The National Transportation Safety Board (NTSB) released their report on a deadly incident in South Dakota in which two railroad workers were killed after being struck by a BNSF Railway train. The report’s conclusion was that a series of human errors led to the tragedy.

The incident occurred near Edgemont, SD on January 17, 2017 and the NTSB released their report September 6^th. The train was traveling at 35 mph and killed two workers who had been clearing snow from a track switch. There were three workers at the scene. One of the workers killed was the designated lookout. The train’s crew sounded the horn and bell and applied emergency braking, but the group did not respond and the train was unable to stop before reaching them.

The NTSB determined that the cause was the improper user of train approach warning by the BNSF Railway roadway work group to provide on-track safety. There was incorrect information provided in the job briefing, including a miscalculated sight-distance assessment. The sight distance at the switch was not adequate for safely using a train approach warning method with only one lookout. The investigation also determined that the lookout did not devote his full attention to approaching trains and was not given the necessary equipment mandated by federal regulations.

Further, the work group had incorrect information about the minimum-required sight distance and lacked the required time they needed to move to a predetermined place of safety.

A BNSF spokeswoman, Amy McBeth said that they follow Federal Railroad Administration (FRA) standards for proper lookout equipment but the company “further developed” existing and robust safety protocols.

The NTSB said that the FRA’s inconsistent enforcement of federal regulations for lookout/watchman equipment contributed to the accident.

Robert Hall, the NTSB director of the Office of Rail, Pipeline and Hazardous Materials said it was the 52^nd fatal accident in the past 21 years that involved railroad worker safety. In total, 55 workers have been killed in these kinds of accidents.

“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,” Hall said.

Read the report from the NTSB and read more here.