NTSB Report re UP Head On Collision from June 2012

The NTSB reports have to be taken with a grain of salt.

Basically, the NTSB suggests ways to prevent future incidents of the same nature as the one investigated, and "Monday Morning quarterbacks" everybody with any oversight.  These reports contain criticism and suggestions that have no relevance to practicability, and, while they might be useful at some time or another, the NTSB has no further responsibility for implementation.  So, usually, the railroad(s) and the FRA are left to explain why they did not have positive train control, in-cab cameras, event recorders that download remotely as they upload in the field, etc.

I have been on Federal accident investigation committees and seen all the politics in action.  The NTSB shoves its way to the top of the pyramid, and then says, "Okay, you fix it."  Don't get me wrong . . . the NTSB serves a purpose.  However, it is extremely politically driven in its investigations.  For a more realistic report of a train accident, the FRA railroad accident reports are considerably more informative, and are limited to determination of the circumstances and the cause of the accident.

As information, the eyesight of the Engineer who ran the red signal is now being looked at as the likely root cause of the collision, and the railroad is on the spot for not having taken action, as they allegedly knew about it for over a year.  So, expect a lot of finger-pointing and posturing to result.  Meanwhile, three railroaders are dead, one of whom was entirely innocent of any rule violations or any failure to diligently perform his duties.  That's all but forgotten in the scramble to assess blame and avoid responsibility. 

Very good point Tom.  But what was the excuse for the Conductor not responding to the flashing yellow, then the yellow, and finally the red signals. In fact, no speed reductions whatsoever took place at any of the three restrictive signal indications.

I understand your point, Hot, and you are correct in pointing out that there is no excuse -- none -- for the inaction on the part of the Conductor.  The most likely suspicions would be that he was distracted by something or asleep, but, in either case, it would only be a reason and not an excuse.  He had an obligation to determine and record the aspect of every signal his train passed, call the signal indication to the Engineer, and to take action to stop the train if the Engineer did not respond to the signal indications as required.  For some reason that can never be known for sure, he didn't do that, and the train continued down the main track at high speed, passed the Stop signal at the leaving end of the siding, and collided head-on with the other train, whose crew was properly slowed in preparation for taking the siding.  However, the seriously impaired vision of the Engineer, as allegedly documented in his personal medical records is being looked at as the root cause.  If the Engineer could not recognize the block signals as displaying Approach and Stop indications, then the inaction of the Conductor was a contributing cause, and, if it is proven that the railroad was aware of the vision problems and did not medically examine the Engineer, then that is also a contributing cause.  Other possible contributing causes could be the inaction of other employees who may have been concerned about the Engineer's vision, but properly performed their duties when they worked with him, covering it up and keeping silent because they did not want to report him. Doing so would have resulted in his being unable to continue to work as an Engineer or Conductor, causing unavoidable family hardship when his pay was reduced to a disability benefit.  He and two other railroaders would still be alive, but sometimes it is not easy to summon the courage to do the right thing for the right reason.  And that is also not an excuse.

The failure of the Conductor to persuade the Engineer to slow, and then stop the train, was the primary contributing cause, and, in this case, was of equal importance to the root cause.

In determining the root cause, one has to drill down until one finds the single factor without which the accident would likely never have occurred.  In this case, it is suspected to be the inability of the Engineer to recognize the indications of the block signals due to a vision impairment.

If the engineer had an eyesight issue, then he should have flunked the DOT physical.  How often does one have to pass a DOT physical?

On the Glidden Sub out of houston, I have heard train crews call out signals.  Are the DS's actually listenening to this?  Are the transmissions being recording?

Now just why would any railroad be administering a "DOT physical", when the railroads come under FRA jurisdiction???

quote:

 If the Engineer could not recognize the block signals as displaying Approach and Stop indications,

On this point alone, you will never convince me that CPL signals, such as the N&W used, would have helped to prevent just such a situation. Even if the man was color blind, he still would have been able to read the aspect.

EXACTLY!

Not to mention the first restrictive signal he encountered was "Advanced Approach", i.e. FLASHING YELLOW!  In that particular territory, no other indication "flashes" except YELLOW on main line single track CTC. Thus, one wonders just what happened to both the Engineer AND the Conductor!

That's what it's all about in "The Land Of Liability" we live in today. That's all the big corporations care about, especially the railroads! 

Unlike the FAA licensing of pilots, the certification of Locomotive Engineers is done by the employing railroad -- not by the FRA.  The railroad submits a plan for certifying Engineers, and, after the FRA reviews it for compliance with the Code of Federal Regulations, and approves it.  Thereafter, the railroad issues and, if required, revokes the certificates of its own Engineers, in compliance with the guidelines previously submitted and approved by the FRA.  This includes a vision test when recertifying (every third year).  The test includes an eye chart test (corrective lenses allowed) and a color blind test that requires identification of a hidden number on a page of dots that look like a mud splatter.  This Engineer may have developed vision problems after his last recertification vision test.  If his vision was as reported, he would not have passed his next one.

He may have been faking it on the road, because that stretch of railroad is equipped with color light signals, using a separate lens for each color of a signal unit ("signal head").  These positions can be memorized.  Most of the signals are of current UPRR standard -- vertically oriented -- but there are still some Rock Island cast triangular signal units and some triangular modular units from the period when SP/SSW was installing that type.

So . . . as to the flashing yellow aspect?  I was being charitable when I wrote that the Engineer possibly "could not" recognize the signal aspects displayed for his train.  No sense to over-state the obvious, I always say, particularly since he paid the ultimate price for his negligence.  So some other factor never to be able to be known to us, figured into this accident.  Perhaps he dozed.  They went on duty, if I recall correctly, just at daybreak or a little before, and had not gone far when the accident happened.

In a nutshell, it seems very likely that this Engineer no longer should have been working in that craft, or as a Trainman, because of his vision problems, which were most likely known to many (and obviously to him) and nobody -- not the railroad or the union or the other employees who knew or the Engineer -- did the right thing about it because nobody wanted to be the one to cause him lose his job.  I'm not heaping blame on anybody -- just trying to present a realistic analysis of how the conditions became right for this to happen.  I could write pages on this, but have tried to make it concise for readability.

Hi Folks,

I just saw an Extreme Trains show on TV.  A portion of the show was filmed inside UP's central dispatch center.  Dispatchers were radioing trains about where to meet other trains in addition to changing the switch and signal positions.  The train crews were acknowledging the meet locations and other information such as the meet time.

Shouldn't this crew also had written orders before they left or radio orders to meet the opposing train at the siding where the crash occurred?  Wouldn't this have alerted them to the opposing traffic?

Joe 

There are some SP searchlights out there also.

If the signal system was working correctly, and there were no other track issues, there would be NO ORDERS in CTC territory.  The signals themelves are the "train orders">

The dispatcher will tell a crew of meeting points and possible holding points (i.e. red signals) as a COURTISY to the train crews.  It is not the dispatcher's responsibility to provide the crews with constant updates on the moves he/she is making.  While we do try to provide that information when possible, a dispatcher is responsible for 100's of miles of territory and at times may become too busy to provide these "heads up" to the crews; that's why there is a signal system.

Dispatchers are NOT allowed to give crews a signal indication. As Form D said above, dispatchers can give us a "heads up" (courtesy) as to what they have planned, but in now way are they to inform us of that actual signal indication (color). In fact, about a year ago, we had a road foreman get fired because he gave a crew a signal indication over the radio. Granted this guy had been in trouble already for a couple rule violations, and he is not a dispatcher.... but still not allowed to give out signal indications over the radio to a crew. It's strictly the crew's responsibility to observe and act on every signal indication.