a, Close-up view
of depression in
the roof of car
number one
made during the
impact with the
wheels of the
baggage car,

b. Inside view
carno, one looking

toward the rea

Railroad seats are
designed to be r
tated a
them toward the

aisle $/4-inch to

er pulling

unhook a catch,
Note that all the
seats in the left of
the picture (right
side of car) are un-

hooked and rotate

aisle-end forward,

Freure 6. Close-up views of external damage caused when the top of Passenger Car No. 1 impacted the wheels
of the baggage car.

14


a, Front end of diner as it appeared
with car on its side, Passengers
escaped by climbing up on the booth
and out the end door,

_b. Rear end of diner on its side
offered a more difficult escape
route, One passenger climbed
up into the 2-ft, high tunnel shown
here and was rescued through the
small broken window.

c. As the diner overturned |
Two passengers were
ejected through this win-
dow into a depression
under the car but could
not crawl out from under
the car, They climbed
back through the window
and weni out tie end door
shown in a.

Ficurr 23. Photographs showing escape routes from the Diner.

31




a. Two rails pene-
trated rear roof of
car angled front to
back, Note car no,
one, at right, still
near the roof de-
pression in carno, 2.

b, Close-up of a rail penetration
still in place. As shown in pic-
ture above, the second rail has
been removed. A body of one of
the fatally-injured is trapped
under the car after having been
ejected through a window. The
car was later righted to rescue
the body.

¢, End of the rail shown in
above picture terminated its
travel against the steel floor
of the right rear boarding
station, Note roof metal
and insulation still wrapped
around the end,

a, Mark on rest room wall at the rear end
of the passenger area made as the end of
the second rail slid down the wall

Ficure 10. Two rails also penetrated Passenger Car No. 2,

18



TABLE OF CONTENTS

ABSTRACT ----------------------------------------------------
ACKNOWLEDGMENTS ----------------------------------------
INTRODUCTION --.--------------------------------------------
REPORT OF ACCIDENT

Crash Sequence ~-__--------------
External and Internal Damage to Train Components

Passenger Distribution -----
Discussion of Injuries --.
Escape ------------------
Description and Location of

DISCUSSION .-----------------------------

Carry-On Luggage ---
Crashworthiness Design

Passenger List
CONCLUSIONS
REFERENCES .-------------------------------------------------

ally Injured

Page

A ® PAA PROYODYH BH



a, Passenger car no, 5 overturned but was unoccupied
and is not shown, This is passenger car no, 6, It
remained upright as did cars 7, 8 and 9 with passen-
gers and cars 10, 11, 12 (empty), Damage is slight
and injuries to the passengers were minor or none.

b, Even though the
car remained up-
right, some seats
became unhooked
and rotated, The
passengers in
these cars stated
they were able to
remain in their
seats by holding
on,

Ficure 21. Passenger Cars 6, 7, 8, and 9 did not overturn and Passenger Car No. 6 is shown here to depict rela-
tively minor damage to these cars.

29


a. Right forward
section--very
minor damage--
seats rotated,

b, Large windows
(5 ft, long, 2 ft,
high) broken out
by body impacts
as car rolled
over, Note seat
in foreground
rotated 90° to
face window.
Passengers
ejected (at least
two).

Ficure 7. Seat distortion in Passenger Car No. 1.

15


a, Inside view of diner looking toward the rear of the
car while it was still on its left side, Passengers,

loose chairs and broken tables were all thrown into
a pile.

b. Same view as a above except that the car has been
righted, At least two passengers were ejected
through one of the windows in the right of the picture.

Ficure 13. Loose chairs inside the Diner were thrown into a pile.

21


a, Right side (down

ide) of passenger
carno, 2, Sixof 7
large windows

t, Note
window shades are

knocked c

up, Depression in
roof is from contact
with wheels of car
no. one.

b. Angle of skidmarks
indicates car was slid-
ing frontend forward.

te

left side (up side) of
car no, 2, Missing win-

dow re broken out by

personnel, Some

ades are down,

Fieure 9. Four views of the exterior of Passenger Car No. 2 after having been set back upright.

wv


a. Injured passengers being
helped out the end of the car
and down to the ground after
having climbed over parti.

high tunnels over or under
the rest rooms as shown in
Figure 25,

j ip,

nh

c. Other rescue workers brought
ladders to assist passengers to
the ground after they climbed up
means of ropes. the seats and out the windows,

b. Some were rescued by being
lifted up through windows by

ad. View of rescue
workers lowering a
ladder through a
window they have
knocked out to
rescue passengers,

Fraure 22. Photographs of passenger escape taken soon after the crash,

30


a. Rail
penctration of
left forward
roof of car
number one,
The angle of
penetration
indicates that
the car was
sliding rear-end
forward when it
picked up the
rail,

b. Rail went between
“first and second seats.
Fortunately this area
was not occupied at the
time of rail penetration,

& Rail stopped
when the end of

it rammed against
the floor.

Ficurr 4. Close-up views of a rail penetration into Passenger Car No. 1.

12


the minor injuries, occurred in the first five cars
that were overturned onto their sides.

In addition, as a point of interest, it should
be noted that each of the overturned cars had
some form of penetration by foreign objects as
they continued to slide on their sides. Cars 1, 2,
and 4 each had double rail penetrations. A
heavy compressor was driven through the roof
of the Diner and broke off a bar stool; Car Num-
ber 3 was penetrated by a full-length cross tie.
The potential lethality of these objects is obvious
but, in this accident, only the cross tie struck a
passenger and resulted in a fatal head injury.

E. Escape. There are no emergency escape
hatches or doors leading directly to the outside
of a passenger car. As long as the car remains
upright on its wheels, able-bodied passengers can
wind their way through the narrow doors and
passageway (slightly over 2 feet wide) around
the restroom at either end of the car and go out
the end of the car. It was impossible for rescue
workers to move a seriously injured passenger
on a 6-foot stretcher through the narrow, crooked
passageway. Those that had broken arms or
legs, or fractures of the vertebrae, could not
escape on their own and had to wait to be lifted
up through windows or carried up and down
ladders. While five passengers were ejected
through windows and fatally injured, at least
three others were ejected through windows and
survived with minor to serious injuries, and one
was thrown from the end of the car (she was
going from one car to another at the time of the
derailment) into a field and survived with severe
injuries. Figure 22 shows rescue workers help-
ing passengers to escape from the overturned
passenger cars.

The only car on the train having a direct
escape route to the outside was the Diner (see
Figure 23). Figure 23 @ shows the forward
end of the diner as it appeared to the passengers
after the derailment. All that was necessary to
escape was to climb up on the booth seats, hold
up the heavy metal door, climb through, and
drop 3 feet to the ground. The rear end of the
Diner (Figure 236) presented a sheer wall and
a narrow tunnel giving access to a small window
on top of the car. Only one passenger was known
to have climbed up on the counter into the tunnel
and out the small window. All the rest used the
door at the front of the Diner.

F. Description and Location of Fatally In-
jured. The diagrammatic sketch presented as
Figure 24 identifies the locations of the bodies
of the 11 people killed in this derailment in
reference to the overturned cars.

Body Number 1 was ejected through a window
of Car Number 2 and pinned beneath the car.
Injuries included scalp laceration with possible
skull fractures and fractures of the right shoul-
der, right upper arm, left forearm, and both
knees.

Body Number 2 was found inside the second
passenger car with fractured skull, severe lacera-
tions of scalp and forehead, lacerations under
both arms and across the chest, and severe lacera-
tions of the right hip around to the groin. This
passenger was probably ejected partly through
a window and then fell back, or was pulled back,
into the car.

Body Number 3 was found under the Diner.
Injuries include massive skull fracture with drag
marks on the side of the face and head and
lacerations of the left knee and chest. This
passenger was ejected through one of the win-
dows of the Diner and dragged under the car
as it slid on its side.

Body Number 4 was ejected from Car Number
1 as the car rolled onto its side; the body then
became pinned under a rail between the Diner
and Car Number 3. This person suffered head
injuries, fractured pelvis, and lacerations of the
shoulder, hip, and both lower legs. In addition,
there was evidence of peritoneal bleeding.

Body Number 5, found between the Diner and
Car Number 3, was crushed and torn beyond
recognition. The body was ejected from one of
the cars and was crushed as one or more cars
slid over it.

Body Number 6 was found inside Passenger
Car Number 3. Injuries included severe scalp
lacerations and possible skull fracture, and lac-
erations of both arms and the left side of the
neck. lacerations indicate that the head and
upper trunk were partially ejected through a
window.

The seventh body was also found in Car Num-
ber 3. Injuries included skull fracture and lac-
erations of the back of the head. The color of
hair matched that found on the end of a cross
tie found in the car and it can be assumed this


a. Hole made by the
second rail penetra-
tion in passenger car
no. 4, Note also
outside wall collapse
has almost complete-
ly obstructed aisle-
way under ladies
rest room,

b. End of rail slid down the
wall and pinned a woman's
dress to the floor, but did
not injure the woman,

Frevre 19. Internal damage from a second rail penetration into Passenger Car No. 4.

27


a. Interior view of the
Tight side of car no. 3
showing heavy damage
to seats where the wall
was crushed in,

b, Close-up view of
damage caused by
intrusion of a cross-
tie.

. One seat was
almost completely
demolished,

Fievre 16. Seat and window damage inside Passenger Car No. 3.

24



APPLICATION OF COMMERCIAL AIRCRAFT ACCIDENT INVESTIGATION
TECHNIQUES TO A RAILROAD DERAILMENT

I. Introduction.

In the investigation of a commercial aircraft
crash, the human factors team is concerned with
the following tasks:

1. Try to reconstruct the crash sequence and
estimate the magnitudes and directions of the
deceleration forces in relation to the occupants.

2. Using still photography, record in detail
the post crash environment, including external
and internal structural damage, displacement of
loose objects, intrusion of foreign objects, and
the effects of fire.

3. From survivor interviews, medical records,
and autopsy reports, determine the relationship
of injuries to ejections, seat tie-down, restraint
of occupants, body impact with surrounding
structures, presence of loose flying objects, and
intrusion of foreign objects.

4, Determine the effectiveness of escape and
rescue efforts in terms of fire, exits available,
escape routes, and functioning of escape equip-
ment.

5. Note and record the locations of the fatally
injured.

This report is unique in that it is believed to
be the first attempt to apply these crash investi-
gation procedures to a railroad passenger train
derailment. It is stated in the DOT Fifth An-
nual Report (FY 71)! that there was a total of
5,602 railroad derailment accidents in 1970. This
figure includes freight as well as passenger
trains.

Il. Report of Accident.

A. Crash Sequence. The train, which con-
sisted of four locomotives, one baggage car, two
passenger cars, a diner, six passenger cars, a
club car, and three passenger cars, in that order,
suddenly derailed while traveling in a south-
westerly direction at a speed of approximately
90 miles per hour.

Figure 1 shows diagrammatically in five steps
the sequence of events following derailment as
reconstructed by the investigators. Step (a)
shows a portion of the train before derailment
on the center track with a main line track on its
left and a spur line to the right. A distance of
50 feet separated the two outermost rails of the
triple track system, The arrow indicates that
the train was traveling from right to left on the
page and the R’s and L’s designate the right
and left sides of the coaches.

In (0) of Figure 1, the cars have begun to
jackknife after the engineer has applied emer-
gency brakes (“shot the bill”), locking all the
wheels on the train, At this point the lead cars
have jackknifed to about a 45° angle from the
line of travel and, since each car is over 80 feet
long, a path approximately 60 feet wide was
swept by the sliding cars, In other words, all
six rails, cross ties of three tracks, and the rail
beds were destroyed at this point. Note further
that the right sides of cars are approaching right
sides of other cars and left sides are approaching
left sides.

In (c) of Figure 1 the lead cars are approach-
ing an angle of 90° to the original line of travel
and are sweeping a path about 85 feet wide. At
about this point the friction caused by the cars,
trucks, and wheels sliding sideways and their
gouging into earth, rails, and cross ties increased,
causing the cars to overturn onto their sides (see
step d).

It will be noted in (d) a pattern of overturn
has been established. The baggage car (first car
shown on the left of Figure 1d) is on its right
side with front end up; the first passenger car
is on its left side with front end down, and so on
right-left-right-left. The cause for this arrange-
ment becomes obvious from parts (b) and (¢)
of Figure 1, which show right sides approaching
right sides and left sides left.





a. Hole in roof made as a
second rail penetrated the
roof of car number one about
5 feet ahead of the one shown
in the previous figure, This
rail penetrated the car at
about the same angle and pro-
bably about the same time as
the one previously described.

b. The leading end of
this rail entered the
ladies rest room and
smashed the commode,
Fortunately the room
was unoccupied at the
time.

Fieure 5. Damage to Passenger Car No. 1 made by a second rail penetration.

13


Taste 1

Car
Capacity

Passenger
Car No.

Passenger Statements

Our
Estimate

24 or 25.
20 or 21.

Some room in front.

20

Pretty full.

Almost full.

All bar seats taken (10).

People at all tables but not full.
, Bar pretty full.
About 20 people.

80% full.
30 people.

40

Completely filled or almost.
Pretty full.
Almost full.

rs

Empty.

wraa
Sseaes 8

Car pretty full.
Practically full (Porter).

About 30 people.
20 people.
12 people.

BSSo

About 12 people.

10 people.

9 46 3 people,

Total:

arms while those thrown across the aisle had
lacerations of the lower extremities indicating
that they- were thrown up into the luggage rack
with their feet and legs penetrating the windows.
If the left side of the car went down, those
seated on the left side received fractures of the
upper left portions of the body. Conversely, if
the right side of the car went down, those pas-
sengers seated next to the windows received more
injuries to the upper right side of the body.
Ten people were known to have received lacera-
tions of the head and neck, seven of the arms
and upper trunk, one of the lower trunk, and
five of the feet and legs.

For the convenience of comparing the number
and severity of injuries inflicted in the various
cars of the train, injury severity has been divided
into the following categories:

Class A. Severe—cranial fracture, spinal frac-
tures with paralysis, internal injuries.

Class B. Fractures of arms, legs, ribs, and
spine without paralysis.

Class OC. Bruises, contusions, slight concussion,
lacerations.

To summarize the injuries, 11 passengers were
fatally injured, five received Class A injuries,

3

225

21 Class B injuries, and 52 Class C injuries.
Table 2 presents the distribution of these in-
juries in Passenger Cars 1 through 10.

Taste 2. Distribution of Injuries

Passenger
Car No. Fatal A BC Tota
1 (overturned) 1 2 4 3 10
2 (overturned) 2 0 1 8 11
Diner (overturned) 2 0 5 9 16
3 (overturned) 2 3 4 12 21
4 (overturned) 4 0 5 11 20
5 (overturned—Empty) 0 0 0 0 0
6 (upright) 0 0 1 5 6
7 (upright) 0 o 0 0 0
8 (upright) 0 0 1 1 2
9 (upright) 9 o 0 3 3
Totals: i 5 21 52 89

The injuries of an additional 13 passengers are
known but it was not determined in which cars
they were riding. Of this group, three had
Class A injuries, four Class B, and six Class C.

From Table 2 it becomes obvious at a glance
that all the fatalities and serious injuries, as
well as 91% of the severe injuries and 82% of



a. Interior view of the right side of car no. 2, looking
from the rear, Note that the roof depression with
sharp edges is not as severe as in car one, leaving
about 5 feet of clearance above the floor. Seats are
relatively straight, but damage to windows is severe.

Fieure 11.

b, All seats on the left side of the car are unhooked
and rotated aisle side forward approximately 45°,
This rotation may have protected some passengers
to a degree as some were trapped in their seats
and not thrown to the opposite side of the car.

Photographs showing seat cocking and roof and window damage as viewed from the inside of Passen-
ger Car No. 2.

19


TECHNICAL REPORT STANDARD TITLE PAGE

T. Report No. %, Government Accession No. 3. Recipient's Catalog No.
FAA-AM- 73-1

‘Title ond Subtitle 5. Report Date
APPLICATION OF COMMERCIAL AIRCRAFT January 1973
ACCIDENT INVESTIGATION TECHNIQUES TO 6. Performing Organization Code

A RAILROAD DERAILMENT,

7. Author(s) 8. Performing Organizetion Report No.

Gale Braden, William Reed, and
John J. Swearingen, D. Av. T.

9. Performing Organization Name and Address 10. Work Unit No
FAA Civil Aeromedical Institute
P. O. Box 25082 TT. Contract or Grant No.

Oklahoma City, Oklahoma 73125

13. Type of Report and Period Covered

12, Sponsoring Agency Name and Addrese

Office of Aviation Medicine OAM
Federal Aviation Administration
800 Independence Avenue, S. W. 4.” Sponsoring Agency Code

Washington, D. C, 20591

15. Supplementary Notes

Research leading to preparation of this report was performed under
Project AM-A-72-PRS- 37,

16. Abstract
Crash investigation techniques utilized by human factors teams in investigating

commercial airline crashes have been applied in the analysis of a railroad train
derailment - crash,

Passengers in cars that remained upright experienced very low deceleration
forces and practically no injuries in stopping from a speed of 90 miles per hour
over distances in excess of 1, 000 feet.

Four passenger cars and the diner were turned over on their sides and continued
to slide after jackknifing. During the turnover and slide these cars were pene-
trated by railroad rails, cross ties, and a heavy compressor, Several passenger
were ejected through windows and crushed beneath the cars, The 1] deaths and
all severe and serious injuries occurred in these five overturned cars,

An analysis of escape routes from an overturned railroad passenger car is
presented and shows that it is difficult for an injured passenger to escape.

17. Key Words 18. Distribution, Statement
Availa’ ality ‘Ts unlimited, Document may
Crash injury, railroad accidents, be released to the National Technical
vehicle design, emergency escape, Information Service, Springfield, Virginia
crash safety. 22151, for sale to the public,
19. Security Classif. (of this report) 20. Security Classif, (of this page) 21. No. of Pages | 22, Price
Unclassified Unclassified 33 $3.00

Form DOT F 1700.7 (e-69)



95th percentile adult male, and some of the large
adults will be forced to scoot through the tunnel
under or over the restrooms on their bellies.
(3) The third and last means of escaping an
overturned railroad car is to climb up on the
seats using the seat arms as steps and break out
one of the double-pane windows on top of the
car (Note none of the top windows of the over-
turned cars in this crash were broken out during
the crash). Only those passengers with minor
or no injuries were able to utilize one of these
three difficult routes of escape on their own
initiative.

It would appear that an escape hatch in the
top of all passenger railroad cars would greatly
enhance the escape procedures from an over-
turned car.

Other areas which merit discussion include
carry-on luggage, crashworthiness design, and
the need for a passenger list.

A. Carry-On Luggage. Flat, open-ended
shelving for storing luggage is located at eye-
level in one end of the passenger compartment
of most of these cars. There were no luggage
restraints and most of the shelves in the over-
turned cars were broken during the derailment,
allowing the baggage to become flying missiles.
After the derailment this luggage was scattered
in the seats and aisle, impeding evacuation and
rescue.

B. Crashworthiness Design. The electrical
equipment and table storage cabinet doors were
the type that could be lifted up and off the hinge
pins. When the cars overturned, the doors moved
free of the hinge pins and the doors and cabinet
contents fell into the aisle, blocking escape routes
and possibly causing injury. Another example
of similar design was found on the bar stool
seats in the Diner. Attached to the under side
of the seat pan was a shaft 114 inches in diameter
and 6 inches long. This shaft rested inside the
pedestal column and was free to rotate. It was
also free to slide out of the pedestal column
when the Diner car overturned as shown in
Figure 14.

None of the chairs in the Diner or in the rest-
rooms were secured to the floor or wall . A large
number of heavy base ashtrays were also not
secured. These items became missiles during the
derailment.

Sharp edges and protruding objects are two
factors which could cause injury. Most serious
are sharp edges of the structures associated with
the window and window shade framework in the
passenger compartments. The passenger over-
head light switch, a long-handle metal toggle-
type switch pointing almost straight down toward
the passenger’s head, should also be redesigned
or relocated.

C. Passenger List. In this derailment, fire or
water submersion was not a factor, yet of the 11
fatalities, one still had not been identified at the
time of the investigation. The possibility of a
railroad accident involving extensive fire or de-
railment into a body of water must be considered.
Under those circumstances a complete loss of
bodies or destruction of remains beyond recog-
nition is likely to occur. Identification of fatali-
ties under these conditions would be extremely
difficult without a passenger list which is kept
separate from the train.

IV. Conclusions.

In this particular derailment of a passenger
train traveling at a speed of approximately 90
miles per hour, the individual units of the train
experienced linear deceleration of slightly more
than the passengers of a Boeing 747 during a
normal landing; the passengers in those cars that
remained upright received no significant injuries.
Four passenger cars and the Diner were turned
over onto their sides and slid a considerable
distance after jackknifing. All 11 fatalities and
all severe to serious injuries occurred in the five
cars that overturned. As these cars overturned,
passengers were thrown across the cars; some
were ejected through the large observation type
windows, and many were severely injured by
secondary impact with broken glass, baggage
racks, and other structures on the lower side of
the cars. Lap belts would have prevented a
large portion of the injuries due to secondary
impact and ejections.

If this jackknifing phenomenon could be
eliminated, the number of deaths and serious
injuries could have been reduced. In addition,
prevention of cars from overturning would have
significantly reduced the financial loss. The
estimated cost of repairing the two overturned
locomotives ($325,000) was more than five times
that for repairing the two that remained upright
($60,000). Damage to the seven overturned cars


person was killed by the intrusion of the cross
tie into the passenger area.

Bodies 9 and 10 were found just inside the
forward end (the boarding area) of Passenger
Car Number 4. Both bodies received crushing
injuries, but those of Number 9 were more severe
than Number 10’s. Number 9 had been decapi-
tated and mangled. Injuries of Number 10 in-
cluded head injuries and fractures of the left
leg, right arm, and right knee. Since Bodies 8,
9, and 10 were all found in or just outside the
boarding area of Passenger Car Number 4 and
were the remains of a woman and two children,
all with the same last names, it is possible that
these three were caught in the boarding area on
their way to or from the Diner and died from
crushing injuries as the front end of the car was
crushed in (see left side of Figure 182).

The injuries of Fatality Number 11, who was
found inside and near the rear of the fourth
passenger car, are not known to the authors.
She was rescued from the train and died enroute
to the hospital.

III. Discussion.

This train had a capacity for carrying 450
passengers in addition to the crew as compared
to a Boeing 747 aircraft which can carry 451
passengers and crew. Although the passenger-
carrying capacity of these two modes of trans-
portation is almost identical, the weights of the
two vehicles is considerably different, with the
train outweighing the 747 by a factor of almost
five to one. If one compares the kinetic energy
of this 1,500-ton train traveling 90 miles per
hour (132 ft./sec.) with a 350-ton Boeing 747
landing at a velocity of 165 miles per hour (242
ft./sec.), it is interesting to note that the 800,-
000,000-foot pounds for the train is less than 25
per cent higher than the 650,000,000 foot pounds
for the 747.

Translating these estimates of energy inertia
forces imposed on the passengers, one can calcu-
late an average deceleration of .15G for a normal
747 landing at a velocity of 242 ft./sec. Each
portion of the train stopped in a different dis-
tance after the emergency braking procedure.
The lead engine had a stopping distance of 990
feet while the last passenger car stopped in 1,450
feet. Deceleration distances of other units of the
train were between the two values. With a given

initial velocity of 90 miles per hour, one can
calculate an average linear deceleration of .27G
for the lead locomotive and .18G for the last
passenger car. In other words, the average
linear deceleration in this train derailment only
slightly exceeded the deceleration forces experi-
enced by the passengers of a 747 aircraft during
a normal landing.

It is difficult to calculate forces imposed on car
occupants when the passengers were thrown
across the 10-foot-wide car into the luggage rack
and/or windows on the opposite side as the car
overturned. However, since it is known that the
lead passenger car slid nearly 200 feet after
overturning, or about one-fifth of its total stop-
ping distance, one can estimate that the passen-
gers still had a forward velocity of 37 miles per
hour as their cars overturned. Impact with the
opposite sides of the cars at this body velocity
could result in substantially high deceleration
forces.

Escaping from a railroad car is radically dif-
ferent than escape from a commercial aircraft.
If the car is turned over onto its side, the pas-
sengers have three primary means of escape (see
Figure 25). (1) They can climb over the ends
of the seats through the aisle; through a 2-foot,
2-inch door; drop 8 feet, 8 inches to the floor;
scale a 714-foot-high wall; crawl through a
2-foot, 4-inch-high tunnel, being careful not to
fall through the restroom door; drop down 3
feet, 4 inches, and out the end door; and drop
3 feet to the ground. (2) On the other end of
the car, the escape is similar with the exception
that they eliminate climbing a 744-foot-high
wall and, instead, craw] through a tunnel under
the restroom up over a 3-foot, 8-inch-high wall
and out the door. The door is heavy metal and
is hinged on the top side, requiring that someone
hold it up while others escape. After getting
through the door and dropping down 3 feet,
8 inches, they can climb up another 3-foot wall
and go out the end door and drop 3 feet to the
ground. While this is the more desirable of the
two escape routes discussed thus far, it should
be noted that this route will always be on the
down side of the car and may be blocked by the
wall being pushed in (see Car Number 5, Figure
19a). Also, according to the Human Engineer-
ing Guide to Equipment Design,? a crawl space
must be 30.5 inches high to accommodate the



a, Passenger car
no, 4 down on its
left side with two
rail penetrations,
One passenger
crawled through
the hole made by
the rail and
walked down the
railto the ground,

b, View of left side after
it had been righted shows
side caved in sinsilar to
car no. 3. The number
of deaths and seriously
injured in this car was
greater than in any

other single car.

>, Close-up of
everely damaged
end shows scratch
marks to indicate
that the car was
sliding perpendicu-
lar to the tracks
after it turned over,

Fievre 18. Views showing rail penetrations and external damage to Passenger Car No. 4.

26


a, Seats are un-
hooked and ro-
tated aisle end
forward as in
previous cars.
As upper right
wallwas pushed
in, the baggage
rack broke down
and leftnumerous
sharp edges,
Passengers re-
ceived severe
injuries when
thrown against
these edges as
car rolled over,

b, Close-up view of
sharp end of baggage
rack,

¢. Sharp baggage
rack support struc-
tures exposed when
rack collapsed.

Figure 17. As the luggage rack failed on the right side of Passenger Car No. 3, sharp structures were exposed.

25


After overturn, the cars still had considerable
velocity and continued to slide. Passenger Car
Number One is known to have slid 180 feet after
turnover (with one passenger ejected through a
window) and was stopped only after the top of
the car impacted the leading trucks of the bag-
gage car (see d of Figure 1). Other overturned
passenger cars continued to slide and the second
passenger car and the Diner had impacts with
the wheels of the cars ahead of them, leaving
depressions in their roofs similar to Car Number
One. In all, two locomotives, the baggage car,
five passenger cars, and the Diner overturned.
The rest of the train remained upright. Occu-
pants of Passenger Cars 6, 7, 8, and 9, none
of which overturned, stated they were able to
stay in their seats by holding onto the seat in
front; these passengers escaped with minor or
no injuries. Unfortunately, the last three cars
(Numbers 10, 11 and 12), possibly the safest cars
to be in during this accident, were unoccupied.

All deaths and serious injuries occurred in the
five overturned cars which followed the baggage
car. The sixth car also overturned but was un-
occupied since the air conditioning unit was in-
operative,

CAMI investigators arrived at the scene of
the accident the day following the derailment,
but because of the urgency to clear the area and
re-lay the tracks for other train traffic, all over-
turned cars had been righted and grading was
already underway in preparation for laying new
tracks. Figure 2 presents an aerial view of the
train crash and two close-up scenes of overturned
ears taken shortly after the derailment.

B. Eaternal and Internal Damage To Train
Components. All four locomotives remained in
line and did not jackknife. The lead and second
locomotives were turned over onto their right
sides while the last two locomotives remained
upright. Following the locomotives, the bag-
gage car was also turned over onto its right side.
However, discussion of these cars is omitted from
this report since, of this group, only the lead
locomotive was occupied (by one engineer and a
fireman who escaped through the left door with
minor injuries). Fire occurred only in the sec-
ond locomotive, and it was quickly extinguished
by the fire department. As previously stated,
Passenger Cars Number 5, 10, 11, and 12 were
unoccupied and, for the sake of brevity, are

omitted from the report. Passenger Cars 6, 7,
8, and 9 remained upright and sustained rela-
tively minor damage. Car Number 6 is pre-
sented to represent this group of four cars. The
captions accompanying the photographs of ex-
ternal and internal damage as well as penetration
by foreign .objects of the Diner and Passenger
Cars 1, 2, 3, and 4, as presented in Figures 3
through 21, are in sufficient detail to afford the
reader a clear understanding of the situation and
will not be discussed further in the text.

C. Passenger Distribution. While this par-
ticular passenger train had a capability of carry-
ing 450 passengers and the crew, the actual
number aboard at the time of the derailment was
211 passengers, five crew members, and 10 em-
ployees (bartenders, waiters, porters, etc.). Be-
cause of the inherent difficulty of locating people
after they have left the scene of the accident,
only about fifty per cent of the passengers were
interviewed. However, from statements of those
interviewed, it was possible to compile a close
approximation of the number in each car. Table
1 gives the capacity of each car, statements of
occupants, and, based on the latter, our estimates
of passenger distribution. It may be seen that
our estimates for each car total 225 passengers,
a difference of only 14 from the actual passenger
load of 211.

D. Discussion of Injuries. According to medi-
cal reports, 97 of the 211 passengers were taken
to hospitals for examination and treatment.
CAMI investigators were able to obtain medical
reports on 91 of the 97 passengers treated and
succeeded in establishing the railroad car in
which 78 were riding. Eleven passengers re-
ceived fatal injuries (to be discussed later).

Since railroad seats are not equipped with
safety belts, passengers on the top side of the car
were thrown across the 10-foot-wide cars when
they overturned, while passengers on the lower
side were thrown against various structures next
to them. Pinpointing the exact structure that
caused a particular injury under the circum-
stances is impossible. However, some general
observations may be made. For example, at
least 23 survivors were treated for lacerations,
the majority of which resulted from contacting
and breaking the large observation windows, In
general, those seated next to the lower side re-
ceived lacerations of the head, upper trunk, and


a, Window
Shades bent out
and windows
broken by body
impact.

b. Close-up of
dents in window
shade rod and
lower window sill,
Since the sun was
shining in the left
side of the car,
some shades were
partly drawn and
probably prevent-
ed ejection of
some passengers,

c, Window shade rod bent upward as
passenger from right side of car was
thrown across the car and cjected
through this window.

Fiaure 8, Inside views of window damage on the left side of Passenger Car No. 1.

16


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its side,




a, The diner was
not penetrated by
any railroad rails,
but a heavy com-
pressor entered
through the upper
left corner of the
car above the
counter serving
area and hit one

of the stools,
breaking it off,
Hole and com-
pressor are visible
in the picture.

b, Close-up of hole made
by entrance of the com-
pressor, Fortunately,

no one was struck by this
heavy missile since most
of the passengers had been
thrown to the front of the
car before the car turned
over and picked up the
compressor.

c. Close-up view of
compressor and
broken stool,

Ficure 14. A heavy compressor penetrated the roof of the Diner just ahove the counter service area and broke off
one of the stools at the counter.

22




59.5'
dase

R R

R

R

R

L L

L

L

L

coe toe bo cL UCU

Ficure 1. Sequence of events following derailment presented diagrammatically.

9



a, Passenger car number one
directly behind the baggage car
ended up on its left side with
the top of the car against the
leading trucks (wheels) of the
baggage car, This view shows
the right side (up side) of the
car, The two missing windows
were knocked out by rescue
personnel in order to lift the
injured up and out of the car.

b, Damage to the left side
of car number one as
viewed from front to back,
Note the area of the roof
crushed in by contact with
the wheels of the baggage
car, two rail penetrations,
and broken windows with
window shades bent outward,

c. Left side of car number
‘one as viewed from the rear.
This car slid over 180 feet
after turning over onto its
side,

Fievure 3. Three views of the exterior of Passenger Car No. 1 after haying been righted by construction crews.

iL



ACKNOWLEDGMENTS
Photographs shown as Figure 2 a, b, and c; 10 a and }; 18 a, and 22 a,
b, c, and d, are presented with the compliments of the Salem Times Com-

moner, Salem, Illinois.



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382


a, Lett side (down side)

of diner as viewed from
front end, ‘Three of the
five 420826" windows in
the dining area have
been knocked wut, Note
car frame structure
showing through side
metal covering at left
of picture, indicating
forward end of car went
up into the air as it
rolled over and then
impacted the ground,

b, Skid marks on the rear end
‘of the left side of the diner indi-
cate that the car slid at about a
45° angle rear-end forward
after it rolled over onto its side.
The area of most severe damage
(without windows) is the kitchen
and counter serving area,

cc, Right side (up side) of diner had very little damage.
The small window at the extreme left of the picture
was broken out by rescue personnel after a passenger
had climbed into the narrow passageway alongside the
kitchen,

Figure 12. Three views of external damage to the Diner taken after this car had been righted.

20




a. Interior view
of passenger car

no. 4, looking

forward, Most
of the seats are

unhooked and
rotated aisle
end forward,

b. Seat damage in

the area where the
side wall was pushed
in,

Frevre 20, Seat and window damage in Passenger Car No. 4.

28


lc ee

a, Right side of passenger
car no, 3, showing the most
severe damage was to the
central portion. This area
near the roof was pushed in
over 2 feet, Note windows
in this car are smaller (34!
long, 24" high) and less
glass is broken out,

b. One passen-
ger was killed
when a cross-
tie came into
the car through
the hole near
the center of
the picture.

¢. Left side (up side) of
passenger car no, 3
shows little damage.
Missing windows were
knocked out by rescue
workers,

Fievre 15. Three views of Passenger Car No, 3 after it had been set back up on its wheels.

23


($297,400) was nearly six times that for the
seven cars that remained upright ($52,000).

As the five occupied cars continued to slide on
their sides they were penetrated by a total of six
railroad rails, a heavy compressor, and at least
one cross tie. To the knowledge of the authors,
only the cross tie struck and injured a passenger.

Since the train was traveling in a southwest-
erly direction at the time of derailment and it
was only a few minutes after 12:00 Noon, a
number of passengers on the left side of the
train had their window shades partly drawn to
keep the sun out of their eyes. In some instances
these sunshades helped prevent occupant ejection
from those cars that went down on their left
sides. Installation of permanent retention de-
vices to prevent ejection through these large
5-foot observation windows is indicated.

The most serious problem associated with an
overturned railroad passenger car is that it is
impossible for an injured person to escape on his
own and, regardless of the seriousness of the
injuries, it is necessary for rescue workers to
pull the injured passengers up through the win-
dows on the top side of the car by means of
ropes or to carry them up and down ladders.
The necessity for rough handling during such
rescue efforts may have contributed to the serious-
ness of some injuries. An emergency escape
hatch in the top of each railroad passenger car
would seem advisable. Such an emergency door
would allow an uninjured passenger to open it
and step to the ground and would permit rescue
workers to remove the passengers with severe
injuries on stretchers.

REFERENCES

1. DOT Fifth Annual Report for FY 1971. Department
of Transportation, Washington, D.C., 1971.

2. Morgan, ©. T., J. S. Cook, A. Chapanis, and M. D.
Lund: Human Hngineering Guide to Equipment De-
sign, McGraw-Hill Book Co., Copyright 1963.



a, Aerial view of train
derailment site. Of the four
locomotives and 14 cars
involved, it may be observed
that the two lead locomotives,
the baggage car, and the first
six passenger cars are over-
turned and lying on their sides,
The accident occurred ata
location where three sets of
tracks ran parallel to one
another. Note that all rails,
cross ties and road beds have
been swept clean by the forward
two-thirds of the train,

b, Close-up view
of the ends of four
of the overturned

cars,

&. Twisted rails
and splintered

to the severity
of the forces
involved, Note
large loose gas
bottles (used for
air conditioning),

Fieure 2. Photographs of the crash scene taken soon after the accident (before the start of the clean-up opera-
tion).

10