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Safety Recommendation Details

Safety Recommendation R-17-031
Synopsis: On September 29, 2015, at 11:15 a.m. central daylight time, Union Pacific Railroad (UP) remote control train YAR-24R-29 struck and fatally injured a foreman conducting switching operations at the east end of Armourdale Yard in Kansas City, Kansas. The foreman was found in the gage of track 5 under the lead railcar. A second switching crew foreman working in the yard was operating the striking train. There was no property damage. The weather was partly cloudy with a temperature of 70° F. As a result of this investigation, the NTSB is making a recommendation to UP.
Recommendation: TO UNION PACIFIC: Develop and implement a modification to the existing man-down alarms that allows yard workers to reliably differentiate between legitimate and noncritical man-down messages from remote control units.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: Kansas City, KS, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA15FR017
Accident Reports: Railroad Accident Brief: Union Pacific Railroad Employee Fatality, Kansas City, Kansas
Report #: RAB-17-13
Accident Date: 9/29/2015
Issue Date: 1/8/2018
Date Closed:
Addressee(s) and Addressee Status: Union Pacific (Open - Initial Response Received)

Safety Recommendation History
From: Union Pacific
Date: 3/6/2018
Response: -From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer: Thank you for your accident brief and correspondence adopted December 29, 2017, wherein you detail the latest recommendations made to Union Pacific Railroad ("Union Pacific") as a result of the Armourdale Yard, Kansas City, Kansas investigation. Below we have outlined our response to this recommendation. A Union Pacific Railroad foreman was fatally injured after being struck by a remote-control train during switching operations at the east end of Armourdale Yard, Kansas City, Sept. 29, 2015. The NTSB determined the probable cause of the accident was "the foreman being in the gage of the track, for unknown reasons, while a train switching movement was being performed by another crew." The report also states inadequate radio communications and inadequate work coordination between crews working in the yard contributed to the accident. In the course of the investigation the NTSB learned Union Pacific employees received frequent, non-critical, man-down alarms which the NTSB believes likely reduced the attention and reaction crewmembers made to actual critical alarms. A man-down alarm is an audible warning transmitted of the yard's radio channels from a remote-control unit (used to remotely control locomotives in the yard) indicating the remote-control unit is not in a vertical position and its operator may be in danger. As a result of the investigation, NTSB issued a safety recommendation to the Union Pacific Railroad to develop and implement a modification to the man-down alarms that would allow workers to differentiate between legitimate and non-critical alarms. As stated previously, man down alarms indicate the remote control unit is not in a vertical position and could potentially mean its operator is in danger. By regulation, this feature is required to be tested frequently throughout the day: at every shift change and each time an operator control unit (OCU) is linked to a remote control locomotive(RCL), per 49 C.F.R 229.15 (b)(ii). NTSB mentioned in its report that multiple UP employees commented negatively about the number of noncritical alarms transmitted over the Armourdale Yard radio channel. It is true that there is no way to differentiate critical v. non critical alarms, as the alarm performs exactly as intended each time it activates indicating the position of the unit, not the current health status of its wearer. Any modification to this notification, specifically having a differential audible warning, must get regulatory approval. Additionally, this modification would most likely be developed by the manufacturer, and need to be part of an industry wide solution to this issue. Union Pacific is happy to address remote control safety in its yards, and has continued to evolve its remote control safety practices at yards throughout its network, but is unable to meaningfully address this recommendation as it is currently posed. Union Pacific recommends NTSB reissue this recommendation to either the Federal Railroad Administration or the manufacturers of these OCUs, or both, to develop potential solutions and a path forward. Thank you for the opportunity to communicate with you regarding Union Pacific's response to NTSB's Armourdale Yard, Kansas City, KS R-17-031 recommendation. We appreciate the dedication of your investigative professionals, their pursuit of meaningful recommendations, and their tireless commitment to safety. We look forward to working with you in the future.

From: NTSB
To: Union Pacific
Date: 1/8/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On December 29, 2017, the NTSB adopted its brief Union Pacific Railroad Employee Fatality, Kansas City, Kansas, September 29, 2015, RAB-17/13. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at Among the Safety Recommendations is one issued to the Union Pacific Railroad, which can be found on page 8 of the report. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement this recommendation.