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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: Until you have implemented a validated, reliable, and comparable colorvision field test, perform a safety analysis and undertake measures to manage the risk created by the use of an inadequate test. Such measures might include, but are not limited to, restricting crewmembers who have failed primary color vision testing to yard assignments or unsignaled territory.
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 conducted a thorough internal assessment of train crew members who had initially failed their color vision test, and that you have incorporated a medical questionnaire to identify any potential medical issues that would impact vision for employees who fail the first-level Ishihara exam. Further, employees reporting relevant medical conditions and those identified as candidates for a color vision field test are being temporarily assigned to non-safety-related work until they successfully complete the field test, and you have developed and implemented a medical rules training module to ensure that employees in safety-sensitive positions are aware of the reporting requirements regarding significant vision changes. However, please note that one component of this recommendation is that all employees who have failed primary color vision testing on their last medical certification exam be retested using the new procedure. You have told us that you are evaluating the feasibility of retesting employees based on data-driven risk factors. Until we review documentation showing that all employees who had previously failed color vision testing have now passed, and pending our review of your color vision testing program, Safety Recommendations R-13-32 and 33 are classified OPEN--ACCEPTABLE RESPONSE.
-From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer, Union Pacific: Following the Goodwell incident, Union Pacific conducted a thorough internal assessment of train crew members who had initially failed their color vision test. Union Pacific has incorporated a medical questionnaire to identify any potential medical issues that would impact vision for employees who fail the first-level Ishihara exam. Employees reporting conditions of concern are further reviewed and periodic monitoring criteria are established if applicable. Additionally, any employees identified as candidates for a color vision field test are temporarily assigned to non-safety related work until successful completion of the field test. To ensure safety sensitive employees are also aware of reporting requirements regarding significant vision changes, a medical rules training module has also been developed and implemented.
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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