Western Railroad Discussion > BNSF Safety Alert re: Gunter collision

BNSF Safety Alert: Self-Critical Analysis 2004-08

May 24, 2004



Head On Train Collision and Employee Fatality


This alert is issued to BNSF employees to help them work safely. The incident outlined
in this self-critical analysis is currently under investigation. Causes, contributing factors and preventive measures presented may not be all-inclusive, but they reflect the
information available at the time they were posted.


Date and Description of Incident:

At approximately 5:46 p.m. on May 19, 2004, near Gunter, Texas, loaded rock train U-MAODON1-19 collided head-on with empty rock train U-SHTIRB1-19 at mile post 661.9 on the Madill Subdivision of the Texas Division. The trains were being operated under Track Warrant Control Non-Signaled territory. The operating plan directed that the two trains meet at Dorchester, Texas, with train U-MAODON1-19 holding the main track.

For an undetermined reason, the U-MAODON1-19 proceeded from Dorchester before the
U-SHTIRB1-19 arrived.

The U-MAODON1-19 had met another train at Dorchester before it departed.

Both trains were traveling approximately 40 mph at the time of the collision.

The collision and subsequent derailment resulted in one fatality, four injuries and $2.1 million
in damages.


Contributing Factors:

This incident is currently under investigation and this alert does not represent BNSF’s
position on the cause or causes of the incident.

However, the major contributing factor
may have been a failure to wait at and properly identify the arrival of the trainU-SHTIRB1-19
(with lead locomotive unit BNSF 6351) at Dorchester, Texas as required by the track
warrant given to the U-MAODON1-19.


Preventative Measures:

It is evident that after the track warrant was issued, there was no positive identification of
the arrival of the opposing train before proceeding.

To ensure that positive identification takes place, beginning June 1, 2004 the following rule amendment will be implemented:

In non-signaled territory, a train may only be granted a Box 7 “Not in Effect Until
After the Arrival of _________” track warrant, after the following requirements
have been completed:



1. Dispatcher advises the train that will receive the Box 7 track warrant of the identification of train(s) to be met (by initials, engine number and direction).

2.The train that will receive Box 7 track warrant establishes the location of the train(s) to be met advising the dispatcher when direct communication has been made and the location of the train(s) contacted.

3.The train to receive the Box 7 track warrant has stopped at the meeting point and has notified the dispatcher that they are stopped. (Note: A train stopped short of the meeting point for topographical reasons, i.e., blocking crossings, grade considerations, etc., may be considered as stopped at the meeting point for application of this process).

Thank you Topper for posting this update on this
VERY TRAGIC collision!

I myself am growing VERY TIRED of seeing these tragic
events repeatedly occuring all too frequently.
As an interested railfan using some common sense I can make the following comments:
The ROOT CAUSE of this tragedy and PUBLIC POLICY issue
is pretty well spelled out by now. For whatever reason one train (U-MAODON1-19)was
PHYSICALLY ABLE to EXCEED their dispatched AUTHORITY by EXITING the siding area TOO SOON!!

I can pretty well GUARANTEE we will NEVER EVER know exactly WHY
this one enginner made this horrible mistake(forgot 2nd train, distracted, or fell asleep).
It would be a VERY LENGTHY and time-consuming process
to try to sort through all the rumors about what was happening in the cab just prior to this collision.
That end of the investigation would likely just delay any installation
of upgraded signaling devices as both sides stage an ENDLESS ARGUEMENT.
We need to admit that fact upfront and ABOVE ALL
work to PREVENT yes PREVENT this chain of events from happening in the future.

The United States and World deserve
far-far better railroad anti-collision systems and devices
than Track Warrants (TWC)or Direct Traffic Control (DTC)
here in the 21st Century (year 2004).
We badly need to be raising safety standards as better signaling and dispatching systems are deveolped.


If we truly want to PREVENT these circumstances from
happening in the future we badly need some form
of CAB SIGNALING system installed on ALL MAINLINES in the US.
I have seen good things posted here on Trainorders
about the C&NW style ATC Cab Signal system.
I might remind folks that tragedies such as this recent event can
EASILY happen even under FULL CTC controlled mainlines:
http://shorterlink.com/?INZ88K
and
http://www.trainweb.com/cgi-bin/top/tw_do.cgi?derailments/2002d23a.html

If this ATC signal system is good enough to be used today on the
former C&NW then it is good enough for ALL US mainlines!!
Better yet we could eventually install TWO SEPERATE and REDUNDANT systems
to protect against false indications on either system.
If my suggestion had been installed prior to this event
this collision would have been PREVENTED.
It would NOT matter if either train crew TRIED to
EXCEED any authority this collision would have been
MECHANICALLY PREVENTED by the signal system.
For heaven sakes!! if BOTH the BART and SF Muni Subway transit systems
here in the SF Bay Area can use some form of cab signaling then the US railroads can as well!
Thank you all very much for reading my rant and allowing
me to get this off my chest!
-- Daniel

You make a very good arguement with some good points but, you left a huge question on the table. Who will pay for the upgrades? ATC and PTC does not come cheap and that is the main reason why it is not as wide spread as it is. Many territories that are dark (such as the line through Gunter) do not have enough traffic to warrant spending the money to install and maintain any kind of signal system. Railroads would rather change a rule or two (such as what looks like will happen on BNSF) than to spend the millions of dollars it would take to install these systems (or billions of dollars if we are talking system wide). Even the losses that BNSF has from this one accident are cheaper than installing and maintaining an ATC or PTC system on this line (plus in the locomotives).

Thank you for your kind words about my argument!
Perhaps we should have a federal tax on all financial and stock transactions.
We need some way to recover the DAILY corporate WINDFALL that is funneled up to the elite and therefore REMOVED from PRODUCTIVE use by society!
Every day we delay INSTALLATION of ATC/PTC we condemn more innocent crews to REPEAT this VERY TRAGIC and easily PREVENTED mistake!
We need to INSTALL ATC across the country NOW!!
The ATC system is a known quantity that WORKS TODAY!
AFTER ATC is installed across the nation then you will have bought TIME to perfect a better system!
Continuing to do NOTHING (ENDLESS DELAYS!!) in this era of HIGH-TECH wizardry while a WORKABLE alternative(ATC) EXISTS is frankly VERY EVIL!!!!

Ask yourself what just one SHATTERED life is worth to PREVENT. Easily billons!!!
I am sure many creative ways can be devised to FIND the MONEY for this BADLY NEEDED safety advance!
-- Daniel

tucker Wrote:
-------------------------------------------------------
> You make a very good arguement with some good
> points but, you left a huge question on the table.
> Who will pay for the upgrades? ATC and PTC does
> not come cheap and that is the main reason why it
> is not as wide spread as it is. Many territories
> that are dark (such as the line through Gunter) do
> not have enough traffic to warrant spending the
> money to install and maintain any kind of signal
> system. Railroads would rather change a rule or
> two (such as what looks like will happen on BNSF)
> than to spend the millions of dollars it would
> take to install these systems (or billions of
> dollars if we are talking system wide). Even the
> losses that BNSF has from this one accident are
> cheaper than installing and maintaining an ATC or
> PTC system on this line (plus in the locomotives).

What a lot of people forget is that anything made by man will eventually fail. Or,"If it can go wrong it will."
While I do not like to offend anyone, it is important that one realizes that there is a whole litany of blame to go around. Everyone and anyone with direct connections to the railroads of today needs to take responsibility for their actions. Here's just a few of the "Blame List" items that are always on one's mind.

Management and their minions management only sees the bottom line, not the people on the bottom. Government always wants to make a law that ultimately will so overburden railroads that they will not survive. Railroaders that think that they are owed a living. Hours that would, and do, make anyone, do to fatigue, miss such an important thing. A public that doesn't want them within 100 miles of where they live and think working rails are the root cause, and sometimes rightfully so, of these kind of things.

Nuff Said.

The collision at Gunter is another tragic reminder of the advantages of DTC over TWC in Non-block territory.

Had DTC been in use instead of TWC, the computer would not have allowed the southbound train to receive further authority to proceed until the second northbound train released its authority after clearing the block, thus providing a built-in safety guard that would've prevented this collision and others like it.

UP has had two similar head-on collisions resulting in fatalities (one in Texas, one in Iowa).

topper Wrote:
-------------------------------------------------------
> The collision at Gunter is another tragic reminder
> of the advantages of DTC over TWC in Non-block
> territory.


It's obvious you are not a dispatcher, or you'd realize TWC overall is a much more flexible system than DTC. With the size of the territories most dispatchers have these days, taking away the ability of a dispatcher to work ahead will only slow things down more. If you're not hearing a DS on the radio it does not mean he is sitting around twiddling his thumbs. There is plenty to do that does not involve radio conversation. The basic thing to realize here is that at least two crew members did not do their job which was to merely identify the trains they were to meet. All they had to do is observe a couple of 3 or 4 digit numbers! How much simpler can that be?

All track warrant territory on the BNSF, as far as I know, is CTWC. Computerized Track Warrant Control. It has the same fail safes as DTC, with much more flexibility for dispatchers. The Legacy system is in effect on BNSF, and dispatchers can only issue track warrants that the computer will allow. Sometimes work trains and locals will have some strange things on their warrants (like not in effect until after arrival of their own engine no. when they change directions) due to computer "failsafes".

Who knows what the root causes were. The railroad always points at the crew, no matter what, even if the crew is CLEARLY not to blame. I have seen it first hand...so I wouldnt take anything the railroad says as the gospel. There are other human factors; dispatchers are humans, computer programmers are human.

Wrecks have always been a part of railroading, and always will be. To think that they will someday not exist is as absurd as thinking that auto accidents and plane crashes can be completely eliminated. Hundreds of meets are successfully made in dark territory every day by conscientious train and engine men, sometimes at 3:AM while the rest of the world is sound asleep.

I, for one, am glad I know longer work in dark territory because track warrants have become so ridiculous now with all of the new box 7 requirements, and the "this track warrant contains" crap. This will happen again someday, no matter how many times you have to read the box 7.

topper Wrote:
-------------------------------------------------------
> > BNSF Safety Alert: Self-Critical Analysis
> 2004-08
>
> May 24, 2004
>
>
>
> Head On Train Collision and Employee Fatality
>

Topper:

Did this alert come via someone's e-mail or the corporate website? If via the website, under which link do these alerts appear? I'm still trying to figure out where everything is on the website.

Thanks,

Mike
#2883
NH99

Perhaps you should take humans out of the cabs! A couple of R2 units in the cab...like in Star Wars.

>>>Perhaps we should have a federal tax on all financial and stock transactions.
We need some way to recover the DAILY corporate WINDFALL that is funneled up to the elite and therefore REMOVED from PRODUCTIVE use by society!

<If we truly want to PREVENT these circumstances from
happening in the future we badly need some form
of CAB SIGNALING system installed on ALL MAINLINES in the US.
I have seen good things posted here on Trainorders
about the C&NW style ATC Cab Signal system.>

Last cost estimate I have seen is $4 to $5 billion to make this happen. When the price comes down enough, and/or the technology improves enough to generate a return on the investment to the owners of the railroads, it will happen. In the meantime, as tragic as accidents such as Gunter are, for saving perhaps a few dozen lives per year, I would much rather see the $4 plus billion dollars that one way or another will come out of your and my pockets get spent on improving highway safety that claims more than 40,000 lives per year (equal to three 747's crashing per week). We need to prioritize scarce dollars to where we get most bang for the dollar.

Rathole Wrote:
-------------------------------------------------------
> topper Wrote:
> --------------------------------------------------
> -----
> > The collision at Gunter is another tragic
> reminder
> > of the advantages of DTC over TWC in
> Non-block
> > territory.
>
>
> It's obvious you are not a dispatcher, or you'd
> realize TWC overall is a much more flexible system
> than DTC. With the size of the territories most
> dispatchers have these days, taking away the
> ability of a dispatcher to work ahead will only
> slow things down more. If you're not hearing a DS
> on the radio it does not mean he is sitting around
> twiddling his thumbs. There is plenty to do that
> does not involve radio conversation. The basic
> thing to realize here is that at least two crew
> members did not do their job which was to merely
> identify the trains they were to meet. All they
> had to do is observe a couple of 3 or 4 digit
> numbers! How much simpler can that be?
>
>

Right on, Rathole.

If crews cannot be relied upon to observe a few locomotive digits, then we are in trouble.

It makes one wonder if some of today's T&E crews could handle the old train order and timetable system with first, second, third, and even fourth class trains listed, with class being superior, but then there is also direction involved within class. Of course, what the timetable giveth, the dispatcher taketh away with "right over" orders, annulled schedules, etc. Toss in a few extra trains, a work extra with the "protect against . . . ." and you had great chances for a mixup. Oh yes, let's not forget the trains carrying green flags with more than one section running on the same "schedule." Of course, a train could be up to 12 hours late and still be using its original schedule. Or, the practice of annulling a schedule and then running the train as an extra.

Let's hope today's T&E folks are up to the standard formerly expected of T&E workers in busy train times such as WWII. Hopefully, they are, but one wonders. Granted, in the old days there were no less than five men and often six on some of the jobs so there were a few extra minds to help keep things safe.

Compared to the old train order system, anyone who is luke warm ought to be able to keep things straight in track warrants - providing the employee is paying attention.

Oh yes, the old dispatchers did not have a "fail safe" computer to help them. They had a train order book and a multi-column train sheet. Much of the rest was carried in their head.

Rathole Wrote:
-------------------------------------------------------

> It's obvious you are not a dispatcher, or you'd
> realize TWC overall is a much more flexible system
> than DTC.

You are correct on the first part.

As to the second part, I would agree that TWC is indeed more flexible that DTC, and it's exactly that flexibility that can cause errors.

With DTC there are only a handful of authority types, all of which are standardized and have permanently fixed locations. The opposite is true with TWC.

As we've seen with other Box 7 authority failures, making a mistake can have tragic consequences.

> With the size of the territories most
> dispatchers have these days, taking away the
> ability of a dispatcher to work ahead will only
> slow things down more.

I'll respectfully disagree on that point. My experience has been that it's more of a matter of the individual dispatcher's skill and intelligence, rather than the size of his or her territory. As the saying goes, "Size doesn't matter."

> If you're not hearing a DS
> on the radio it does not mean he is sitting around
> twiddling his thumbs. There is plenty to do that
> does not involve radio conversation.

True. For example, most of the folks - maybe all of 'em - at the HDC go out into the parking lot for a "smoke break". And last Super Bowl Sunday, the dispatcher I worked with kept his trains apprised of the score... albeit after "toning him up" repeatedly for 20 minutes or so each time someone wanted to talk to him.

To be fair, I'm indeed aware that dispatchers have a heavy load and do the best they can under the circunstances they're presented with.

> The basic
> thing to realize here is that at least two crew
> members did not do their job which was to merely
> identify the trains they were to meet. All they
> had to do is observe a couple of 3 or 4 digit
> numbers!

That's correct. And whatever the reason was for their failure to do so no longer matters.

But as I mentioned previously, having DTC in effect instead of TWC would've prevented the consequences of their oversight, since the southbound train could not have received authority to proceed until the second northbound train had cleared the block and had released its authority.

>How much simpler can that be?

One of the advantages of DTC, versus TWC, is its simplicity. Keeping things as simple as possible reduces the chance for error.

FresnoSub Wrote:
-------------------------------------------------------

> Topper:
>
> Did this alert come via someone's e-mail or the
> corporate website?

It was sent to me as a Word.doc.

> If via the website, under
> which link do these alerts appear?

In all honesty, I don't know if it's on the BNSF website somewhere, or if it is, if it's only accessible to employees. I have enough trouble trying to figure out the UP website!

Hi!


There is no reason whatsoever to create
a new train separation system. You can
buy everything off the shelf from the
trucking industry. Qualcomm makes a
satellite comm system that lots of trucks
use, and it comes with maping software.
Each engineer would see the location of
each and every train on the system by
zooming in to the location. Easy!


Track warrants disappear, as dispatchers
KNOW the location of trains. No defects.


As a by product, you even get locomotive
diagnostic uploads so you know what is
wrong as an engine arrives at the repair
depot.


It works for trucks, every day, rain and
shine. Look for the white domes behind
the wind screen of the tractor!


Tony Burzio
San Diego, CA

Why do it partially, invest heavily in technology, and we can take the human factor out all together. ATS etc is good, but there will STILL be human error.

TR
Austin TX

topper Wrote:
-------------------------------------------------------
> Had DTC been in use instead of TWC, the computer
> would not have allowed the southbound train to
> receive further authority to proceed until the
> second northbound train released its authority
> after clearing the block, thus providing a
> built-in safety guard that would've prevented this
> collision and others like it.

I suppose you're referring to SP's "flavor" of DTC, as I know for a fact that KCS's DTC does allow contingent authorities at meet points without the opposing train already having cleared to that point. I hear those on the scanner all the time.

I received a copy of this safety notice at work the other night, only had one copy in the shack so I didn't bring home a copy.
Chris S.

waybill Wrote:
-------------------------------------------------------
>
> It makes one wonder if some of today's T&E
> crews could handle the old train order and
> timetable system with first, second, third, and
> even fourth class trains listed, with class being
> superior, but then there is also direction
> involved within class.


Waybill, I often wonder the same thing. I worked many years with train orders, both copying them and issuing them.

SHF

topper Wrote:
-------------------------------------------------------
> Rathole Wrote:
> --------------------------------------------------
> -----
>
> > It's obvious you are not a dispatcher, or
> you'd
> > realize TWC overall is a much more flexible
> system
> > than DTC.
>
> You are correct on the first part.
>
> As to the second part, I would agree that TWC is
> indeed more flexible that DTC, and it's exactly
> that flexibility that can cause errors.
>
> With DTC there are only a handful of authority
> types, all of which are standardized and have
> permanently fixed locations. The opposite is true
> with TWC.
>
> As we've seen with other Box 7 authority failures,
> making a mistake can have tragic consequences.
>
> > With the size of the territories most
> > dispatchers have these days, taking away the
> > ability of a dispatcher to work ahead will
> only
> > slow things down more.
>
> I'll respectfully disagree on that point. My
> experience has been that it's more of a matter of
> the individual dispatcher's skill and
> intelligence, rather than the size of his or her
> territory. As the saying goes, "Size doesn't
> matter."

>
> > If you're not hearing a DS
> > on the radio it does not mean he is sitting
> around
> > twiddling his thumbs. There is plenty to do
> that
> > does not involve radio conversation.
>
> True. For example, most of the folks - maybe all
> of 'em - at the HDC go out into the parking lot
> for a "smoke break". And last Super Bowl Sunday,
> the dispatcher I worked with kept his trains
> apprised of the score... albeit after "toning him
> up" repeatedly for 20 minutes or so each time
> someone wanted to talk to him.
>
> To be fair, I'm indeed aware that dispatchers have
> a heavy load and do the best they can under the
> circunstances they're presented with.
>
> > The basic
> > thing to realize here is that at least two
> crew
> > members did not do their job which was to
> merely
> > identify the trains they were to meet. All
> they
> > had to do is observe a couple of 3 or 4
> digit
> > numbers!
>
> That's correct. And whatever the reason was for
> their failure to do so no longer matters.
>
> But as I mentioned previously, having DTC in
> effect instead of TWC would've prevented the
> consequences of their oversight, since the
> southbound train could not have received authority
> to proceed until the second northbound train had
> cleared the block and had released its authority.
>
> >How much simpler can that be?
>
> One of the advantages of DTC, versus TWC, is its
> simplicity. Keeping things as simple as possible
> reduces the chance for error.



Topper, have you ever visited the HDC? If not, please make arrangements with your trainmaster to do so. You have only a field view of things. I think a visit to the dispatching office might change your point of view. I personally do not smoke but I do get out of the office for a few minutes several times a day especially on my first shifts; then some crewmen and MofW personnel get impatient when they cannot get the dispatcher right away and continually tone in. We do not have the luxury of an uninterrupted lunch break. Someone is always wanting something. You can only answer so many radio and phone calls and issue so many track and time permits before you have to get away and get your head cleared. Why does the dispatcher have to be the one to babysit crews by waiting until the meet has occurred before issuing DTC or TWC authority to leave? Do you have trouble observing your slow orders on your dispatcher's bulletin? Then why can't you be trusted to operate on an "after arrival" on a track warrant? Waybill brought up a good point - how did we ever make it with train orders and timetables?