This is an abstract from the Safety Board's report and does not include the Board's rationale for the conclusions and recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients and investigation parties as soon as possible. The attached information is subject to further review and editing.
About 2:15 a.m., July 2, 1997, westbound Union Pacific (UP) freight train NP-01, operating on a siding track, proceeded past a wayside stop signal at the end of the siding and collided with the side of eastbound UP freight train ME-29, which was operating on a mainline track on the UP railroad near Delia, Kansas. The NP-01 train engineer was killed, and the NP-01 train conductor sustained minor injuries.
The major safety issues discussed in this report are the NP-01 train engineer's performance, crew resource management, the UP's fatigue education program, and positive train separation (PTS) control system.
As a result of its investigation of this accident, the Safety Board makes recommendations to the Federal Railroad Administration, the Union Pacific Railroad, the Brotherhood of Locomotive Engineers, and the United Transportation Union.
- The train equipment, the track, and the signal system functioned as designed; the dispatcher and train crews were qualified, trained, and tested to properly perform their duties; and no UP employee tested as a result of this accident was impaired by alcohol or drugs.
- The hazardous materials cargo did not cause or increase the severity of this accident.
- The NP-01 engineer failed to stop the train at the stop signal.
- Both the handbook and video provided by the UP to employees are valuable resources for helping railroad personnel and their families to understand fatigue issues.
- The UP did not have procedures enabling the company to track the employees who had received the fatigue awareness material.
- The NP-01 train conductor did not provide proper supervision when he left the engineer alone in the locomotive cab for 20 minutes before the collision.
- A fully implemented PTS control system would have prevented the collision at the UP railroad's Kenefick siding, thus saving the life of the NP-01 engineer.
- Had the striking locomotive been equipped with an alerter, it may have helped the engineer stay awake while his train traveled through the siding.
The National Transportation Safety Board determines that the probable cause of this collision and derailment was the failure of the NP-01 engineer to stop at the stop signal, enabled by the failure of the Union Pacific management to ensure redundant safety systems for train operation and control, including effective crew resource management techniques and technological advances for crew alertness. Contributing to the collision and derailment was the failure of the Federal Railroad Administration and the railroad industry to aggressively develop a positive train separation control system.
As result of its investigation the National Transportation Safety Board makes the following recommendations:
To the Federal Railroad Administration:
Revise the Federal regulations to require that all locomotives operating on lines that do not have a positive train separation system be equipped with a cognitive alerter system that cannot be reset by reflex action. (R-98-X)
To the Union Pacific Railroad:
Issue to all employees, including management personnel, current fatigue awareness material regarding shift work, work-rest schedules, and proper regimens of health, diet, exercise and rest. (R-98-X)
Revise your fatigue awareness program to include a process for documenting which employees receive the currently available fatigue awareness material, any new or updated fatigue-related information, or both, and for determining whether the recipients understand the dangers of working while fatigued. (R-98-X)
Establish, at a minimum, an annual management oversight review process for the fatigue awareness program to ensure its effectiveness and to identify ways of improving it. (R-98-X)
In conjunction with the operating unions, discuss the circumstances of this accident with employees and advise them about the operating danger of working while fatigued. (R-98-X)
Require that freight trains not equipped with cab signals, speed control, and alerters, or with a positive train separation system stop when either one of the two operating crewmembers must leave the operating cab, except in instances when the conductor must perform operating tasks actively supporting safety redundancy in train operations. (R-98-X)
Install a cognitive alerter system that cannot be reset by reflex action on all locomotives that operate on lines that do not have a positive train separation system. (R-98-X)
To the Brotherhood of Locomotive Engineers:
In conjunction with other operating unions and with the Union Pacific Railroad, discuss the circumstances of this accident with your members and advise them about the operating danger of working while fatigued. (R-98-X)
To the United Transportation Union:
In conjunction with other operating unions and with the Union Pacific Railroad, discuss the circumstances of this accident with your members and advise them about the operating dangers of working while fatigued. (R-98-X)