NTSB reports that a distracted conductor played a large part of 2015 collision

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This BNSF Railway train crashed into a parked Southwestern Railroad train in 2015 after a conductor on the short line failed to line a switch properly.
William P. Diven
WASHINGTON — The National Transportation Safety Board on Tuesday reported the probable cause of the deadly collision of two Southwestern Railroad trains adding details about drug use and the sudden disappearance of an alleged drug dealer employed by a railroad contractor.

The weight of the findings, however, fell on the conductor of a local freight backed into Chisum siding south of Roswell, N.M., on April 28, 2015. He failed to restore the switch to normal position yet told both the crew of a through freight approaching at 40 mph and the dispatcher that the switch was aligned properly, NTSB investigators reported.

The NTSB also concluded the inability of the main line crew to see the switch banner showing the misalignment until it was too late, contributed to the crash. NTSB members, however, made clear that was the result of circumstances — a manual switch on unsignaled track with only the small banner as warning — and not an operational error by the crew.

“Switch banners are known to be weak safeguards for misaligned switches,” Dr. Bob Beaton, chief of the System Safety Division of the Office of Railroad, Pipeline and Hazardous Materials Investigations, said during the hearing. “They provide little to no margin of safety.”

The freight was headed timetable west (compass south) while the local was eastbound.

Trains on the Southwestern's Carlsbad Subdivision operated under track warrants issued by the dispatcher granting each train rights to run on a specific section of track. The former BNSF Railway line from Clovis to Carlsbad in eastern New Mexico is considered dark territory since it lacks trackside signals.

BNSF later canceled its lease with the short line and in January 2017 took over operations, which serves mostly agricultural, mining and oil-field customers. Southwestern continues to operate its Whitewater Division in southwestern New Mexico where in 2013 two crewmen, a crew member's girlfriend, and a dog, died when the engine of a runaway mine train sailed into a dry streambed.

The Federal Railroad Administration investigated that crash and issued a blistering report on the safety culture of both Southwestern lines. It reported the crew failed to perform a brake test or open their locomotive’s brakeline angle cock before taking eight loads down a steep mine spur.

The FRA also reported numerous violations of regulations covering safety, operations, maintenance, and recordkeeping.

The NTSB’s Ted Turpin, lead investigator on the Chisum crash, credited the short line with making management and supervisory changes to improve safety after the 2013 incident. One of the newcomers was Bruce Carswell, who is now CEO and senior vice president of Southwestern parent company The Western Group.

“The Western Group respects the findings of the NTSB investigation and appreciates the positive acknowledgment regarding our commitment to safety in the workplace," Carswell said in a statement released to Trains New Wire. “We will continue to focus on maintaining the highest standards of safety for our employees and the communities we serve.”

In the 2015 crash the local crew went off duty and left Chisum about 20 minutes before the 79-car freight with its brakes in emergency lunged into the siding striking the local’s lead locomotive at 6:23 a.m. The engineer and conductor jumped moments before contact leaving the engineer dead among derailed cars and the conductor so severely injured NTSB investigators were unable to interview him.

Two locomotives on the local and nine on the freight, most of them deadheading, derailed with several rolling over. Damage was estimated at $2 million.

NTSB Member Earl Weener revealed the switch was lined and locked for the siding when he spoke with Trains News Wire at the scene on the day of the crash. The conductor’s statement that he erroneously believed he restored the switch was released along with other documents several months later.

Why that happened led to a discussion Tuesday of research into how repeated performance of routine tasks can lead to complacency and allow interruptions cause someone to miss a step when they return to the task. At Chisum the local conductor driving a pickup truck was in the process of removing the end-of-train device and realigning the switch when a fuel truck arrived unexpectedly.

The conductor talked with the truck driver, finished his work, or at least thought he did, and drove himself and the engineer back to Roswell.

“They are not specific to the railroad industry. It’s specific to human behavior,” Beaton said. “We are not machines. We do not operated error-free 100 percent of the time despite our best intentions.”

Drug use by the main line crew apparently played no role in the collision although the autopsy on the engineer showed he had recently smoke marijuana, possibly while on duty. The conductor tested positive for the prescription opioid Oxycodone although not at levels suggesting impairment.

Oxycodone is not banned outright although investigators said they could not determine whether the conductor had a prescription for the painkiller. The apparent reactions of both men to the emergency was consistent with other crews in similar incidents, the investigation found.

The final report issued on Tuesday also revealed the Southwestern worked with local law enforcement to identify the source of drugs being sold to crew people. That led authorities to suspect a contract driver who shuttled train crews.

“Once they got really close, the driver disappeared,” Turpin said. The company was still working to elevate the safety culture at the time, he added.

“They tried to raise the level,” Turpin continued. “The drug issue may have caught them off guard.”

The short line later staged a safety stand down, assembled 98 employees, distributed a stronger alcohol and drug policy and began drug testing all present. Two employees tested positive while five others refused the test, Turpin added.

In addition to the probable and contributing causes, the NTSB issued a new recommendation urging the FRA to require railroads adopt a device or technique to assure employees perform critical tasks such as lining switches and derails and making sure cars are in the clear.

The NTSB also reiterated past recommendations to install inward- and outward-facing video cameras to record crew actions and conversations, to require railroads review those recordings to confirm crews are acting within rules and procedures and to develop technology to provide advance warning of misaligned switches in dark territory.

Other collisions involving misaligned switches in dark territory entered the discussion as well including the Feb. 4 crash at Cayce, S.C., where Amtrak’s Silver Star plowed into a CSX freight parked on a siding. The signal system there had been turned off for installation of PTC, and trains were operating under track warrants issued by the CSX dispatcher.

After that crash the NTSB urged the FRA to adopt an emergency rule governing signal suspensions so the first train nearing a freshly used switch would approach at restricted speed allowing time to stop if the switch is misaligned. The recommendation was rescinded, however, after the FRA said it would address it in a pending risk-reduction program, said Robert Hall, director of the Office of Railroad, Pipeline and Hazardous Materials Investigations.

The Carlsbad Subdivision, which does not carry passengers or certain hazardous materials, does not meet the criteria for mandatory installation of positive train control.
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