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On Sunday, June 24, 2012, at 10:02 a.m. central daylight time, eastbound Union Pacific Railroad (UP) freight train ZLAAH-22 and westbound UP freight train AAMMLX-22 collided head-on while operating on straight track on the UP Pratt subdivision near Goodwell, Oklahoma. Skies were clear, the temperature was 89°F, and visibility was 10 miles. The collision derailed 3 locomotives and 24 cars of the eastbound train and 2 locomotives and 8 cars of the westbound train. The engineer and the conductor of the eastbound train and the engineer of the westbound train were killed. The conductor of the westbound train jumped to safety. During the collision and derailment, several fuel tanks from the derailed locomotives ruptured, releasing diesel fuel that ignited and burned. Damage was estimated at $14.8 million. The National Transportation Safety Board determines that the probable cause of this accident was the eastbound Union Pacific Railroad train crew’s lack of response to wayside signals because of the engineer’s inability to see and correctly interpret the signals; the conductor’s disengagement from his duties; and the lack of positive train control, which would have stopped the train and prevented the collision regardless of the crew’s inaction. Contributing to the accident was a medical examination process that failed to decertify the engineer before his deteriorating vision adversely affected his ability to operate a train safely.
TO UNION PACIFIC: Audit your medical records to ensure that all personnel in safety-sensitive positions have adequate documentation of appropriate medical testing.
Original recommendation transmittal letter:
Open - Acceptable Response
Goodwell, OK, United States
Head-On Collision of Two Union Pacific Railroad Freight Trains
Addressee(s) and Addressee Status:
Union Pacific (Open - Acceptable Response)
Safety Recommendation History
We note that you have audited your medical records to ensure personnel in safety sensitive positions, specifically train crews, have adequately documented appropriate medical testing. Further, we note you audited the medical records of all active employees in safety sensitive positions who previously failed the first-level Ishihara exam to confirm subsequent adequate documentation of appropriate medical testing, and that you audited a statistical sample of employees who had passed the first-level Ishihara exam to ensure all results were correctly recorded and reported. However, this recommendation asks you to audit the medical records of all personnel in safety-sensitive positions (which includes train dispatchers) to ensure the appropriate medical testing has been done. Until we receive confirmation that you have audited the medical records of all employees in safety-sensitive positions, and pending our evaluation of your audit, Safety Recommendation R-13-30 is classified OPEN--ACCEPTABLE RESPONSE.
-From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer, Union Pacific: After the Goodwell incident, Union Pacific conducted a thorough audit of its medical records to ensure that its personnel in safety-sensitive positions, specifically its train crews, had adequate documentation of appropriate medical testing. Union Pacific audited medical records for all active safety sensitive employees who previously failed the first-level Ishihara exam to confirm subsequent adequate documentation of appropriate medical testing. Additionally, a statistical sample of employees recorded as passing the first level Ishihara exam was audited to ensure all results were correctly recorded .and reported.
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.
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