NTSB: Crew error caused 2010 train crash north of Two Harbors
A head-on collision between two ore trains north of Two Harbors that sent five workers to the hospital in 2010 was the result of crew error, the National Transportation Safety Board said in a determination released Tuesday. The federal agency also said the Canadian National Railway Co. deserves part of the blame for a lax policy on train right-of-way communication on a route without signals.
The NTSB said the Sept. 30, 2010, accident that injured five crew members from both trains was the fault of the southbound CN train carrying 116 rail cars full of ore. The crew left a siding and entered the main track before getting permission. It later collided with a CN train headed north out of Two Harbors with 118 empty rail cars.
The agency also said crews on both trains were using cell phones, a violation of safety rules that added to their distraction.
"The use of cell phones by crewmembers on the southbound train and by the engineer on the northbound train was a distraction to the safe operation of both trains and an indication of a clear disregard for Canadian National Railway rules and Federal Railroad Administration regulations," an NTSB summary of the accident read.
"The southbound train crew displayed poor coordination of activities and inadequate communication, which are indicative of poor crew resource management," the summary continued. "Had the crewmembers on the southbound train received training in, and practiced the principles of, crew resource management, they may have demonstrated better coordination and communication."
The NTSB also cited "fatigue-induced performance errors" as a contributing factor in the crash.
The northbound train was traveling with an engineer and a conductor going 29 mph while hauling 118 empty railcars. The southbound train was traveling at 14 mph and consisted of an engineer, a conductor and a student engineer who was operating the train, which was pulling 116 cars of taconite.
The two trains collided about a half-mile south of Highland Siding, an area termed "dark territory" where no signals guide trains. Three locomotives and 14 rail cars derailed in the crash, which caused $8.1 million in damages to trains and track.
While it's common for two taconite trains to use the same track, they travel under orders, called track authority, that require one train to use a siding to let an oncoming train pass, industry observers say. Those orders are radioed to conductors on each train before or during each run, with conductors confirming the orders with the dispatcher.
The NTSB said the system lacks redundancy and relies too heavily on crews, leaving room for human error.
The agency recommended that CN use electronic equipment to better identify which trains have passed others on sidings. Relying on crew members to visually identify trains leads to assumptions about which one has the authority, the preliminary report stated. The NTSB also said there should be an update in training for CN's North Division crews.
Patrick Waldron, a spokesman for CN, told the News Tribune that the NTSB conclusions will be reviewed and the company will provide a response after doing so. Attempts by the newspaper to reach crew members or union representatives were unsuccessful Tuesday.
The investigation results do not stray far from a preliminary report issued a few days after the accident blaming the southbound crew and questioning the track authority procedure.
When told of those preliminary reports in 2010, Duluth's Jerry Bakke, an independent railroad industry consultant, told the News Tribune that head-on collisions were rare.
"Any time that happens, generally there's a communication gap somewhere," he said at the time of the accident.
Crews returning from the Iron Range with a load of taconite are typically near the end of their 11- or 12-hour shift, while those heading north are typically at the beginning of their shifts.
In investigation documents from the NTSB, the southbound crew was running out of time on its shift and expected a crew change at Highland.