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Safety Recommendation Details

Safety Recommendation R-12-018
Details
Synopsis: On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway (BNSF) coal train C-BTMCNMO-26, BNSF 9159 East, travelling about 23 mph, collided with the rear end of standing BNSF maintenance-of-way (MOW) equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost (MP) 448.3 on main track number two on the Creston Subdivision of the BNSF Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Conduct research on new and existing methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Red Oak, IA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11FR002
Accident Reports: Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train
Report #: RAR-12-02
Accident Date: 4/17/2011
Issue Date: 5/10/2012
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 12/1/2015
Response: We are encouraged that, in addition to the actions described above in response to Safety Recommendation R-12-17, you are actively seeking railroads to participate in pilot projects to examine the effects of scheduling pools, advance call times, and decreased time at the away from home terminal to evaluate the fatigue experienced by train crews. Pending completion of these actions, Safety Recommendation R-12-18 is classified OPEN—ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 2/11/2015
Response: -From Sarah Feinberg, Acting Administrator: See our response to R-12-17 above. Under Section 20156(c), (d)(2), and (f), a railroad developing an RRP must conduct a risk analysis that includes fatigue-related risks and a fatigue management plan. This risk analysis must: "identify and analyze the aspects of its railroad, including operating rules and practices, infrastructure, equipment, employee levels and schedules, safety culture, management structure, employee training, and other matters, including those not covered by railroad safety regulations or other Federal regulations, that impact railroad safety." 49 U.S.C. § 20156(c).FRA is also actively seeking railroads to participate in pilot projects that will examine the effects of scheduling pools, advanced call times, and decreased time at the away-from-home terminal on the fatigue experienced by train crews.

From: NTSB
To: FRA
Date: 10/16/2012
Response: The NTSB is aware that section 103 of the RSIA requires the Secretary of Transportation to conduct an annual review of a railroad’s risk reduction plan to ensure the railroad is complying with its plan and that railroads will be required to review and revise their Fatigue Management Plans at least once every 2 years. Because the FRA is working with the RSAC to address Safety Recommendations R-12-17 and -18 as well as the RSIA requirements, these recommendations are classified OPEN—ACCEPTABLE RESPONSE pending completion of these efforts.

From: FRA
To: NTSB
Date: 7/31/2012
Response: -From Joseph C. Szabo, Administrator: Thank you for your May 10, 2012, letter to the Federal Railroad Administration (FRA) concerning National Transportation Safety Board (NTSB) Safety Recommendations R-12-16 through -22, R-02-24 through -26, and R-10-01 and -02. These recommendations were issued as a result the April17, 2011, rear-end collision of eastbound BNSF Railway (BNSF) coal train C-BTMCNM0-26, BNSF 9159 East, into standing BNSF maintenance-of-way equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. FRA has enclosed its responses to the above-mentioned recommendations. The FRA respectfully requests that NTSB classify Safety Recommendations R -12-16 through -20 and -22 as "Open-Acceptable Response." Additionally, we request that NTSB classify Safety Recommendations R-12-21 as "Closed-Reconsidered," and R-02-24 as "Closed-Acceptable Alternative Action." Lastly, FRA requests Safety Recommendations R-02-25 and -26, and R-10-01 and -02, remain "Open-Acceptable Response." I appreciate your interest in this important transportation matter. We look forward to working with you. The RSIA further requires under Section 103 that the Secretary conduct an annual review of a railroad’s risk reduction plan to ensure the railroad is complying with its plan. Under the RSIA, railroads will be required to review and revise their Fatigue Management Plans at least once every 2 years. Currently, FRA, in conjunction with an RSAC working group, is working on a regulation document that is responsive to the requirements outlined in RSIA. Additionally, FRA has developed a Fatigue Risk Management Systems (FRMS) guidance document for the railroads that outlines the components of an FRMS, the steps to establishing an FRMS, and evaluation requirements. Additionally, the RSIA requires under Section 103(c) that a railroad developing an RRP must conduct a risk analysis. The risk analysis will include fatigue-related risks. This risk analysis must “identify and analyze the aspects of its railroad, including operating rules and practices, infrastructure, equipment, employee levels and schedules, safety culture, management structure, employee training, and other matters, including those not covered by railroad safety regulations or other Federal regulations, that impact railroad safety.” FRA is also actively seeking railroads to participate in pilot projects that will examine the effects of scheduling pools, advanced call times, and decreased time at the away-from-home terminal on the fatigue experienced by train crews.