A misaligned switch leading into an Iowa rail yard caused a freight train to slam into some empty train cars, killing the conductor and engineer, the National Transportation Safety Board said Wednesday.
The collision happened about 2 a.m. on July 14, 2009, when a Dakota, Minnesota & Eastern freight train went into the rail yard instead of staying on the main track. It hit 19 Burlington Northern Santa Fe cars that were parked in the rail yard.
The NTSB said in a report that the hand-operated switch had been “left incorrectly lined” from the main track onto the yard track by the BNSF crew, which had entered the rail yard about two hours earlier. Workers then failed to catch the mistake.
After parking the cars and while waiting for the other train to pass, the BNSF crew conducted a job briefing to discuss the rest of the work.
“Neither the BNSF engineer nor the conductor discussed the north yard hand-operated switch that had been used and they did not follow up or confirm the position of the switch among themselves or the DME dispatcher,” the NTSB said.
BNSF spokesman Steven Forsberg said the railroad wasn’t aware the report had been issued and had no immediate comment on it.
The NTSB also said a contributing factor in the collision was a Dakota, Minnesota & Eastern dispatcher who authorized the DM&E train to use the track “without holding a job briefing, which would confirm the accurate positions of all applicable main track switches.”
Another contributing factor was a hand-operated switch position reflector target that couldn’t be seen by the crew of the DM&E train at a sufficient distance to stop the train and avoid the accident.
The NTSB in its report made several safety recommendations to the Federal Railroad Administration and the Canadian Pacific Railway. The NTSB cited two earlier train accidents involving switches left in the wrong position in South Carolina and in Texas in 2005.
The NTSB recommended that the Federal Railroad Administration require railroads to install appropriate technology that warns approaching trains of incorrectly lined main track switches sufficiently in advance to permit stopping.
It also recommended that train crews hold job briefings with dispatchers and “clearly convey” the position of all main track switches that were used.
The NTSB said when a main track switch has been reported relined, the next train should travel at restricted speed and the crew should then report to the dispatcher that the switch is correct before trains are allowed to operate at maximum speed.
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