calling for the elimination of after-arrival orders. In the report of the Gunter, Texas, accident, the Board concluded that had the FRA required railroads to permanently discontinue the use of after-arrival orders in dark territory, as the Board had called for in one of its previous recommendations (R-98-27), the Gunter accident would not have happened. In dark territory, there are no signals to warn trains as they approach each other, and the avoidance of collisions relies solely on dispatchers and train crews adhering to operating procedures. Because the Board believes that the FRA has delayed action too long on this issue, Safety Recommendation R-06-10 is classified OPEN -- UNACCEPTABLE RESPONSE. Given that some class 1 railroads continue to use after-arrival orders, the Board urges the FRA to act expeditiously on this issue.

From: FRA
To: NTSB
Date: 10/23/2006
Response: Letter Mail Controlled 10/23/2006 12:01:40 PM MC# 2060525: - From Joseph H. Boardman, Administrator:Thank you for your letter to the Federal Railroad Administration (FRA) concerning the issuance of Safety Recommendation R-06-10 by the National Transportation Safety Board (NTSB). This new recommendation arose from the NTSB’s investigation of the head-on collision of southbound BNSF Railway Company (BNSF) Train 6789 and northbound BNSF Train 6351 near Gunter, Texas, on May 19, 2004. The FRA has reviewed this recommendation and offers the following response. Safety Recommendation R-06-10: Prohibit the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. In 2002, the NTSB issued safety recommendation R-03-2: In territory not equipped with a positive train control system, restrict the issuance of track warrant authority that contains an after-arrival requirement to trains that have stopped at the location at which they will meet the opposing train. In FRA’s final written response to recommendation R-03-2, dated October 3, 2003, (copy enclosed), FRA summarized its views on the subject by stating that prohibiting after-arrival orders in non-signaled territory would reduce flexibility and hinder the efficient movement of trains. Furthermore, FRA stated it expects that railroad employees will adhere to all applicable operating rules. On August 6, 2004, NTSB classified Recommendation R-03-2 as Closed-Unacceptable Action. On June 29, 2006, NTSB issued safety recommendation R-06-10. FRA notes that this recommendation is a significant departure from R-03-2, in that NTSB is now proposing and absolute ban on the issuance of after-arrival orders. The following is the status of after-arrival orders (Box 7 on a track warrant) on the seven Class I railroads, in alphabetical order: BNSF has placed heavy restrictions on the issuance of after-arrival orders in non-signaled, Track Warrant Control (TWC) territory. A train to receive a Box 7 must first contact the other train(s) that will be listed in the Box 7 and ascertain their location. The train to receive the Box 7 must notify the train dispatcher that it is stopped at the meeting point. The train to receive the Box 7 must then visually identify the train(s) that will be met and establish positive radio contact with them as well. After notifying the train dispatcher that the train(s) to be listed in the Box 7 has/have been identified, the dispatcher may then issue the train a Box 7. Canadian National (U.S. operations) has no restrictions. Canadian Pacific (U.S. operations) has no restrictions. CSX does not issue after-arrival orders. Kansas City Southern requires the engineer to be present and alert the entire time a crewmember copies an after-arrival order and to conduct a job briefing with the dispatcher to confirm that the engineer has knowledge that the authority his train received contains an after-arrival order. Norfolk Southern has no restrictions. Union Pacific, in non-signaled, TWC territory, requires the train to be stopped at the point of restriction before it may copy an after-arrival order. The FRA agrees that use of after-arrival orders merits further study. FRA will refer this recommendation to the Railroad Operating Rules Working Group of the Railroad Safety Advisory Committee for discussion and careful consideration in early 2007. FRA would appreciate the participation of NTSB’s staff in this discussion. Based upon the results of that discussion. FRA will then determine what additional action to take. In light of these undertakings, FRA respectfully requests that Safety Recommendation R-06- 10 be classified in the status of Open-Acceptable Action.