The National Transportation Safety Board (NTSB) on Nov. 21 released the final report for its investigation of the April 16, 2023, Union Pacific (UP) train collision with a parked UP train in Chico Yard in Texas.
What happened?
On April 16, 2023, at about 6:44 p.m. local time, southbound UP train GSHFCC 15 (train GS15) crossed a main track switch lined toward yard track C-4 and collided with parked UP train RDACO 14 (train RD14) in Chico Yard on the UP Duncan Subdivision (see figure 1, above), according to the report (download below). As a result of the collision, 12 loaded hoppers and two locomotives from train GS15 and one empty gondola and two locomotives from train RD14 derailed. Additionally, the conductor and engineer from the train GS15 were “seriously injured.” Visibility conditions at the time of the accident were daylight and clear, NTSB noted, and the temperature was 68°F with no precipitation. According to the agency, UP estimated damages to equipment and track infrastructure to be approximately $4.9 million.
NTSB Analysis
According to the NTSB, in this accident “train GS15 crossed the C-yard main track switch, which was incorrectly lined and diverted train GS15 to a yard track, where it collided with parked train RD14.” Before the collision, it said, “the crew of a third train, train RH15, performed work in the area that required them to line the Lonestar main track switch, which was near the C-yard main track switch and had the same style of handle and target.” Train RH15’s external locomotive image recorder data showed that the C-yard main track switch was lined for the main track when train RH15 arrived at Chico Yard, according to the NTSB. “When the UP superintendent arrived on scene, he found both the C-yard and Lonestar main track switches lined away from the main track,” it reported. “The crew of train RH15 was operating under a track warrant from their arrival in Chico Yard until shortly before the collision and was the only crew present to manipulate switches. Therefore, at some point during their work, the RH15 train crew lined both switches away from the main track and did not restore them. The crew lined the Lonestar main track switch away from the main track to park their train in the Hanson Rock Plant. When the conductor went by himself to restore the Lonestar main track switch, he walked downhill and lined a switch across from a pile of railroad ties and a downward-sloping embankment, a location consistent with the C-yard main track switch, not the Lonestar main track switch. (The Lonestar main track switch was in a flat area with no railroad ties nearby, about 135 feet south of the C-yard main track switch.) The conductor likely lined the C-yard main track switch away from the main track and toward yard track C-4 when he intended to restore the Lonestar main track switch. After mistakenly lining the C-yard main track switch to yard track C-4, the train RH15 conductor briefed the engineer, by radio and in person, that the Lonestar main track switch was restored to the main track. During a phone call with the dispatcher to release the track warrant, the RH15 engineer told the dispatcher he and the conductor had signed the conductor’s logbook. However, in post-collision interviews, the crew told the NTSB they had not recorded the realignment of the Lonestar main track switch in the conductor’s logbook.”
UP System Special Instructions Item 10-K is said to require train crews to reline main track switches to the main track after use and record the action in the conductor’s logbook; the NTSB noted that logbook entry is intended to aid crews in confirming the “safety critical task” is completed. “The crew’s failure to make the logbook entry may have resulted in a missed opportunity for the conductor to think through his actions, note the location of the Lonestar main track switch, and recognize that he had lined the C-yard main track switch instead,” the NTSB reported. “Not realizing their error, the crew of train RH15 released their track warrant and left the yard. About two minutes later, the dispatcher issued a track warrant to the train GS15 crew to proceed southbound on the main track, unaware that both main track switches were lined to divert trains off the main track. Subsequently, train GS15 crossed the incorrectly lined C-yard main track switch, diverted onto yard track C-4, and collided with parked train RD14 before the engineer’s emergency braking application could bring the train to a stop. This collision resulted from the crew of train RH15 lining the wrong switch and not recognizing their mistake, combined with the inability of the dispatcher to determine that the C-yard main track switch was incorrectly lined. The dispatcher had no way of verifying the switch position because Chico Yard was (1) in an area without PTC [Positive Train Control], (2) in non-signaled territory (territory that does not have a signal or train control system), and (3) in an area that did not have switch-position technology installed. In the absence of these technologies, all of which would have provided the dispatcher with real-time information on the position of the main track switches, operational safety depended on administrative controls. These controls failed when the train RH15 crew did not follow UP instructions, both by inadvertently leaving switches lined away from the main track and by not completing the associated logbook entry. After the collision, the FRA [Federal Railroad Administration] issued a related safety bulletin. UP issued an alert to its employees about rules governing manipulation of switches and reduced the timetable speed in the area of the collision to 20 mph to give crews time to react if they see an incorrectly lined switch.”
The NTSB pointed out that it has investigated several similar accidents where the use of administrative controls failed to prevent collisions resulting from switches being left in the wrong position. Following one such collision in Bettendorf, Iowa, the NTSB said it issued the following safety recommendation to the FRA: “Require railroads to install, along main lines in non-signaled territory not equipped with Positive Train Control, appropriate technology that warns approaching trains of incorrectly lined main track switches sufficiently in advance to permit stopping (R-12-27).” In February 2019, it said, “the FRA communicated to the NTSB that it does not plan to act on this recommendation because, while effective technologies exist, the ‘FRA could not determine a cost-justified regulatory solution.’ Further, in a December 2023 report to Congress, eight months after the Chico collision, the FRA indicated that it has no plans to address Safety Recommendation R-12-27. As of the date of this report, Safety Recommendation R-12-27 has been classified Open—Unacceptable Response since April 18, 2013.”
The UP accident’s probable cause, NTSB reported, “was the lining of the C-yard main track switch to yard track, a human error made by the Union Pacific Railroad train RHKPHQ 15 conductor.” Contributing to the collision, it added, “was the inability of the dispatcher and the crew of train GSHFCC 15 to determine the position of the main track switch in non-signaled territory in time to prevent the collision.”
