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Executive Summary
On July 16, 2013, at about 1:20 a.m., central daylight
time, westbound Union Pacific Railroad (UP) freight train MSIDV16
unexpectedly encountered a hand-operated main tracks witch at MP 288 in the
reverse position diverting the train from the main track onto two adjacent
tracks at the Sharon Springs subdivision in Hays, Kansas.
The switch was not equipped with technology to warn
oncoming trains that it was in the reverse position.
At the time of the accident, the train was traveling in no
signaled track warrant territory at a timetable speed of 49 mph.
The lead locomotive collided with standing cars on the
spur track.
Diesel fuel leaked from the ruptured locomotive fuel
tanks, ignited, and burned.
The three crew members were injured.
Damage was estimated by the UP to be $1.4 million.
Probable Cause
The National Transportation Safety Board determines that
the probable cause of the accident was the failure of the brakeman of train
LDG8915 to return a main track switch to the normal position after the crew
had secured the train on a siding track.
Contributing to the accident was the inability of the crew
of train MSIDV 16 to determine the position of the main track switch in no
signaled territory.
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Previous NTSB
Recommendations
Following the January 6, 2005, accident at Graniteville,
South Carolina, the NTSB made the following safety recommendation to the Federal
Railroad Administration (FRA) (aka: the railroad lobby):
Require that,
along main lines in non-signaled territory, railroads install an automatically
activated device, independent of the switch banner that will, visually or
electronically, compellingly capture the attention of employees involved with
switch operations and clearly convey the status of the switch both in daylight
and in darkness. (R-05-14)
After completing the Bettendorf, Iowa, accident
investigation, the NTSB reclassified Safety Recommendation (R-05-14) from
“Open—Acceptable Alternate Response,” to “Closed―Superseded ”by Safety
Recommendation (R-12-27), and issued the following new recommendations to the
FRA, aimed at addressing the hazard of switch misalignments:
Require railroads
to install, along mainlines in non-signaled territory not equipped with
positive train control, appropriate technology that warns approaching trains of
incorrectly lined main track switches sufficiently in advance to permit
stopping. (R-12-27)
Revise Title 49 Code
of Federal Regulations Section 218.105(d) (1) to require that, until the
appropriate switch position technology is installed on main track switches in
non-signaled territories that are not equipped with positive train control,
train crews releasing track authority to the dispatcher must hold job briefings
with the dispatcher and clearly convey the position of all main track switches
that were used prior to releasing track warrant authority. (R-12-28)
Require that
until appropriate switch position warning technology is installed on main track
switches (in non-signaled territory not equipped with positive train control),
when a main track switch has been reported relined for a main track, the next train
to pass the location approach the switch location at restricted speed. That
train crew should then report to the dispatcher that the switch is correctly
lined for the main track before trains are allowed to operate at maximum
authorized speed. (R-12-29)
These
recommendations are for additional layers of protection intended to prevent
accidents due to single point failures.
However, in response to these recommendations, the FRA
responded by letter to the NTSB on December 28, 2012, stating in part, “The
preliminary cost-benefit analysis conducted related to this recommendation shows
that rulemakings cannot be justified as having benefits outweighing cost.”
The NTSB replied to the FRA on April 18, 2013,“…we urge the
FRA to consider an appropriate alternate means of warning approaching trains of
incorrectly lined main track switches. ”Pending completion of a plan for doing
this, Safety Recommendation R-12-27 is classified “Open—Unacceptable Response.”