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Safety Recommendation Details

Safety Recommendation R-06-012
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 BURLINGTON NORTHERN SANTA FE RAILWAY COMPANY: Discontinue 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 - Acceptable 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: 1/8/2016
Addressee(s) and Addressee Status: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Closed - Acceptable Action)
Keyword(s): Positive Train Control,

Safety Recommendation History
From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 1/8/2016
Response: We classified Safety Recommendation R-06-12 “Closed—Unacceptable Action” on May 23, 2013. We are pleased that you have discontinued the use of after-arrival authorities in non signaled territory as of October 14, 2015. Accordingly, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 10/14/2015
Response: -From Douglas B. Jones, AVP Safety and Tech Training, BNSF Railway: I write in response to the National Transportation Safety Board (NTSB) concerning Safety Recommendation R-06-12 issued in July of 2006. NTSB recommended BNSF: "Discontinue use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with positive train control systems." Since NTSB issued this recommendation in 2006, BNSF has continued to work on limiting the use of after-arrivals track warrants in non-signaled territories and establish protocols to ensure the safety of the operation when such warrants were used. Across the last 9 years, BNSF continued to provide updates to NTSB on its progress in this regard. Subsequent to our latest communication, in early 2013, BNSF continued to identify processes to limit the use of after arrival authorities. BNSF provides this update to NTSB to advise that this month BNSF has discontinued the use of after-arrival authorities in nonsignalized territory. Given this update, BNSF requests that NTSB update its records and close Recommendation R-06-12 as "Closed: Acceptable Action."

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 5/23/2013
Response: The NTSB is somewhat encouraged that the BNSF has restricted and limited the use of after arrival track warrants in non-signaled tracks. However, as the NTSB stated following its recent investigation of a Collision of Two Canadian National Railway Freight Trains near Two Harbors, Minnesota , we remain convinced that the use of after-arrival track authorities in nonsignaled territory is a flawed process with inherent risks that will inevitably result in future accidents. Becauuse the BNSF does not intend to take the recommended action, Safety Recommendation R-06-12 is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
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. As a result of the Gunter, Texas, accident, the NTSB made the following safety recommendation to BNSF Railroad: Discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-12) BNSF responded that the railroad had implemented procedures to significantly reduce the number of after-arrival track authorities used in nonsignaled territory and implemented additional procedural safeguards. NTSB classified safety recommendation R-06-12 “Open?Unacceptable Response” on September 7, 2007. NTSB appreciates that BNSF has recognized the risks of using after-arrival track authorities in nonsignaled territory and has taken steps to reduce the frequency of their use on BNSF, as well as clarified and tightened communication protocols. However, NTSB remains convinced that the use of after-arrival track authorities in nonsignaled territory is a flawed process with inherent risks that will inevitably result in future accidents. Therefore, NTSB reiterates safety recommendation R-06-12 to BNSF.

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: BNSF has given careful consideration to the Board's recommendation to discontinue the use of after arrival track warrants in non-signaled territory, and while we continue to believe they play an important role in safe and efficient train operations, we have enacted new tighter controls to protect and limit their use across our system. Since the correspondence of December 2006, BNSF has exchanged communications with NTSB staff members concerning its ongoing efforts to reduce the use of after arrival track warrants in non-signaled territory. Attached is the latest communication from February 2012 which summarizes BNSF's position. Subsequent to that communication, BNSF has established the following relevant dispatching control. The added rule text is as follows: Non-Signaled Territory Movements Against the Current of Traffic It is intended to limit the use of after arrival authorities for trains on territory where a signal system is not in place. Only issue after arrivals: • To accommodate public road crossings from being blocked for an extended period of time for train meets . • To accomplish train meets anticipated to occur during dispatcher shift transfer. Consistent with previous communications, BNSF has enacted tight controls to protect and limit the use of after-arrival track warrants. Controls were established to ensure train/train communication and train/dispatcher communication regarding train positions prior to the issuance of track warrants. After the receipt of a track warrant, additional train/train communications and documentation requirements must be completed before a train crew acts on the warrant's authority and the train departs the meeting point. In addition to the new dispatching control Rule text provided above, BNSF's Rule text further detailing the procedure for use of after-arrival track warrants is as follows: When track warrant requires "After Arrival" of another train, the limits must not be occupied until the train to be met has been identified by engine number and the rear end marker has passed the meeting point. In non-signaled territory, a train may only be granted "After Arrival" track warrants, after the following requirements have been completed: 1. Dispatcher advises the train that will receive the "After Arrival" track warrant of the identification of train(s) that will be met (by initials and engine number). 2. If a controlled signal does not govern movement at the meeting point, the train that will receive the "After Arrival" track warrant must establish the location of the train(s) that will be met (by initials and engine number), advising the dispatcher that direct communication has been made and the location of the train(s) contacted. 3. If a controlled signal does not govern movement at the meeting point, the train to receive the "After Arrival" track warrant has stopped at the meeting point and has notified the dispatcher that they are stopped. (Note: A train stopped short of the meeting point for topographical reasons, i.e., road crossings, grade considerations, etc., may be considered as stopped at the meeting point for application of this process.) In non-signaled territory after the meet has occurred, the train with the "After Arrival" must establish positive radio contact with the train listed in the "After Arrival" to confirm the identity of the passing train. If radio communication cannot be established, the train dispatcher must be contacted to provide the required confirmation. The train identification, time passed, location passed, or current time and location must be written on the track warrant form by both the conductor and engineer of the train being so restricted. Radio Announcement Approaching Siding/Junctions: In non-signaled TWC territory, when a train is approximately 2 miles in advance of a siding or junction, a crew member must transmit the following by radio: "Train identification (initials, engine number and direction) is approaching (location name) at (speed) MPH." Based on the tight controls BNSF has in place and the overall reduction in the use of after arrival track warrants since 2006, BNSF respectfully requests that the NTSB close Recommendation R-06-12 as "Closed: Acceptable Alternate 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 6 years old, and the NTSB has received no update regarding progress to address this recommendation since December 19, 2006. Pending our receipt of such an update, the recommendation remains classified OPEN--UNACCEPTABLE RESPONSE. 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/2006/R06_11_12.pdf. The full report of the Gunter, Texas, accident investigation (Report Number NTSB/RAR-06/02) is available on our website at http://www.ntsb.gov/doclib/reports/2006/RAR0602.pdf.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 9/4/2007
Response: The Safety Board notes that the BNSF has not discontinued the use of after-arrival track warrants as recommended but has implemented what BNSF believes to be alternatives to satisfy the objective of the recommendation. Specifically, the BNSF issues after-arrival orders in advance of locations where trains meet and pass for operational purposes, to allow train dispatchers to plan work during peak demands and around shift transfers. The Safety Board also notes that the BNSF has added steps to its process, which BNSF believes will improve safety for its employees and the public. In non-signaled territory, a train may only be granted an after-arrival track warrant after these requirements are met: (1) the train dispatcher notifies the train crew of an impending after-arrival authority and of the address of the train the crew will be meeting; (2) the restricted train notifies the opposing train of its location; (3) the restricted train reports to the dispatcher that it has completed steps (1) and (2); (4) the train receiving after-arrival authority is stopped at the meeting point before movement authority is given; (5) the after-arrival is given to the train, and a software check of the traffic control system is conducted to verify that no unprotected authorities are present; (6) the dispatcher verbally transmits a computer-generated summary of track warrant items issued and verbally verifies to the train crew the after-arrival authority and the identification of the opposing train; and (7) after receiving the after-arrival authority and before leaving the station, the restricted train verifies the opposing train’s identification by visual observation, verbal communication with the opposing train, or verification from the train dispatcher that the other train has passed. This information must be entered on the train’s authority form. Supervisors monitor the use of these directives on a quarterly basis, and the last review indicated fewer than 10 after-arrival track warrants issued per day. The Safety Board acknowledges that the BNSF has made a concerted effort to reduce the number of after-arrival warrants issued each day and that the BNSF has implemented more elaborate procedures for the issuance of such warrants. Although these measures may lower the inherent risk of after-arrival warrants, the Board is concerned that the risk has not been eliminated. Therefore, we urge the BNSF to reconsider its position on this issue and discontinue the issuance of all after-arrival warrants. Accordingly, Safety Recommendation R-06-12 is classified OPEN -- UNACCEPTABLE RESPONSE, pending BNSF’s consideration of the Board’s comments.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 12/19/2006
Response: Letter Mail Controlled 1/3/2007 9:44:55 AM MC# 2060618: - From Mark Schulze, Vice President, Safety, Training, and Operations Support: BNSF has made a concerted effort to reduce the amount of "after arrivals" that are used in non-signaled territory or where a controlled signal provides direct access to non-signaled territory. Supervisors monitor the use of these types of directives on a quarterly basis and the last review indicated less than 10 of these orders per day for this type of operational territory. As discussed with NTSB representatives, there are circumstances when there is a need to issue "after arrival" orders. These circumstances include: ·Holding trains off of grade crossings where emergency vehicles, law enforcement agencies, etc, may need to pass. ·Holding trains off grade crossings in communities where local ordinances provide time restrictions for blockage. ·Limited issuance in advance to allow train dispatchers to plan work around shift transfers and peak demands. BNSF has added several redundancies to the process when necessary to issue after arrival orders that are designed for the safety of our employees and the general public. Following is a more detailed list of the checks and balances put in place when "after arrival" authorities are issued on the referenced territory: 1.The train dispatcher conducts a briefing with the train crew to notify of upcoming receipt of an after arrival authority and additionally provides the address of the train they will be meeting. 2.The train being restricted is then required to contact the opposing train to establish their location. 3.The train being restricted then notifies the train dispatcher that they have contacted the opposing train and lave confirmed the train's location. 4.The train receiving the after arrival authority must be stopped at the meeting point before movement authority is transmitted. 5.The after arrival is then given to the train and includes a computerized software check in the traffic control system to ensure there are no unprotected authorities. 6.The train dispatcher verbally transmits a computer-generated summary of track warrant items issued. The dispatcher then states to the train that they have received an after arrival authority and again states the train identification they will be meeting. 7. After receiving the after arrival authority and before leaving the station location, the restricted train must verify the opposing train's identification by visual observation, verbal communication with the opposing train or verification from the train dispatcher that the other train has passed. This information must be entered on the train's authority form. The NTSB report indicated the conductor on the BNSF 6789 South was having difficulty with copying track warrants. While the NTSB did not indicate this was a contributing factor to the accident, it raised a concern on our part. Because of this issue, BNSF implemented a policy that allows an employee three attempts to accurately repeat a track warrant to the train dispatcher. If an accurate repetition cannot be successfully accomplished, the train will be stopped. At that time a supervisor will be contacted to determine what actions are necessary for crew intervention. Based on this additional information, 1 would request that the NTSB close recommendation R-06-12 as "Closed: Acceptable Alternate Action".

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 8/17/2006
Response: Letter Mail Controlled 9/6/2006 1:19:24 PM MC# 2060443: - From Matthew K. Rose, Chairman, President, and Chief Executive Officer: BNSF has developed and implemented a process where a train movement will not inadvertently occupy the track prior to another train arriving at that location. Current instructions state: When track warrant requires "Not in Effect Until After the Arrival of____________” the limits must not be occupied until the train to be met has been identified by engine number and the rear end marker has passed the point of restriction. In non-signaled territory, a train may only be granted a Box 7 “Not in Effect Until After the Arrival of ______________ track warrant, after the following requirements have been completed: 1.Dispatcher advises the train that will receive the Box 7 track warrant of the identification of train(s) that will be listed in Box 7 (by initials, engine number and direction).