Collision Between Two BNSF Railway Company Freight Trains Near

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• Collision Between Two BNSF Railway Company
  Freight Trains Near
• Gunter, Texas
• May 19, 2004

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NTSB Team

• Mike Flanigon IIC/Report Writer
• Russ Gober Operations
• Rick Narvell Human Performance
• Ruben Payan Event Recorders
• Dave Watson Track Mechanical
• Kathleen Curry Editor
• Dr. Mitch Garber Medical Officer
• Gina John Graphics
• Christy Spangler Graphics
• Over 4000 staff work hours

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Parties

• Federal Railroad Administration
• BNSF Railway Company
• Brotherhood of Locomotive Engineers and Trainmen
• United Transportation Union

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Courtesy of Dallas Morning News
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Issues Discussed

• Informal communication of proposed meeting points
• After-arrival track warrants in dark territory

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Human Performance
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Communications Between the Dispatcher and the
BNSF 6789 South Train Crew
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Track Warrant Rules

• Identify trains by
• - railroad initials
• - engine number
• - direction
• Southbound train
• - BNSF
• - 6789
• - South

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Nicknames
BNSF 6789 South BNSF 2917 North BNSF 6351 North
Doni Rock 641 Sherman Rock
Doni Madill 641 Job Sherman Rock Train
Doni Train Sherman Switcher Sherman Clark Rock Train
Road Switcher Am Rock
Rock Train
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Dispatcher Communicationswith the BNSF 6789 South

• Ill roll up the 641 job and have you meet
  them at Dorchester is whats going to be.

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Dispatcher Communicationswith the BNSF 6789 South

• Sherman Switcher is gonna clear up for you,
  and well just take you to Prosper to meet the
  Sherman Clark Rock Train

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Dispatcher Communicationswith the BNSF 6789 South

• youre going to hold there till the Sherman
  Rock, excuse me, until the Sherman Switcher
  clears up at Dorchester. Then Ill take you guys
  on south to Prosper to meet the Sherman Rock
  Train.

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BNSF 6789 South Final Track Warrant

• BNSF 6789 South crew was issued their final track
  warrant at 539 p.m.
• Proceed to Hebron after arrival of the BNSF 6351
  North.
• BNSF 6789 South proceeded south without waiting.
  

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BNSF 6789 South Crews Decision to Prematurely
Depart Dorchester

• BNSF 6789 South crew was informed on four
  occasions they would meet one train at
  Dorchester.
• Referred to as the 641 job, the 641, and the
  Sherman Switcher.
• Never referred to by its engine number and
  direction.
• Crew expected to meet one train at Dorchester.

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BNSF 6789 South Crews Decision to Prematurely
Depart Dorchester (cont.)

• BNSF 6789 South was also informed on two
  occasions that beyond Dorchester they would meet
  a second train.
• Referred to as the Sherman Clark Rock Train and
  the Sherman Rock Train.
• Not told of the change in plans.

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Conclusion

• Had the dispatcher routinely referred to the
  trains by their engine numbers - the
  identification mechanism required in mandatory
  directives - it would have reinforced the need to
  verify engine numbers when the trains met.

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Conclusion

• Informal communications between the dispatcher
  and train crews regarding authority limits, train
  names, and meeting or stopping points may lead to
  misunderstandings and errors.

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Operations
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Track Warrant Control

• Verbal directives
• After arrival, mark Box 7 on form
• Cannot move until after arrival of specific train
• Visually confirm engine number
• Confirm location by radio number

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After-Arrival Track Warrants

• Issued in advance of train movement
• Mandatory compliance
• Errors can lead to conflicting movements

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After-Arrival Track Warrants

• Accurate communications
• Absolute compliance
• No real time location information

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Previous Accidents

• Smithfield, West Virginia - 1996
• Devine, Texas - 1997
• Clarendon, Texas - 2002

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Recommendation R-98-27

• Advised FRA to permanently discontinue the use of
  after-arrival orders in non-signaled territory.
• Closed Unacceptable Action

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Conclusion

• Had the FRA required railroads to permanently
  discontinue the use of after-arrival orders in
  dark territory as advised in Safety
  Recommendation R-98-27, this accident would
  not have happened.

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