Human error, procedural failures, insufficient equipment and an inaccurate job briefing were among the causes and contributing factors in the deaths of two workers struck by a BNSF Railway train last year in southwest South Dakota, according to a National Transportation Safety Board report released Thursday.
The accident, which the NTSB described as preventable, happened on the morning of Jan. 17, 2017, after a westbound train came around a curve and passed under the U.S. Highway 18 overpass just north of Edgemont.
As the train proceeded around the left-hand curve, the engineer and conductor spotted a three-man crew working to clear snow and ice from a switch on the tracks ahead. The engineer and conductor began the first of several horn blasts and applied the brakes, but the train, which was going 35 mph with four engines and 135 empty cars weighing a total of 3,687 tons, could not be stopped in time.
Meanwhile, there was no response from the crew working on the tracks, one of whom was using a backpack blower to remove snow.
Twelve seconds after the train’s horn began blowing, the train struck and killed the two members of the three-man crew who were within the tracks: Richard Lessert, 35, of Black Hawk, and Douglas Schmitz, 58, of Custer.
The deaths were the 54th and 55th to result from 52 fatal railroad roadway worker accidents in the United States over the past 21 years, according to the NTSB.
“These accidents are completely preventable when the people involved, from the workers to the regulators, follow well-established rules and perform their duties with a focus on safety,” said Robert Hall, director of the NTSB’s Office of Rail, Pipeline and Hazardous Materials.
The NTSB’s report on the Edgemont accident reveals a litany of mistakes and system failures.
The NTSB said none of the members of the three-man crew had been tested on the visual detection of trains during the year prior to the accident, and the sight distance at the accident scene was inadequate for a train-approach warning by a single watchman/lookout. Furthermore, the NTSB said, the member of the three-man crew who was serving as the watchman/lookout was not devoting his full attention to detecting approaching trains.
The NTSB said the watchman/lookout had not been provided with the necessary equipment, such as a whistle, air horn, white disk, red flag, or fusee, to perform on-track safety duties as required by federal regulations. The absence of on-track safety warning equipment likely allowed the watchman/lookout to engage in other work activities, the NTSB said, rather than his assigned duty of watching for trains.
The investigation also found that the job briefing conducted by the watchman/lookout and the other workers in the group had included incorrect information regarding the minimum-required sight distance and the required time to move to a predetermined place of safety.
The NTSB additionally criticized the Federal Railroad Administration, saying the FRA’s inconsistent enforcement of federal regulations for watchman/lookout equipment requirements contributed to the accident.
An FRA spokesman said Thursday that the agency recommended civil penalties against BNSF for two regulatory violations associated with the fatal accident, but the spokesman did not immediately have any information about the nature of the violations or the amount of the penalties. He said violations by operators such as BNSF are lumped together and addressed in larger settlements; for example, BNSF was assessed about $3.45 million in total civil penalties during the 2017 fiscal year for 858 closed cases involving 1,559 violations.
At least one pending lawsuit has arisen from the Edgemont accident. In April 2017, Lessert’s father, Gerald Lessert, filed a lawsuit in federal court against BNSF on behalf of Richard Lessert's widow and three children.
BNSF Railway, which operates 32,500 miles of track in 28 states and three Canadian provinces, responded to a Rapid City Journal request for comment Thursday with a written statement.
"The accident that killed two BNSF employees near Edgemont last year is tragic and preventable. We will review the final NTSB report and recommendations," the statement said. "BNSF follows FRA standards for proper lookout equipment. After the incident, we further developed our already robust safety protocols. BNSF is committed to preventing all incidents and believes we can do so by continuing to identify and eliminate at-risk behavior, and through the use of technology and ongoing training."