Western Railroad Discussion > "Final" NTSB Accident Report Issued on BNSF Wreck - June 28, 2016

I could be wrong, but I get the impression that this is the "final" accident report on the head-on collision of two BNSF trains at Panhandle, TX on June 28, 2016.  

Obstructive Sleep Apnea, prescription drugs, over the counter medication and resulting lack of ability to safely operate machinery are the known contributing factors, along with the lack of reporting of certain medical conditions to their employer.

It took nearly THREE years for this "final" report to be completed, perhaps due to the total destruction of each trains' lead engines and the unavailability of the associated event recorders and outward facing camera equipment and video.

https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1902.pdf

I am not trying to generate any hard feelings here, but I do think it helpful to recall all of the speculation that happened when this accident first occurred.
 
http://www.trainorders.com/discussion/read.php?1,4074991,page=1
 
 
 
 



Edited 1 time(s). Last edit at 06/24/19 07:51 by ldstephey.

Working on the railroad is like living a life of continuous jet lag.

The 2016 post reads like a bad YouTube comment thread. There were 3 *theories* put forth: the striking train's crew disregarded
signals account being incapacitated by carbon monoxide or a bad order toilet. Also, *planned* suicide (as if there's any other type).
At least nobody suggested extraterrestials.

It's not until the final response on the third page does a poster suggest the actual reason, that the crew was asleep. 

Robert Pierce
Sugar Land, TX
SWRails.com

I don’t see enough in this brief to answer all the questions I would have.  Just enough for the conclusion they came up with.  I’m sure they investigated what the Eastbound crew did during their off duty time.  30 and 60 hours off seems pretty generous compared to the olden days of 15’59” and back in 8 hours.

OliveHeights Wrote:
-------------------------------------------------------
> I don’t see enough in this brief to answer all
> the questions I would have.  Just enough for the
> conclusion they came up with.  I’m sure they
> investigated what the Eastbound crew did during
> their off duty time.  30 and 60 hours off seems
> pretty generous compared to the olden days of
> 15’59” and back in 8 hours.

Are there more rail collisions now than there were in the old days, say, the 1950s?

My guess is the % of accidents compared to train starts is way down, now.

OliveHeights Wrote:
-------------------------------------------------------
>  I’m sure they
> investigated what the Eastbound crew did during
> their off duty time.  30 and 60 hours off seems
> pretty generous compared to the olden days of
> 15’59” and back in 8 hours.

I've never seen an accident investigation that stated that the (probably) many lineups that were issued during the copious rest time were examined. I have an example that I use regularly that involves a "fully rested" crew that was running on no sleep because of a series of bogus lineups - sleep now, no, stay up for a while, no sleep now, no stay up now, no sleep n....you're called.

I had many arguments, knock-down-drag-out fights, and repeated threats over not putting out a sufficient number of wrong and useless lineups instead of constructing one that was accurate as posible for at least 16 hours and pretty good for 24. Every shift, I had to start from scratch because the previous shift covered up to exactly the begining of mine. That was the way it was always done and was the root of the myriad of useless lineups. The same disregard applied to the gandys. Twice a day, useless lineups full of bogus trains were issued, basically keeping all of the work in he clear for trains that were not coming. Lineups were one reason for getting off of the chief jobs.

...in an accident investigation report - never!

TAW

Report shows the striking train crew unresponsive to radio and signal compliance for up 19 minutes before the collision. I wonder was the alerter functioning and when was it last tested. Nothing in the report except the crews medical conditions and the conclusion the crew must have been asleep.

Is there a protocol to follow when dispatch loses contact with a crew?


AmHog Wrote:
-------------------------------------------------------
> Report shows the striking train crew unresponsive
> to radio and signal compliance for up 19 minutes
> before the collision. I wonder was the alerter
> functioning and when was it last tested. Nothing
> in the report except the crews medical conditions
> and the conclusion the crew must have been asleep.

Usually the train dispatcher tries to contact a crew on multiple radio bases and often other radio channels. In this case it was a "heads up" kind of message. Meets and crossovers happen all the time. So it was not a red flag when the crew didn't answer. Often the dispatcher will have other crews in the field (T&E, M of W etc) to try and contact the crew if it is something of major importance. 

It's not like the dispatcher can remotely stop the train. Though I bet they wish they could.

AmHog Wrote:
-------------------------------------------------------
> I wonder was the alerter functioning and when was it last tested. 

If you can believe this, some railroads don't invest in alerters as a cost-saving measure.  

CA_Sou_MA_Agent Wrote:
-------------------------------------------------------
> AmHog Wrote:
> --------------------------------------------------
> -----
> > I wonder was the alerter functioning and when
> was it last tested. 
>
> If you can believe this, some railroads don't
> invest in alerters as a cost-saving measure.  

How did you come up with THAT? By "some railroads", you are obviously NOT including class 1 railroads.

HotWater Wrote:
-------------------------------------------------------
> How did you come up with THAT? By "some railroads", you are obviously NOT including class 1 railroads.

Who said I had to?  Do you have it on good authority that ALL railroads with CTC signaled territory have alerters on all their locomotives?    Do you know for a fact that ALL Class Ones have alerters on all their road units?  

CA_Sou_MA_Agent Wrote:
-------------------------------------------------------
> HotWater Wrote:
> --------------------------------------------------
> -----
> > How did you come up with THAT? By
> "some railroads", you are obviously NOT including
> class 1 railroads.
>
> Who said I had to?  Do you have it on good
> authority that ALL railroads with CTC signaled
> territory have alerters on all their
> locomotives?    Do you know for a fact that ALL
> Class Ones have alerters on all their road
> units?  


According to FRA Part 229.140:

 A locomotive that is placed in service for the first time on or after June 10, 2013, when used as a controlling locomotive and operated at speeds in excess of 25 mph.

.All controlling locomotives operated at speeds in excess of 25 mph on or after January 1, 2017.............

has to be equipped with an operative alerter.

It's always related to "untreated OSA."   BS I say. 

No one understands the life of a rail, but a rail.  NEVER knowing for sure when you are working or for how long.  NEVER knowing when to sleep.  Many times I have laid down to sleep and couldn't.  Too many interuptions, family stuff, pets.  The point is the RR won't do anything to help their employees know better when they are working.  You almost have to be psychic.

OSA is today's carpel tunnel from years ago.  It's all about the money.

Eng.Shadetree

AmHog Wrote:
-------------------------------------------------------
> Report shows the striking train crew unresponsive to radio and signal compliance for up 19 minutes before the collision. 

The way I read this is that there was an alerter that was inoperative.  An operable alerter that no one was responding to would have eventually stopped the train.  

Is there a way to disable an alerter?

CA_Sou_MA_Agent Wrote:
-------------------------------------------------------
> AmHog Wrote:
> --------------------------------------------------
> -----
> > Report shows the striking train crew
> unresponsive to radio and signal compliance for
> up 19 minutes before the collision. 
>
> The way I read this is that there was an alerter
> that was inoperative.  An operable alerter that
> no one was responding to would have eventually
> stopped the train.  

There is, but it's a huge no-no. Doubt that the crew disabled the alerter. It shows up on tape and probably now days sends an email to a Road Foreman.

CA_Sou_MA_Agent Wrote:
-------------------------------------------------------
> AmHog Wrote:
> --------------------------------------------------
> -----
> > I wonder was the alerter functioning and when
> was it last tested. 
>
> If you can believe this, some railroads don't
> invest in alerters as a cost-saving measure.  

Yep, my railroad does not have an alerters in any of the locomotives..   Though none of the locomotives meet the requirement and we don't go over 25mph..



SP8100



Edited 1 time(s). Last edit at 06/24/19 20:05 by SP8100.