Two BART workers killed on the tracks never saw the train coming before they were hit and apparently ignored safety procedures requiring that one serve as a lookout, according to autopsy reports released Friday.

The men were inspecting a dip in the tracks between the Walnut Creek and Pleasant Hill/Contra Costa Centre stations Oct. 19 and failed to follow regulations requiring one person to stand outside the train's path and watch for oncoming trains, the reports indicate. The accident occurred during the most recent BART strike when trains were running only for maintenance and training, not in regular service.

Both BART employee Christopher Sheppard, 58, of Hayward and BART contractor Laurence Daniels, 66, of Fair Oaks were on the tracks and facing away from the train when they were hit, according to the Contra Costa Coroner's Office findings, which provide the most detailed description of the accident to date. Neither man had drugs or alcohol in his system, according to the reports.

Forensic Pathologist Arnold Josselson, who performed the autopsies, ruled the deaths an "accident."

"It is BART's practice for one employee to perform the work and another employee to watch for oncoming trains. It is believed the decedent and Laurence both had their backs to the oncoming train," Hoffman wrote in his initial report.


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In a follow-up report Nov. 7 -- both reports were released Friday -- he clarified that the two men did not follow BART protocol.

"The decedent was working in (tandem) ¿with an employee from BART, but appears neither was acting as a lookout for oncoming trains," he wrote.

Immediately following the deaths, BART eliminated the controversial "simple approval" procedure that allowed wayside workers to go on or near the tracks, largely at their own risk, while trains were still running through the area. State regulators have since added stricter safety requirements, including a schedule for incorporating train-warning technology, and the district is creating a long-term plan to allow workers to access to the tracks in a safe manner.

Unions, still locked in acrimonious contract negotiations with BART, have blamed the agency for the two men's deaths, saying managers should never have been allowed to operate trains while rank-and-file operators were on strike. The train that hit the inspectors was operated by a manager, who was being trained to run trains in the event of a prolonged strike, according to the National Transportation Safety Board, which is leading the investigation.

"The investigation is active and continuing," said NTSB spokesman Eric Weiss, who declined to comment further Friday.

Federal investigators have said the four-car train was traveling about 70 mph on automatic computer control at the time of the accident. The coroner had previously ruled Sheppard died of multiple blunt force injuries and Daniels died of multiple extreme blunt force injuries.

"This tragedy is under NTSB investigation," said BART spokeswoman Luna Salaver. "BART cannot comment at this time."

The two men were inspecting the track that runs parallel to Jones Road in Walnut Creek, and had been working for about 45 minutes when they were hit, coroner's deputy Kevin Hoffman wrote in his initial Oct. 20 report. The train came to a stop about 1,070 feet after impact, he wrote.

The coroner's deputy spoke to BART superintendent Duncan Lawson at the scene, who told him "It is not uncommon for BART employees to work on the track while trains are also running."

"Duncan did not know what exact function the decedent was performing at the time of the incident, but said they were probably making sure the tracks were level," Hoffman wrote.

The men, both wearing safety vests, were declared dead 15 minutes after the collision by first responders, Hoffman wrote. Sheppard was carrying a simple approval form in his shirt pocket, which trackside workers had to fill out and carry with them per BART's former rules, according to the report.

The report did not mention a manager was being trained on train operation at the time of the accident -- only that the train was being transferred from Richmond to Concord.

Contact Matthias Gafni at 925-952-5026. Follow him at Twitter.com/mgafni.