NTSB Determines Probable Cause for UP Train Collision, Conductor Fatality Accident

What happened?

On July 6, 2024, at about 1:36 a.m. local time, a UP conductor was killed in a raking collision while protecting a shoving movement (see Figure 1, above), according to the report that was issued June 25 (download below). At the time of the accident, eastbound train MPRNL-06 was traveling along the South Melrose Track out of Proviso Yard 4. At the same time, train MCBCH-05 was shoving west on the City Lead Track, which merges with South Melrose Track. The NTSB said the conductor of train MCBCH-05 was positioned on the leading end of a tank car when it struck the right side of train MPRNL-06.

“The striking train arrived at City Lead Track around 12:45 a.m., stopped movement, and radioed the Proviso Yard controller to await further instruction,” the NTSB reported. “Shortly after, the Proviso Yard controller provided a job briefing to the two-person crew and instructed them to shove west down City Lead Track—a connecting track that merges with the South Melrose Track—and wait at the designated stopping point before entering Proviso Yard 4. (See figure 1.) As the crew of the striking train was receiving instructions from the yard controller, the departing train was simultaneously leaving Proviso Yard 4, pulling east on the South Melrose Track. The striking train was approved to shove into the yard and tie down after the departing train was safely clear of the merging point at City Lead Track and South Melrose Track.”

Probable Cause

The probable cause of the train collision “was the conductor, who Union Pacific Railroad sent into the field without performance-based verification that he could safely navigate the territory, not alerting the engineer to stop the train before reaching the designated stopping point,” the NTSB reported. “Contributing to the accident was Union Pacific Railroad’s failure to provide the required and requested assistance to the inexperienced conductor who was not familiar with the territory. Further contributing to the accident was the striking train crew proceeding with riding the shoving movement after being informed by the yard controller that no additional support would be provided.”

NTSB Analysis

According to the NTSB, the raking collision, and the subsequent death of the striking train conductor, resulted from the train shoving past its designated stopping point. “The conductor did not alert the engineer in time to safely stop the train from traversing the track and colliding with the departing train,” the agency said in its report. “The striking train conductor had only been certified since June 24, 2024—just 12 days before the accident. The conductor served as the lead of a shoving movement only five times before the accident. He had never worked in that section of Proviso Yard, and he had not received any training on traversing City Lead Track. As a result, the conductor did not know precisely where City Lead Track merged with South Melrose Track and failed to alert the engineer to halt the train at the designated stopping point, which ultimately caused the collision. The conductor had minimal experience leading shoving movements after UP certified him, and he was not adequately familiar with the territory on which he was working when the accident occurred. The conductor’s inexperience and lack of familiarity with Proviso Yard and the surrounding area left him unprepared to carry out his job requirements safely on his own.”

The NTSB said that a  “location-specific job aid likely could have reduced the risk of operating in an unfamiliar environment, but one was not provided to the crew of the striking train.” Such aids, it noted, “are acknowledged safety tools that can help conductors safely navigate unfamiliar territory and are required by federal regulation.” The NTSB pointed out that this accident “may still not have been avoided” with the provision of a job aid. “The engineer recognized the limitations in the conductor’s experience and lack of knowledge of the surrounding area and expressed the need for assistance,” the agency reported. “Despite the request, the Proviso Yard controller did not comply with the striking train engineer’s request. This lack of assistance introduced unnecessary risk, as it left the crew of the striking train to attempt the shoving movement with inadequate knowledge of the environment.”

Lessons Learned

According to the NTSB, as a part of UP’s accident response, it issued a Critical Incident Alert “reaffirming safety standards and regulations for job aids and shoving movement procedures, and further stressing the importance of staying vigilant, maintaining situational awareness of the current task, and being aware of present conditions while performing tasks.” During its investigation, the NTSB said it “concluded that UP was not providing job aids throughout its system.” As part of UP’s response, the railroad “indicated that they corrected the issue systemwide, and that all UP locations now have up-to-date job aids,” the NTSB reported. “This accident demonstrates the importance of ensuring that conductors tasked with more complex maneuvers, such as leading a train during a shoving movement, possess the training, experience, and personnel support needed to safely perform the task.”