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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: Replace your color vision field test with a test that has established and acceptable levels of reliability, validity, and comparability to ensure that certified employees in safety-sensitive positions have sufficient color discrimination to perform safely.
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 completed an overhaul of the color vision field test and developed new standardized color vision field test protocols, increased the number of signals tested, established multiple versions of the test reflecting various light sequences, established time requirements, and designed a new light cannon test device for consistent application. The field testing devices were deployed in 2016, and you are considering a comprehensive validation process in conjunction with the FRA. We would like to review how the light cannon device functions, how it is used, and the associated testing parameters. Until we receive and review that additional information, Safety Recommendation R-13-31 is classified OPEN--ACCEPTABLE RESPONSE.
-From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer, Union Pacific: Union Pacific has recently completed an overhaul of its color vision field test. Union Pacific developed new standardized color vision field test protocols, increased the number of signals tested, established multiple versions of the test reflecting various light sequences, established time requirements and designed a new light cannon test device for consistent application. This process and light cannon final design reflects input and feedback received from expert reviewers. Implementation of the new process will be finalized by December 31, 2015. More comprehensive validation steps are currently being considered in conjunction with guidance from the Federal Railroad Administration.
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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