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Safety Recommendation Details

Safety Recommendation R-18-020
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 BNSF RAILWAY: Include evaluations on the visual detection of trains as a regular component of roadway work group employees’ required operational testing.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
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: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 1/2/2019
Response: -From Mark A. Schulze, Vice President, Safety, Training and Operations Support: I write in response to the National Transportation Safety Board's (NTSB) recommendations to BNSF Railway Company (BNSF) found in report/docket RAR-1801 adopted August 27, 2018. These Recommendations, R-18-20, R-18-21 and R-18-22 relate to the incident and Accident Report NTSB/HAR-18/01, "BNSF Railway Roadway Worker Fatalities, Edgemont, South Dakota, January 17, 2017." As an integral part of reaching our safety vision and to protect ourselves and others, BNSF trains, teaches and tests on compliance with rules and procedures. Specific to the NTSB recommendations, we believe BNSF appropriately addresses each recommendation and we remain committed to continuing to work with the NTSB Board and its staff concerning any technical details. Related to the recommendations, BNSF requirements for employee use of visual detection of trains, including use of lookouts, is, are covered thoroughly under BNSF Maintenance of Way Operating Rule 6.3.3. Following are actions taken in support of each NTSB recommendation. BNSF concurs with NTSB that testing for performance is an important part of the evaluation of compliance with operational and safety requirements, including for the use of visual detection of trains. To that end, BNSF uses its Operations Testing Reference Guide to provide guidance to BNSF supervisors for the preparation, procedures and performance of operational testing. This guide also assigns test codes to represent various testing areas that include testing for compliance with specific rules. Operations test series 350 covers testing of maintenance of way employees for compliance with track occupancy rules, and specifically includes testing for the above mentioned visual detection of trains rule 6.3.3 as test code 350-3. 350-3 Visual Detection of Trains - MWOR 6.3.3 •Employee using visual detection is being utilized has properly completed the Statement of On-Track Safety and/or the requirements of MWOR 6.3.3 have been met. Rules related to track occupancy are also included in BNSF's Engineering life/safety critical rules, called "Critical Decisions." Engineering supervisors are required to perform a minimum of 6 Critical Decision tests each month, and 350-3 testing for compliance with rule 6.3.3, is included as testing to meet Critical Decision testing expectations. For calendar years 2016, 2017 and to-date in 2018, BNSF has performed over 2,000 350-3 tests each year which represents approximately 7-8% of BNSF's total tests related to use of MOW authorities. Based on BNSF's existing requirements, processes and testing performance related to this recommendation, BNSF respectfully requests that NTSB close Recommendation R-18-20 as "Closed: Acceptable Action".

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 9/5/2018
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 August 27, 2018, the NTSB adopted its report BNSF Railway Roadway Worker Fatalities, Edgemont, South Dakota, January 17, 2017, RAR-18/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the safety recommendations are three issued to BNSF Railway, 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 10 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.