Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation R-13-016
Details
Synopsis: On September 30, 2010, about 4:05 p.m. central daylight time, a southbound Canadian National Railway freight train collided head on with a northbound Canadian National Railway freight train near Two Harbors, Minnesota. The collision occurred near milepost 13.5 on Canadian National Railway’s Iron Range Subdivision. The trains were operating in nonsignaled territory. The northbound train had 118 empty iron ore railcars and had authority to operate on the single main track. The southbound train had 116 railcars loaded with iron ore and did not have authority to operate on the single main track. The crew of the southbound train entered the main track after failing to properly execute an after-arrival track authority. A total of three locomotives and 14 railcars derailed. All five crewmembers on the two trains were injured and transported to hospitals. Four crewmembers were treated and released; one crewmember remained hospitalized for further treatment. Canadian National Railway estimated damages at $8.1 million. As a result of its investigation of this accident, the National Transportation Safety Board (NTSB) makes recommendations to the Federal Railroad Administration, Canadian National Railway, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, Canadian Pacific Railway Limited, Kansas City Southern Railway Company, Norfolk Southern Railroad, and Union Pacific Railroad. The NTSB also reiterates previous recommendations to the Federal Railroad Administration, BNSF Railway, and the American Short Line and Regional Railroad Association. The NTSB also reiterates and reclassifies recommendations to the Federal Railroad Administration.
Recommendation: TO CANADIAN PACIFIC RAILWAY LIMITED, KANSAS CITY SOUTHERN RAILWAY COMPANY, NORFOLK SOUTHERN RAILROAD, AND UNION PACIFIC RAILROAD: Discontinue the use of after-arrival track authorities for train movements in nonsignaled territory not equipped with a positive train control system.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Two Harbors, MN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10FR009
Accident Reports: Collision of Two Canadian National Railway Freight Trains
Report #: RAR-13-01
Accident Date: 9/30/2010
Issue Date: 3/8/2013
Date Closed:
Addressee(s) and Addressee Status: Canadian Pacific Railway (Closed - Unacceptable Action)
Kansas City Southern Railway Company (Open - Unacceptable Response)
Norfolk Southern Corporation (Closed - Unacceptable Action)
Union Pacific (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Canadian Pacific Railway
Date: 12/3/2013
Response: We are disappointed that the CP continues to believe that an overall prohibition on the use of after-arrival track authorities would present operational challenges in certain instances, as we remain convinced that the use of such orders presents unacceptable and unnecessary safety risks and will continue to result in accidents. After-arrival track authorities are very vulnerable to human error, such as the behavioral distractions that contributed to the crew’s disregard of the orders, the inadequate crew resource management, and the crew communication problems that occurred in the May 19, 2004, Gunter, Texas accident. Our recent investigation report on the Two Harbors accident describes our concerns in detail. Despite our continued belief in the recommendation’s merit, given the CP’s position, Safety Recommendation R-13-16 is classified CLOSED—UNACCEPTABLE ACTION.

From: Canadian Pacific Railway
To: NTSB
Date: 9/24/2013
Response: -From Robert A. Johnson, Vice President Operations, Southern Region: I am writing to you in response to the National Transportation Safety Board’s (NTSB) July 29, 2013 letter Mr. Doug McFarlane, Sr. VP US Operations, regarding recommendation R-13-16 to Canadian Pacific. I am disappointed that the NTSB has not accepted CP’s May 29th response and have left this recommendation classified, “Open, Unacceptable Response”. As we outlined in our letter of May 29th, CP’s track record of safely using After Arrival Track Warrants proves that the process can be used safely. CP has a robust procedure that has accountability and redundancy built into the process. Furthermore, it is quite apparent that the use of After Arrival Track Warrants is still prevalent in the North American railroad industry. There is a clear need for this process in enabling safe and efficient railroad operations. Finally, CP finds it inconsistent that regulatory agencies on one hand suggest redundancy in crew and dispatcher communication processes, as in the case of Emergency Order 28, yet on the other hand suggest that the same form of process redundancy is insufficient to ensure safe operations in the case of the use of After Arrival Track Warrants. CP has not examined the After Arrival Track Warrant process in isolation. Instead we have taken a systematic approach to examining all interrelated processes, their inherent risks and the potential of unforeseen consequences that can occur if change is not properly considered. It was only after following this process that CP elected to put sufficient risk mitigation in place to ensure not only safety in the After Arrival Warrant process, but also ensure that unforeseen risks are avoided, such as dispatcher task overload, blocked public road crossings and impedance to the operation generally. It is CP’s view that well educated train and engine crew members, trained to execute well designed operating procedures, is sufficient to ensure safe operations. CP’s track record in this regard is a clear indication that its processes are safe. In light of the aforementioned actions taken by CP, I respectfully request that recommendation R-13-16 be classified closed – acceptable alternate action. If you or your staff have any questions or would need any additional information please do not hesitate to contact me. Thank you and I look forward to hearing from you in the near future.

From: NTSB
To: Canadian Pacific Railway
Date: 7/29/2013
Response: We are disappointed that the CP continues to issue more than 23,000 after-arrival track authorities per year in non-signaled territory, as we believe that this practice presents unacceptable and unnecessary safety risks. We note that the CP currently issues 80 percent of its after-arrival authorities on non-signaled track on which the railroad plans to install a signal system by the end of 2017. Although we are encouraged that the CP shares our interest in improving railroad safety regarding best operating practices in non-signaled territory, we have investigated too many accidents in which avoidance of the accident depended on the use of an operating rule or standard practice that proved insufficient to prevent an accident caused by human error. Accordingly, we remain convinced that the use of after-arrival track authorities in non signaled territory is a flawed process with inherent risks that will inevitably result in future accidents. Our investigation report on the Two Harbors accident describes our concerns in detail. I urge you to review this report and reconsider your position on this important safety issue. Pending implementation of the recommended action, Safety Recommendation R-13-16 is classified OPEN—UNACCEPTABLE RESPONSE. The NTSB points out that another Class I railroad has discontinued the use of such authorities. We encourage you to follow its lead and do the same.

From: Canadian Pacific Railway
To: NTSB
Date: 5/29/2013
Response: -From Doug McFarlane, Senior Vice President, U.S. Operations, Canadian Pacific: I am writing to you in response to the National Transportation Safety Board’s (NTSB) March 8, 2013 letter issuing recommendation R-13-16 to Canadian Pacific. This recommendation promulgated from NTSB’s investigation into the September 30, 2010 accident in which two Canadian National Railway freight trains collided near Two Harbors, Minnesota. The recommendation to Canadian Pacific (CP) requests the discontinuance of the use of after-arrival track authorities for train movements in nonsignaled territory not equipped with a positive train control system. CP uses after arrival track authorities quite extensively on its network. In fact, approximately 24,000 such authorities are issued on an annual basis, with 80% of the total issued on the Portal, ND to Glenwood, MN corridor. CP employs a set of rigorous processes that ensure safety of the system. The safety inherent in CP’s processes is proven out by the fact that CP has not recorded any incidents that have been attributed to the use of after-arrival authorities. CP after arrival issuance processes are described as follows: 1. Train Dispatcher Accountability: • Train Dispatcher will indicate the Total Lines Checked and then each individual line number. • Crew will repeat back to train dispatcher. • Train dispatcher before giving time of completion will again indicate total lines checked and line numbers. • If track warrant indicates a line 7 After Arrival, the train dispatcher will advise the train crew that this track warrant contains a meet. 2. Train Crew Accountability - governed by GCOR 6.2.1 Train Location which reads: Trains or maintenance of way employees who receive authority to occupy the main track after the arrival of a train or to follow a train must ascertain the train’s location by one of the following methods: • Visual identification of the train. • Direct communication with a crew member of the train. Or • Receiving information about the train from the train dispatcher or control operator. 3. GCOR 6.2.1 is supplemented by CP Timetable Special Instructions as follows: The main track or controlled siding must not be entered or fouled until the movement has passed the point where the track will be entered or fouled. Note: Visual identification must be made by both a crew member and engineer and then communicated to each other the number of the designated engine of each train they are required to identify as arriving. If either are unable to observe the arrival of the train or both are unable to communicate with a member of the crew for such train, the train dispatcher must be contacted for verification of train location before proceeding. 4. Employees are also governed by Timetable Special Instruction: 6.1.1 Verbal Communication – New Rule added as follows: Crew members are jointly responsible to make verbal communication between each other and confirm it is properly understood when any of the following work activities apply to them: • switches are properly lined and/or locked, visually confirming route to be used, • derails are properly applied or removed and visually checked, • handbrakes are applied or released, • shove movements are protected, • employees are getting on or off moving equipment, • employees crossing between equipment, • when a situation changes, • when entering a track with restricted clearance, • when cars are left out to foul another track during switching, • before entering a classification track in a hump yard, • before entering a main track to confirm movement authority, • before reporting a track release. This rule will also apply to other employees, where applicable. CP’s exceptional safety record is directly attributed to the time tested success of the processes described above. In addition, CP is currently working on a project that is planned to implement Centralized Traffic Control in the Portal, ND to Glenwood, MN corridor. CP currently plans to have this project completed by the end of 2017. In light of the aforementioned actions taken and underway by CP, I respectfully request that recommendation R-13-16 be classified closed – acceptable alternate action. If you or your staff have any questions or would need any additional information please do not hesitate to contact me. Thank you and I look forward to hearing from you in the near future.

From: NTSB
To: Kansas City Southern Railway Company
Date: 7/29/2014
Response: We are disappointed that you believe that the use of after-arrival track authorities can be a safe and efficient option, as we remain convinced that the use of such orders presents unacceptable and unnecessary safety risks and will continue to result in accidents. After-arrival track authorities are very vulnerable to human error, such as the behavioral distractions that contributed to the crew’s disregard of the orders, the inadequate crew resource management, and the crew communication problems that occurred in the May 19, 2004, Gunter, Texas accident. Our investigation report of the September 30, 2010 Two Harbors, Minnesota accident describes our concerns about the use of after-arrival authorities in detail. We therefore request that you reconsider your position on this issue. Pending your further response, Safety Recommendation R-13-16 is classified OPEN—UNACCEPTABLE RESPONSE.

From: Kansas City Southern Railway Company
To: NTSB
Date: 6/10/2014
Response: -From Steven E. Truitt, Vice President Safety and Standards: In reference to R-13-16 in which NTSB recommends discontinuing the use of after-arrival track authorities for train movements in non-signaled territory not equipped with a positive train control system, our records indicate a response was offered to the NTSB on July 13, 2012 by then KCS Vice President Transportation, Mark Redd. Mr. Redd addressed the response to a Mr. Mark Jones of NTSB, which may not have been the correct routing. KCS did experience an unfortunate incident involving an after-arrival authority on June 28, 2005 in which a west bound freight train departed the yard at Jackson, MS without properly verifying the correct train to be met, resulting in a head on collision at MP 101.6 on the Meridian Subdivision. KCS has since implemented measures to eliminate future occurrence of this nature by making changes to some of our rules and operating practices. KCS no longer issues after arrival authorities to any train located within Yard Limits. The following requirements must also be complied with prior to any train acting upon an after arrival authority as well. • The authority must include the words “Not in effect until after the arrival of engine(s) (direction) at (location)”. • The assigned engineer will be present and alert the entire time the crew member copies and activates the authority. • Following the copying and issuance of the authority the assigned engineer will conduct a job briefing with the train dispatcher to confirm he or she has knowledge that the authority they received contains a “Not in effect until after the arrival of” condition requiring their train to be met or passed by another train(s). • Crew members are to comply with all requirements of GCOR rule 6.2.1 (Train Location) before proceeding on this authority. It is the position of KCS these requirements along with proper education of train crew members and train dispatchers ensure after arrival authorities to be a very safe and efficient option.

From: NTSB
To: Kansas City Southern Railway Company
Date: 5/13/2014
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Because we have received no reply from you regarding Safety Recommendation R-13-16, -26 or -27, these recommendations are classified OPEN—UNACCEPTABLE RESPONSE. Please inform us within 90 days regarding actions you have either taken or plan to take to implement them, preferably electronically.

From: NTSB
To: Kansas City Southern Railway Company
Date: 12/18/2013
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Normally, we expect action to address our recommendations to be completed within 5 years. Because we have received no reply from the KCSR regarding Safety Recommendations R-07-30, R-13-16, or R-13-26 or -27, please inform us within 90 days about the status of actions to implement them, preferably electronically at the following e-mail address: correspondence@ntsb.gov.

From: NTSB
To: Norfolk Southern Corporation
Date: 10/29/2013
Response: We are disappointed that the NS (1) continues to believe that the continued use of after arrival track authorities is safe and (2) remains convinced that the information contained in these authorities provides its crews with valuable information regarding a pending meet. Because the NS does not believe the recommended action is needed and does not plan further action, Safety Recommendation R-13-16 is classified CLOSED—UNACCEPTABLE ACTION.

From: Norfolk Southern Corporation
To: NTSB
Date: 7/18/2013
Response: -From C.W. Moorman, Chairman and Chief Executive Officer: Please reference your letter, dated June 26, 2013, requesting Norfolk Southern reconsider its position regarding the NTSB Safety Recommendation R-13-16 to Norfolk Southern Railroad reading: "Discontinue the use of after-arrival track authorities for train movements in non-signaled territory not equipped with a positive train control system." As stated in our response dated March 25, 2013, Norfolk Southern believes the outright banning of "after-arrival authorities" is not the best answer to addressing incidents such as the September 30, 2010 head-on collision between two CN freight trains near Two Harbors, Minnesota. As requested, Norfolk Southern has reviewed the NTSB report regarding the Two Harbors, Minnesota incident and continues to believe that safety is best served by the continued use of "after-arrival authorities". We remain convinced that the information contained in these authorities provides our crews with valuable information regarding a pending meet. Norfolk Southern has surrounded the use of"after-arrival authorities" with rules intended to assist crews in maintaining situation awareness. Additionally, our Unified Train Control Dispatching System (UTCS) restricts the number of trains that can be met using an "afterarrival authority" to one train in non-signaled territory. In summary, Norfolk Southern appreciates and supports the efforts to improve safety and stands willing to work with the NTSB and FRA to develop alternative best practices for operating in non-signaled territory.

From: NTSB
To: Norfolk Southern Corporation
Date: 6/26/2013
Response: We are disappointed that the NS continues to issue more than 13,000 after-arrival authorities per year in non-signaled territory, as we believe that this practice presents unacceptable and unnecessary safety risks. Although we are encouraged that the NS shares our interest in improving railroad safety regarding best operating practices in non signaled territory, we have investigated too many accidents in which the avoidance of the accident depended on the use of an operating rule or standard practice that proved insufficient to prevent an accident caused by human error. Accordingly, we remain convinced that the use of after-arrival track authorities in non signaled territory is a flawed process with inherent risks that will inevitably result in future accidents. Our investigation report on the Two Harbors accident describes our concerns in detail. I urge you to review this report and reconsider your position on this important safety issue. Pending the discontinuance of after-arrival track authorities in non-signaled territory, Safety Recommendation R-13-16 is classified OPEN—UNACCEPTABLE RESPONSE. Another Class I railroad has discontinued the use of such authorities. We encourage you to follow their lead and do the same.

From: Norfolk Southern Corporation
To: NTSB
Date: 3/25/2013
Response: -From C.W. Moorman, Chairman, President and Chief Executive Officer: Please reference the NTSB Safety Recommendation R-13-16 to Norfolk Southern Railroad reading: "Discontinue the use of after-arrival track authorities for train movements in non-signaled territory not equipped with a positive train control system." Norfolk Southern shares the NTSB interest in improving railroad safety regarding best operating practices in non-signaled territory. Specific to the NTSB recommendation R- 13-16, Norfolk Southern believes the information contained in these authorities provides our crews with valuable information regarding a pending train meet. Norfolk Southern has surrounded the use of "after-arrival authorities" with rules intended to assist crews in maintaining situational awareness, improve communication between crews, and to enhance the overall safety of operations. Norfolk Southern believes the elimination of these authorities will increase delay to the public and emergency responders at highway-rail grade crossing and have a negative impact on train operations. For example, during 2012 we issued 13,864 "after-arrival authorities" in non-signaled territory. Banning the use of these authorities will reduce planning by the Train Dispatcher and unnecessarily delay trains and the public during train meets. This delay will result from trains remaining stopped until the opposing train has cleared the siding, restored the switch, and cleared any authorities. Additional train delay will result if highway-rail crossings must be cut. Additionally, the workload and stress on the Train Dispatchers will increase due to working in a reactionary mode rather than in a planning environment. Norfolk Southern believes the outright banning of "after-arrival authorities" is not the best answer to addressing incidents such as the September 30, 2010 head-on collision between two CP freight trains near Two Harbors, Minnesota. In summary, Norfolk Southern has reviewed our rules and practices for operating in non-signaled territory and believes safety is best served by the continued use of "after arrival authorities" at this time. However, Norfolk Southern appreciates and supports the efforts to improve safety and stands willing to work with the NTSB and FRA to develop alternative best practices for operating in non-signaled territory.

From: NTSB
To: Union Pacific
Date: 1/25/2018
Response: We are disappointed that you are unwilling to address this recommendation, as we believe that not doing so presents unacceptable and unnecessary safety risks. Although federal regulations do not prohibit after-arrival track warrants, other railroads have discontinued their use. Although we are encouraged that you have changed your operating and dispatching rules to ensure safety when using after-arrival authority in nonsignaled territory, we remain concerned because we have investigated too many accidents that occurred when an operating rule or standard practice proved insufficient to prevent an accident caused by human error. Because your letter indicates that you do not intend to take further action to satisfy Safety Recommendation R 13 16, it is classified CLOED--UNACCEPTABLE ACTION.

From: Union Pacific
To: NTSB
Date: 5/2/2017
Response: -From Rodney Doerr, Vice President- Safety, Chief Safety Officer: As mentioned in our earlier response, Union Pacific is currently unable to discontinue the use of after arrival authorities for train movements in nonsignalized territory. As laid out for you in our initial response, we have implemented several additional safety measures to increase the layers of safety redundancy and avoid any communication errors. We continue to vigorously address and mitigate any additional risks associated with this type of train movement, as we are committed to unparalleled safety of our operations.

From: NTSB
To: Union Pacific
Date: 3/27/2017
Response: We are disappointed that you are unwilling to comply with this recommendation, as we believe that not doing so presents unacceptable and unnecessary safety risks. Although the use of after arrival is not prohibited by federal regulations, other railroads have discontinued the use of after-arrival track warrants. Although we are encouraged that you have made changes to your operating and dispatching rules to ensure safety when using after-arrival authority in nonsignaled territory, we have investigated too many accidents that occurred when an operating rule or standard practice was used that proved insufficient to prevent an accident caused by human error. Therefore, Safety Recommendation R-13-16 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: Union Pacific
To: NTSB
Date: 12/16/2015
Response: -From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer, Union Pacific: Union Pacific is unable to comply with NTSB's recommendation in this instance. After arrival authorities are used in "dark" territory or in places where signal systems governing train movements are not utilized. Authorization comes from the train dispatcher. After this recommendation, as relayed to NTSB in earlier correspondence, Union Pacific made several changes to our operating and dispatching rules to ensure safety when utilizing after arrival authority. Additionally, Union Pacific's Positive Train Control (PTC) system will provide certain protections for the movement of trains by authorities which include after arrival conditions. Based on an analysis of data for a 30-day period in 2015, 82% of after arrival authorities issued specified an arrival location that falls within UP's currently-planned PTC territory. When PTC is implemented on all Union Pacific lines, all train movements under such authorities will be made under PTC protection, but until that point, we remain dedicated to the safety of operations utilizing after arrival authorities.

From: NTSB
To: Union Pacific
Date: 10/26/2015
Response: This letter concerns the 12 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the Union Pacific Railroad (UP) between 2006 and 2014. Enclosure 1 is a list of these recommendations; Enclosure 2 is a copy of the correspondence history regarding them. Based on information contained in your February 24, 2015, update, Safety Recommendations R 13 26 and R-14-56 were classified “Open—Acceptable Response,” on August 3, 2015. See Enclosures 3 and 4. We are concerned because we have not received updates regarding action either taken or planned to address the remaining 10 open recommendations for some time?in some cases, for nearly 5 years; for others, not at all. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we request an update as soon as possible regarding your plans or actions to address these 10 remaining recommendations.

From: NTSB
To: Union Pacific
Date: 5/13/2014
Response: Because we had not received any information from you over the past year regarding actions being taken in response to this recommendation, we recently contacted Mr. Cecil Copeland, General Director for Operating Practices. On March 20, 2014, Mr. Copeland replied that you do not plan to implement this recommendation. We remain convinced that the use of after arrival track authorities in non signaled territory is a flawed process with inherent risks that will result in future accidents. Our investigation report on the Two Harbors accident describes our concerns in detail. I urge you to review this report and reconsider your position on this important safety issue. The report may be found at http://www.ntsb.gov/doclib/reports/2013/RAR1301.pdf. In the meantime, pending implementation of the recommended action, Safety Recommendation R-13-16 is classified OPEN—UNACCEPTABLE RESPONSE.

From: Union Pacific
To: NTSB
Date: 3/20/2014
Response: -From Cecil E. Copeland, General Director, Operating Practices, Union Pacific Railroad: At this time we do not plan on changing our operation regarding, "After the Arrival" authorities. We had made several changes to our operating and dispatching rules and our CAD dispatching system to ensure safe operation in use of "After the Arrival" authorities . The following changes made were to GCOR 6.2.1. We modified this rule in 2010 to disallow visual identification as a means of determining train location before another train can act on the Track Warrant box 7 "After the Arrival": •GCOR Rule 6.2.1: Train Location, Trains…who receive authority to occupy the main track after the arrival of a train…must ascertain the train’s location by one of the following methods: • Visual identification of the train • Direct communication with a crew member of the train or • Receiving information about the train’s location from the train dispatcher or control operator We also modified Train Dispatcher rule 26.6 and made a modification to the CAD dispatching system, In non-signaled TWC territory, a train receiving a track warrant containing a Box 7 must be stopped at the meeting point prior to the issuance of the track warrant. CAD system was modified to provide the verification of the train ID before the track warrant issuance can be completed. Verifying any train(s) listed on an “After Arrival” track warrant – the CAD system modified to enforce an additional confirmation step – the crew reads back the unit number(s) on the “After Arrival” to the dispatcher, who types them into the CAD edit check function. Unless the numbers agree, the warrant cannot be OK’d.