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Safety Recommendation Details

Safety Recommendation R-06-020
Details
Synopsis: On April 3, 2005, about 9:35 a.m., westbound Amtrak (National Railroad Passenger Corporation) passenger train No. 27, consisting of a single locomotive unit and four passenger cars, derailed at milepost (MP) 58.56 on the BNSF Railway Company’s (BNSF’s) Northwest Division. The train was traveling 60 mph on single main line track when it derailed as it was traveling through a cut section of the Columbia River Gorge on the north side of the Columbia River near Home Valley, Washington. The train remained upright; however, the cars came to rest leaning up to approximately 35 against the outside curved embankment. There were 106 passengers and 9 Amtrak employees on board. Thirty people (22 passengers and 8 employees) sustained minor injuries; 14 of those people were taken to local hospitals. Two of the injured passengers were kept overnight for further observation; the rest were released. Track and equipment damages, in addition to clearing costs associated with the accident, totaled about $854,000.
Recommendation: TO THE BURLINGTON NORTHERN AND SANTA FE RAILWAY COMPANY: As part of your track inspector audit program, determine whether inspectors are provided adequate track time to perform their duties, and take corrective action if necessary.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Home Valley, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA05FR010
Accident Reports: Derailment of Amtrak Passenger Train No. 27
Report #: RAB-06-03
Accident Date: 4/3/2005
Issue Date: 10/25/2006
Date Closed: 5/23/2013
Addressee(s) and Addressee Status: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Closed - Acceptable 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 BNSF’s addition of 11 positions to oversee the training and qualification of track inspectors and to determine whether inspectors are provided adequate track time to perform their duties satisfies Safety Recommendation R-06-20. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE 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: Since this recommendation was issued, BNSF has had communications with NTSB staff concerning its track inspection program and undertaken numerous actions, detailed below, which we believe satisfy the Board's recommendation regarding our track inspector audit program. BNSF agrees with the Board that track inspectors must have adequate time to perform their duties, and believes it does provide that time and has processes in place to ensure that corrective action be taken as necessary. Subsequent to this recommendation, the Federal Railroad Administration (FRA) organized a Rail Safety Advisory Committee (RSAC) to investigate track inspection time as required pursuant to §403 of the Rail Safety Improvement Act of 2008, which directed FRA to study track inspection time including: the required inspection intervals, remedial action requirements, the need for amendments to track inspection and repair priorities, and whether track inspection speed and scope needed to be regulated by the Secretary. The RSAC accepted this study on August 16,2011 , and the first meeting was held on October 18, 2011. The RSAC was comprised of members from FRA, industry (including BNSF) and labor. NTSB staff members also attended these meetings. On March 28, 2012, after three RSAC meetings and robust discussion of ongoing industry action, FRA communicated that it had reviewed and considered the information and documentation from the RSAC and had determined that industry action was sufficient. Furthermore, FRA stated that the obligations under §403 were fulfilled without the need for additional rulemaking or regulatory action. As further responsive action, BNSF has in place a track audit process which continuously monitors the quality of track inspections and the availability of adequate inspection time and which further emphasizes the need to perform an inspection at the appropriate speed. This audit process has both a field and remote audit component. BNSF's system track audit group monitors track inspections, and each month the territory Roadmaster performs a ride-along to ensure track inspectors are performing quality track inspections. Additionally, BNSF instituted a remote audit process in which the remote audit team monitors the performance and quality of track inspections. In the event an auditor encounters a concern with adequate track inspection time, inspection speed, or other quality concerns, BNSF elevates that concern to the appropriate supervisor for corrective action. To enhance the track inspection program further and to provide inspectors sufficient and safe access to track, BNSF instituted Smart Mobile Client technology. Smart Mobile Client improves interaction between the field engineering personnel and, specifically, track inspectors by providing computer access in the field. Smart Mobile Client operates on a small hardened laptop type device that displays the same screen and information to the field that is available to the dispatcher. Such shared information allows the dispatcher and the track inspector to work together to identify safe, efficient, and adequate track inspection opportunities. Finally, BNSF has established a new training and certification organization adding 11 positions to its Engineering Department, overseeing training and qualification of engineering employees. These positions work directly with the field personnel, on a division level, to guarantee employee qualification on regulatory requirements, specifically ensuring that track inspectors have the requisite knowledge of the applicable rules to achieve compliance with FRA requirements. Based on all of the aforementioned processes and actions, BNSF respectfully requests that NTSB close Recommendation R-06-20 as "Closed; Acceptable Action."

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 12/18/2012
Response: Although this recommendation is over 6 years old, the NTSB has received no reply to date regarding actions that BNSF has taken to address it. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding BNSF’s actions or plans to address Safety Recommendation R-06-20. In the meantime, because of the lack of timely action, the recommendation is classified OPEN—UNACCEPTABLE RESPONSE. A copy of the safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2006/R06_20.pdf. The full report of the Home Valley, Washington, accident investigation (Report Number NTSB/RAB-06/03) is available on our website at http://www.ntsb.gov/doclib/reports/2006/RAB0603.pdf.