National Transportation Safety Board

Office of Highway Safety

Washington, DC 20594

RRD22MR010

HIGHWAY SAFETY

Group Chair's Factual Report

August 22, 2022

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A. CRASH

Location: BNSF Railroad Milepost 363.8 US DOT Crossing 005284Y at Porche

Prairie Ave., Mendon, MO
Date: June 27, 2022
Time: 12:42 Central Daylight Time CDT
Vehicle 1: 2007 Kenworth W900B Loaded Dump Truck
Train 1: Amtrak Train #4 with two locomotives and 8 passenger cars

B. HIGHWAY SAFETY GROUP

Group Co-Chair Eric Gregson

National Transportation Safety Board (NTSB)
Washington, DC

Group Co-Chair David Rayburn

NTSB

Group Co-Chair Shawn Currie

NTSB

Group Member Troy E. Hughes P.E.

Administrator of Railroads
Missouri Department of Transportation (MODOT)
Jefferson City, MO

Group Member Howard J. Gillespie

District Specialist Grade Crossing Division
Federal Railroad Administration
Washington, DC

Group Member Joe Lair

Senior Railroad Safety Inspector
Missouri Division of Railroad Safety
Jefferson City, MO

Group Member Aaron Ratledge

Director of Transportation Safety
BNSF Railroad
Fort Worth, TX

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Group Member Detective Robert N. Hanson
Amtrak Police Department
New Haven, CT

Group Member Sergeant Glen Ward

Missouri State Highway Patrol
Mendon, MO

C. SUMMARY

On Monday, June 27th, 2022, about 12:42 p.m. central daylight time, an
eastbound Amtrak passenger train struck a northbound 2007 Kenworth dump truck
(Kenworth) loaded with aggregate, at a grade crossing in Mendon, Chariton County,
Missouri. The Amtrak train was on Burlington Northern Santa Fe (BNSF) railway tracks
and struck the left rear of the Kenworth dump truck.

The highway portion of the grade crossing, Porche Prairie Avenue consisted of
a northbound and southbound lane.

The highway-railroad grade crossing was controlled by a passive warning

system with a single crossbuck in conjunction with a stop sign. The highway intersected
with the grade crossing at approximately 45 degrees.

As a result of the collision one (1) locomotive and eight (8) railcars derailed.
Three (3) passengers on the train and the driver of the Kenworth were fatally injured.

D. HIGHWAY FACTORS

1.0 Introduction

On Monday, June 27th, 2022, the NTSB initiated an investigation of a highway-

railroad grade crossing (rail crossing) collision that occurred on Porche Prairie Ave.,
Mendon, MO. 1 A 2007 Kenworth dump truck, loaded with aggregate, had been
travelling northbound on Porche Prairie Avenue attempting to traverse the crossing.

The rail crossing was controlled by a passive warning system. 2 The passive
warning at the crossing consisted of a single crossbuck in conjunction with a stop
sign.

1
The grade crossing is owned and operated by the Burlington Northern and Santa Fe Railway (BNSF)
and is identified by the DOT grade crossing inventory #005284Y, at BNSF milepost 363.8.
2
According to the Highway-Rail Crossing Handbook, 3rd Edition, a passive crossing is where warnings
and traffic control is provided by passive devices such as signs and pavement markings where no
Active Grade Crossing Warning System is present.

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 As the Kenworth entered the rail crossing, Amtrak Train 4 (Southwest Chief)
consisting of two locomotives and seven passenger carrying cars, and one baggage
car was approaching from the southwest. The train engineer sounded the horn and
placed the train into emergency braking. The front of the lead locomotive collided
with the left side rear of the Kenworth.

The impact propelled the Kenworth into a counterclockwise rotation. Due to

the collision the dump bed and the cab portion of the Kenworth were torn from the
chassis.

The Highway Safety group for this investigation was convened for the purpose
of obtaining information related to the design, maintenance, and operation of the
highway environment to establish a foundation for evaluation whether the condition,
design, or operation of the highway facility contributed to the collision. In support,
the on-scene documentation of the crash location consisted of ground based
terrestrial photography of the scene and Kenworth coupled with aerial photographs
of the scene. Documentation of the damage to the Kenworth and train was also
obtained.

The Highway group further obtained information about the design of the
railroad/highway grade crossing including location, geometric design, traffic metrics,
accident history, and traffic control devices. Focus areas included examining previous
crossing studies by the Missouri Department of Transportation establishing the need
for the stop sign at the crossing and examining the decision-making process to
determine if improvements are needed at the crossing. Further documentation and
information were obtained from MS Contracting LLC., the motor carrier involved in
the collision.

Factual reports prepared by other NTSB investigative groups should be

consulted for information related to other aspects of the investigation, including
information used within this report.

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2.0 Collision Site and Geometric Design

Figure 1 is a crash map that depicts the crash location which was
approximately 3.2 miles southwest of the city of Mendon, MO.

Figure 1. Crash map (Source: Google Maps revised).

Figure 2 is a site map of the Porche Prairie Avenue and BNSF double grade
crossing #005284Y. The collision occurred on Track #2.

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 Figure 2. Site map of the Porche Prairie Avenue and BNSF double grade
crossing showing geometry and signage. (Source: Google Earth revised).

2.1 Collision Site

The highway-railroad grade crossing is in the Burlington Northern Santa Fe

(BNSF) railroad Chicago division and Marceline subdivision. The Federal Railroad
Administration (FRA) Grade Crossing Inventory form submitted by BNSF on 9/3/2020
shows the railroad measured the Global Positioning Satellite coordinates (GPS) at
39.5605810 degrees latitude and -93.181186 degrees longitude. BNSF indicated
crossing 005284Y was located on their railroad tracks at milepost 363.876. The
highway location is on Porche Prairie Avenue about .7 miles north of Missouri
supplemental route BB. The inventory form also lists Porche Prairie Avenue as
Chariton County Road 113 (CR113).

Porche Prairie Avenue intersected the grade crossing at a 45° angle and was
oriented in a north-south direction with the rail line running northeast to southwest.
The roadway was constructed of gravel and had a varying width of 17-20 feet. The
surface had humps and potholes on the approach to the crossing.

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2.2 Horizontal Geometry

The crossing is on a right skew angle of approximately 45 degrees. A skew

angle is any angle less than 90 degrees. 3 The text describes skewed intersections as
undesirable because they can result in a driver having to turn their head at larger
angles to see, and interior components of the vehicle can restrict or obstruct a drivers
view. Earlier version of the American Association of State Highway and
Transportation Officials (AASHTO) manual recommended intersection angles no less
than 60 degrees, but the 2018 version recommends intersection angles be as close
to 90 degrees as practicable and no less than 75 degrees for new construction or
realignment. The AASHTO text also suggests several ways to realign roadways so that
they can intersect closer to 90 degrees. Figure 3 is a photograph of a NTSB
investigator, in an exemplar truck, at this crossing leaning well forward and looking
over his left shoulder to overcome the restriction of the skewed crossing angle and
vehicle “B” pillar sight obstruction.

Figure 3. View of NTSB investigator leaning forward almost to the steering wheel to see around the
"B" pillar sight obstruction caused by the skew angle of the crossing. Using this strategy, the
investigator was able to see the following view in figure 4.

3
American Association of State Highway and Transportation Officials (AASHTO) “A Policy on
Geometric Design of Highway and Streets”, 2018, 7th Edition.

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Figure 4 depicts the view seen by the above investigator after leaning forward.

Figure 4. View of a freight train approaching from approximately the whistle post located 1,328 feet
from the crossing.

2.3 Vertical Alignment

The vertical profile at this crossing exceeded the roadway approach grade
found in the current American Association of Railroad Engineering and Maintenance
of Way Association’s (AREMA) Railway Engineering Manual (REM 2020). In earlier
versions of the AASHTO geometric design policy The American Railway Engineering
Association (AREA), which later became The AREMA standards and guidelines were
adopted by AASHTO. These guidelines apply to new construction and
reconstruction. The elevations standards adopted in the 1990 AASHTO geometric
design policy indicated that from the nearside rail the elevation could slope down no
more than 6 inches in 30 feet from the rail. The current AASHTO policy and REM
2020 recommends the approach roadway surface not slope down more than 3 inches
in 30 feet from the nearside rail. The maintenance of grade outside the railroad right-
of-way was the responsibility of Chariton County. The Burlington Northern Santa Re
Railroad (BNSF) right-of-way extended 50 feet south of the center of rail #2. Research
into whether the operating railroad or the public road authority was responsible for
maintain the approach grade to the crossing even though it was on the railroad right-

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of-way indicated the following: There are no existing federal regulations requiring in-
service improvement to maintain approach grades to current design standards. And
the practice of the highway authority funding horizontal and vertical alignment
improvements as well as funding crossing replacements themselves has evolved or
the decades with the states formally and informally entering into agreements to fund
approach grade improvements. 4 MoDOT safety rules indicate the roadway authority
is responsible for maintenance of the approach grade. At this site, the railroad was
constructed approximately 1910-1920 by the Atchison Topeka Santa Fe Railroad
(ATSF) and the County Constructed County Road 113 or Porche Prairie Avenue. The
construction date was not available through Chariton County. The crossing and
approach grades were constructed where the gravel roadway was constructed. In
summary, the earliest guideline for approach grades to crossings was published by
AREA in 1971and by AASHTO in 1990. Currently, Missouri has regulations in its’ Code
of State Regulations (CSR 265-8.130) governing construction/reconstruction and
maintenance of grade crossings. The regulations mirror the guidelines found in the
AREMA REM Part 8 (2013) which is adopted by reference. 5

Article 8.1.0 of the REM provides the following text regarding the scope of
recommended guidelines: “The fact that design values and practices for new
construction or for the reconstruction of highway/railroad at-grade crossings are
presented in this Part does not imply that existing non-conforming crossings are
unsafe, nor does it mandate the initiation of improvement projects. For projects
involving rehabilitation, restoration, replacement, renewal, resurfacing or
maintenance of existing tracks through crossings, crossing surfaces, or roadway
approaches to crossings, where major revisions to alignment, elevation, or profile are
deemed impractical or beyond the scope of the work being undertaken, existing
design values may be retained, particularly if a site investigation indicates the existing
site design features are performing in a satisfactory manner for the normally
anticipated traffic exercising due care. Absent other compelling factors, the cost of
full reconstruction of these facilities solely to conform to the recommended practices
contained herein, particularly on lower volume roadways, will often not be justified.”
See figure 5 for a view of the severe approach grade. Figure 6 is a diagram
displaying the current AASHTO recommendation in relation to the measurements
recorded at the scene for the grade crossing approach.

4
For more information see Highway-Rail Crossing Surfaces, Washington, D.C. National Cooperative
Research Program Report Synthesis of Practice 250 (1997) Washington D.C. NCHRP.
5
MO CSR accessed on January 22, 2023.

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Figure 5. View of exemplar truck on approach to the railroad tracks.

Table 1 below shows elevation measurements that were taken by the highway group
from the nearside rail on Wednesday, two days after the crash.

Table 1. Lists the elevation drop as measured from the near side rail.
Distance from crossing (near side Elevation
rail) drops
30 feet 39 inches
40 feet 44 inches
50 feet 57 inches
80 feet 70 inches

On the day of the crash the Missouri State Highway Patrol (MSHP) crash
reconstruction team documented the grade via drone measurements and smart level
before the surface changed from all the heavy vehicle activity associated with rescue
and recovery. The MSHP measurements indicated the slope near the top of the grade
was 15.8 percent and near the bottom of the grade before it leveled out was 4.3
percent. See figure7 below for MSHP Grade measurements.

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Figure 6. Diagram showing the AASHTO standard related to
the actual grade crossing approach measurement.

This area intentionally left blank.

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Figure 7. Image of slope calculations completed by MSHP.

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2.4 Traffic Control Devices

There were no advance warning signs on either side of the crossing as

required by the Manual on Uniform Traffic Control Devices (MUTCD). The placement
of advance warning signs was the responsibility of the roadway owner, Chariton
County. The dimensions, lateral placement and mounting height of the passive traffic
control devices were documented. The stop sign and crossbuck were on the same

Figure 8. View of stop sign and crossbucks at the crossing. (Source: MSHP)

mast which was located laterally approximately 14 feet from the roadway edge. The
MUTCD designation for the stop sign was R-1 and the crossbuck designation was R-
15-1. The crossbuck also had the 2-track designation and mast had retroreflective
tape. The center of the 36-inch stop sign was approximately 7 feet high and the
crossbuck mounting height was approximately 9 feet high. Both signs had the
correct dimensions, lateral placement, and mounting height. The MUTCD requires
an engineering study be performed before a stop sign can be used at a passive
grade crossing. 6 The decision to upgrade highway/railroad grade crossing warning
devices requires public governing body approval. See figure 8 above for a view of
the Stop sign and crossbucks with 2 tracks plaque.

6
MoDOT is searching for the study documenting the reasons a stop sign was used at this crossing. As
of August 1, 2022, they have been unable to locate the study.

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2.4.1 Special Stops Required

The Motor Vehicle Revised Statutes of Missouri Sec. 304.035

specifies the following duties of a driver approaching a railroad
/highway grade crossing: “When any person driving a vehicle
approaches a railroad grade crossing, the driver of the vehicle shall
operate the vehicle in a manner so he will be able to stop, and he shall
stop the vehicle not less than 15 feet and not more than 50 feet from
the nearest rail of the railroad track and shall not proceed until he can
safely do so if:

(1.) A clearly visible electric or mechanical signal device warns of

the approach of a railroad train; or
(2.) A crossing gate is lowered or when a human flagman gives or
continues to give a signal or warning of the approach or
passage of a railroad train; or
(3.) An approaching railroad train is visible and is in hazardous
proximity to such crossing; or
(4.) Any other traffic sign, device or any other act, rule, regulation,
or statute requires a vehicle to stop at a railroad grade crossing.

2. No person shall drive any vehicle through, around or under any

crossing gate or barrier at a railroad crossing when a train is approaching
while such gate or barrier is closed or is being opened or closed.

3. No person shall drive a vehicle through a railroad crossing when

there is not sufficient space to driver completely through the crossing.

4. No person shall drive a vehicle through a railroad crossing

unless such vehicle has sufficient undercarriage clearance necessary to
prevent the undercarriage of the vehicle from contacting the railroad
crossing.

5. Every commercial motor vehicle as defined in section 302.700

shall, upon approaching a railroad grade crossing, be driven at a rate of
speed which will permit said commercial motor vehicle to be stopped
before reaching the nearest rail of such crossing and shall not be driven
upon or over such crossing until due caution has been taken to ascertain
that the course is clear. This section does not apply to vehicles which are
required to stop at railroad crossings pursuant to section 304.030.

6. Any person in violation of the provisions of this section is guilty

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of a class C misdemeanor.

2.4.2 Track Safety Standards and FRA Highway-Rail Grade Crossing

Guidelines for High-Speed Passenger Rail

49 CFR Part 213.347 requires FRA approved barriers at crossing where train
speeds of 110 mph are permitted, and where train speeds of 125 mph or greater a
grade separation is required. In guidance provided through the 1990s, the DOT
advocated for a minimum of active warning systems with gates, controlled by
constant warning time circuitry, on rail lines with speeds of 80 mph and greater. 7
Gates provide an unequivocal indication to the motorist regarding the behavior
expected. This continues to be a good foundation for crossing safety on HSR lines,
but developments since that time point the way to additional strategies. 8 Sealed
corridor programs where passive crossing elimination has been the most recent focus
on high-speed passenger trains.

2.5 Traffic Metrics

The Missouri Department of Transportation records indicated the Average

Daily Traffic (ADT) for the crossing was 8 vehicles per day. Truck traffic was
approximately one truck per day. The BNSF data on the grade crossing inventory
showed that approximately 58 freight trains and two passenger trains came through
the crossing each day. The speed limit for the track was 90 mph. The speed limit on
a gravel road when not otherwise posted was 50 mph. 9

2.6 Crash History

There was no record of any other crashes at this crossing. Information provided
by MoDOT showed that there are 1,703 grade crossings in Missouri with active
warning devices and 1,450 crossings with passive devices (either crossbucks, stop
signs, or both). In the five-year-period 2017-2021 there were 22 fatalities at public
railroad/highway grade crossing in Missouri.

2.7 Design Clearing Sight Distance

Design clearing sight distance is the distance a vehicle operator needs to see
an approaching train to be able to start forward from a stopped position 15 feet from
the nearside rail and clear the tracks and dynamic envelope before the arrival of the
train even if the train comes into view when the vehicle starts forward. The following

7
FRA Highway-Rail Grade Crossing Guidelines for High-Speed Passenger Rail 2009
8
8 Constant warning time circuitries may not be practical on electrified rail lines under some
conditions (including the nature of the legacy train control system). If that is the case, special care
should be given to ensuring that warning system traffic control at the crossing is observed.
9
Revised Statutes of Missouri RSMO Section 304.010.

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 Figure 9. Basic Calculation Values for Design Clearing Sight Distance.

equations provide the designer with procedures to estimate this distance on a

level surface at a near 90-degree crossing. Modifications to the calculation
procedures need to be made for skewed crossing angles, steep grades, and multiple
tracks:

In this accident the nearside track was track number 2 and the far sidetrack was
track number one. Since multiple tracks had to be crossed on a skewed angle
crossing with a severe grade, adjustments were made by conducting an acceleration

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test with a similar vehicle. The accident truck weighed 76,120 pounds. The exemplar
truck weighed approximately 71,600 pounds. An acceleration test was performed to
find the design clearing sight distance required for the accident driver. The exemplar
truck was accelerated in the same gear from the stopping point 15 feet from the
nearside rail; it required 20.3 seconds to clear track 2, 27.3 seconds to clear track 1
and 33.53 seconds for the rear of the truck to clear the dynamic envelope, which was
6 feet past the far side rail. Using the train speed limit of 90 mph or 132.3 feet per
second shows the driver would need to be able to see the train from 4,366 feet away
to start forward from a stopped position and clear the tracks before the train arrived.
From the stopped position 15 feet from the nearside rail the only vision restrictions or
obstructions were the vehicle “B” pillar. However, it is permissible to stop no closer
than 15 feet and no farther than 50 feet from the nearside rail. If a driver stops farther
back at this crossing, vegetation could restrict the view of an approaching train.

2.7.1 External Sight Restrictions at the Crossing

The following vegetation growth was documented:

1. A Maple tree was located 959 feet from the crossing and laterally it was
located 32 feet south of the center of track #2

2. A Crepe Myrtle tree was located 1226 feet from the crossing and 29 feet 6
inches from the center of track #2.

3. An approximate 20-foot-tall pecan tree was located 1247 feet west of the
crossing and 31 feet 6 inches south of the center of track #2.

All the vegetation growth listed above could restrict a driver’s view if they
chose to stop 50 feet from the crossing instead of 15 feet from the crossing. See
figures 10 and 11 for views of the vegetation.

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Figure 10. View of vegetation on the south side of track #2 that could restrict a driver's view. This view
shows the Amtrack's eastbound approach.

This area intentionally left blank.

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 Figure 11. View of vegetation from 50 feet south of the nearside rail looking to the west. (Source:
MSHP).

3.0 MoDOT Railroad/Highway Grade Crossing Improvement Program

Since 2017 MoDOT has been partnering with Railroads and Local Public
Agencies (LPA’s) to identify and address crossing improvement needs. The
Department has been awarded two Consolidated Rail Infrastructure and Safety
Improvement Grants (CRSI) and is working to address the identified needs on two
southwest Missouri corridors which do not include this location. Missouri’s
constitution requires MoDOT to spend the dedicated State Road Fund (SRF) on the
State Highway System. MoDOT’s crossing improvement program is funded 7.5
million annually by 6 million from Section130 funds and 1.5 million from the Grade
Crossing Safety Account (GCSA). These funds may be spent on public crossings
located on the State Highway System and local road systems.

Table 2. Rail crossings in Missouri.

Owner Total Active Passive Upgrade Costs 10
State Highway 496 471 25 $10 Million
Local Roads 2,658 1,208 1,425 $570 Million
Private 2,183

10
Estimated costs to install active warning devices at the passive crossings.

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 The Department administers the grade crossing program with the assistance of
local communities helping to identify rail crossings for improvement. While MoDOT is
responsible for administering this process, nothing prevents any entity, including
railroads and LPAs, from approaching MoDOT to improve safety at a particular rail
crossing. In fact, MoDOT encourages communities to engage in this process by
identifying crossings for closure and those most in need of safety improvements. This
mix of closures and safety improvements has always been the Department’s
approach to rail crossing safety. Using this collaborative approach, the Department
has worked with local communities and roadway authorities to upgrade or close
more than half of the previously identified rail crossings.

The Department has worked to improve safety at rail crossings on the State
Highway System (SHS) by closing some crossings and installing active warning
systems or grade separations on other rail crossings. The result of this effort is that
95% of the nearly 500 rail crossings on the SHS have been closed, separated, or
improved with active warning devices. MoDOT's other primary focus has been
improving the safety of the state sponsored intercity passenger rail service, Amtrak's
Missouri River Runner route that crosses the state from Kansas City to St. Louis. Rail
crossings along this corridor have been improved with grade separations, active
warnings, closures, leaving only I passive public crossing on the corridor. The
Department has also worked with all railroads operating within the state to
implement recent revisions required by the Manual on Uniform Traffic Control
Devices (MUTCD). Finally, MoDOT is seeking to upgrade the rail crossings along the
corridor of the other two passenger rail routes in the state, The Southwest Chief and
The Texas Eagle.

Railroads and LPAs have contributed their own money with in-kind services on
many of the rail safety improvement projects. Since 2017, railroads have used more
than four million dollars to partner with MoDOT and the communities to make safety
improvements. Federal CRSI grants, coupled with state, railroad, and local funding
for improvements along rail corridors in the southwest region of Missouri will result in
closing 13 crossings, placing active crossing protection at 4 crossings, construction of
I railroad overpass, enhancing pedestrian safety, and a myriad of other safety
improvements, all focused on saving lives and preventing injuries.

4.0 Grade Crossing Maintenance Requests by Chariton County

Commissioner’s Court

The following notes by the Presiding Commissioner of Chariton County reflect

maintenance complaints received and requests by the County Commissioners to the
BNSF Railroad and MODOT for maintenance.

Timeline of information from my personal notes concerning the Porche Prairie

Avenue rail crossing.

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Chariton County Presiding Commissioner

• December 2, 2019
o The Commission spoke to Mike Spencer about his concerns at the
Porche Prairie Ave rail crossing.
o He said the approach is very steep and needs addressed.
o He has been in contact with the railroad but said they were not being
very cooperative.
o We gave him the contact information for MoDOT railroad safety.
• December 9, 2019
o The Commission spoke to Jack Wright, MoDOT Railroad Safety, about
the Porche Prairie Ave crossing.
o They told us they were aware of the issues at the crossing, and it is on
their plans to repair.
o They said they would start talking to landowners to get dirt to fix the
approach.
• March 3, 2021
o The Commission met at the Porche Prairie Ave rail crossing with Jack
Wright of MoDOT Railroad Safety, Mike Spencer, and Jon Dwigging of
Howe Company.
o The approach to the crossing is very steep and needs to be addressed.
o Since the gravel road and railroad intersect at an angle, it can make it
difficult to see.
o The crossing is used by a lot of farm equipment which would make it
especially difficult to navigate.
o Mo DOT still has the crossing on their list to repair but no timeline was
given to us.
• May 23, 2022
o Commissioner Milford was contacted by residents about brush
obstructing the view at the Porche Prairie Ave rail crossing.
o The Commission contacted Jack Wright of MoDOT Railroad Safety by
email about the visibility issues but never received a response.
• May 31, 2022
o The Commission called the Mariano Rodriguez, Roadmaster with BNSF,
to express our concerns with the visibility issues at the Porche Prairie
Ave rail crossing.

5.0 Audibility of Train Horns at Passive Grade Crossings

Due to recovery operations and Amtrak locomotive availability actual audibility

testing was not performed at the site. However, research and testing by the NTSB in
other cases provided a foundation for assessing the audibility of the train horn in this
investigation. The Federal Railroad Administration’s (FRA) regulation for audible

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warning devices states that locomotives shall be provided with an audible warning
device that produces a minimum sound level of 96 dB(A) at 100 feet forward of the
locomotive in its direction of travel. 11 Typical test values of Amtrak locomotive horns
indicate they can produce a 100-105 decibel sound pressure level at the 100-foot
distance. FRA test records for ATK 133, the accident lead locomotive showed that the
certification test for the locomotive horn was performed in 2010. The horn could emit
a sound pressure level of 101.4 dB(A).

Audibility testing of outdoor sounds show that the sound pressure levels
typically reduce in intensity by 6 decibels for each doubling of distance from the
sound source. 12 The Amtrak locomotive began sounding its horn near the Whistle
post which was 1,328 feet from the crossing. At this distance from the crossing the
sound pressure level would be reduced by approximately 24 decibels.

Table 3. Reduction in decibels at certain distances.

Distance Reduction in Sound
Density
200 feet 6 dB
400 feet 12 dB
800 feet 18 dB
1600 feet 24 dB

Also, the wind conditions could have lessened the sound pressure levels; the
wind was blowing 3-7 mph from 3 to 87 degrees or carrying the sound to the south
and west of the crossing.

Sound pressure testing in a previous NTSB investigation in a conventional cab

straight truck on a gravel surface indicated the ambient noise levels varied between
80-85 decibels. 13 Audibility research indicates that the sound pressure level needs to
be 3-8 decibels higher than the ambient noise level to detect sound and 10 decibels
greater for the detected sound to be alerting. 14 In this investigation insertion loss did
not have to be accounted for because the post-crash inspection showed that the
dump truck windows were down when the crash occurred. 15

11
49 CFR Part 229.212a
12
Acoustical Society of America 1994. Procedures for outdoor measurement of sound pressure level.
American National Standard Institute (ANSI) ANSI Standard S12.18-1994. New York, NY ANSI S-12.18
Page 4.
13
Blum, Texas investigation HAB02-10 HWY98Sh007.
14
Lipscomb, David M. 1982. Audibility and the Law. In: Kramer, M.B.; Armbruster, J.M., eds. Forensic
Audiology. Baltimore, MD. University Park Press: 191-222. Chapter 11. “The alerting level is the sound
level at which a person is aware of a sound and recognizes its source.
15
Insertion loss is the difference between the measured values of a sound from an exterior sound
source taken outside the vehicle and inside the vehicle.

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6.0 Enforcement Activity

A five-year historical search of traffic enforcement records was performed by

the Missouri State Highway Patrol and Chariton County Sheriff’s Office. No crashes or
enforcement records for the crossing were located.

E. TECHNICAL RECONSTRUCTION

7.0 Vehicle Documentation

7.1 Locomotive

Upon arrival of NTSB investigators, the lead locomotive, identified as ATK 133,
was derailed and still attached to the remainder of the train. The locomotive was
examined by investigators on June 28th, 2022. Additional examination and
photography occurred on June 30th, 2022, at a location northeast of the rail crossing.

The lead locomotive, ATK 133, was identified as a General Electric model
P42DC and was 69 feet in length, and 14’9” tall. The locomotive was photographed
utilizing a small Unmanned Aircraft System (sUAS). Figure 12 depicts the damage
sustained by the lead locomotive from the collision.

Figure 12. Photograph depicting the damage to the front of the locomotive.

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 Direct impact occurred on the front and left side of the locomotive. The
damage to the front extended inboard an approximate distance of 6.45 feet and
upward to the top of the left windshield. The coupling device was damaged. The
fiberglass covering on the front was cracked in several locations. The main impact
was located on in the area around the left light and left front corner of the locomotive.

7.2 Commercial Motor Vehicle

The involved commercial motor vehicle was identified as a 2007 Kenworth

W900 dump truck. The dump truck had been removed from the scene and secured
indoors at a storage facility. On June 30th, 2022, NTSB investigators attended an
examination/inspection of the dump truck conducted by MSHP investigators. The
vehicle was photographed during the examination. Post-collision the cab, dump bed,
and rear drive axle, axle #5, had been torn away from the frame of the dump truck.
Figure 13 is a photograph of the dump truck frame.

Figure 13. Photograph showing the damage to the rear of the dump truck.

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Figure 14. Photograph depicting the damage to the 5th axle sustained during the collision.

Figure 14 is a photograph of the 5th axle showing the damage described

above. The frame rails at the rear of the dump truck at about the 4th axle were bent
towards the right (passenger) side at about a 30° angle. Both right tires on the 4th axle
had separated from their respective wheels. The 5th axle left (drivers’ side) outer steel
wheel was torn and the pieces that were torn away were bent. The tire had
completely separated from the wheel. The inner steel wheel was also bent, and the
inner sidewall of the tire had torn open. The left side of the axle had been
compressed inwards toward the differential, decreasing the track width. The left
brake chamber was bent inwards towards the center of the axle, and the left side
outer cover of the differential was dented inward.

The cab suffered extensive overall damage. All the glass had been broken out
and the roof was torn away. The steering column was bent forward, toward the
dashboard, and the upper rim of the steering wheel was bent forward. The seatbelt
and belt buckle were observed retracted and against the “B” pillar. During the
inspection of the cab MSHP investigators removed the instrument gauge clusters
from inside the cab. Figure 15 is a photograph of the one of the clusters removed.
The pictured cluster housed two gauges, speedometer, and revolutions per minute

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(RPM). Of note, the speedometer needle was stopped at approximately 5 mph and
the RPM was displaying 1100 rpm.

Figure 15. Image of instrument gauge cluster from the 2007 dump truck.

Contact damage to the left rear corner was observed. The left rear corner was
pushed upward, with the side wall being pushed inward. The upper steel rail, left
side, and the tailgate had been torn off. The front wall of the dump bed separated
from the left side at the corner seam, and the front wall was pulled forward away from
the left wall.

7.3 Electronic Event Data

The commercial motor vehicle involved was powered by a diesel engine

manufactured by Caterpillar. The engine is controlled by several controllers which are
generally referred to as electronic control modules (ECMs). The ECMs may be
capable of recording and storing engine data relating to parameters and event data.
Depending on engine and vehicle setup the data may be recorded and stored on a
single module or multiple modules. The modules can be accessed through
commercially available software or require manufacturer assistance where the data is
proprietary.

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 The Kenworth was equipped with a 14.6-liter Caterpillar six-cylinder diesel
engine, and a 10-speed Eaton Fuller transmission. MSHP investigators were able to
locate and remove the ECM from the vehicle. Due to damage the ECM was
photographed and shipped to the NTSB Office of Research and Engineering for
examination and imaging. Figure 16 is a photograph of the damaged ECM.

Figure 16. Photograph of damaged ECM removed from the Kenworth. (Photograph courtesy of
MSHP).

Caterpillar uses proprietary software that is not commercially available. The

software program is Electronic Technician. The software will report calibration
information, trip data, fault codes, and critical event snapshots. There are three
scenarios in which data records to the ECM.

1. Critical event snapshot: i.e., low oil pressure, low engine coolant
2. Driver triggered snapshot
3. Quick stop
Investigators from the Office of Research and Engineering located a Caterpillar
representative whose services were engaged to conduct an image of the ECM. The
ECM was hand carried to Carter Machinery for the imaging by a Research and
Engineering recorder specialist and Office of Highway Safety investigator. Refer to

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the NTSB Electronic Control Module Specialist’s Factual Report for details about the
imaging.

The Electronic Technician software provides a multiple page report that

includes ECM Summary, Critical Events, Configuration, Logged Event Codes, as well
as data regarding Total Time vs. Vehicle Speed and Engine Speed. 16

The ECM Summary reported the Engine Serial Number as MXS85820 and the
ECM Serial Number as 10266994JX. The record reported one critical event for very
low coolant level, reported on June 21, 2022, at approximately 8:43 pm. The ECM
reported the event codes along with the diagnostic codes in relation to the internal
diagnostic clock which was at 6,236 hours. Table 4 shows the logged event codes
that were recorded by the ECM. The occurrence is the number of times the event had
been logged. The first and last are the first time (diagnostic clock), and the last time
the code was logged.

Table 4. Logged event codes from the truck ECM.

Code Description Occurrence First Last
J1939 Device Not
231-12 1 6236 6236
Responding
Low Coolant Level
111-1 11 6121 6214
Warning
Very Low Coolant
111-11 10 6121 6214
Level

Eight current diagnostic codes were also reported. Each had only one occurrence
and the first and last reported time was 6236, which as mentioned above was the
current diagnostic clock count.

As mentioned above the third scenario for triggering a critical event is with a
quick stop. Within the ECM configuration the quick stop rate is a setting that can be
activated by the vehicle owner through the Caterpillar software. According to the
configuration of the truck the quick stop rate was set to 0.0 miles per hour per
second.

8.0 Video Study

The lead locomotive was equipped with a forward-facing camera that captured
the collision and the movement of the truck prior to impact. The truck was visible
within the camera frame along with a dust cloud that trailed the truck as it traveled
northbound on Porche Prairie Ave. Refer to the NTSB Office of Research and
Engineering Video Study for further details.

The Caterpillar Electronic Technician Product Status Report can be found with the Electronic Control
16

Module Specialists Factual Report.

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 F. MOTOR CARRIER HISTORY AND OPERATIONS

The motor carrier involved in this crash was MS Contracting LLC. (MS).
According to the Federal Motor Carrier Safety Administration (FMCSA) Motor Carrier
Management Information System (MCMIS), the carrier was issued USDOT number
3383523. The carrier is registered as an Intrastate for hire carrier of large objects,
gravel and sand and is domiciled in Brookfield, Missouri. Per the carrier’s latest MCS-
150, the carrier utilized 14 trucks and employed M9 drivers. 17 18

9.0 History of MS Contracting LLC.

MS was established on May 27, 2015, through a filing with the state of
Missouri. 19 They were primarily in the business moving aggregates and equipment.

MS was subject to an off-site New Entrant audit by state investigators. MS

exited the new entrant audit on January 8, 2021. The state of Missouri investigators
completed an on-site comprehensive compliance review (CR) because of this crash.
A comprehensive CR may be used if the carrier was involved in a crash or there has
been a complaint made. A comprehensive CR addresses all aspects of the carrier’s
operation and may result a safety rating. The review was completed on August 4,
2022 and was not rated. 20

The following violations were noted on the post-crash review:

• Using a driver before the carrier has received a negative pre-
employment-controlled substance test (49CFR382.301(a))
• Using a commercial vehicle not periodically inspected (49CFR396.17(a))
• Failing to ensure that each driver subject to random alcohol and
controlled substances testing has an equal chance of being selected
each time selections are made (49CFR382.305(i)(2))
• Failing to ensure person designated to determine that drivers undergo
reasonable suspicion testing receive 60 minutes training for alcohol
and/or 60 minutes of training for controlled substances (49CFR382.603)
• Failing to conduct an annual query (49CFR382.701(b)(1))
• Failing to conduct a pre-employment query (49 CFR382.701(a))
• Failing to register in the Clearinghouse (49CFR382.711(b))
• Using a driver who has not completed and furnished an employment
application (49CFR391.21(a))

17
Form MCS-150 and Instructions - Motor Carrier Identification Report | FMCSA (dot.gov)
18
Motor Carrier Attachment - MCS – 150 dated August 25, 2022.
19
Motor Carrier Attachment – Articles of Organization
20
Motor Carrier Attachment – Post crash compliance review

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 Approximately June 7, 2022, MS Contracting entered into a verbal
agreement with Better by Design and the US Army Corps of Engineers to haul
rock to the Garden of Eve levee in the local area to repair flood damage to the
levee. MS Contracting had hauled approximately 56 loads of shot road to this
designated area between June 7th and the date of this crash across the
highway/rail at-grade crossing on Porche Prairie Avenue. MS Contracting had
reportedly received verbal instructions to use the route that traversed the
passive grade crossing at this location because it was determined that another
route, that would lead to a crossing protected by signals, was not feasible
because the loaded trucks could not safely turn into an access road off County
Road 122 and Porche Prairie Avenue. The corner was too tight to make the
turn. MS Contracting also confirmed on the day of the Pre-job meeting the
Corps of Engineers gave verbal instructions to use the route where this crash
occurred. 21

10.0 Commercial Motor Vehicle Driver

According to the MSHP a records check conducted on the driver identified that
he was exempt under Missouri law from possessing a medical certificate. 22

G. LIST OF ATTACHMENTS

1. Highway Attachment – Letter from MODOT Director to NTSB Chair

Homendy.
2. Highway Attachment – Police Accident Report.
3. Highway Attachment – FRA Grade Crossing Inventory Report.
4. Motor Carrier Attachment – MCS – 150 dated August 25, 2022.
5. Motor Carrier Attachment – Articles of Organization.
6. Motor Carrier Attachment – Post crash compliance review.
7. Motor Carrier Attachment – Email from MS Contracting providing
information on construction contract route.

21
See email from MS Contracting to NTSB dated January 24, 2023.
22
MoDOT.org/mcs. The driver possessed a Chauffeurs license prior to May 13, 1988, which exempted
him from the need to have a DOT medical card.

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Submitted by:

Eric Gregson
Technical Reconstructionist

David S. Rayburn
Senior Highway Factors Investigator

Shawn Currie
Senior Motor Carrier Factors Investigator

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