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Safety Recommendation Details

Safety Recommendation R-12-019
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: Require the implementation of methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews that are identified or developed in response to Safety Recommendation R-12-18.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Red Oak, IA, United States
Is Reiterated: No
Is Hazmat: 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)

Safety Recommendation History
From: NTSB
Date: 12/1/2015
Response: We understand that the FRA and a Railroad Safety Advisory Committee working group are developing guidance for implementing fatigue risk management systems. We point out that we have recommended that you institute a requirement, and not simply guidance, which railroads may or may not choose to follow. Pending the timely completion of efforts that satisfy Safety Recommendation R-12-19, it is classified OPEN—ACCEPTABLE RESPONSE.

From: FRA
Date: 2/11/2015
Response: -From Sarah Feinberg, Acting Administrator: As previously mentioned, FRA and an RSAC working group are developing guidance for implementing Fatigue Risk Management Systems.

From: NTSB
Date: 10/16/2012
Response: The NTSB is aware that the RSIA requires an implementation plan as part of a Fatigue Management Plan. Because the FRA is working with the RSAC to address Safety Recommendation R-12-19, the recommendation is classified OPEN—ACCEPTABLE RESPONSE pending completion of the recommended action.

From: FRA
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 requires an implementation plan as part of a Fatigue Management Plan. Currently FRA in conjunction with an RSAC working group is developing guidance for the creation of an FRMS implementation plan. Although final guidance document language has not been developed draft language includes the following components for an implementation plan: (1) mapping of existing and future processes, (2) determining any organizational change (e.g., reporting relationships) that may be induced or required by the system, (3) developing a communications plan, (4) creating a fatigue training and education plan, (5) identifying key people whose participation will ensure success, (6) consensus and coalition building, (7) identifying facilitators and inhibitors to successful implementation, (8) monitoring and evaluation of the FRMS, and (9) an evaluation and feedback mechanism.