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NTSB Cites BNSF Crew's Inattentiveness in Metrolink, BNSF Accident In 2002
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 NTSB Cites BNSF Crew's Inattentiveness in Metrolink, BNSF Accident In 2002

The National Transportation Safety Board determined today that the probable cause of a collision between a Burlington Northern Santa Fe (BNSF) freight train and a Metrolink commuter in Placentia, California was the freight train crew's inattentiveness to the signal system and their failure to observe, recognize, and act on the approach signal.

Contributing to the April 23, 2002 accident was the absence of a positive train control system that would have automatically stopped the freight train short of the stop signal. Additionally, if the BNSF conductor had been more actively involved in monitoring the signals, he may not have misidentified an approach signal as clear, the Board found.

"This accident, which happened during rush-hour on a commuter route, illustrates how each employee is responsible for safety and how implementation of new technology can save lives," said Ellen G. Engleman, NTSB Chairman.

During an interview conducted following the accident, both the conductor and the engineer said they approached Atwood thinking they were operating on a clear signal and that they were not required to stop or even slow the train. Just before the freight train reached Atwood, both crewmembers realized that the signal at MP 40.71 was showing stop and noticed the Metrolink train on the same track headed towards them.

As a result of the accident, there were two fatalities, 22 serious injuries, and 162 persons taken to the hospital.

"The Safety Board has issued recommendations on Positive Train Control since 1969. The technology these systems provide are the best approach to reducing human error collision," Engleman said. "The Board's strong interest in this issue was further demonstrated when we placed PTC on our Most Wanted list in 1990."

Among the recommendations the Board issued as a result of this accident were one to Burlington Northern Santa Fe Railway Company to revise their signal awareness form procedure to require recording of time, speed, and aspect name for all signals at the time they are encountered, and another to the American Association of Railroads to report to the Board the milestones and activities needed for completion of the interoperability standards for positive train control systems and their priorities for completion of this effort. Interoperability is the capacity of a railroad's PTC system to operate safely on other railroads.

The Safety Board also reiterated a recommendation to the Federal Railroad Administration to facilitate actions necessary for development and implementation of positive train control systems that include collision avoidance, and require implementation of positive train control systems on main line tracks, establishing priority requirements for high-risk corridors such as those where commuter and intercity passenger railroads operate.

A synopsis of the Placentia, California rail accident investigation report, including the findings, probable cause, and safety recommendations, can be found on the Publication page of the Board's web site, The complete report will be available in about six weeks.

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Contact: NTSB Media Relations
490 L'Enfant Plaza, SW
Washington, DC 20594