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    Safety Bulletin 2023 03 Mis Aligned Switch Dark Territory

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    Safety Bulletin 2023 03 Mis Aligned Switch Dark Territory

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    safety infra
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    Safety Bulletin 2023 03 Mis Aligned Switch Dark Territory

    Uploaded by

    safety infra

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    SAFETY BULLETIN

    2023-03
    SUBJECT: Train Collision Involving a Mis-Aligned Switch – Dark Territory

    The Federal Railroad Administration (FRA) is currently investigating a train collision in dark
    territory (non-signaled) with no PTC overlay that occurred on April 16, 2023, after a train
    operating at speed encountered a switch improperly lined into a yard track, which was occupied
    by a stationary train. The incident resulted in the derailment of three locomotives and twelve
    grain cars, with both members of the crew sustaining serious injuries.

    Although FRA’s investigation into this incident is ongoing, FRA emphasizes the importance of
    ensuring safe operations of hand-operated main track switches by:

    • Conducting proper training, periodic oversight, and adherence to railroad operating rule
    requirements for hand-operated, main track switches.
    • Ensuring that the switches are visually verified to be properly lined for the intended
    route, and if uncertainty arises, conducting a double check as needed.
    • Ensuring clear and concise verbal communication among all crewmembers to confirm the
    position of the switch before leaving the location where any hand-operated main track
    switch was operated.
    • Releasing the limits of main track authority in non-signaled territory only after reporting
    to the train dispatcher that all hand-operated main track switches have been restored to
    their normal positions and locked. Exceptions can be made if the train dispatcher directs
    otherwise, and the necessary protection is provided.
    • Guarding against complacency derived from repetitive task performance by using
    multiple methods or tools to validate safety critical tasks are complete.
    • Encouraging employees to, when in doubt about switch positions, take the safe course
    and reverify the position of the switch before releasing track authority.

    The purpose of this Safety Bulletin, which is informal in nature, is to ensure the railroad
    industry, including railroad employees and contractors, are aware of this recent incident that
    resulted in injuries to employees and to recommend that railroads brief their employees and
    contractors about the circumstances of the incident. As FRA completes its investigation, it may
    take additional actions with respect to this incident.

    FRA requests that railroads review this Safety Bulletin with employees and contractors to
    increase awareness of hand-operated main track switches in non-signaled territory. FRA also
    reminds railroads of the need to ensure all individuals involved in operating hand-operated, main
    track switches are properly trained and qualified on how to conduct those operations safely.

    Issued: May 9, 2023


    ##

    Prepared by: The Federal Railroad Administration, Office of Railroad Safety

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