The Accident
On October 8, 2014, at 12:30 p.m. mountain daylight time, a
BNSF Railway (BNSF) conductor died while BNSF local train L-PWR0223-8 I was
pulling nine railroad cars on an industry track on the Pikes Peak Subdivision
near Colorado Springs, Colorado.1 The weather was clear, with light winds and a
temperature of 64°F.
On the day before the accident, the engineer and conductor
had attempted to switch the railroad cars on the industry entry track owned by
Thompson and Sitz Construction, Inc.2 This site consisted of a main industry
entry track and Drennen siding.3 The crew attempted to switch the railroad
cars, but were unable to do so because the industry entry track was occupied by
track maintenance equipment that could not be moved. After consulting with
their supervisor, the crew secured the train on the Drennen siding and were
driven to Denver, where they went off duty. Before departing the Thompson and
Sitz industry track, the conductor and engineer walked the tracks and noted the
position of the railroad cars.They prepared a plan on how they were going to
switch the cars the next day.
On October 8, 2014, at 8:00 a.m—the morning of the accident.,
the engineer, conductor, and an extra board brakeman went on duty in Denver,
Colorado.4 The crewmembers were driven to
Colorado Springs, where they had left their train the previous day.
Upon arrival, the engineer prepared the two locomotives and
the conductor and brakeman released the hand brakes on the four railroad cars
left on the siding the day before. The first task was to enter the Thompson and
Sitz industry entry track.
The conductor coupled the four loaded railroad cars and two
locomotives of the local train to six empty flat railroad cars that were on
track 813 and track 815, which were connected by a switch. (See figure 1.) The
conductor then moved these railroad cars off track 815 and lined the switch for
movement to track 813. The railroad cars were then moved to the end of track
813. The conductor separated three of the railroad cars and had the engineer
pull forward, leaving the three railroad cars on track 813. According to the
brakeman, the handbrakes were applied on these railroad cars before the
switching move was made and the handbrakes were never released.5
The conductor told the engineer to stop the movement when
the railroad cars passed the switch for track 816. The conductor then lined the
switch reverse for railroad movement onto track 816 in preparation for coupling
the train to two empty flat railroad cars on that track. The conductor
instructed the engineer to shove the train back toward track 816. While
positioned on the north side of the two empty flat railroad cars, the conductor
tried several times to couple the train to the cars on track 816, but was
unsuccessful. The engineer informed the conductor that highway traffic had
backed up on a highway-rail grade crossing blocked by their train and that he
wanted to clear the crossing. The conductor agreed and the engineer pulled the
entire train out of the industry tracks and cleared the crossing.
After the highway traffic cleared, the train re-entered the
industry track. The conductor, now on the south side of the train, but still
north of track 813, continued trying to couple with the two flat railroad cars
on track816. After several attempts, the conductor was successful coupling the
railroad cars.
The brakeman stated during his interview with the NTSB investigator
that the conductor celebrated making the coupling. The brakeman said, “She let
out a big hurrah and exclaimed, ‘You know, we got it. We coupled the cars.’”
The conductor then instructed the engineer to pull the railroad cars out of
track 816. Soon after starting the movement, the engineer heard a strange noise
on the radio and stopped the movement. At about the same time, the brakeman
radioed to the engineer to stop the train.
According to the brakeman, he witnessed the conductor
standing between the railroad cars on track816 and track 813, and was standing
about four railroad car-lengths away from her.6 The conductor was between track
816 and track 813 when the railroad cars were finally coupled together. When
the train pulled the railroad cars out of track 816, the conductor became
caught between the railroad cars.The brakeman told the engineer to stop the
movement and went to the conductor. The brakeman instructed the engineer to
back up gently to try to free the conductor. The brakeman realized this was not
working and stopped the movement. The engineer used the locomotive radio to
make an emergency call to the train dispatcher. Meanwhile, a nearby Thompson
and Sitz employee, who also witnessed the event, called 911.7 The brakeman said
that by the time the emergency responders arrived, the conductor had died.
The Investigation
Site Description
There were three tracks in the Thompson and Sitz property.
Track 813 was straight and ended at the company’s back fence. It was used for
unloading lumber from railroad flat cars. Short stub track 815 diverted from
track 813 in the middle of the property on the south side of track813. Track
815 was used for unloading wood chips from railroad cars. Track 816 diverted
from track 813 on the north side and was parallel to track 813 up to the
company’s back fence.
Accident Re-enactment
The postaccident examination showed that the standing
railroad cars on track 813 had insufficient clearance from the railroad cars
moving on track 816 to avoid a collision. During a re-enactment, the cars on
track 816 were moved in the same directionas during the accident. When the
80-foot railroad car negotiated the curvature in the track to pass through the
switch to enter track 813, the distance between the railroad car on track 813
and the moving railroad cars narrowed dramatically. NTSBinvestigators confirmed
that if the railroad cars were in the same position as the day of the accident,
the railroad cars would have made contact. (See figure 2.)
The railroad cars were then placed in the same position as
when the conductor attempted to couple the railroad cars on track 816. The
railroad cars were about 24 inches apart where the conductor was standing
(between tracks 813 and 816) before the conductor instructed the engineer to
pull the railroad cars out of the track.
Railroad car clearance from an adjacent track can be checked
manually. If a person can stand with one foot against the rail and the hand of
their outstretched arm cannot touch the side of the standing railroad car, the
car would be in the clear,in other words, not fouling the adjacent track.8 When
this was done during the postaccident examination, with the standing railroad
cars in their original position on track 813, the railroad car could be touched
with an individual’s hand and, therefore, not clear of moving railroad cars on
track 816. (See figure 3.)
Other Investigative Factors
The portable electronic device records for all crewmembers
were obtained by the NTSB. The records did not indicate any calls or text
messages by the crewmembers at the time of the accident.
The engineer and brakeman were tested for illegal drugs and
alcohol. Postmortem toxicological testing was also performed on the conductor.
The test results for all three crewmembers werenegative.
The railroad cars involved with the accident were inspected
and the coupler mechanisms tested. No mechanical defects were found.
Personnel Information
The 42-year-old conductor had 3 years of railroad experience
and had worked this particular job for the 6 months immediately prior to the
accident. The conductor attended all mandatory training classes, passed all
required tests, and held a current conductor certification.
Work/Rest Cycle
For the 30 days immediately prior to the accident, the
conductor’s work schedule was Monday through Friday. Most days started at 8:00
a.m. when the crew went on duty in Denver. Depending on the workload, the daily
shifts would range from 10 to 12 hours. If the crew stayed overnight in
Colorado Springs, they would often start work at 6:00 a.m. or 7:00 a.m. This
normally occurred 2 days a week. Primarily, the conductor worked a daylight
shift with a nighttime rest period.
General Code of Operating Rules
The Sixth Edition of the General Code of Operating Rules(GCOR)
was in effect at the time of the accident.9 This edition of the GCOR had
several passages that were applicable to the switching safety issue found in
this accident. The applicable passages were as follows:
7.1 Switching Safety and Efficiently [applicable portions]
Do not leave equipment standing where it will foul equipment
on adjacent tracks or cause injury to employees riding on the side of a car or
engine.
If the clearance point is not indicated or visible, determine
the clearance point by standing outside the rail of adjacent track and extend
arm towards the equipment.
8.2 Position of Switches [applicable portion]
When equipment has entered a track, the switch to that track
is not lined away until the equipment has passed the clearance point of the
track.
BNSF Managerial Oversight
Operational Testing
Title 49 Code of Federal RegulationsPart 217 contains
specific requirements for the observation and testing of operating employees while
performing duties. BNSF maintained an operational testing/observation program
to monitor the performance of employees operating trains on the railroad, along
with the employees’ compliance with railroad rules and federal laws.
Over the previous 12 months, BNSF supervisors recorded over
2,300 observations on the120-mile Pikes Peak Subdivision where the accident
occurred. Fifty observations were of employees properly leaving railroad cars
clear of adjacent tracks.
The conductor’s operational testing records had 54 entries
during the previous 12 months. Each entryrepresented an operating or safety
rule performed correctly by the conductor while being observed by a supervisor.
Several entries pertained to the same rule, but were entered on different
dates. It was common for employees who perform repetitive tasks from day to day
to
undergo regular testing on the same rules associated with
the applicable tasks. During the 12-month period, the conductor had 32
observations (with no exceptions noted by supervisors) that entailed the use of
switches, securing equipment, and safety around railroad equipment. There were
five specific entries that indicated the conductor had been observed properly leaving
railroad cars clear of an adjacent track.
BNSF Postaccident Actions
Following the accident, on October 14, 2014, BNSF issued a
safety briefing that gave a brief description of the accident.10 The safety
briefing also explained preventative measures and provided discussion questions
related to fouling tracks. The safety briefing was distributed to all managers,
train crews, engine crews and yard employees throughout BNSF.In addition to the
safety briefing, BNSF included a review and discussion, using visual animation,
surrounding the dynamics of long railroad cars versus short railroad cars
negotiating turnouts in the annual2015 safety training for train, yard, and
engine employees.11 The safety briefing can be found in the public docket for
this investigation.
Probable Cause
The National Transportation Safety Board determines that the
probable cause of the accident was the conductor leaving cars on track 813 with
insufficient clearance to the adjacent track and then instructing the engineer
to move the railroad cars on track 816 before stepping clear of the moving
cars. The conductor’s focus on successfully coupling the railroad cars on track
816 likely contributed to the accident.
For more details about this accident, visit www.ntsb.gov/investigations/dms.htmland
search for NTSB accident ID DCA15FR001.
Footnotes
1 All times in this
report are mountain daylight time.
2 An industry trackis defined as a switching track or series
of tracks serving the needs of a commercial industry other than a railroad;
Thompson and Sitz received loaded wood chip hoppers and flat railroad cars
loaded with lumber for construction projects.
3 The Drennen sidingwas an auxilary track to the main track
near the Thompson and Sitz switching tracks.
4 An extra board employeedoes not have a regular job
assignment. These employees are used to fill an assignment that has been left
open when the regular assigned employee is not available.
5 Postaccident inspection confirmed that handbrakes were
applied on the three railroad cars on track 813.
6 The cars were 80 feet long; therefore, he was about320
feet away.
7 The employee provided a statement to law enforcement that
corroborated the brakeman’s account.
8 Fouling a trackmeans equipment located such that the end
of the equipment is between the clearance point and the switch points leading
to the track where the equipment is standing.
9 General Code of Operating Rules Committee, General Code of
Operating Rules, Sixth Edition, effective April7, 2010.
10 BNSF Safety Briefing, SB-2014-4G, October 14, 2014.
11 This training also addresses multiple topics related to
safety when working with railroad equipment including shoving, position of
switches and derails, restricted speed, and equipment in the foul.