NTSB Determines Probable Cause for BNSF M/w Employee Fatality

What Happened?

On Nov. 4, 2024, at about 11:00 a.m. local time, a BNSF m/w employee (a grinder) driving a welding truck was fatally struck by a BNSF freight train as the welding truck was crossing a private highway/rail grade crossing at milepost 128 near New Rockford, N.Dak. (see figure 1, top), according to the report that was issued Jan. 20 (download below). Another BNSF m/w employee (a welder) who was on the passenger side of the welding truck was injured, transported to a nearby hospital, and released. At the time of the accident, the NTSB said, “visibility conditions were daylight but cloudy with about four miles visibility; the weather was 36°F with no precipitation but the ground was wet and soggy.”

Background

According to the NTSB, the accident site had a single main track running southeast to northwest on BNSF’s KO Subdivision. On this subdivision, the maximum authorized speed for freight trains was 55 mph and train movement was coordinated by a BNSF train dispatcher from BNSF’s Network Operations Center located in Fort Worth, Tex. The track was signalized and equipped with a positive train control system, which was enabled and operating at the time of the accident, the NTSB said.

“At milepost 128.1, an unpaved farm road which ran east and west intersected the track at a skew angle of about 30°, making the grade crossing (accident grade crossing) a skewed intersection [known as any angle less than 90°],” the NTSB reported. “The accident grade crossing was paved to facilitate the movement of vehicles and was at a higher elevation than the unpaved farm road. The accident grade crossing was passive but equipped with stop signs on either side of the track for eastbound and westbound vehicles traveling on the farm road. A gravel road on the south side of the track ran parallel to the track. This road was used by MOW employees to access the track for repair work.”

According to the NTSB, on the day of the accident, a BNSF m/w team had been assigned to replace “a defective rail” at the accident grade crossing. The team consisted of a welding team (a grinder and a welder in the welding truck) and a maintenance team (four employees, a foreman who was also the roadway worker-in-charge of the m/w team, and a laborer in a pickup truck; and two vehicle operators in a boom truck).

“The roadway worker-in-charge had planned for the welding team and the maintenance team to position their trucks on either side of the track so that the rear of the trucks would be within a few feet of the track with the front of the trucks facing away from each other,” the NTSB reported. “This position would allow the welding team and the maintenance team to access the hydraulic systems of both trucks to facilitate the replacement work. According to this plan, the welding team and the maintenance team would wait for scheduled trains to pass, the roadway worker-in-charge would then establish track protection and conduct a job briefing, after which the welding team and the maintenance team would begin the replacement work.”

At about 10:40 a.m., the welding team drove down the gravel road on the south side of the track and waited for the maintenance team to arrive, according to the NTSB. About 15 minutes later, it said, the roadway worker-in-charge of the m/w team and the laborer drove down the same gravel road in the pickup truck and stopped behind the welding truck. Shortly after this, the NTSB continued, the vehicle operators backed the boom truck down the gravel road and stopped beside the pickup truck. “Because the boom truck arrived on the south side of the track, the welding team decided to back the welding truck over the accident grade crossing to the north side of the track because the trucks needed to be on either side of the track to perform the rail replacement work,” the NTSB reported.

The NTSB said that its review of the inward-facing camera in the welding truck “showed that at 10:59:45 a.m., the grinder began to back the welding truck toward the accident grade crossing. Video footage from the camera revealed that the welder was mostly looking out of the passenger side window and the grinder was using the side-view mirrors on the driver and the passenger sides to maneuver the truck. Video footage showed that the grinder did not accelerate to clear the track as the train was approaching from the 64th Avenue grade crossing.” According to the NTSB, its interview with the welder “confirmed that he did not see the train as they were backing over the accident grade crossing until about 4 seconds before the accident when he saw the train’s headlights in the side-view mirror on the driver side.” The maintenance team on the south side of the track “saw the train approaching and broadcast warnings over their radios to alert the welder and the grinder,” the NTSB reported.

The government agency noted that BNSF Safety Rule S-12.8 on backing vehicles, instructs employees to “position the vehicle, when possible, to avoid backup movement.” According to the rule, in cases where there are no other options, the NTSB reported, “BNSF requires a person to be present on the ground to guide the movement” and “also requires the person to inspect the ground to the rear of the vehicle and the driver to sound the horn if the vehicle is not equipped with backup alarms and to stop the vehicle if the person guiding the movement disappears from view.”

In its report, the NTSB said its review of the forward-facing cameras in the train’s lead locomotive revealed that at 10:59:47a.m., “the train horn sounded multiple times as the train approached the 64th Avenue grade crossing.” Additionally, the NTSB’s review of the inward-facing camera in the train’s lead locomotive “confirmed that the train crew was alert in the moments leading up to the accident.”

The NTSB said its “investigation confirmed that the actions of the train crew did not contribute to the accident” and the crew “took prompt action when they saw the welding truck backing over the accident grade crossing and applied the emergency brakes.”

Probable Cause

The probable cause of the accident, the NTSB reported, “was the welding team’s failure to detect the approaching BNSF Railway freight train as they were backing the welding truck over the private highway-railroad grade crossing.” Contributing to the accident: “the welding team’s noncompliance with BNSF Railway’s Safety Rule S-12.8, which requires positioning a person on the ground to guide the movement,” according to the government agency. Further contributing to the accident, it noted, “was the inadequate understanding of BNSF Railway’s Safety Rule S-12.8 by BNSF Railway employees.”

Lessons Learned

“This accident highlights the dangers of backing vehicles over railroad tracks without positioning a person on the ground to guide the movement and the importance of following safety rules when backing vehicles over railroad tracks,” the NTSB said. “After the accident, BNSF clarified the backing rule by adding a section (Section S-12.8.1) that focuses on backing vehicles over railroad crossings, which emphasizes that either a person on the ground or on-track safety should be used during the movement.”