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.
At 10:52 p.m. on June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided head-on in Devine, Texas. The trains were operating on a single main track with passing sidings in dark (nonsignalized) territory in which train movement was governed by conditional track warrant control authority through a dispatcher. The conductor from 5981 North, the engineer from 9186 South, and two unidentified individuals who had apparently been riding on 5981 North were killed in the derailment and subsequent fire. The engineer from 5981 North received minor injuries, and the conductor from 9186 South was seriously burned. Estimated damages exceeded $6 million.
The major safety issues discussed in this report are the train dispatcher's performance and workload, the adequacy of the UP management oversight of the dispatcher apprentice program and dispatching operations, the sufficiency of the FRA oversight of dispatching operations, the effectiveness of conditional track warrant control authority, the adequacy of disaster preparedness, the crashworthiness of locomotives and event recorders, and the merits of positive train separation control systems.
As a result of its investigation, the Safety Board makes recommendations to the UP, the FRA, and the Texas Department of Public Safety. In addition, the Safety Board reiterates a safety recommendation to the FRA.
1. Neither the weather nor the train equipment or track caused or contributed to the collision. The computer-generated track warrant 8289 information was correct. Both operating traincrews were in compliance with the requirements specified in the Hours-of-Service Act and were qualified to perform their duties; no crewmember or dispatcher fatigue was indicated. Neither alcohol nor drug use appears to have been a factor in the accident.
2. The third-shift dispatcher's failure to accurately issue track warrant 8289 to train 9186 South and his failure to detect and correct the 9186 South conductor's repeat of the track warrant authority limit resulted in the crew receiving an incorrect track warrant that allowed the opposing trains 5981 North and 9186 South to operate on the same track through Devine on June 22, 1997.
3. The third-shift dispatcher did not communicate the accurate information in track warrant 8289 to the crew of train 9186 South.
4. The Union Pacific Railroad dispatchers' elevated workload at the beginning of shifts may contribute to the disproportionately greater number of dispatching violations occurring during this time.
5. Some Union Pacific Railroad apprentice dispatchers may not have been adequately prepared to be placed and operate safely in territories of high-operating demands immediately after completing the training program.
6. The Union Pacific Railroad may have jeopardized safe dispatching operations by qualifying unprepared apprentice dispatchers and assigning less experienced dispatchers to territories of high-operating demands.
7. Because the Union Pacific Railroad did not meet its 5-year experience standard for OJT dispatcher trainers, complying with the higher standard of a minimum 10-year experience level for OJT dispatcher trainers may not be achieved.
8. The third-shift dispatcher's failure to communicate the information in track warrant 8289 accurately to the 9186 South traincrew and to verify the accuracy of the read-back information resulted from operational shortcomings at the Harriman Dispatch Center.
9. Some Union Pacific Railroad corridor managers did not consistently provide appropriate technical support to the train dispatchers.
10. Although no evidence was found that adjacent noises in the dispatching area contributed to the third-shift dispatcher's inattention to the track warrant 8289 information in the Devine accident, a dispatcher's performance may be affected by unnecessary, avoidable sound distractions.
11. Had the Union Pacific Railroad after-arrival system in dark (nonsignalized) territory operations not been used in the Devine accident area, the opposing trains 5981 North and 9186 South would not have been occupying the same block of track.
12. The Federal Railroad Administration has failed to develop dispatcher standards and needs to accelerate the establishment of regulatory standards for train dispatchers.
13. The Federal Railroad Administration surveillance and enforcement of compliance with Federal regulations at the Harriman Dispatch Center before the Devine accident was inadequate and ineffective.
14. Although the local emergency response was timely and adequate, the lack of readily available fire suppression foam equipment shows a need for additional firefighting equipment to mitigate such significant fire events.
15. Based upon the estimated speeds of the locomotives at impact, the loss of survival space in the locomotives, and the severity of the massive fire, the collision in Devine was not survivable for crewmembers or anyone occupying the locomotive equipment at the time of the impact.
16. Had the event recorders been designed to withstand crash forces and fire exposure, the three destroyed event recorders would have survived and could have provided data for the investigation.
17. Had a positive train separation control system been installed and working in the Devine accident area, the two trains would not have been allowed to enter the same block of track traveling in opposite directions and, as a result, the head-on collision on June 22, 1997, would not have occurred.
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the third-shift dispatcher to communicate the correct track warrant information to the traincrew and to verify the accuracy of the read-back information because the UP management had not established and implemented workload policies and operational procedures to ensure a safe dispatching system and the Federal Railroad Administration (FRA) had failed to provide standards and oversight in all aspects of train dispatching operations. Contributing to the accident was the lack of an installed positive train separation control system that would have prevented the trains from colliding by automatically intervening in their operation because of inappropriate actions being taken.
As a result of its investigation, the National Transportation Safety Board makes the following recommendations:
-- to the Union Pacific Railroad:
1. Evaluate your train dispatcher training program and make necessary revisions to place greater emphasis on all safety critical activities including procedures used to issue and confirm track warrants. (R-98-XX)
2. Audit and revise your train dispatching operation to address specific factors that can lead to dispatching errors. Include in your review an assessment of dispatching errors that occur because of improper radio procedures and errors which occur during or shortly after shift changes. (R-98-XX)
3. Conduct an audit of your train dispatchers' activities to evaluate current workload. Make necessary changes to dispatcher operations to distribute workload based on the individual dispatcher's qualifications, ability, and experience. (R-98-XX)
4. Examine the circumstances in which your policy to require a minimum of five-years of experience to qualify as an OJT dispatcher trainer was not followed. Take action to ensure that Union Pacific qualification policies are followed. (R-98-XX)
5. Develop and implement a comprehensive program to select and train experienced dispatchers to serve as dispatcher trainers. (R-98-XX)
6. Evaluate and determine the technical expertise required of corridor managers and make the necessary changes to ensure that corridor managers are qualified to provide proper dispatching assistance to the train dispatchers. (R-98-XX)
7. Identify and evaluate all distractions to train dispatchers and take action to establish a working environment conducive to safe dispatching operations. (R-98-XX)
8. Permanently discontinue the use of after-arrival orders in dark (nonsignalized) territory. (R-98-XX)
--to the Federal Railroad Administration:
9. Require railroads to permanently discontinue the use of after-arrival orders in dark (nonsignalized) territory. (R-98-XX)
10. Develop and establish dispatcher selection standards, dispatcher training standards, dispatcher trainer standards, and dispatcher workload limits by January 1, 2000. (R-98-XX)
11. Evaluate your surveillance and enforcement activities at dispatching centers and take appropriate corrective actions to ensure that Federal oversight is adequate and effective. (R-98-XX)
12. Working with the railroad industry, develop and implement event recorder crashworthiness standards for all new or rebuilt locomotives by January 1, 2000. (R-98-XX)
13. Revise the Code of Federal regulations to include track warrants and other current railroad operating practices. (R-98-XX)
--to the State of Texas:
14. Develop a system that would make fire suppression foam equipment readily available to emergency management agencies and local rural fire departments for the fighting of hazardous materials fires. (R-98-XX)
Also, as a result of its investigation, the National Transportation Safety Board reiterates the following recommendation:
--to the Federal Railroad Administration:
Promulgate Federal standards to require the installation and operation of a train control system on main line tracks that will provide for positive separation of all trains. (R-87-16)