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Safety Recommendation Details

Safety Recommendation R-12-025
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 BNSF RAILWAY: Require all employees and managers who perform or supervise safety-critical tasks to complete fatigue training on an annual basis and document when they have received this training.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate 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: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Open Acceptable Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 7/17/2018
Response: We note that you began fatigue training on a 24-month training cycle in 2013; however, we did not have the opportunity to review the training curriculum until Mr. Ringelman sent it with his February 2018 e mail. We have now reviewed the training curriculum and we are concerned that it may be confusing to your employees and the managers who supervise them. For example, the fatigue training claims at different times that adults need 6, 8, and 9 hours of sleep. Also, although the training discusses circadian rhythm cycles, it does not cover the consequences of shifting sleep time (such as when employees work at night during the week but shift their sleep time on the weekends to coincide with that of family or friends). Research has shown that anything more than a 1 hour shift in sleep time can desynchronize a person’s circadian rhythm. Further, your fatigue training lists several ambiguous alertness strategies, including “Medications,” which seems to imply that employees should medicate themselves to stay alert. We are encouraged that you have implemented a fatigue training program for your employees in safety critical positions, but we believe you should ensure that the training is clear and accurate to prevent confusion. We would appreciate learning about any modifications you make to your training to address these issues. Pending further updates, Safety Recommendation R 12-25 remains classified OPEN--ACCEPTABLE ALTERNATE RESPONSE.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 2/9/2018
Response: -From Ryan E. Ringelman, General Director System Safety: As follow-up to our previous response, BNSF initiated the recommended fatigue training (attachment A) as paii of its annual training programs beginning in 2013, with employees receiving refreshed training on a 24-month training cycle. Each employee's training is recorded and tracked in BNSF' s Learning Management System. BNSF has now completed over two full 24-month training cycles with well over 40,000 total training events, including 10,286 in calendar year 2017. With these actions and the supporting training documentation, BNSF respectfully requests that this recommendation be classified as "Closed-Acceptable Response".

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 1/31/2013
Response: -From Mark A. Schulze, Vice President, Safety, Training, and Operations Support: Turning now to the specific recommendations, we acknowledge NTSB's classifications for R-12-25 and R-12-26, and will follow up with the appropriate Board staff to discuss our expectations for when the requested supporting documentation will be available.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 12/18/2012
Response: The NTSB notes that the BNSF will begin the recommended fatigue training in 2013, on a 24-month training cycle. Pending our receipt of documentation that all employees and managers have completed this training, Safety Recommendation R-12-25 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 8/23/2012
Response: -From Mark A. Schulze, Vice President, Training and Operations Support, BNSF Railway: Fatigue Training Safety Recommendation R-12-25 states that all employees and managers who perform or supervise safety-critical tasks should complete fatigue training on an annual basis and document when they have received this training. BNSF has a long history of fatigue education and innovative fatigue countermeasures. This includes formal fatigue training that was outlined in your correspondence that has been available to all employees since 2004. Additionally BNSF has had in place other fatigue countermeasures such as: • Allowing employees to lay-off work due to fatigue • Labor agreements that enable our employees to request additional rest beyond the statutory minimum • A formal Napping Policy instituted over a decade ago (1997) • Implementation of innovative work/rest agreements that provide for predictable time off for our employees (e.g. 6 days onl2 days off) • Pre-approved layoff requests for days off • 7 a.m. markup. allowing for midnight placement to occur at 7 a.m. the next morning • Improved standards for lodging surrounding sleeping quarters • Smart phone technology with customizable alerts to notify employees of upcoming on duty time BNSF understands the benefit that fatigue training may provide employees to ensure that they have the knowledge and tools to combat fatigue. Based on this, BNSF intends to include fatigue training in our mandatory training program beginning in 2013. That being said, BNSF has concern about the frequency that NTSB recommends for this training. Most training requirements mandated by the Federal Railroad Administration (FRA) for safety-sensitive activities such as engineer and conductor certification, hazardous material handling and power brake law are on a 36-month cycle. BNSF typically trains its employees on FRA required training every other year (a cycle that exceeds the FRA training cycle requirement). BNSF intends to schedule the fatigue training for our current employees in our existing 24-month training cycle starting in 2013. We will additionally include the fatigue training for new hire employees that will perform safety-sensitive tasks. BNSF intends to apply this recommendation for training to employees and managers that are described in 49 CFR part 209.303 as follows: This subpart applies to the following individuals: (a) Railroad employees who are assigned to perform service subject to the Hours of Service Act (49 U .S.C. Chapt. 211) during a duty tour, whether or not the person has performed or is currently performing such service, and any person who performs such service. (b) Railroad employees or agents who: (1) Inspect, install, repair, or maintain track and roadbed; (2) Inspect, repair or maintain, locomotives, passenger cars, and freight cars; (3) Conduct training and testing of employees when the training or testing is required by the FRA's safety regulations; or (4) Perform service subject to the Transportation of Hazardous Materials laws (49 U .S.C. Ch. 51), or any regulation or order prescribed thereunder; (c) Railroad managers, supervisors, or agents when they: (1) Perform the safety-sensitive functions listed in paragraphs (a) and (b) of this section; (2) Supervise and otherwise direct the performance of the safety-sensitive functions listed in paragraphs (a) and (b) of this section.