NTSB Identifies Probable Cause in 2021 Worker Fatality in Texas

Written by Kyra Senese, Managing Editor
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The National Transportation Safety Board has issued Railroad Investigation Report 23/04 for the investigation of an accident on Sept. 22, 2021, involving an equipment operator who was struck and killed by a load of steel he was transporting by a roadway maintenance machine near Castroville, Texas.

A W.T. Byler Company contract equipment operator was struck and killed on the Union Pacific Railroad Del Rio Subdivision near Castroville, Texas, on September 22, 2021, around 2:40 p.m. local time, by a suspended load of steel grating material that he was transporting with the boom and stick of a roadway maintenance machine, the NTSB reported.

The equipment operator was part of a contract W.T. Byler crew assisting UP workers with a timber replacement project on the Chacon Creek railroad bridge. The accident happened near milepost 240.65, as the operator was transporting a 2,200-pound load of three steel grating panels, each 20 feet long by 3 feet wide, from the bridge structure at milepost 240.37 to a staging area west of the bridge at milepost 240.74.

The accident was not witnessed by any employees. At the time of the accident, visibility was good with clear skies and a temperature of 84°F. W.T. Byler estimated the equipment damage to be around $32,000, according to the report. 

During a post-accident interview with NTSB investigators, the UP bridge supervisor stated that he radioed the equipment operator before 3 p.m. but received no response. 

He and two other UP employees then approached the accident scene, observed the RMM stopped on the tracks, and advised another UP employee to dial 9-1-1. Responders from the Lacoste Volunteer Fire Department, Allegiance EMS Castroville, and the Medina County Sheriff’s Office arrived at the scene around 3:38 p.m., and the equipment operator was pronounced dead, the report said. 

The equipment operator had reported to the worksite at 7:30 a.m. on the day of the accident. The UP bridge foreman stated to NTSB investigators that he instructed the equipment operator to use the RMM to remove steel grating panels from the bridge structure and stack the materials along the ballast shoulder at milepost 240.37. The operator was then directed to transport the panels westward to the material staging area.

The RMM involved in the accident was a Caterpillar mini hydraulic excavator that Ballast Tools Equipment outfitted with retractable railroad wheels so that it could operate as a rail-mounted RMM. The machine had a lifting capacity of 6,549 pounds and was equipped with a standard boom and stick for lifting materials over the front of the machine. Various work heads, such as grapples, digging buckets, and clamping attachments, could be attached to the stick; a clamping work head attachment was chosen for this job.

The equipment operator used a clamping work head attachment made by BTE called the Tie Talon to lift and transport the steel grating panels to the material staging location. NTSB investigators reviewed BTE’s work head specifications, which state that the attachment is intended for use with single crossties. The specification makes no mention of other applications for this attachment.

During a post-accident interview with NTSB investigators, the UP bridge supervisor stated that he saw the equipment operator use the clamping work head attachment to grip the steel grating panels and transport the load suspended in front of the RMM with the panels oriented lengthwise above the track’s centerline.

The equipment operator began working for W.T. Byler on Sept. 6, 2016. In a postaccident interview with NTSB investigators, the W.T. Byler director of safety stated that all W.T. Byler workers receive safety training during new hire orientation and must follow UP safety procedures. A review of training records showed that the equipment operator had completed contractor safety orientation on Jan. 17, 2020. He also received training from BTE on the mini excavator RMM on Jan. 7, 2021.

Central Texas Autopsy conducted an autopsy of the equipment operator. The cause of death was hemorrhagic shock, according to the autopsy report. In accordance with Title 49 Code of Federal Regulations Part 219, the equipment operator underwent postaccident toxicology tests for alcohol and other drugs. The results were negative for all tested-for substances.

The NTSB examined records for the equipment operator’s mobile phone, which he had on him at the time of the accident. According to the review, an 11-minute incoming call was answered around 2:38 p.m., just 2 minutes before the accident.

W.T. Byler had a safety training and inspection program in place at the time of the accident, but RMM operator training was provided by BTE. W.T. Byler had no policies or procedures in place for transporting suspended loads with RMMs, the report said.

According to W.T. Byler’s cellular phone policy, employees must not operate any equipment while on the phone. To use a cellular phone, an operator must stop, turn off, and dismount the equipment, as well as stay at least 50 feet away from the track.

During initial training, each employee must learn and sign this policy and the signed policy is kept in their employment records. 

On Sept. 24, 2021, NTSB investigators examined impact markings in the track gauge’s center. The steel grating panels had fallen from the clamping work head attachment, as indicated by gouges and scrapes in the crossties and ballast in front of the accident RMM.

The final resting position of the RMM on the track was described in the report: the steel grating panel, still gripped by the clamping work head attachment, was positioned with one end of the panel stuck in the ground directly in front of the RMM, in the center of the track gauge, and the other end extending through the broken front windshield of the RMM.

W.T. Byler prohibited the use of the clamping work head attachment to move steel grating panels as a result of this accident. To move these panels, employees must use a grapple truck. W.T. Byler also revised their safety program to prohibit workers from transporting materials suspended in front of RMM equipment above the track’s centerline. 

According to these rules, operators who use RMMs to transport suspended loads must position the loads over the field side of the track and use tag lines to stabilize the loads. When railroad clearance issues obstruct material movement, rail carts must be used. 

W.T. Byler provided employees with initial and refresher safety training in roadway worker protection regulations. The company hired two railroad safety professionals and contracted with a third-party vendor to provide Occupational Safety and Health Administration fall protection and bridge worker safety training programs. Audits of proper employee credentials and safe working habits are also being conducted by the company, according to the report. 

Although the investigation did not determine whether the equipment operator’s cellular phone use contributed to the accident, use of a personal electronic device while operating an RMM is a violation of W.T. Byler’s operating rules. W.T. Byler reiterated this rule to employees, NTSB said. 

The NTSB concluded that the probable cause of the Sept. 22, 2021, accident was the use of a roadway maintenance machine to move a load of steel grating panels suspended in front of the machine with a clamping work head attachment that was not designed for use with such a load.