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Safety Recommendation Details

Safety Recommendation R-18-017
Details
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 railroads’ on-track safety programs to determine if the necessary equipment is required and provided for a watchman/lookout to notify roadway work groups of approaching trains. If deficiencies are discovered, use enforcement options to encourage compliance.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Edgemont, SD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: 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 - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/16/2019
Response: On December 21, 2018, you told us that you agree with our findings in the Edgemont report that the probable cause of the accident was the improper use of train-approach warning by the BNSF roadway work group responsible for providing on-track safety, and that incorrect information provided in the job briefing, including a miscalculated sight-distance assessment, contributed to the accident. However, you disagree with our 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 your enforcement of regulations requiring railroads to equip watchmen/lookouts, contributed to the accident. We note that you believe Safety Recommendations R-18-16 through -18 are based on incorrect conclusions and are not supported by the facts outlined in our report; further, you believe that Safety Recommendation R-18-19 is not applicable because your National Inspection Plan is not the correct mechanism through which to require periodic, unannounced inspections for roadway worker protection regulatory compliance. We are disappointed by your position on these recommendations and respectfully disagree that they are not supported or applicable. We consider roadway worker safety to be of the utmost importance. In addition to the multiple accidents we have investigated, we addressed this issue in 2014 with our Special Investigation Report on Railroad and Rail Transit Roadway Worker Protection. In that report, we stated the following: Railroad and rail transit roadway workers are subject to on-the-job risks and hazards markedly different from those faced by other railroad employees. The jobs of railroad engineers and conductors include risks primarily related to moving trains—derailments, and collisions with other trains. . . . The jobs of roadway workers involve hazards that include moving rolling stock and other equipment and vehicles, as well as falls, electrocution, and natural hazards. We urge you to reconsider your position on these recommendations and to take action to protect vulnerable roadway workers. Pending such a response, Safety Recommendations R-18-16 through -19 are classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
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. Over the past year, FRA has reviewed numerous roadway worker protection (R WP) plans for compliance with Part 214, which included ensuring that railroads list acceptable means of providing a warning. At FRA's insistence, BNSF specifically revised its on-track safety manual to ensure that the means of providing the warning was specifically listed. Any railroad discovered during the continuing review process that had not listed the means of providing the warning has immediately revised its policy to do so. Thus, the NTSB should close Safety Recommendation R-18-17.

From: FRA
To: NTSB
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
To: FRA
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 http://www.ntsb.gov. 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 correspondence@ntsb.gov. 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.