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Safety Recommendation Details

Safety Recommendation R-18-016
Synopsis: On January 17, 2017, about 10:09 a.m. mountain standard time, BNSF Railway westbound train E DOLEBM0 01E, traveling at 35 mph, struck and killed two roadway workers, including the watchman/lookout. The accident occurred at milepost 477, on the Black Hills subdivision, in Edgemont, South Dakota. The three-member roadway work group had been cleaning snow and ice from the track switch on the main track to prepare for the movement of a train that was to have its air brake system tested in a stationary test on the main track. The crew of the striking train sounded the train horn and bell, and both members of the train crew applied emergency braking; however, there was no response from the roadway work group, and the train was unable to stop before reaching the work location. At the time of the accident, the sky was clear, the wind was calm, and reported temperatures ranged from 13° to 18°F. The accident occurred in the west leg of the Deadwood wye switch. Train movements on the main tracks in this area are controlled by centralized traffic control and governed by operating rules, general orders, timetable instructions, and the signal indications of an absolute block system. The Black Hills subdivision consisted of two main tracks. The maximum operating speed was 35 mph between milepost 476.1 and milepost 477.0 on both main tracks. About 20 eastbound and 20 westbound trains per day operated on the main tracks through the accident area. There were multiple main tracks in this area with eastbound trains typically operating on main track 2 and westbound trains operating on main track 1. This report addresses the following safety issues: • Train Approach Warning. The investigation found that the sight distance at the Deadwood wye switch was inadequate for the safe use of the train approach warning method of on-track safety when using a single watchman/lookout. The watchman/lookout was not devoting his full attention to detecting approaching trains. In addition, in the year prior the accident, none of the members of the roadway work group were tested on the visual detection of trains. • Watchman/Lookout Equipment. The investigation found that the watchman/lookout involved in this accident was not provided with the necessary equipment, such as a whistle, air horn, white disk, red flag, or fusee, to perform on-track safety duties, as required by federal regulations. The absence of on-track safety warning equipment likely allowed the watchman/lookout to engage in other work activities, rather than his assigned duty?watching for trains. • Roadway Worker-in-Charge to Roadway Work Group Job Briefings. The investigation found that the job briefing conducted by the watchman/lookout and the other roadway workers in the work group fouling the track had incorrect information regarding the minimum-required sight distance and the required time to move to the predetermined place of safety.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Review, and modify if necessary, your current inspection guidance regarding watchman/lookout equipment to verify that it requires railroads to provide the necessary equipment for a watchman/lookout to notify a roadway work group of approaching trains and that this accurately reflects the definition contained in Title 49 Code of Federal Regulations 214.7.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: Edgemont, SD, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA17FR004
Accident Reports: BNSF Railway Roadway Worker Fatalities, Edgemont, South Dakota, January 17, 2017
Report #: RAR-18-01
Accident Date: 1/17/2017
Issue Date: 9/5/2018
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Initial Response Received)

Safety Recommendation History
From: FRA
Date: 12/21/2018
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA) response to the National Transportation Safety Board's (NTSB) Safety Recommendations R-18-16, R-18-17, R-18-18, and R-18-19. These recommendations arise from an accident on January 17, 2017, in Edgemont, South Dakota, in which a train struck and killed two roadway workers. FRA agrees with the NTSB's findings that the probable cause of the accident was the improper use of train approach warning by the BNSF Railway (BNSF) roadway work group responsible for providing on-track safety. FRA also agrees that incorrect information provided in the job briefing, including a miscalculated sight-distance assessment, contributed to the accident. However, FRA disagrees with the NTSB's finding that BNSF's failure to provide the watchman/lookout with the necessary equipment to alert the work group of oncoming trains and equipment or FRA's enforcement of Federal regulation requiring railroads to equip watchmen/lookouts contributed to the accident. Although the roadway workers in the job briefing incorrectly determined that train approach warning could be safely used as the method of providing on-track safety in this instance, the method of providing a warning in no way contributed to the accident. This accident was caused by the watchman/lookout not devoting his full attention to detecting approaching trains and failing to provide any warning to the roadway workers. NTSB' s Safety Recommendations R-18-16, R-18-17, and R-18-18 are based on incorrect conclusions and are not supported by the facts outlined in the NTSB's report. FRA's responses to each recommendation are summarized as follows: FRA considers NTSB's Safety Recommendation R-18-19 to be not applicable because FRA's National Inspection Plan is not the mechanism to require periodic, unannounced inspections for roadway worker protection regulatory compliance. Detailed responses to each recommendation are provided in the enclosure. As FRA has made clear in our answers above and in the enclosure, the agency will not take any further action on these recommendations, and so respectfully request that the NTSB close them. The definition of a watchman/lookout in 49 CFR § 214.7, states: Watchman/lookout means an employee who has been trained and qualified to provide warning to roadway workers of approaching trains or on-track equipment. Watchmen/ lookouts shall be properly equipped to provide visual and auditory warning such as whistle, air horn, white disk, red flag, lantern, fuse. A watchman/lookout 's sole duty is to look out for approaching trains/on-track equipment and provide at least fifteen seconds advanced warning to employees before arrival of trains/on-track equipment. Chapter 1 of FRA' s March 2018 Track and Rail and Infrastructure Integrity Compliance Manual, Volume Ill (Compliance Manual) also explains under 49 CFR § 214.7 that roadway workers acting as watchmen/lookouts "shall be properly equipped to provide visual and auditory warning such as whistle, air horn, white disk, red flag, lantern, fuse." FRA has reviewed its current inspection guidance regarding watchman/lookout equipment and is confident that it accurately reflects the regulatory requirements and intent. Section 214.7 is a definitional section that supports substantive rule provisions, notably 49 CFR § 214.329 (Train Approach Warning Provided by Watchmen/Lookouts). Section 214.329 states, in part: (c) The means used by a watchman/lookout to communicate a train approach warning shall be distinctive and shall clearly signify to all recipients of the warning that a train or other on-track equipment is approaching. (g) Every watchman/lookout shall be provided by the employer with the equipment necessary for compliance with the on-track safety duties which the watchman/lookout will perform. The preamble to the 1996 roadway worker protection regulation under 49 CFR § 214.329 states, in part: This section further imposes a duty upon the employer to provide the watchman/lookout employee with the requisite equipment necessary to carry out his on-track safety duties. It is intended that a railroad 's on-track safety program would specify the means to be used by watchmen/lookouts to communicate a warning, and that they be equipped according to that provision. 61 Fed. Reg. 65959, 65970 (Dec. 16, 1996). Likewise, Chapter 3 of FRA's Compliance Manual under 49 CFR § 214.329 states, in part: Paragraph (g) requires the employer to provide the watchman/lookout employee with the requisite equipment necessary to carry out his on-track safety duties. It is intended that a railroad's on-track safety program specify the means to be used by watchmen/lookouts to communicate a warning, and that they be equipped according to that provision. Thus, FRA has made clear that a railroad must properly equip a watchman/lookout with the equipment specified by the railroad's on-track safety program to properly communicate a warning. Except in limited circumstances (e.g., a watchman/lookout assigned to provide train approach warning for a single welder and who is located immediately next to the welder to provide a warning), if a railroad does not provide equipment with the specified auditory or visual warning capabilities to the roadway workers a watchman/lookout is protecting, the railroad is in violation of 49 CFR § 214.329. If an on-track safety program fails to specify the "requisite equipment necessary" for a watchman/lookout to provide on-track safety for a roadway work group, the program also is not compliant with Part 214. Although the 49 CFR § 214. 7 definition of "watchman/lookout" does mention both visual and auditory warnings, it does not supersede the clear requirements of 49 CFR § 214.329, and the unambiguous intent of the regulation as conveyed in the preamble to the final rule. FRA's guidance is consistent with both the regulatory text and the preamble to the final rule, and it requires no modification at this time. Further, there has been no "inconsistent enforcement" of Federal regulations requiring railroads to equip watchmen/lookouts. Thus, the NTSB should close Safety Recommendation R-18-16.

From: FRA
Date: 9/6/2018
Response: -From Karl Alexy, Deputy Associate Administrator, Office of Railroad Safety: Thank you for the report BNSF Railway Roadway Worker Fatalities, which was sent to the Federal Railroad Administration (FRA) on September 5, 2018. In the '"Recommendations" section of the report, the National Transportation Safety Board (NTSB) issued Safety Recommendations R-18-16 through -19 to FRA. Improving safety is FRA's top priority, and FRA will continue to work to make rail shipments as safe as possible. FRA is committed to working with the NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.

From: NTSB
Date: 9/5/2018
Response: On August 27, 2018, the NTSB adopted its accident report, BNSF Railway Roadway Worker Fatalities, Edgemont, South Dakota, January 17, 2017, RAR-18/01. The details of this accident brief and the resulting safety recommendations may be found in the accident report, which can also be accessed at Among the safety recommendations are four issued to the Federal Railroad Administration, which can be found on page 19 of the report. The NTSB is vitally interested in these recommendations because they are 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 these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.