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Safety Recommendation Details

Safety Recommendation R-18-021
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: Revise your on-track safety program to include the proper equipment for watchmen/lookouts to provide train approach warning for roadway work groups.
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. The decision to use visual detection of trains requires several important regulatory and rule based considerations prior to use to ensure the protection is appropriate. NTSB's report detailed these considerations and this recommendation highlights the identification of the appropriate method of warning as one important consideration. In establishing its program, BNSF recognized that these considerations are interdependent and not made in individual disconnected assessments. Rather, a complete risk assessment flows together through multiple considerations and variables. BNSF's on-track risk assessment is aided by utilization of the on-track risk assessment tool, referenced in the Accident Report Appendix D. This assessment tool provides a clear and concise flow of the risk assessment considerations the work group utilizes when determining the use of lookout protection. Importantly, the risk assessment makes clear the requirement that all employees participate in identifying the risks as part of the job safety briefing. Only through a full assessment can the group determine whether lookout protection is appropriate for the situation, and if so, in combination with the other risk assessments what method of warning is most appropriate. As part of the method of warning risk assessment, the regulation clearly states that the method of warning cannot "require a warned employee to be looking in any particular direction at the time of the warning, and that can be detected by the warned employee regardless of noise or distraction of work." (49 CFR 214.329(e)). Rather than providing a singular tool, or piece of equipment such as a flag or whistle, BNSF's rules, training, job-aids and oversight supports individual workers and work groups in accurately assessing the risk of the immediate task. Supporting that approach is industry research provided in this docket, which details the extensive review and analysis of the Fatality Analysis of Maintenance-of-way Employees and Signalman (FAMES) working group. This working group report identified that in the majority of reviewed incidents, a lookout was in-fact using equipment such as NTSB references in this report. BNSF developed and implemented its approach to on-track safety through incorporation of the above-mentioned requirements, recognition of the interconnected considerations, and review of the industry incidents. When followed, use of the on-track assessment tool provides a more comprehensive analysis and leads to better informed safety decision-making for BNSF's maintenance operations. As noted in the Accident Report, FRA reviewed the watchman/lookout provisions of BNSF's On-Track Safety Program and noted no exceptions. BNSF recognizes that NTSB additionally provided recommendations to the Federal Railroad Administration (FRA) related to this area. BNSF stands ready to support any additional regulatory review or analysis related to enhancing the safety of employees, and specifically employees engaged in on-track activities. Based on BNSF's existing rules, instructions and processes created in compliance with FRA regulations, BNSF respectfully requests that NTSB close Recommendation R-18-21 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.