Management & Operations

Positive train control urged in NTSB report on 2002 crash

Posted on August 1, 2003

The National Transportation Safety Board (NTSB) determined that the probable cause of the April 23, 2002, collision of a Burlington Northern Santa Fe (BNSF) freight train and a Metrolink commuter train in Placentia, Calif., was the freight train crew’s inattentiveness to the signal system and their failure to observe, recognize and act on the approach signal. Contributing to the accident was the absence of a positive train control (PTC) system that would have automatically stopped the freight train short of the stop signal. Additionally, if the BNSF conductor had been more actively involved in monitoring the signals, he may not have misidentified an approach signal as clear, the NTSB found. “This accident, which happened during rush hour on a commuter route, illustrates how each employee is responsible for safety and how implementation of new technology can save lives,” said NTSB Chair Ellen G. Engleman. As a result of the accident, there were two fatalities and 22 serious injuries. In all, 162 people were taken to the hospital. “The safety board has issued recommendations on PTC since 1969. The technology these systems provide are the best approach to reducing human-error collision,” Engleman said. Among the recommendations the NTSB issued as a result of the accident were one to BNSF to revise its signal awareness form procedure to require recording of time, speed and aspect name for all signals at the time they are encountered. The board also recommended that the American Association of Railroads report on the milestones and activities needed for completion of the interoperability standards for PTC systems and its priorities for completion of this effort. Interoperability is the capacity of a railroad’s PTC system to operate safely on other railroads. A synopsis of the Placentia rail accident investigation report, including the findings, probable cause and safety recommendations, can be found on the publication page of the NTSB’s Website at At press time, the complete report was not available.

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