PB98-916303

NTSB/RAR-98/03

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

RAILROAD ACCIDENT REPORT

DERAILMENT OF AMTRAK TRAIN 4, SOUTHWEST CHIEF,

ON THE BURLINGTON NORTHERN SANTA FE RAILWAY

NEAR KINGMAN, ARIZONA

AUGUST 9, 1997

6912B
Abstract: About 5:56 a.m., on August 9, 1997, National Railroad Passenger Corporation

(Amtrak) train 4, the Southwest Chief, derailed on the Burlington Northern Santa Fe Railway

tracks about 5 miles northeast of Kingman, Arizona. The engineer and assistant engineer saw a

“hump” in the track as they approached bridge 504.1S. The train derailed as it crossed the bridge.

Subsequent investigation revealed that the ground under the bridge’s supporting structure had

been washed away by a flash flood. One hundred seventy-three passengers and 10 Amtrak

employees were injured. No fatalities resulted. Damages totaled about $7.2 million.

The major safety issues discussed in this report are: safety of structures subject to damage

in severe storms, passenger safety and emergency response procedures, and protection of

employees on or adjacent to the track in the performance of their duties.

As a result of its investigation, the National Transportation Safety Board issued

recommendations to the Burlington Northern Santa Fe Corporation, the Federal Railroad

Administration, the Federal Highway Administration, the Arizona Department of Transportation,

Amtrak, the Mohave County Sheriff’s Department, the International Association of Chiefs of

Police, the National Sheriffs’ Association, the Association of American Railroads, and the

American Short Line and Regional Railroad Association. Also, the Safety Board reiterated one

safety recommendation to the Federal Railroad Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established

in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to

investigate transportation accidents, determine the probable causes of the accidents, issue safety

recommendations, study transportation safety issues, and evaluate the safety effectiveness of

government agencies involved in transportation. The Safety Board makes public its actions and

decisions through accident reports, safety studies, special investigation reports, safety

recommendations, and statistical reviews.

Recent publications are available in their entirety on the Web at http://www.ntsb.gov/. Other

information about available publications may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202) 314-6551

(800) 877-6799

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 605-6000
Railroad Accident Report

Derailment of Amtrak Train 4, Southwest Chief,

on the Burlington Northern Santa Fe Railway

near Kingman, Arizona

August 9, 1997

Notation 6912B

Adopted August 31, 1998

National Transportation Safety Board

490 L’Enfant Plaza East, S.W.

Washington, D.C. 20594

August 7, 2003 

On August 31, 1998, the National Transportation Safety Board adopted 

final report on the accident. Following the report’s adoption, the

Burlington Northern Santa Fe Corporation sent the Safety Board a 

Petition for Reconsideration, dated December 3, 1998. Based on this 

petition, the Safety Board reopened the investigation and contracted for 

additional research to be conducted by the civil engineering consulting 

firm Ayres Associates. 

a

The Safety Board used the information developed by Ayres Associates 

to supplement the original investigation. Based on the new information, 

the Safety Board amended the report by adding text, revising text, and 

revising findings as summarized below. A concurring statement was 

added, and this statement is also included below. 

For more information, see the full Response to Petition for 

Reconsideration at the Safety Board website <www.ntsb.gov>. 

The following text is inserted at page 22 before the “Signals” section: 

Results of Study by Ayres Associates 

After the completion of its initial investigation of this accident, the 

Safety Board contracted with Ayres Associates of Fort Collins, Colorado, a 

civil engineering consulting firm, to perform additional tests and research, to 

include a hydraulic analysis and a hydrology study.1

 This information was 

used to supplement the original investigation and provide additional 

information on the relationship between the Burlington Northern Santa Fe 

Corporation railroad bridge and the ADOT highway bridge. 

The tests and research assigned to Ayres Associates had two 

objectives: 

• Reanalyze the hydrology and hydraulics and conduct a detailed 

scour analysis of the failure of BNSF bridge No. 504.1S near 

Kingman, Arizona, on August 9, 1997. 

• Determine the relationship between the scour at the BNSF bridge 

and the ADOT reinforced concrete box (RCB) culvert located 

approximately 1,000 feet downstream. 

 1

 Ayres Associates Final Report: Hydraulic, Erosion, and Scour Analysis of the 1997 BNSF Bridge 

Failure Near Kingman, Arizona. March 2001. 

a-1 
As part of its work on this project, Ayers Associates developed the 

following timeline: 

BNSF Bridge 504.1 Historical Timeline 

Year Comment

1883 Single main track constructed (now north track); consisted of 

4 timber spans with total length of 37 feet.a

 

1907 Bridge 504.1N replaced on driven timber piles, bridge length 

37 feet. 

1922 South track and bridge 504.1S constructed on mud sills on 

hardpan. 

1934 Hwy 66 with box culvert constructed 1,000 ± feet 

downstream of bridge 504.1N. 

1940 Bridge 504.1N replaced; it is on driven timber pile bents; 

piles range from 19 to 22 feet from cutoff to pile bottom. 

1940 ATSF records show a drainage area of 3.8 square miles 

draining to the bridge. 

1954 Aerial photograph shows a headcut approximately 580 feet 

upstream of Hwy 66 culvert. 

1958 ATSF replaces mud sills for bridge 504.1S. 

1959 ATSF bridge inspector recommends putting grout and stone 

between spans 1 and 2. Work performed 1964. 

1963 Stock tank constructed immediately upstream of bridge. 

1964 Grout and stone placed between spans 1 and 2. 

1966 Inspection records indicate riprap floor first placed in 1966. 

1967 Aerial photograph shows a headcut approximately 690 feet 

upstream of Hwy 66 culvert. 

1971 ADOT widens Route 66 and extends concrete box culvert 20 

feet upstream. 

1975 Bridge inspector first notices some erosion at the streambed 

under the railroad bridge. 

1/2/1975 ATSF engineering department letter recommends replacing 

bridge 504.1 under 1977 CIP because of scouring at mud 

sills. 

1975 ATSF bridge forces place grout and stone between spans 2 

and 3. 

a-2 
BNSF Bridge 504.1 Historical Timeline 

Year Comment

12/9/1975 ATSF engineering calculates 19.09 square-mile drainage 

area. 

1976 Aerial photograph shows a headcut approximately 760 feet 

upstream of Hwy 66 culvert. 

1/13/1976 Hydraulic calculations, sketch of bridge opening, and flow 

line elevation with initials AAM made, flow line Elev. 

3272.34 NAVD. 

1/13/1976 ATSF management expresses concern about proposed 

concrete crosswall and removal of the bridge from the 1977 

CIP. 

5/18/1976 ATSF maintenance-of-way forces install concrete crosswall 

on downstream side of bridge. 

1976 More riprap and grout placed in July; grouted riprap lined 

entire channel under bridge but upstream and downstream

extent unknown. 

5/1976 Bridge 504.1 removed from 1977 CIP. 

7/24/1976 High water recorded over top rail. 

7/29/1976 High water measured over 2 inches above base of bridge rail. 

1978 Aerial photograph shows a headcut approximately 775 feet 

upstream of Hwy 66 culvert. 

4/5/1987 I-90 bridge over Schoharie Cr., Albany, NY, fails killing 10 

people. 

4/29/1988 NTSB determines probable cause of I-90 bridge failure was 

severe erosion in the soil beneath the spread footing; spread 

footings without piles had supported the piers. 

9/1988 FHWA issues TA5140.20 and “Interim Procedures for 

Evaluating Scour at Bridges.” TA5140.20 requires the States 

to evaluate all their bridges over water for scour. The interim

procedures and subsequent HEC-18 states: 

a. Spread Footing on Soil 

Insure that top of the footing is below the sum of the long 

term degradation, contraction scour, and lateral migration. 

Place the bottom of the footing below the total scour line 

from step 4. 

Top of the footing can act as a local scour arrestor. 

a-3 
BNSF Bridge 504.1 Historical Timeline 

Year Comment

2/1991 FHWA issues HEC-18, “Evaluating Scour at Bridges,” which 

replaces “Interim Procedures for Evaluating Scour at 

Bridges.” 

10/28/1991 FHWA issues TA5140.23, which supersedes TA5140.20. 

1992 Aerial photograph shows a headcut approximately 930 feet 

upstream of Hwy 66 culvert, within 50 feet of crosswall. 

1993 FHWA issues second edition of HEC-18. 

1995 FHWA issues third edition of HEC-18. 

2/18/1997 BNSF bridge inspector performs programmed bridge 

inspection. 

7/3/1997 Aerial photograph shows a headcut approximately 930 feet 

upstream of the Hwy 66 culvert. 

7/9/1997 BNSF bridge inspector performs bridge inspection, noting no 

problems. 

8/9/1997 BNSF track supervisor is at bridge for special high water 

inspection at 4:30 a.m.; water is “lapping against bottom of 

bridge.” 

8/9/1997 Amtrak Train 4 derails while crossing bridge at 5:56 a.m. a

The year 1883 is listed as the year of construction for the railroad. ADOT 

provided the study team with an Arizona map dated 1874 that shows the 

Atlantic & Pacific Railroad in place, apparently on the alignment of today’s 

BNSF railroad. It is not clear whether 1883 or 1874 or some time earlier 

should be stated as the railroad’s construction date.

Ayres Associates conducted a hydrology study to estimate the peak 

discharge rates through bridge 504.1S for floods of various recurrence 

intervals and for the flood of August 1997 that resulted in the bridge failure. A 

secondary objective was to quantify the hydrologic impact of the construction 

of the railroad embankment in 1883. The peak discharge values developed 

were used to analyze potential bridge scour and as input in the hydraulic 

computer modeling study. 

The most significant results and conclusions of the hydrology study 

were as follows: 

• The flood-frequency relationship for bridge 504.1S was determined. 

• Construction of the railroad significantly increased the peak 

discharge rate at the upstream side of bridge 504.1S for every 

recurrence interval. 

a-4 
• The range of plausible peak discharge values for the flood of 

August 1997 is from 450 cubic feet per second (cfs) to 875 cfs. 

• The most probable peak discharge rate is 875 cfs, based on the box 

culvert high-water marks. 

• The peak flow of 875 cfs is found to have a recurrence interval 

greater than 2 years but less than 5 years. 

A bed profile and wash section survey was conducted on portions of 

seven channels in the vicinity of the accident site, including the channels 

associated with railroad bridges 501.5, 503.1, 503.7, 504.1, 505.6, 505.9, and 

506.9. The purpose of the survey was to document the condition of the wash 

and to determine the location and extent of existing headcuts and knickpoints 

along the surveyed channels. 

The most significant results and conclusions of the channel profiles 

and cross sections survey were as follows: 

• Following the construction of the railroad in 1883, sheet and 

discontinuous channelized flows were concentrated at the railroad 

bridges. 

• In 1934, ADOT constructed Highway 66 downstream of the 

railroad and placed its box culverts directly downstream of the 

railroad bridges. In most places, the culvert inverts (bottoms) were 

constructed below the invert of the channel, thus requiring 

excavation of the channel bed. The presence of two bridges along 

each drainage way resulted in the concentration of flow in the reach 

between the bridges causing general degradation of the channels. 

The placement of the Highway 66 culvert inverts below the channel 

bed probably produced short oversteepened reaches upstream of the 

culverts, causing small headcuts to form. 

• The headcuts migrated upstream as flood events occurred over 63 

years and helped accelerate channel incision and degradation on all 

the channels. 

• The rate at which the headcuts progressed upstream and the rate of 

general degradation of the channel were dependent on the 

competence of the caliche. The caliche in the lower half of the 

reach between the bridge 504.1 and Highway 66 RCB culvert 4217 

was less erosion resistant and allowed a relatively rapid progression 

of degradation and upstream headcut migration. 

• Channel incision, the upstream progression of headcuts, and the 

downstream extension of the channels below the highway were 

caused primarily by flow concentration at both the railroad and 

Highway 66. 

• It is likely that if the highway had not been built, flow concentration 

at the railroad bridge would still have resulted in the downstream

a-5 
extension of the channel, which was already evident in the 1939 

railroad ravine section. The general degradation that produced the 

downstream extension of the channel below the railroad bridge 

would have eventually extended beyond the erosion-resistant 

caliche. Once the degrading channel extended beyond the erosionresistant caliche, a headcut would have developed that would then 

have migrated upstream and caused bridge 504.1S to fail. 

• The stock tanks and grading activities in the watershed above 

bridge 504.1 had no significant effect on the incision of the channel 

or the failure of bridge 504.1. 

A geotechnical investigation was conducted to determine the extent 

and variability of the caliche along channel 504.1. The most significant results 

and conclusions of the geotechnical investigation were as follows: 

• The caliche horizon within the study area is variable in extent, 

thickness, degree of cementation, and resistance to erosion by 

flowing water. 

• Based on the blow count data from the borings, there is a significant 

reduction in the hardness of the caliche near U.S. Highway 66. This 

is also verified by observations in the channel banks and in the pit 

and trench excavations, and by the results of the erodibility tests 

made at Texas A&M and Colorado State Universities. 

• The caliche horizon near the upstream end of the Highway 66 box 

culvert is neither hard nor uniform. It is highly erodible. 

• The caliche horizon is more resistant to erosion in the area upstream

of and just downstream of the railroad bridge. 

• Erosion of the caliche horizon is by surface shear from flowing 

water, plunging flow, and the undermining of the competent portion 

by erosion of the weaker underlying sediments. The undermined 

competent portion of the caliche horizon fails by gravity. 

Total scour at a bridge is the combination of long-term degradation of 

the streambed, general scour of the stream channel under the bridge, and local 

scour at the piers and abutments. The measurements of the three components 

are added together to obtain the total scour at a pier or abutment. A scour 

study was conducted to determine: 

• The relative importance and role of each of the three components of 

scour; 

• The morphology of the channel, and human impacts on the 

morphology; 

• The significance of the type of bridge foundations used; 

a-6 
• The interaction between bridge No. 504.1 and the U.S. Highway 66 

box culvert (RCB culvert 4217) downstream; 

• The importance of the crosswall downstream of bridge 504.1, and 

the cause of the failure of the crosswall; and 

• The importance of the stock tank just upstream of the bridge. 

The most significant results and conclusions of the scour study were as 

follows: 

• The grouted riprap that was placed on the streambed under bridge 

504.1N and 504.1S apparently had sufficient thickness, rock size, 

and binding to protect the piers from local scour. 

• Assuming that the grouted riprap covered the channel bed beneath 

the bridge, as indicated by BNSF personnel, there was no 

contraction scour beneath the bridge deck in the August 1997 flood 

because the area was protected by grouted riprap. 

• The August 1997 flood might have caused as much as 3.3 feet of 

local scour at the crosswall if the peak discharge rate was 450 cfs 

and as much as 5.6 feet if the peak discharge rate was 875 cfs. 

Either of these scour depths could have caused failure of the 

crosswall. The local scour downstream of the crosswall might not 

have attained its full depth because of the underlying caliche. The 

caliche at the location of the crosswall was highly resistant to 

erosion but was still erodible. 

• A combination of long-term degradation and local scour 

downstream of the crosswall caused the crosswall to fail. Its failure 

allowed the long-term degradation of the streambed to undermine 

the grouted riprap, which was protecting the shallow mudsill 

foundations of the bents. The undermining of the grouted riprap 

allowed the foundations of bents 3, 4, and 5 to be undermined and 

to fail. 

• Incision of the channel crossed by bridge 504.1 was initiated when 

the railroad was constructed in 1883. The construction of RCB 

culvert 4217 probably accelerated the long-term degradation, but it 

also formed an elevation control, which will limit the ultimate depth 

of degradation at bridge 504.1. Long-term degradation in this 

channel has occurred by headcut migration in the upstream

direction and by gradual channel lowering progressing in the 

downstream direction. 

• Without direct profile or photographic evidence from the late 

1930s, it is difficult to conclusively determine the importance of the 

excavation of the channel at Highway 66 in the formation of the 

headcut that contributed to the failure of bridge 504.1. 

a-7 
• The construction of the crosswall and the placing of grouted riprap 

up to 20 inches thick across the bed under bridge 504.1 reveal that 

ATSF/BNSF personnel knew the bridge was vulnerable to scour. 

• The stock tanks and grading activities in the watershed above 

bridge 504.1 had no significant effect on the incision of the channel 

or the failure of bridge 504.1. 

The Ayres Associates study team conducted one-dimensional 

hydraulic analyses in order to clarify the impacts and relative importance of 

the railroad and Highway 66 on the morphology of the channel downstream of 

bridge 504.1. 

The most significant results and conclusions of the hydraulic computer 

modeling study were as follows: 

• The construction of the railroad in 1883 increased the velocity and 

erosion potential in the channel downstream from bridge 504.1 by 

increasing the drainage area (relevant for 2-year and smaller floods) 

and by constricting the flow to the width of the bridge opening 

(relevant for all floods). Because of the gradual rate of re-expansion 

downstream of the bridge (an assumption whose validity can be 

verified only by site observation of flooding or by two-dimensional 

modeling), the increase in velocity extended downstream beyond 

the present-day location of Highway 66. 

• The construction of Highway 66 in 1934 caused an increase in 

velocity downstream of the box culvert for all discharge rates, 

leading to a markedly increased erosion potential downstream of 

the highway. Upstream of the box culvert, the highway 

embankment caused backwater, leading to reduced velocities and 

erosion potential, for discharges equal to and greater than the 5-year 

peak. For smaller flows, the excavation of the streambed, and the 

resulting oversteepened reach just upstream of the box culvert, led 

to locally increased velocities and a hydraulic jump. The higher 

velocities and hydraulic jump almost certainly led to significant 

scour upstream of the box culvert. If the conditions in the model are 

representative of the post-highway condition, they could definitely 

have led to the initiation of the headcut that is observable moving 

upstream toward the bridge in the historic aerial photographs. 

• The excavation to place the culvert was and is a common practice. 

When the invert of a culvert is depressed below the natural channel 

grade, it is now advisable to consider the possible need for erosion 

protection in the oversteepened reach just upstream of the culvert. 

• If the bottom of the box culvert had been placed at the existing 

channel grade, the potential for erosion upstream of the culvert 

would have been reduced, rather than increased, for all discharge 

a-8 
rates. The maximum velocity downstream of the box culvert, 

however, would not have been any less under these alternative 

conditions than under the actual conditions. 

• There was little or no impact on the erosion or morphology of the 

channel imposed by the widening of Highway 66 in 1971. 

[ORIGINAL REPORT TEXT RESUMES AT THIS POINT.] 

The text beginning on page 60 is revised as follows: 

However, the BNSF report did not include ADOT bridge inspection 

data or pictures of the streambed dating back to 1971, information that would 

have been helpful in determining the relationship between the box culverts 

and the railroad bridges. The Safety Board therefore concludes that the 

relationship of the two structures and their respective zones of influence is not 

fully understood. The relationship between the U.S. Highway 66 box culvert 

and railroad bridge 504.1 is complex. Bridge 504.1, built in 1883, 

concentrated overland sheet flow into a single drainage course. The 

concentrated flow had more sediment transport capacity than the upland sheet 

flow and began to erode a channel at the railroad bridge. With time, the 

channel increased in size and progressed downstream. In the early years, the 

flow partially re-expanded downstream of the railroad bridge. 

Highway 66, built in 1934, 1,000 feet downstream from the bridge, reconcentrated the flow that had re-expanded downstream of the railroad bridge. 

The concentrated flow through the box culvert accelerated channel incision 

downstream of the culvert. The bottom of the box culvert was set about 2 feet 

lower than the level of the existing swale. 

The excavation to place the box culvert probably left a short, steep 

reach of streambed just upstream of the culvert. This could have initiated the 

headcut that the aerial photographs show moving upstream from 1954 to 1997 

and that eventually contributed to the failure of the crosswall downstream of 

bridge 504.1. 

Unfortunately, the available aerial photographs date back only to 1954, 

and no detailed channel bed profiles just upstream of the highway are 

available from the period just after the construction of the highway. Without 

direct profile and photographic evidence from the late 1930s, it is difficult to 

precisely determine the importance of the box culvert channel excavation in 

the formation of the headcut. 

The box culvert also provided a positive benefit to the channel. The 

concrete floor of box culvert 4217 is now an elevation control point that will 

limit the ultimate depth of the long-term channel incision and degradation at 

a-9 
the bridge. Had ADOT constructed a bridge on piles at this location instead of 

a box culvert, the ultimate degradation at the railroad bridge would have been 

deeper. 

The Safety Board therefore concludes that both the railroad 

construction in 1883 and highway construction in 1934 concentrated the 

overland flow of water and accelerated erosion of the ephemeral streambed. 

The headcut that contributed to the failure of the crosswall and railroad bridge 

may have originated at the highway bridge after construction of U.S. Highway 

66 in 1934; the upstream progression of the headcut was primarily caused by 

flow concentration between the railroad bridge and the highway bridge. 

The American Association of State Highway and Transportation 

Officials provides guidelines for highway bridge construction.2

 The 

association’s 1931 guide, “Standard Specifications for Highway Bridges and 

Incidental Structures,” advises that 

a careful study shall be made of local conditions, including flood 

height and flow, size and performance of other openings in the 

vicinity carrying the same stream, characteristics of the channel 

and of the watershed area, climatic conditions, available rainfall 

records and any other information pertinent to the problem and 

likely to affect the safety or economy of the structure. 

However, ADOT reported that it did not have any hydrology studies or 

hydraulic design documents from the initial bridge construction in 1934 or 

from the widening project in 1971. The construction drawings do have 

annotations denoting drainage areas, but no calculation sheets or other 

evidence was provided to demonstrate how those numbers were derived. 

According to ADOT, the highway bridge was performing well in 1971 and 

there was no reason to change the size of the waterway opening;3

 therefore, no 

hydrologic or hydraulic studies were needed prior to the roadway-widening 

project in 1971. ADOT also reported that since the accident, it has completed 

studies confirming that the highway bridge culverts are adequately sized and 

designed. However, the Safety Board believes that an opportunity was missed 

in 1971 when ADOT did not carry out comprehensive studies that would have 

identified the already existing upstream channel deterioration and that could 

have prompted ADOT and ATSF efforts to assess the interaction between the 

bridges and develop strategies to address erosion problems. 

 2

 Before the 1970s, this organization was known as the American Association of State Highway

Officials. 

3 According to ADOT, the highway bridges along this stretch of highway were not designed to deal

with heavy flooding and, in fact, water has crossed above the highway in the area of the subject bridge 

several times since 1934. The 1969 “Standard Specifications for Highway Bridges” published by the 

American Association of State Highway Officials states that, “On wide flood plains, the lowering of 

approach fills to provide overflow sections designed to pass unusual floods over the highway is a means of 

preventing loss of structures.” 

a-10 
In 1975, the ATSF engineering department recommended that the 

railroad bridge be replaced because of concerns about the bridge’s ability to 

provide an adequate waterway opening and recurring erosion problems. 

Although the bridge was not replaced, records in 1976 indicate the addition of 

riprap along the streambed and a concrete crosswall downstream of the bridge. 

Therefore, the railroad also had an opportunity to communicate with ADOT 

and develop joint strategies to address erosion problems. Nevertheless, the 

railroad was aware of the vulnerability of the bridge and should have closely 

monitored erosion in the vicinity and taken whatever measures were necessary 

to ensure safe operations. Although a track supervisor conducted a track 

inspection during the severe weather and flooding on the morning of the 

accident, he was not qualified to conduct bridge inspections, and no 

restrictions were placed on train speeds. 

The additional information developed by the Ayres Associates’ study 

reinforces the finding that an adequate bridge inspection could have detected 

risk to the bridge. According to the historical photographs, at the time the 

crosswall was constructed, the headcut that threatened the bridges was about 

240 feet away. For at least the 5 years preceding the south bridge failure 

(1992–1997), the headcut was about 80 feet from the bridge and less than 50 

feet from the crosswall. 

The railroad bridge concentrated the water flow to form a channel, 

which would erode and deepen over time even if the highway bridge/box 

culverts did not exist. Although both structures accelerated erosion of the 

streambed, it is the owner’s responsibility to monitor and ensure a bridge’s 

structural integrity against the effects of erosion, including headcuts or any 

other changes that may arise over time. Therefore, the Safety Board concludes 

that regardless of the cause of the headcut, Burlington Northern Santa Fe 

Railway and its predecessors were aware of the erosion problems affecting the 

railroad bridge and had ample opportunity over the years to detect the headcut 

and take appropriate remedial action. Moreover, the railroad decided not to 

replace the bridge in its 1977 Capital Improvement Program as recommended 

by its engineering department in 1975, reflecting that department’s concern 

about the bridge’s ability to provide an adequate waterway opening and 

recurring erosion problems. 

[ORIGINAL REPORT TEXT RESUMES AT THIS POINT.] 

Finding 8 on page 75 is deleted and a new finding 8 is inserted as follows: 

8. The relationship of the highway box culverts and the railroad bridges and their 

respective zones of influence is not fully understood. Both the railroad 

construction in 1883 and highway construction in 1934 concentrated the 

overland flow of water and accelerated erosion of the ephemeral streambed. 

The headcut that contributed to the failure of the crosswall and railroad bridge 

a-11 
may have originated at the highway bridge after construction of U.S. Highway 

66 in 1934; the upstream progression of the headcut was primarily caused by 

flow concentration between the railroad bridge and the highway bridge. 

A new finding 9 is inserted on page 75 as follows: 

9. Regardless of the cause of the headcut, Burlington Northern Santa Fe Railway 

and its predecessors were aware of the erosion problems affecting the railroad 

bridge and had ample opportunity over the years to detect the headcut and 

take appropriate remedial action. Moreover, the railroad decided not to replace 

the bridge in its 1977 Capital Improvement Program as recommended by its 

engineering department in 1975, reflecting that department’s concern about 

the bridge’s ability to provide an adequate waterway opening and recurring 

erosion problems. 

[EXISTING FINDING 9 IS RENUMBERED TO FINDING 10 AND 

SUCCESSIVE FINDINGS ARE RESPECTIVELY RENUMBERED.] 

The National Transportation Safety Board, consisting of Chairman Ellen G. 

Engleman, Vice Chairman Mark V. Rosenker, and Members John J. Goglia, 

Carol J. Carmody, and Richard F. Healing, approved the Response to Petition for 

Reconsideration. A concurring statement was filed with the Response to Petition for 

Reconsideration. Consequently, the following text is inserted on page 79 

immediately following the report adoption date. 

On July 31, 2003, as part of the National Transportation Safety Board’s 

response to a December 3, 1998, petition for reconsideration submitted by 

the Burlington Northern Santa Fe Corporation, John J. Goglia, Member, 

filed the following statement concurring with the Safety Board’s response. 

Richard F. Healing, Member, joined Member Goglia in this opinion. 

Notation 6912E 

Member GOGLIA, concurring: 

Based on the information in the docket, I believe we should have 

included in the contributing causes of this accident the Arizona 

Department of Transportation’s (ADOT’s) failure to react (for years) to the 

erosion that was progressing toward the railroad property. It is also 

interesting to note (and in contrast to ADOT’s inaction, the BNSF’s 

action) that on the upstream side of the railroad property the same type of 

erosion is occurring, yet the railroad (as a responsible landowner) has for 

some time taken actions to prevent this erosion from reaching the adjacent 

property.

a-12 
iii

Contents

Executive Summary .......................................................................................................... v

Factual Information .......................................................................................................... 1

The Accident ....................................................................................................................... 1

Synopsis ....................................................................................................................... 1

Preaccident Events ....................................................................................................... 5

Postaccident Events...................................................................................................... 5

Injuries................................................................................................................................. 7

Damage................................................................................................................................ 8

Amtrak Train 4............................................................................................................. 8

Track, Structures, and Signals...................................................................................... 9

Personnel Information ......................................................................................................... 9

Amtrak Train 4 Crew ................................................................................................... 9

BNSF Personnel Information..................................................................................... 13

Train Information .............................................................................................................. 14

Track, Structures, and Signal Information ........................................................................ 15

Track .......................................................................................................................... 15

Structures ................................................................................................................... 15

Bridge 504.1S Maintenance and Inspection............................................................... 18

Signals........................................................................................................................ 22

Operations Information ..................................................................................................... 23

Amtrak/BNSF Train Operations ................................................................................ 23

BNSF Operations Center............................................................................................ 24

Protection for Employees During Special Inspections............................................... 25

Meteorological Information .............................................................................................. 27

Medical and Pathological Information .............................................................................. 30

Emergency Response......................................................................................................... 31

Notification ................................................................................................................ 31

Mohave County Sheriff’s Department Response....................................................... 32

Fire Departments’ and Other Groups’ Responses...................................................... 33

Hospitals..................................................................................................................... 33

Emergency Preparedness............................................................................................ 34

Amtrak Passenger Train Emergency Response Training........................................... 35

Fire .................................................................................................................................... 35

Survival Aspects................................................................................................................ 35

Crashworthiness ................................................................................................................ 37

Locomotives and Fuel Tanks ..................................................................................... 37

Passenger Cars and Emergency Lighting................................................................... 38

Tests and Research ............................................................................................................ 39

Locomotive Event Recorders..................................................................................... 39

Signal Event Recorders.............................................................................................. 41

Equipment Detectors.................................................................................................. 41
iv

High Water Detector .................................................................................................. 41

Amtrak Locomotive Couplers.................................................................................... 43

Stopping Distance ...................................................................................................... 43

Geotechnical Investigation......................................................................................... 44

Postaccident Actions......................................................................................................... 45

The BNSF .................................................................................................................. 45

The FRA..................................................................................................................... 46

Arizona Department of Transportation ...................................................................... 49

Other Information.............................................................................................................. 49

Amtrak’s Proposed Procedures for Passenger Manifests........................................... 49

Amtrak’s On-Board Service Personnel Emergency Situation Training..................... 51

Analysis ............................................................................................................................ 53

General .............................................................................................................................. 53

The Accident ..................................................................................................................... 54

Safety of Structures Subject to Damage in Severe Storms................................................ 55

Failure of Bridge 504.1S............................................................................................ 55

Risk Concern for Route 66 Concrete Box Culverts................................................... 59

Adequacy of Inspection Procedures During Severe Weather Events................................ 60

Protection of Trains During Severe Weather Conditions.................................................. 61

Passenger Safety and Emergency Response Procedures................................................... 63

Passenger and Crew Accounting................................................................................ 63

Adequacy of Emergency Training.............................................................................. 65

Emergency Lighting and Public Address Systems..................................................... 67

Seat Securement......................................................................................................... 69

Emergency Response......................................................................................................... 70

General....................................................................................................................... 70

Unverified Notification Information .......................................................................... 70

Protection for Employees on or Adjacent to Track in Performance of Their Duties........ 71

Locomotive Event Recorders............................................................................................ 73

Locomotive Fuel Tank Crashworthiness........................................................................... 74

Conclusions...................................................................................................................... 75

Findings............................................................................................................................. 75

Probable Cause.................................................................................................................. 76

Recommendations ........................................................................................................... 77

Appendix A—Investigation .............................................................................................. 81

Appendix B—Event Chronology and Layout of Seligman Subdivision........................... 83

Appendix C—Applicable BNSF Instructions................................................................... 89

Acronyms and Abbreviations............................................................................................ 93
v

Executive Summary

About 5:56 a.m., on August 9, 1997, National Railroad Passenger Corporation

(Amtrak) train 4, the Southwest Chief, derailed on the Burlington Northern Santa Fe

Railway tracks about 5 miles northeast of Kingman, Arizona. Amtrak train 4 was en route

from Los Angeles, California, to Chicago, Illinois, and had just left the Kingman station.

The train was traveling about 89 mph on the eastbound track when both the engineer and

assistant engineer saw a “hump” in the track as they approached bridge 504.1S. They

applied the train’s emergency brakes. The train derailed as it crossed the bridge.

Subsequent investigation revealed that the ground under the bridge’s supporting structure

had been washed away by a flash flood.

Of the 294 passengers and 18 Amtrak employees on the train, 173 passengers and

10 Amtrak employees were injured. No fatalities resulted from the accident. The damages

were estimated to total approximately $7.2 million.

The National Transportation Safety Board determines that the probable cause of

this accident was displacement of the track due to the erosion and scouring of the

inadequately protected shallow foundations supporting bridge 504.1S during a severe

flash flood because the Burlington Northern Santa Fe management had not provided

adequate protection, either by inspection or altering train speeds to fit conditions.

Contributing to the accident was the failure of the Burlington Northern Santa Fe

management to adequately address the erosion problems at bridge 504.1S.

The major safety issues identified in this report are:

• Safety of structures subject to damage in severe storms,

• Passenger safety and emergency response procedures, and

• Protection of employees on or adjacent to the track in the performance of

their duties.

As a result of this accident investigation, the Safety Board makes

recommendations to the Burlington Northern Santa Fe Corporation, the Federal Railroad

Administration, the Federal Highway Administration, the Arizona Department of

Transportation, the National Railroad Passenger Corporation (Amtrak), the Mohave

County Sheriff’s Department, the International Association of Chiefs of Police, the

National Sheriffs’ Association, the Association of American Railroads, and the American

Short Line and Regional Railroad Association. Also, the Safety Board reiterates one

safety recommendation to the Federal Railroad Administration.

1

Factual Information

The Accident

Synopsis

About 5:56 a.m.,1 on August 9, 1997, National Railroad Passenger Corporation

(Amtrak) train 4, the Southwest Chief, derailed on the Burlington Northern Santa Fe

Railway (BNSF)2

 tracks about 5 miles northeast of Kingman, Arizona. Amtrak train 4

was en route from Los Angeles, California, to Chicago, Illinois, and had just left the

Kingman station when the accident occurred. The train was traveling about 89 mph on the

eastbound track when both the engineer and assistant engineer saw a “hump” in the track

as they approached bridge 504.1S.3

 They stated that they applied the train’s emergency

brakes. It was later discovered that the ground under the bridge supporting structure had

washed away during a flash flood.

Train 4 had a four-unit locomotive, one baggage car, nine passenger cars, and six

material handling cars (MHCs). As the train passed over bridge 504.1S, the first three

locomotive units uncoupled and separated from the rest of the train and each other, each

unit coming to a stop east of the derailed train. The fourth unit remained coupled to the

train.

The third and fourth units, including all but the last car, derailed in the upright

position. Although some cars were at a slight angle to each other and leaning, all cars

remained coupled and generally aligned with the track. The tenth car, a sleeping car, came

to rest spanning what had been the track at the location of bridge 504.1S. (See figure 1 for

an aerial view, looking south, of the Kingman accident site. Figures 2 and 3 show,

respectively, a map and a schematic of the derailment site.)

 1

 Kingman, Arizona, is in the mountain time zone but does not change to daylight savings time. The

times referenced in this report will be in accordance with the time used by the railroad for the local time,

mountain daylight time (MDT), unless noted.

2

 The BNSF resulted from the October 1, 1995, merger of the former Burlington Northern Railroad and

the former Atchison, Topeka and Santa Fe Railway. The mainline segment through Kingman was part of the

former Atchison, Topeka and Santa Fe Railway.

3

 The BNSF designates bridges by their milepost (MP) numbers. There are two separate bridges at

MP 504.1; one for the eastbound track and another for the westbound track. The bridges are designated by

the BNSF as the south and north bridges, respectively. This report will designate them as bridge 504.1S (for

the eastbound track) and bridge 504.1N (for the westbound track).
Factual Information

2

Figure 1. Aerial view of the derailment site, looking south
Factual Information 3

Figure 2. Map of the derailment site

ARIZONA

Accident Site

Kingman

Seligman

Flagstaff

Phoenix

	


 
 	


 

  


  


   !

BNSF Route Map
Factual Information

4

Figure 3. Schematic of the derailment site

1563

To Kingman

100' 100'

1420 1556 1428 1564 1526 32088 32051 38017

558'

BRIDGE 504.1 

BNSF RIGHT of WAY 

BNSF RIGHT of WAY 

33036 31501 34060 34076 34133 39007 1254 1888'

AMTRAK

ENGINE

52

AMTRAK 

ENGINE 

80

DCA97MR004

Amtrak Train 4 

Burlington Northern Santa Fe 

near Kingman, Arizona

August 9, 1997

MP 504

N

34076 34133 39007 1254 1888' 2304' 919'

AMTRAK 

ENGINE 

52

AMTRAK

ENGINE

80

AMTRAK

ENGINE

50

AMTRAK

ENGINE

47

MP 504

To Flagstaff

A

Source: BNSF RAILWAY 

A
Factual Information 5

Preaccident Events

At 12:06 a.m. August 9, the BNSF contract weather forecasting service issued a

potential severe weather alert for the Kingman area, followed by an update at 12:52 a.m.

At 1:43 a.m., the BNSF received a flash flood warning for the Kingman area from its

contract weather forecasting service. The warning estimated that 2 inches of rain had

already fallen over this stretch of track and that rain was still falling at a rate of about 1

inch per hour. In response to the warning, the BNSF Network Operations Center (NOC)

arranged for a track supervisor to be called about 1:57 a.m. The track supervisor was

instructed to inspect the track in his assigned area, which included the eastbound and

westbound tracks east of Kingman, including the accident site.

About 4:05 a.m., the track supervisor began his inspection at MP 516.5, traveling

by hy-rail vehicle eastward on the eastbound track. He stopped at and inspected three

bridges west of the bridges at MP 504.1. He said that he got out of his vehicle to inspect

each of these bridges. He said he did not note anything unusual.

Between 4:30 and 4:45 a.m., the track supervisor stopped at bridge 504.1S. He

made his observations at this bridge without getting out of his vehicle. He later stated that

he saw water flowing adjacent to and under the bridge from the south side, but that he did

not note anything unusual about the track alignment or take exception to either the

eastbound or westbound bridge. He stated that a light rain was falling at the time. Shortly

after 5:35 a.m., the BNSF freight train B-CHCLAC1-05 passed over the westbound

bridge, bridge 504.1N. The train crewmembers did not note anything unusual about either

bridge from their positions in the locomotive.

The track supervisor finished the special inspection of his territory at 6:01 a.m. He

was about 40 miles east of Kingman when he heard the train dispatcher communicating

with someone over the radio about an Amtrak train derailing at bridge 504.1S. (See

figure 4 for a photo of the water flow under the bridge immediately after the derailment

took place.)

Postaccident Events

About 5:56 a.m., the BNSF NOC received a radio communication from the

engineer of Amtrak train 4 informing it of the train’s derailment and its location. The

NOC passed the information on to its Resource Operations Center (ROC) and a BNSF

special agent, who notified the Mohave County Sheriff’s Department at 6:01 a.m.

Also about 5:56 a.m., the Mohave County Sheriff’s Department received a 911

call from a local resident reporting a train derailment. Three officers, who were already in

the immediate area (searching for people who were reportedly stranded because of flash

flooding), were dispatched to the scene and arrived at 6:05 a.m. Later, a Mohave County

Sheriff’s Department lieutenant arrived on scene and assumed the duties of Incident

Commander.
Factual Information 6

Figure 4. Flow of water under bridge 504.1S after the derailment
Factual Information 7

At 6:06 a.m., the Mohave County Sheriff’s Department requested a medical

response to the derailment from the Kingman Fire Department. About 6:15 a.m., a

paramedic unit, a rescue unit, and a 4x4 brush engine arrived. A rescue unit from the

Hualapai Fire Department was already on scene.

About 6:15 a.m., the Kingman Regional Medical Center was notified by the

Mohave County Sheriff’s Department dispatcher of the derailment and told that it

involved about 300 people. The hospital activated its emergency plan, calling nurses and

emergency room personnel to report to the hospital. Medical supplies, nurses, Red Cross

personnel, and volunteers were sent to the Kingman Junior High School to assist

passengers after they had gone through triage. At 6:17 a.m., the Kingman Fire

Department requested mutual aid assistance from the Valley Vista, Golden Valley, and

Pinion Pines fire departments.

By 6:20 a.m., the first of three Arizona Department of Public Safety helicopters

arrived on scene. Two military helicopters from Nellis Air Force Base arrived on scene

later with a flight surgeon and medical crew. At 6:30 a.m., a medical command post was

set up next to the treatment and triage area. School buses were used to transport people

with minor to moderate (or no) injuries to the local hospital and the Kingman Junior High

School, which was used as a shelter for passengers and crew.

About 6:56 a.m., injured people began arriving at the hospital by helicopters,

ambulances, and buses. Over 100 people were treated. The last person was admitted to

the hospital at 11 a.m. Thirty-four injured people were transported to Bullhead

Community Hospital, Las Vegas University Medical Center, Flagstaff Regional Medical

Center, John C. Lincoln Hospital North Mountain, and Las Vegas Valley Hospital.

By 8 a.m., about 230 people had been transported from the scene. BNSF

personnel, emergency medical services (EMS) personnel, and some passengers helped

throughout the response. Shortly after 9 a.m., the last person was transported from the

scene.

(A chronology of the entire accident event sequence appears in appendix B.)

Injuries

Table 1 is based on the injury criteria of the International Civil Aviation

Organization.4

 4

 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as “Any injury which results in

death within 30 days of the accident” and serious injury as an injury that “(1) Requires hospitalization for

more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a

fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages,

nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree

burns, or any burn affecting more than 5 percent of the body surface.”
Factual Information 8

Table 1. Injuries

*On December 5, 1997, Amtrak submitted documentation compiled by its Claims

Department to the Safety Board that listed 40 reported injuries that had not been

included in the medical records compiled by 6 area hospitals within 24 hours of the

accident.

Damage

The BNSF and Amtrak provided the damage estimate information used in table 2.

Table 2. Damage

Amtrak Train 4

The train came to rest with the last passenger car, sleeping car 32088, bridging the

gap of the collapsed bridge 504.1S. The last locomotive unit, ATK 52, and the rest of the

cars remained coupled. The three locomotive units that uncoupled from the train came to

rest with the lead locomotive unit, ATK 47, about 5,263 feet beyond ATK 52; the second

unit, ATK 50, about 4,268 feet beyond ATK 52; and the third unit, ATK 80, about

1,888 feet beyond ATK 52. All but the first two locomotive units and the last car

derailed. All cars derailed upright with the passenger cars at shallow angles to each other.

Damage to the locomotive units and cars affected the end vestibule and

diaphragm, coupler and coupler pocket, and undercar-mounted equipment. A rail

penetrated the 4th locomotive unit, ATK 52, from its front, exited through the rear, and

extended 19 feet into the first baggage car, ATK 1425. The rail penetrated below the floor

level of ATK 52 through the top of the fuel tank; no significant amount of diesel fuel was

Train Crew Passengers Total

Fatal 0 0 0

Serious 1 24 25

Minor 9 149* 158

None 8 121 129

Total 18 294 312

Equipment: Locomotives $ 400,000

Equipment: Cars $ 5,627,400

Track $ 454,000

Structures $ 681,000

Signal/Communications $ 17,000

Engineering and Other $ 42,000

Total $ 7,221,400
Factual Information 9

lost. Several passenger cars had structural body damage to their exteriors, consisting of

bent or buckled ends. All passenger cars sustained damage to the underside mid-section

areas, which rendered the service lighting, emergency lighting, and public address system

inoperable. Amtrak considered car ATK 31501, the 6th car in the train, a possible total

loss. The supporting trucks on five of the six MHC cars had to be rebuilt. (Figures 5 and 6

show, respectively, overall damage to the north side of the train and typical damage to a

single coach.)

Track, Structures, and Signals

Damage to the track required the replacement of 5,390 feet of 136-pound

continuous welded rail (CWR), which comprised 3,650 feet on the south track and

1,740 feet on the north track. Bridge 504.1S was destroyed. It was subsequently replaced

with three 20-foot prestressed concrete spans on steel H-pile bents. Bridge 504.1N

sustained less extensive derailment damage but was replaced when bridge 504.1S was

replaced with three 20-foot prestressed concrete spans on steel H-pile bents to provide the

same waterway opening for the parallel bridges. Signal and telecommunications damages

and costs were incidental to the track damage.

Personnel Information

Amtrak Train 4 Crew

The operating train crew consisted of an engineer, an assistant engineer, a

conductor, and two assistant conductors. All five crewmembers had completed their

mandatory off-duty time, as required by Federal Railroad Administration (FRA)

regulations, and all were qualified on the operating rules and the area’s physical

characteristics to operate passenger trains over this territory. During the interviews with

Safety Board investigators, all five said that they had felt well rested on the morning of

the accident and that they had had no physical problems before the accident.

Engineer. The engineer of train 4, age 52, began work in the railroad industry in

1967 with the former Chicago, Burlington and Quincy Railroad. He became a brakeman

in 1969, and was promoted to engineer in 1973. In August 1987, he went to work for

Amtrak as an engineer. On the day of the accident, he was working as the locomotive

engineer on his regular assignment. He became certified to operate over the Kingman

territory in October 1996 and had worked over that territory for about 7 months. On his

latest Amtrak locomotive engineer evaluation, March 25, 1997, his supervisor had noted

that he was a “thorough engineer.” He had no record of any disciplinary actions.
Factual Information 10

Figure 5. Damage to the north side of Amtrak train 4

Figure 6. Damage typical to Amtrak train 4 coaches
Factual Information 11

His last physical examination took place in July 1997, and it determined that he

was in good health. He wears glasses and has stated that he has some hearing problems

that he believes do not affect his ability to operate a train safely. He stated that he is not

required to wear a hearing aid. He was taking a prescription nasal spray prescribed by his

physician. He stated that his physician had said it was not necessary to obtain company

approval to take this medication, so he did not obtain written approval.

According to statements he made to investigators, on Thursday, August 7, 1997,

the engineer awoke about 8 a.m. and spent the day at home doing chores. He traveled to

Kingman on Thursday night and arrived at 3:18 a.m. He went to sleep and awoke at

8:30 a.m. on Friday. He was not on duty during the day and spent it doing miscellaneous

activities. On Friday night, he went to bed between 6 and 7 p.m. and slept until about 2 or

2:30 a.m. He stated that he awoke Saturday morning feeling rested and went on duty at

4:12 a.m. at Kingman.

Assistant Engineer. The assistant engineer, age 53, began railroad work in

August 1972 with the former Southern Railroad as a switchman. In 1974, he was

promoted to engineer. In 1987, he went to work as an engineer for Amtrak. He became

qualified to work over the Kingman territory in March 1997, and he had worked over that

territory for almost 7 months when the accident took place. He was not assigned to a

specific train and worked as an extra board employee.5 On the day of the accident, he was

working as the assistant engineer. On his last Amtrak locomotive engineer evaluation,

dated January 15, 1997, his supervisor noted that he displayed good trainhandling skills.

His employee record showed three instances of disciplinary action involving suspension

for operating rules violations: a STOP signal violation (30 days in 1988); a switch

operating violation (5 days in 1989); and his train occupying a track without dispatcher

authority (30 days in 1993).

His last physical examination took place in December 1996, and it showed that he

was in good health. He wears glasses while operating the train. He reported some hearing

loss that does not require the use of a hearing aid. He stated that he was not taking any

medications at the time of the accident.

According to his statements, the assistant engineer reported for work on Thursday

at 4:33 p.m. and departed Albuquerque, New Mexico, for Kingman at 6:30 p.m. He

arrived on Friday morning about 3:18 a.m., went to a hotel, and went to bed. He said he

awoke Friday morning about 11:30 a.m., felt relaxed and took a nap during the day, and

went to bed Friday night about 8 p.m. He slept until 12:30 a.m. Saturday morning and

went on duty at 4:12 a.m. in Kingman.

Conductor. The conductor, age 54, began railroad work in May 1964 on the

former Penn Central Railroad as a road freight conductor. He began working for Amtrak

in April 1986 as a conductor. He became qualified to work over the Kingman territory in

November 1995 and had worked over the territory for about 11⁄2 years. On the day of the

 5

 An extra board employee is a qualified employee not working a regularly assigned position.
Factual Information 12

accident, he was working his regular assignment, which he had worked for about a week.

He had no record of any disciplinary actions.

His last physical examination took place in March 1995, and it showed that he

was in good health. He wears glasses for reading. He told investigators that he has

suffered some hearing loss (he does not wear a hearing aid). He stated that he was not

taking any medications at the time of the accident.

The conductor said he awoke about 7 a.m. on Thursday and did some work

around the house. He arrived at the train station in Albuquerque about 3:26 p.m. and

traveled to Kingman. He arrived at 3:18 a.m. Friday morning and slept from 4 a.m. to

about 6:30 a.m. He reported that he went to breakfast, later napped for about 2 hours, and

spent the rest of the day in town. On Friday night, he went to sleep about 6:30 p.m.,

awoke about 2 a.m., and reported for duty about 4:27 a.m. in Kingman.

Assistant Conductors. One assistant conductor, age 46, began railroad work in

August 1974 as a brakeman with the former Denver and Rio Grande Western Railroad.

He started working for Amtrak in April 1989 as a conductor. He was working the extra

board on train 4, and he had worked over this territory for 3 weeks. He had no record of

disciplinary actions. His last physical examination took place in November 1995, and it

showed that he was in good health. He wears glasses and, according to him, has “bad”

hearing but does not wear hearing aids. He was taking the prescription medications

Norflex and Tranxene (muscle relaxers) to help him sleep; he had received company

approval to use these medications.

On Thursday, the assistant conductor awoke about 10 a.m. and reported for duty

about 4 p.m. He traveled from Albuquerque to Kingman and arrived about 3:18 a.m. on

Friday. He slept from about 4:15 a.m. until about 10:15 a.m., then spent the remainder of

the day in town. He went to bed between 7 and 8 p.m. and slept until 2:30 a.m. Saturday

morning. He went on duty at 4:27 a.m.

The other assistant conductor, age 51, began working for the railroad industry in

1966 with the former Atchison, Topeka and Santa Fe Railway (ATSF); he left and

returned on different occasions to attend college until 1973. In 1973, he began working as

a switchman; he was promoted to conductor in 1976. He started working for Amtrak in

1987. His last physical examination, in April 1996, found that he was in good health. He

worked over this territory on and off for several years and had been assigned to this job

for a couple months before the accident. He became qualified to work over the Kingman

territory in August 1987 and had worked this territory intermittently for several years. He

had no record of disciplinary actions. He awoke Saturday morning about 2:45 a.m. and

reported for duty at 4:27 a.m.
Factual Information 13

BNSF Personnel Information

The BNSF policy at the time of the accident was to use local track inspectors to

perform emergency inspections within their areas.6

 Performing an emergency inspection

included observing track and bridge conditions for the movement of trains. The BNSF

designates track inspectors in accordance with the qualifications prescribed in the FRA’s

track safety standards at 49 CFR 213.7. The BNSF also has bridge inspectors who are

assigned by territory to perform normal bridge inspections. According to the BNSF,

because of the number of bridges and the size of the territories, bridge inspectors do not

normally perform emergency inspections unless the inspector is in the area requiring the

emergency inspection.

Track Supervisor. The track supervisor, age 44, began his railroad career on the

former ATSF in January 1979 as a trackman in San Bernardino, California. He worked as

a heavy equipment operator in 1981. That year he also became a student foreman, a

position he filled until 1987. He later gained additional experience while working as a

foreman in other miscellaneous assignments. In 1995, he became an assistant roadmaster

with the Navajo System steel gang. On July 31, 1995, he started working in his current

position as a track supervisor. One of his responsibilities as track supervisor was track

inspection. His training for track inspection included a 4-week program in Albuquerque,

New Mexico, that provided instruction on track charts, rules, and standards, as well as

railroad maintenance and safety. He received additional on-the-job training and

experience while working on other assignments.

The track supervisor’s bridge inspection training was primarily on the job; he

stated that his knowledge was gained through conversations with bridge inspectors about

their duties and responsibilities. He had not received any formal classroom training in

bridge inspection, bridge maintenance, or high-water inspection. The BNSF formal

training course for Maintenance of Way Track Foremen and Inspectors does not contain a

section on bridge inspections.

The track supervisor reported that he worked on Friday until 4 p.m. He went home

(he lives in the Kingman area near the BNSF tracks) and did household chores and took a

nap from 5 until 8 p.m. He stayed around the house and then went back to sleep at

10 p.m. About 1:57 a.m., he was awakened by a phone call from the BNSF maintenanceof-way dispatch desk in Fort Worth, informing him of heavy rain between Pica

(MP 446.9) and Hackberry [“Berry”] (MP 509.4) in part of his territory and instructing

him to inspect the track in his area (MP 473 to MP 516.5). Had he not been called to

perform an emergency inspection, the track supervisor would have supervised a project

about 4 a.m. that morning.

Bridge Inspector. The bridge inspector for the Kingman area, age 56, began

working for the former ATSF in March 1968 as a bridge helper. In 1969, he became a

bridge foreman; in September 1976, he became a bridge inspector. He had about 200

 6

 In this instance, a track supervisor, who was a qualified track inspector, performed the inspection.
Factual Information 14

bridges on his territory, including the bridges at MP 504.1. He was responsible for

performing an inspection twice a year on each bridge, culvert, and other drainage

structures in the territory. He had no specific training to become a bridge inspector, only

that experience gained on the job. He had attended several company training sessions on

bridge inspection and welding. There are no State or Federal requirements for training or

qualifications of railroad bridge inspectors.

The bridge inspector was on vacation when the accident occurred. He stated that,

had he been called to inspect bridges in the Kingman area at this time, it would have

taken him at least 4 1/2 hours to drive there from his home, which was located 296 miles

from Kingman.

Train Information

Train 4 was assembled at Amtrak’s Redondo Junction facility at Los Angeles,

California. FRA initial terminal air brake tests and mechanical inspections were

performed by Amtrak mechanical forces about 2 p.m., Pacific daylight time, on August 8,

1997. Locomotive daily inspections were also performed. The tests included cab signal

and automatic train stop tests, which were completed without any noted defects. (The

next locomotive daily inspection was scheduled to have taken place at the next crew

change point, Albuquerque, New Mexico. The train was to have received an FRArequired 1,000-mile intermediate inspection upon arrival at Kansas City, Missouri.)

Beyond the initial tests and inspections, no other mechanical tests or inspections were

performed on the train before the accident, nor were any due.

The locomotive consist of train 4 had four P42-8DC, General Electric (GE) diesel

electric units, built in 1997 (ATKs 47, 50, 80, and 52, respectively). The passenger

equipment consisted of one Heritage class baggage car, followed by a Superliner

transition dormitory sleeping car for the on-board service personnel, a Superliner II coach,

two Superliner I coaches, another Superliner coach, a Superliner II Sightseer Lounge, a

Superliner I dining car, a Superliner I sleeping car, and a Superliner II sleeping car

(32088), followed by six MHCs.

A review of locomotive maintenance records revealed no anomalies. The on-site

inspection found that the air brake manifolds of several cars had been knocked off in the

derailment with under-bottom damage. This damage prevented the performance of any air

brake tests.
Factual Information 15

Track, Structures, and Signal Information

Track

The accident site is located about 12.3 railroad miles east of Kingman, Arizona.

The BNSF tracks through the accident area are within the Peacock Mountain range in the

Hualapai Valley flood plain. The general terrain is flat desert land with several dry gullies

that cross under the tracks and the adjacent highway, Arizona State Route 66 (Route 66).

The two main tracks in the accident area are designated as the north track

(signaled for westbound trains) and the south track (signaled for eastbound trains).

Railroad MPs are in descending order from west to east. The Kingman station is at

MP 516.4 and the accident occurred at MP 504.1. The track was straight from MP 512 to

MP 504. The south track gradient from Kingman to Getz (MP 513.9) was ascending for

eastward trains on a 1.0 to 1.5 percent gradient; from Getz to the accident site, the track

was descending for eastward trains from a maximum of 1.0 (MP 512 to MP 511) to

0.06 percent at the bridges at MP 504.1.

The BNSF maintains the track to meet or exceed the minimum requirements of

the FRA Track Safety Standards for Class 5 track, contained in 49 CFR 213. The FRA

Class 5 designation provides maximum allowable operating speeds of 80 mph for freight

trains and 90 mph for passenger trains. The minimum track inspection frequency required

by Class 5 standards is twice a week with 1 calendar day between inspections. The track

had last been inspected on August 6, with no defects noted. The most recent track

geometry test for track alignment, gauge, and surface was on July 16, with no defects

noted in the accident area. A contractor performed the latest ultrasonic rail tests for

determining rail integrity on August 6, with no defects noted in the accident area. Both

tests were performed within the prescribed timeframes of 49 CFR 213.

The south track in the area of the derailment was constructed with 136-pound

CWR. The rail was manufactured by Colorado Fuel & Iron and installed new in 1984.

The rail rested in 7-inch by 14-inch double shoulder tie plates, secured to timber crossties

with three to four track spikes per tie plate. Longitudinal movement of the rail was

restricted by the application of base-applied drive-on rail anchors applied to every other

tie. Track ballast consisted of 2-inch stone ballast with the shoulders maintained to

12 inches beyond the end of the tie.

Structures

The BNSF bridge involved in the derailment was located at MP 504.1. The

railroad through the derailment site was originally constructed as a single main track, now

the north track, in 1883, by the ATSF. In 1922, the south track and bridge were

constructed. The bridges on both tracks at MP 504.1 are identified by the BNSF as bridge

504.1, but the two bridges are structurally independent of each other.
Factual Information 16

BNSF bridge records indicate that the system has 250 timber-framed bent bridges.

Of these bridges, 143 are similar in construction to bridge 504.1S, which is a structure

founded on timber mud sills7

 on erodible soils or rock. Of these 143 bridges, 80 are

located on FRA Class 4 (or higher) track on which passenger trains operate. The other 63

of the 143 bridges are, with the exception of 1 bridge, located on secondary main lines or

branch lines. The 107 timber-framed bent BNSF bridges dissimilar in construction to

bridge 504.1S are either on pilings, on concrete footings in rock, or located over paved

roadways or concrete-lined channels.

Bridge 504.1S. The bridge was a treated timber trestle with four 9-foot spans

supporting a ballast deck spanning a total length of 37 feet, 2 inches. The trestle was

made of: two end framed bents8 and three intermediate framed bents, each consisting of

five round timber posts of 12 inches in diameter; one timber cap,9 12 inches wide by

14 inches deep by 14 feet long; and one timber sill, 12 inches by 12 inches by 16 feet,

resting on timber footer blocks, 6 3/4 inches by 10 3/4 inches by 32 inches, packed tightly

side by side, forming a mud sill 32 inches by 16 feet. The mud sill rested on “hard pan”10

soil and was buried about 12 inches in an upper layer of soil and concrete slurry.

Each intermediate framed bent was braced laterally with two diagonal lateral sway

timber braces; each brace extended from a top corner to the opposite bottom corner of the

framed bent. The bridge was braced longitudinally by four timber struts, or “hog jaws,”

from the top of each end framed bent to the sill of the adjacent intermediate framed bent.

The bridge deck was made of 3-inch by 10-inch transverse deck planks. At each

edge of the deck was a 6-inch by 6-inch timber stringer below the deck planks and a

timber ballast curb 32 inches high with approximately 3 feet of stone ballast. The bridge

had a “free board” (bottom of bridge to bottom of streambed) of 76 inches and a center

height (base of rail to bottom of streambed) of 111 inches. (See figure 7 for a terminology

guide for a timber-bent bridge supported on timber blocking.)

Bridge 504.1N. The existing bridge was built in 1940 to replace a bridge built in

1907, which had replaced the original 1883 bridge. The existing bridge was a ballast-deck

treated-timber trestle with T-rail stringers on driven-timber pile bents.

 7

 A mud sill is a single piece of timber or a unit composed of two or more timbers placed upon a soil

foundation as a support for a single column, a framed trestle bent, or another similar member of a structure.

8

 A framed bent is a framed supporting unit of a trestle made up of two or more timbers as columns

connected at their topmost ends by a cap.

9

 The cap is the topmost piece of a framed timber bent, which serves to distribute loads upon the piles

and to hold them in their proper relative positions.

10 Hard pan is a layer of hard soil cemented by almost insoluble materials that restrict the downward

movement of water.
Factual Information 17

Figure 7. Guide to terms for timber-bent bridges supported on timber blocking

Top Cap 

Vertical Posts 

Ballast Curb 

Grade Tie 

"T" Rails 

Deck Plank 

Firm/Rock Footing 

at Ground Line 

Sediment 

or Loose 

Material 

Bottom Sill 

Bracing 

Mud Blocking 

& Shims 

Timber Bent Supported on Timber Blocking

Terminology Guide 

No Scale 

DCA97MR004 

Amtrak Train 4 

Burlington Northern Santa Fe 

near Kingman, Arizona 

August 9, 1997 
Factual Information 18

The overall length of the bridge was 37 feet, 2 inches; it was made of four spans

with nominal span lengths of 9 feet, 3 inches each. Each of the five bents, numbered 1

through 5 from east to west, had five timber piles ranging from 19 to 22 feet from the

cutoff to the pile bottom. On each framed bent was a 12-inch by 14-inch cap supporting

stringers made from 90-pound steel T-rail. Six live-load T-rail stringers were centered

under each running rail, and one T-rail stringer was outboard of each running rail. The Trail stringers were secondhand rails that weighed 90 pounds per yard and were

approximately 10 and 28 feet long, respectively. Each long stringer spanned three of the

four panels, and each short stringer spanned one panel. The short and long stringers were

interlaced over framed bents numbered 2 and 4.

The deck of bridge 504.1N was made of 3-inch by 10-inch transverse deck planks.

At each edge of the deck was a 6-inch by 6-inch timber stringer below the deck planks

and a ballast curb of two timbers: one 6 inches by 10 inches on the deck planks and a

second 6-inch by 12-inch curb timber above the first. The track rested on approximately

24 inches of stone ballast.

Bridge 504.1S Maintenance and Inspection

Railroad documents dated 1975 showed that the bridges at 504.1 served a

drainage area of 19.09 square miles. However, an ATSF document from 1940 showed

that, during the 1940 renewal of the north track bridge (504.1N), the drainage area was

calculated to be 3.80 square miles. Although the documents showed that a waterway

opening of 267.0 square feet was required, versus the existing 174.8 square feet, they

noted that no scouring11 had occurred at either end of the bridge, and that the present

opening was larger than the 120-square-foot opening under Route 66, which was located

about 1,000 feet downstream to the north.

Maintenance records showed that the mud sills were replaced in 1958. In 1959,

the bridge inspector recommended grouting the water path and adding stones between

spans 1 and 2. This work was performed in 1964.

During 1971, the State of Arizona widened Route 66 and extended the concrete

box culvert downstream from BNSF bridge 504.1. (See figure 8 for a photo of the box

culvert.) The original concrete box culvert had been built in 1936. Following the accident,

Safety Board investigators observed evidence of streambed erosion between the highway

box culvert and bridge 504.1.

 11 Scour is the result of the erosive action of running water excavating and carrying away material from

the bed and banks of streams. Different materials scour at different rates. Loose granular soils are rapidly

eroded under water action while cohesive cemented soils are more scour resistant. (From Underwater

Inspection of Bridges, FHWA-DP-80-1, November 1989.)
Factual Information 19

A January 1975 ATSF internal memo discussed the replacement of bridge 504.1

for the 1977 Capital Improvement Program (CIP), stating that replacement was needed

“due to scouring of the mud blocks for the bridge under the eastbound main track [bridge

504.1S].” Based on its calculations of the larger drainage area, the ATSF believed that a

“structure several times larger than the existing bridge” would be required. The memo

then stated:

Under the circumstances, it is suggested we place a concrete crosswall

downstream from the bridge in order that the streambed will silt in behind

the crosswall covering the mud blocks. As a matter of information we

have already arranged to place the crosswall and in our opinion, this bridge

will now last several more years. In as much as the bridge is not capable of

handling its runoff, the water now presently runs in an easterly direction

adjacent to the track to the next structure.

By December 1975, additional grouted stone was placed at spans 2 and 3 because

of the noted scour at the mud sills. A January 13, 1976, handwritten document from

ATSF management stated, with regard to the proposed concrete crosswall and removal of

bridge 504.1 from the 1977 CIP budget list, that this approach was not the appropriate

way to address existing concerns. In May 1976, ATSF maintenance-of-way employees

installed a 38-foot-long unreinforced concrete crosswall, 16 inches thick and 30 inches

deep, about 17 feet downstream from the north side of the bridge. At this time, the bridge

was removed from the 1977 budget list for replacement.

Figure 8. Highway box culvert downstream from bridge 504.1
Factual Information 20

The BNSF bridge inspection program requires an annual inspection, with

intermediate inspections to be conducted as needed. The last programmed bridge

inspection took place on February 18, 1997. Another bridge inspection was conducted by

the bridge inspector on July 9, 1997. During these inspections, no exceptions were taken

to the condition of the bridge structure. In addition, no scouring was reported at the

crosswall or the supporting mud sills at the timber bridge framed bents. (Table 3

summarizes the history of bridge 504.1S.)

Table 3. Summary of noted events at bridge 504.1S

Date Events

1922 ATSF builds second track bridge (504.1S) south of existing

bridge (504.1N).

1936 State of Arizona constructs Route 66 with box culverts, one

1,000 feet downstream from bridge 504.1.

1940 ATSF bridge records show 3.8 square miles drainage area.

1958 ATSF bridge forces replace mud sills.

1959 ATSF bridge inspector recommends putting grout and stone

between spans 1 and 2.

1964 ATSF bridge forces place grout and stone between spans 1

and 2.

1971 State of Arizona widens Route 66 and extends the concrete

box culverts.

1/2/75 ATSF engineering department letter recommends replacing

bridge 504.1 under 1977 CIP because of scouring at mud

sills.

1975 ATSF bridge forces place grout and stone between spans 2

and 3.

12/9/75 ATSF engineering calculates 19.09 square miles drainage

area.

1/13/76 ATSF engineering department letter expresses concern about

proposed concrete crosswall and removal of the bridge from

the 1977 CIP.

5/18/76 ATSF maintenance-of-way forces install concrete crosswall.

May 1976 Bridge 504.1 removed from 1977 CIP.

7/24/76 High water recorded over top of rail on bridge.

7/29/76 High water measured at 2 inches above base of bridge rail.

2/18/97 BNSF bridge inspector performs last programmed bridge

inspection.

7/9/97 BNSF bridge inspector performs last bridge inspection, noting

no problems.

4:30 a.m. 8/9/97 BNSF track supervisor is at bridge for special high water

inspection.

5:56 a.m. 8/9/97 Amtrak train 4 derails while crossing bridge.
Factual Information 21

About 3:30 a.m. on August 9, before beginning inspection of sections of his

assigned track, including the eastbound and westbound tracks east of Kingman, the track

supervisor contacted the dispatcher to obtain an eastbound train “informational line-up.”12

The dispatcher informed him that a hold had been placed on Amtrak train 4 at Griffith

(MP 526.8). The dispatcher was not required to take this precaution, but the track

supervisor understood it would provide an extra measure of protection for him. He began

his on-track inspection at MP 516.5 about 4:05 a.m. His inspection took place in the dark

while it was raining. He stated that he rode eastbound in a hy-rail vehicle (traveling about

15 to 20 mph) on the south track and looked for water running alongside the track,

making sure it was not going over the track or scouring the ballast. He later told

investigators that while traveling over bridges, he specifically looks at the tracks’ gauge,

line, and surface to determine whether there is trouble on the bridge. He said he pays

closer attention to the bridge if water is running underneath it.

The track supervisor stated that, when beginning his inspection on the day of the

accident, he observed a “greater” volume of fast-moving water running alongside the

track near MP 510; it was an area where he had not seen it before. About 4:30 a.m., he

stopped and got out of the hy-rail vehicle at three bridges west of bridge 504.1. At the

first location where he saw water flowing underneath a bridge (507.4), he got out of his

hy-rail vehicle and checked the earth around the bridge’s framed bents. He repeated this

procedure for the next two bridges where water had accumulated (bridges 507.3 and

505.9). Between 4:30 and 4:45 a.m., he arrived at bridge 504.1 and observed “a greater

portion of water coming from the south side of the south track” from behind him, and that

“a smaller portion of water was coming from in front” of him. He stated, “That’s the first

time that I saw that volume of water under that particular bridge.” The water was “lapping

against the bottom of the bridge.” He did not think the volume was excessive. The water

was moving rapidly, and he believed it was already subsiding. He stated that the best

indicator he had of any problem was “the line gauge and surface of the track structure.”

As to inspecting the bridge for scour problems, he stated that “I knew from experience

that what—that I was looking for anything out of the ordinary—and at the time the

knowledge that I had—I took no exception to anything I observed.” He did not get out of

his hy-rail vehicle to inspect bridge 504.1, as he had at the other bridges.

When the track supervisor was at Truxton, MP 477.3, the dispatcher told the track

supervisor that he was releasing Amtrak train 4 through Griffith and that he would let the

track supervisor know when Amtrak train 4 was leaving Kingman. (Truxton is about

50 miles from Griffith.) The dispatcher informed the track supervisor when he was about

5 minutes from Peach Springs (MP 465.8) that Amtrak train 4 had left Kingman. By this

time, the track supervisor had completed his inspection and had not found any

abnormalities resulting from the storm. The rain had ceased by the end of his inspection.

 12 The term “informational line-up” refers to a list of trains and their approximate locations obtained

from the train dispatcher and used to clear on-track equipment. Line-ups provide information to railroad

personnel on the number, time, and location of trains at designated station or terminal points on the railroad

for a particular track segment. They are usually valid for up to 4 hours; however, they are subject to change

due to train traffic conditions.
Factual Information 22

While he was getting off the track at Peach Springs at 6:01 a.m., he overheard radio

communications about the derailment.

The track supervisor stated that he had been on this job since July 31, 1995, and

had only made special inspections because of heavy rain once or twice (in 1996). This

was the first such occasion in 1997. He stated that “Based on what I—at that time I felt

completely 100-percent confident that my railroad was able to support traffic of any

nature after I had made the inspection.” He estimated that the 40 miles of territory he

covered contained about 50 bridges.

For BNSF track inspectors performing special inspections for high water, the

ATSF instructions, which were dated October 27, 1995, and still in effect for the BNSF,

addressed special inspections in Section 82: Track Inspection - Chief Engineer’s

Instructions, part 82.6 “Special Inspections.” These instructions state, in part:

82.6.1 High Water

Perform these inspections during heavy rain or flooding:

1. Inspect the track for the following:

•Washouts

• Scour

• Surface irregularities

•Water over the rail

2. Inspect drainage structures for the following:

•Erosion behind dump planks and headwalls and around piers and

footings

•Obstructions from drift and debris

The only recorded instances of high water for the Kingman area took place on

July 24, 1976, when a roadmaster recorded high water over the top of the rail on the

bridges at MP 504.1, and on July 29, 1976, when a roadmaster measured high water at 2

inches above the base of the rail. No accidents involving high water or bridge failure were

recorded for the Kingman area.

Signals

The signal system in the accident area is an automatic block signal (ABS) system,

arranged for train movement with the current of traffic (signaled in one direction) and

supplemented by an automatic train stop (ATS) system. The ABS extends about 97 miles

from control point (CP) 526.9 to West Seligman, MP 429.8, on double track, and it has

color light signals controlled by Electro Code Model 4 electronics track circuits. The

BNSF designates the tracks as follows: (1) north track for westward train movements; and

(2) south track for eastward train movements. A failed equipment detector (FED) is

located at MP 512.5 and a high water detector (HWD) is at bridge 505.9. (See Tests and

Research.)
Factual Information 23

Signals on the south track (for eastward train movements) are numbered according

to railroad MPs and end with a numeral 2. Signals on the north track (for westward train

movements) are also identified by MPs, but they end with a numeral 1. (See figure 9.)

Figure 9. Signal system layout

Operations Information

Amtrak/BNSF Train Operations

The accident occurred on the south main track on the Seligman West Subdivision,

Arizona Division of the BNSF. Train operations are governed by the General Code of

Operating Rules, Timetable No. 1, dated August 1, 1996, and by special instructions.

Train movements are controlled by the signal indications of an ABS system. Amtrak

passenger trains operating over this territory are equipped with ATS systems configured

to allow them to operate at the maximum permissible speed of 90 mph. The maximum

permissible speed for freight trains is 70 mph.

The ATS feature is designed so that a penalty brake application will occur if the

engineer does not activate a button when passing a wayside signal. The object is to

enforce the observance of restricting indications of a wayside signal by requiring the

engineer to “acknowledge” (depressing a button) when passing signals displaying such

indications. “Restricting indications” include all signal indications other than a CLEAR

or proceed signal. If the engineer fails to acknowledge such a restrictive indication, the

train will automatically stop.

All four locomotive units were equipped with event recording devices. The data

from the event recorders were downloaded on scene to provide a preliminary readout,

which indicated that the train was proceeding at about 89 to 90 mph, with the throttle in

← Eastward Westward →

5022 5052 5082 5102

South Track

North Track

 5021 5051 5081 5101

 Bridge Bridge MP 512.5 FED

 MP 504.1 MP 505.9 Hot Box & Dragging

 (High Water Detector) Equipment Dete
Factual Information 24

the no. 3 position and the brakes fully released when the brake pipe pressure decreased

from 110 to 0 psi. The data further indicated that a trainline-induced emergency

(TLEM)13 occurred first, followed by an engineer-induced emergency (EIE) about 3 to

5 seconds later. The automatic brake handle changed from the released position to the

emergency position about the same time that the EIE took place.

Amtrak train 4 was scheduled to depart Kingman at 4:57 a.m., but for BNSF

operational reasons (reported as “other trains”) during its trip from Los Angeles,

California, it arrived late. It left Griffith (MP 526.8) at 5:24 a.m.

BNSF Operations Center

The BNSF directs all train movements from its operations center in Fort Worth,

Texas. The train dispatcher directing train movements for the Seligman West Subdivision

works from the operations center and plans, directs, and monitors train movements at a

DigiCon®14 Centralized Traffic Control (CTC) system. From this location, the dispatcher

can also communicate with all trains within his assigned area.

Before the accident, the BNSF did not have a formal method for instructing

dispatchers about their responsibilities in the event of a flash flood warning. On

August 10, 1997, the BNSF issued a “Maintenance Alert” that specified procedures

relating to possible flash floods. (For the complete Maintenance Alert, see appendix C.)

The BNSF provided a comparison of the “before accident” and “after accident”

responsibilities of the dispatcher as follows:

August 8, 1997, instructions

When possible flash flooding conditions were reported, Engineering

Department Personnel were contacted and instructed to patrol track. While

no specific restrictions were placed on train operation, if track inspection

revealed a dangerous condition, the train dispatcher was to require trains to

stop and examine track before movement was authorized. If a train arrived

where an inspection was being made before the inspection was complete,

the train would be held until maintenance personnel determined that track

conditions at that particular location were safe for movement.

August 9, 1997, instructions

In addition to the procedures outlined above, train crews are instructed that

the following will also apply when notified that flash flood warning

conditions exist:

 13 A TLEM means that the emergency brake was applied by some means other than the automatic

brake handle or the “fireman’s” emergency brake valve.

14 Digital Concepts provided the DigiCon® system that is in use on the former ATSF.
Factual Information 25

Passenger trains will operate at restricted speed.15

All other trains will operate at a maximum speed of 40 mph.

These restrictions will apply during the time and limits stated in the

flash flood warning.

At 12:06 a.m. on August 9, the BNSF operations center service interruption desk

received its first alert of potential severe weather from its contract weather service. The

alert was of thunderstorms and heavy rain on the Seligman subdivision. This notification

was followed by an update at 12:52 a.m. (Alert 0000).16 According to the BNSF, the

manager of the service interruption desk distributes the printed information to the train

dispatcher, the train dispatcher’s supervisor, the chief dispatcher or manager of corridor

operations, the corridor superintendent, the maintenance-of-way desk, and other

managers. Table 4 (next page) provides a chronology of weather-related events

concerning the Kingman accident. All events cited took place on August 9, 1997.

Protection for Employees During Special Inspections

When the decision was made to have the track in the Kingman area inspected

because of the flash flood warning, the train dispatcher on duty placed a restrictive label

on the approach to Griffith because a track inspector was out ahead of Amtrak train 4 on

the informational line-up. The restrictive label was noted through the CTC DigiCon®

system and would have prevented the dispatcher from requesting a more favorable signal

than STOP for Amtrak train 4 to move eastward. Amtrak train 4 was not held at Griffith

because the track supervisor did not report any problems to the train dispatcher before the

turnover to the next dispatcher occurred (at about 5:40 a.m.). This information was given

to the train dispatcher who was on duty when the accident occurred, and the restrictive

label was removed.

The second dispatcher told investigators that a track supervisor inspecting track

would call him only if the track supervisor had something to report. Otherwise, the

dispatcher might not hear again from the track supervisor after providing him an

informational line-up. Because he received no reports of adverse conditions from the

track supervisor, the dispatcher saw no reason not to run Amtrak train 4 into the track

limits behind the track supervisor. In addition, he stated that no restrictions would have

been placed on the train as long as the track supervisor was ahead of the train and had not

issued a report requiring a train movement restriction. The dispatcher further stated that

before the Kingman accident no restrictions were issued to trains for flash flood

warnings.

 15 Rule 6.27 of the BNSF General Code of Operating Rules defines “restricted speed” for the engineer

of a train as being able to stop within half the range of vision: short of train, engine, railroad car, men or

equipment fouling the track, stop signal, or derail or switch lined improperly, on the lookout for broken rail,

and not exceeding 20 mph.

16 See Meteorological Information section.
Factual Information 26

Table 4. Weather-related events and information

Time (a.m.) Events before the accident

1:43 BNSF receives flash flood warning (0001) for the

Kingman area.

1:57 Track supervisor for Kingman area is notified.

2:24 National Weather Service issues severe thunderstorm

and flash flood warning for central Mohave County,

effective until 3:30 a.m. Also, before 3 a.m., weather

updates (0002 and 0003) are issued to BNSF, including

to “watch for flash flooding,” effective until 4:30 a.m.

3:39 Crewmembers of westbound train Q-LACMEM1-08

report to the BNSF train dispatcher that the rain is letting

up at Walapai (MP 501.3), and that they saw water in the

culverts.

3:56 Train Q-LACMEM1-08 crewmembers at MP 489.7 report

to the train dispatcher that there is no water on the

ground and only “trickles” in the ditch.

4:05 The track supervisor begins his special inspection at

MP 516.5, moving in an eastward direction.

4:12 Dispatcher tells track supervisor of Q-LACMEM1-08

information.

4:28 Contract weather service issues update 0004 to BNSF,

advising to “watch for flash flooding,” until 6 a.m.

4:30-4:45 Track supervisor reports from Hackberry (MP 509.4) to

the BNSF train dispatcher. He does not report high

water. He inspects bridge 504.1. He notes water flowing

adjacent to and under the bridge. He does not note any

unusual track alignment or take exception to either the

east- or westbound bridge.

5:07 Dispatcher reports to track supervisor that eastbound

Amtrak train 4 is leaving Franconia (west of Kingman).

5:35 Westbound train B-CHCLAC1-05 passes Walapai

(MP 501.3). Shortly thereafter, this train crosses the

bridge on the north track at MP 504.1. Train crew notices

nothing unusual about the bridge on the south track.

5:46 Track supervisor reports from Peach Springs (MP 465.8)

to dispatcher. He says he will clear shortly for Amtrak

train 4. He does not report any high water.

5:56 Amtrak train 4 derails at bridge 504.1S.
Factual Information 27

The track supervisor confirmed that no mechanism is in place to protect him or

other track inspectors if they are unable to contact the dispatcher for any reason; it is up to

the employee to get out of the way of trains. He stated that his protection is “with the

informational line-up.” He stated that the informational line-up is only good for about 4

hours and then “you have no authority to be on the track.” He also stated that the

dispatcher is not expected to locate the inspector. Further, he stated that he does not notify

the dispatcher when he stops to inspect a bridge.

Both train dispatchers told investigators that they had not traveled the track

through the area where they were responsible for dispatching trains.

Meteorological Information

WeatherData, Inc., (WDI) provides track-specific storm weather alerts and

warnings to the BNSF. WDI is a private meteorological company located in Wichita,

Kansas; it has been in business since 1981. WDI employs 38 associates and serves about

200 clients throughout North America. The company has two meteorological divisions;

Weather Research and Weather Operations. Within Weather Operations, meteorologists

are designated to work as either media meteorologists or storm warning meteorologists.

All WDI meteorologists have bachelor’s of science degrees in meteorology or the

equivalent training. All WDI storm warning meteorologists must pass internal training

and certification before issuing storm warnings to WDI clients.

WDI notifies the BNSF service interruption desk at its NOC with either a weather

“alert” or “warning.” Whenever the meteorological state of the art allows, weather

warnings are to be delivered to the NOC no less than 15 minutes before the weather

affecting a certain portion of track is due. Warnings differ from alerts in that warnings

require that some specific, immediate action be taken to safeguard the movement of

trains. Alerts are informational and require no immediate action.

At the time of the accident, BNSF instructions to WDI were that warnings were to

be issued for tornadoes, winds in excess of 60 mph, hurricanes, blizzards, and flash

floods. The actions to be taken by dispatchers and train crews for tornadoes and winds in

excess of 60 mph are defined in System Special instruction number 35 (see appendix C).

The BNSF reported that at the time of the accident no timetable or special instructions

related to flash floods; however, the BNSF had an unwritten policy that a track inspector

would be called to inspect tracks in areas that had flash flood warnings.

The following are excerpts from the alerts and warnings issued by WDI to the

BNSF concerning the weather around Kingman for the period on Saturday, August 9, that

preceded the derailment:
Factual Information 28

Initial alert

Start Time: 12:06 a.m.

Locations: Seligman subdivision

Conditions: Thunderstorms and Heavy Rain

Comments: Strong thunderstorms are rapidly developing just southeast of,

is that Pica, Pica, Arizona, moving east at 15 miles per hour. Radar

estimates, moderate rainfall over track with up to 0.7 inches per hour

rainfall rates. Expect from 0.4 to 0.6 inch of rain in the next 40 minutes,

will monitor for flash flooding.

Alert 0000

Start Time: 12:52 a.m.

Expire Time: 2:30 a.m.

Locations: Pica, AZ, to Kingman, AZ

Conditions: Thunderstorms, Heavy Rain, Moderate Winds

Comments: Update to previous warning. Strong to severe thunderstorms

producing heavy rain with up to 1 inch an hour and gust wind continues to

redevelop over this stretch of track. Kingman, AZ, has reported a gust to

50 miles per hour in the last 45 minutes. Therefore we are extending the

previous warning.

Warning 0001

Start Time: 1:43 a.m.

Expire Time: 2:30 a.m.

Locations: Truxton, AZ, to Hackberry, AZ

Conditions: Flash Flood, Thunderstorms, Heavy Rain

Comments: Thunderstorms continue to move to the east at 20 miles per

hour. Radar estimates that nearly 2 inches of rain has fallen over this

stretch of track with hourly rates of 1 inch an hour still falling. Watch for

flash flooding!

Warning 0002

Start Time: 2:21 a.m.

Expire Time: 4:30 a.m.
Factual Information 29

Locations: Pica, AZ, to Harris, AZ

Conditions: Flash Flood, Thunderstorms, Heavy Rain, Moderate Winds

Comments: Strong thunderstorms continue to redevelop and move over

this stretch of track this morning. Movement of these storms is to the eastsoutheast at 10 miles per hour. Rainfall amounts of 1 to 2 inches is likely,

as well as, peak wind gusts less than 60 miles per hour. Watch for flash

flooding.

Alert 0003

Start Time: 2:32 a.m.

Expire Time: 4:30 a.m.

Locations: Harris, AZ, to Athos, AZ

Conditions: Thunderstorms, Heavy Rain, Moderate Winds

Comments: Strong thunderstorms continue to redevelop and move over

this stretch of track this morning. Movement of these storms is to the eastsoutheast at 10 miles per hour. Rainfall amounts of 1/2 to 1 inch is likely

over this stretch of track, as well as, peak wind gusts less than 60 miles per

hour.

Warning 0004

Start Time: 4:28 a.m.

Expire Time: 6 a.m.

Locations: Truxton, AZ, to Harris, AZ

Conditions: Flash Flood, Thunderstorms, Heavy Rain

Comments: Thunderstorms producing heavy rain continue to remain

nearly stationary around the Kingman, AZ, area this morning. Radar

estimates that nearly 3 to 3.5 inches of rain has fallen near this stretch of

track with hourly rates of 1 inch an hour still falling. Watch for flash

flooding! The threat for high wind has diminished, however, a gust to

45 miles per hour is still possible.

The BNSF NOC managers told Safety Board investigators that “Warning 0001”

had initiated the request to the BNSF maintenance-of-way operations desk to have the

track inspected in the Kingman area. This warning covered the track between Truxton,

MP 477.3, and Hackberry, MP 509.4.
Factual Information 30

A WDI employee told Safety Board investigators that he had been working that

Friday night and early Saturday morning. He said he had issued the warnings on the basis

of base reflectivity, “storm total precipitation,” “1-hour precipitation,” and vertically

integrated products from the National Weather Service’s (NWS’s) Las Vegas and

Flagstaff WSR-88D radar. These sources indicated heavy rates of rainfall, and data from

the National Lightning Detection Network indicated intensifying thunderstorms over

northwest Arizona. His SmartWARN17 Storm Warning System highlighted the area

around Kingman as prone to flash flooding. He was aware that rains had fallen in the

Kingman area during the 24 hours before his shift began.

NWS postaccident interviews with local authorities and citizens showed that a

light rain had begun around 1 a.m., with heavy rain starting around 1:30 a.m. and lasting

for about 2 hours before tapering off to a light rain that continued until about 5 a.m. At

3 a.m., flooding was reported at East Bank and Kingman Avenue, causing people in the

area to require rescue from three stalled cars. A plastic rain gauge at the airport recorded

1.76 inches of rainfall. A “bucket survey” north of the airport, closer to the train

derailment and about where the strongest rain cells were located at 3 a.m., showed an

estimated 3 to 4 inches of rainfall. Public works reported a measured 3.7 inches of rainfall

but was not sure of the report’s source. A rancher to the northwest of the accident site

(about 12 miles north of Kingman) recorded 2 inches in his rain gauge.

NWS reports stated that approximately 2 inches of rain fell within the Hualapai

Valley area, with a possible core precipitation of at least 3 inches, and possibly up to 4

inches, and that a considerable amount of water ran through Kingman, beginning around

1:30 a.m. Police and public works representatives could not get barricades up fast enough

to keep people out of the washes. Four people had to be rescued by helicopter from two

stranded vehicles.

Medical and Pathological Information

The accident caused no fatalities. Of the 294 passengers and 18 train crew

members, 173 passengers and 10 train crewmembers were injured. Passengers and train

crew personnel were injured by striking interior surfaces, such as seats, armrests,

footrests, tables, luggage racks, walls, and beds, and from being thrown into the aisles

during the impact. Passengers and train crewmembers who were injured were treated at

six hospitals. Injuries consisted of strains, sprains, fractures, contusions, and multiple

trauma.

About 2 p.m., or 8 hours after the accident took place, the engineer, assistant

engineer, conductor, and assistant conductors from Amtrak train 4 provided urine

specimens and gave breath tests for postaccident alcohol and drug testing. Amtrak and

 17 SmartWARN is a computer workstation developed by WDI to allow its storm warning

meteorologists to quickly and effectively display meteorological data in a format that can easily be analyzed

so accurate decisions about warnings can be made.
Factual Information 31

BNSF officials were present during the sample collection. All crewmembers tested

negative for alcohol.

Although samples from the train crewmembers had been collected, an FRA

official on scene determined that postaccident toxicological testing for drugs and alcohol

was not required. As a result, neither the track supervisor nor the dispatcher was tested.

According to 49 CFR 219.201(b),

No test shall be required in the case of an accident/incident the cause and

severity of which are wholly attributable to a natural cause (e.g., flood,

tornado or other natural disaster), as determined on the basis of objective

and documented facts by the railroad representative responding to the

scene.

Emergency Response

Notification

About 5:56 a.m., the BNSF NOC received a radio communication from the

engineer of Amtrak train 4 informing it of the train’s derailment and location. The NOC

passed the information on to its ROC and a BNSF special agent, who notified the Mohave

County Sheriff’s Department at 6:01 a.m. The NOC said it did not know the number of

passengers on the train, the extent of the injuries, or the prospect of fatalities. The BNSF

notified the U.S. Coast Guard National Response Center of the accident at 6:15 a.m.

About 6:20 a.m., the BNSF special agent called the ROC manager and advised

that the Mohave County Sheriff’s Department dispatcher had reported that at least two

cars had derailed and that two unconfirmed fatalities were reported on the first car

[dormitory car]. According to the BNSF transcript of the recorded communications

between the BNSF special agent and the Mohave County Sheriff’s Department

dispatcher, the sheriff’s dispatcher said, “Well, I got word that so far one car, two really

serious, probably gonna be DOA [dead on arrival].”

The BNSF special agent’s communication with the NOC Service Interruption

Desk manager about the accident was also recorded. The agent said, “When I talked to

Mohave County, they said ... two fatalities and they’re still trying to get to the scene.”

The NOC manager replied, “Two fatalities?,” and the BNSF special agent said,

Yeah, two DOAs is what they called them, dead on arrival.... That’s just

when they first got on the scene, that’s what they reported. Two cars for

sure derailed and two, it looked like two DOAs.
Factual Information 32

During further conversation with an employee at BNSF operations, the BNSF

special agent said, “... it’s not a confirm, but that’s pretty much what they said when they

first got on [scene].”

At 6:45 a.m., the BNSF special agent called the Mohave County Sheriff’s

Department to get an update and talked to a sergeant who relayed information being

transmitted over his radio from the scene. According to the BNSF transcript of the

recorded communication, the sergeant said, “We’ve got two dead downstairs now...

we’re still in the initial response stage and a lot of our information is gonna be really

confusing.” The BNSF special agent replied, “Right, I understand. I thought I heard her

say six possible on the downstairs side.” The sergeant said “Yes... they were in the first

car.” The updated information was relayed to the BNSF Service Interruption Desk

manager, who communicated it to the FRA and the Safety Board.

The dispatchers at the Mohave County Sheriff’s Department did not remember

whether a sergeant had been present during these conversations or had reported possible

fatalities. The dispatchers did recall reporting critical injuries. A copy of the dispatch tape

recording was provided by the Mohave County Sheriff’s Department to the Safety Board.

The tape included radio and telephone conversations; the conversation between the

Mohave County Sheriff’s Department dispatchers and the BNSF special agent was not

recorded.

The initial reports made by the BNSF to the Safety Board’s communications

center via the U.S. Coast Guard National Response Center cited 8 to 13 fatalities. The

general manager of Operations, Standards, and Compliance for Amtrak stated that the

report of 8 to 13 fatalities resulted in Amtrak’s high-level response to the accident. The

report of 13 fatalities was not recorded in transcripts. The source of the number could not

be verified.

The general manager told Safety Board investigators that he believed, after

consulting Amtrak police officers, that inaccurate information regarding fatalities may

have arisen because of confusion over terminology. He thought that someone on scene

may have referred to the 13 on-board service crewmembers who were asleep in the

dormitory car as “deadheads.”18 He also believed that this expression may have been

misinterpreted by someone unfamiliar with railroad terms as indicating 13 fatalities in the

dormitory car or 2 fatalities downstairs and 6 fatalities upstairs in the dormitory car.

Mohave County Sheriff’s Department Response

At 5:56 a.m., the Mohave County Sheriff’s Department received a 911 call from a

local resident reporting a train derailment. Three officers who were already in the

immediate area (searching for people who were reportedly stranded because of the flash

flooding) were dispatched to the scene and arrived at 6:05 a.m. They helped the Kingman

 18 “Deadhead” is a term used by railroad employees to identify off-duty railroad employees who are

either going to or from work and traveling on the train.
Factual Information 33

Fire Department and emergency services personnel transport passengers and crew to

triage areas, searched for train occupants, and secured the scene. They reported that no

“life threatening” injuries were noted. Later, a Mohave County Sheriff’s Department

lieutenant arrived on scene and assumed the duties of Incident Commander. The Incident

Commander’s responsibilities were to coordinate the activities of the various responding

fire departments (eight fire departments) and medical personnel (six organizations,

including the Kingman Regional Hospital). The Incident Commander stated that he

requested a passenger manifest from an unidentified Amtrak employee but did not receive

one. He stated that Amtrak did not provide a complete passenger manifest. It took several

days for Amtrak to provide an accurate passenger count of the entire train.

Fire Departments’ and Other Groups’ Responses

At 6:06 a.m., the Kingman Fire Department responded to a request from the

Mohave County Sheriff’s Department for a medical response to the derailment. About

6:15 a.m., a paramedic unit, a rescue unit, and a 4x4 brush engine arrived. A rescue unit

from the Hualapai Fire Department was already on scene. At 6:17 a.m., the Kingman Fire

Department requested mutual aid assistance from the Valley Vista, Golden Valley, and

Pinion Pines fire departments. An unidentified Amtrak employee told the captain of the

Hualapai Fire Department that over 300 passengers and crew were on board train 4.

By 6:20 a.m., the first of three Arizona Department of Public Safety helicopters

arrived on scene. Two military helicopters from Nellis Air Force Base arrived on scene

later with a flight surgeon and medical crew. At 6:30 a.m., a medical command post was

set up next to the treatment and triage area. About 6:50 a.m., the city of Kingman

activated its emergency operations plan to provide a shelter and staffing. School buses

were used to transport people with minor to moderate (or no) injuries to a local hospital

and the Kingman Junior High School, which was used as a shelter.

Emergency responders placed injured passengers from the top level of the cars

onto backboards and extricated them through the cars’ emergency windows. Ladders

from fire trucks were used to provide stable platforms for lowering people onto the

ground. By 8 a.m., about 230 people had been transported from the scene. BNSF

personnel, EMS personnel, and some passengers helped throughout the response. No

fatalities were reported by the EMS personnel. Shortly after 9 a.m., the last person was

transported from the scene.

At 11 a.m., the scene was cleared after the Kingman fire chief determined that no

further fire or medical treatment issues were evident. During the emergency response, a

total of 19 paramedics, 44 emergency medical technicians, 11 ambulances, 6 air units,

and 6 school buses responded.

Hospitals

About 6:15 a.m., the Kingman Regional Medical Center was notified by the

Mohave County Sheriff’s Department dispatcher of the derailment and told that it
Factual Information 34

involved about 300 people. The hospital activated its emergency plan, calling nurses and

emergency room personnel to report to the hospital. Nurses, assisted by the Red Cross

and volunteers, and supplies were sent to the Kingman Junior High School to help those

who had completed triage.

By 6:56 a.m., the injured people began arriving at the hospital by helicopters,

ambulances, and buses. Over 100 people were treated. The last person was admitted to

the hospital at 11 a.m. Thirty-four injured people were transported to Bullhead

Community Hospital, Las Vegas University Medical Center, Flagstaff Regional Medical

Center, John C. Lincoln Hospital North Mountain, and Las Vegas Valley Hospital.

Emergency Preparedness

Upon notification of the accident, the Kingman Regional Medical Center

implemented its emergency plan, which had been created in December 1987 and last

revised in June 1996. The plan is designed to provide rapid and effective emergency

services in the event of a disaster internal or external to the facility. Medical staff

members are to work with local police, fire, and ambulance services during an

emergency. No problems were reported with the operation of the plan. Additional staff

was called, and preparations were made for transfer of patients as necessary.

The Mohave County Emergency Management Agency implemented its

Emergency Operations Plan, which had last been updated on May 28, 1997. The plan

detailed the responsibilities of responding agencies and listed the telephone numbers of

agencies such as the Association of American Railroads and the ATSF. It did not include

telephone numbers for Amtrak or the BNSF.

Before the accident, on November 15, 1996, a joint full-scale exercise was held by

Clark County, Nevada, and Mohave County, Arizona. Since the accident, three drills have

been held (a tabletop exercise on September 30, 1997, for the Hoover, Davis, and Parker

Dams to evaluate the operational readiness of the program; a full-scale exercise on

November 11, 1997, involving hazardous materials transportation; and another tabletop

exercise on December 3, 1997, assuming a Statewide flood affecting Mohave County,

Kingman, Lake Havasu, and Bullhead City).

On August 12, 1997, the Mohave County Emergency Management Agency held a

postaccident critique. The critique was attended by the Arizona Department of

Transportation, the Red Cross, the Arizona Department of Public Services, and the

participating fire and law enforcement departments. During the critique, several agencies

noted the need to improve communications. Poor weather conditions reportedly affected

the operation of portable radios used by Mohave County Sheriff’s Department deputies.

Also, because the primary radio frequency was used, it was difficult to hear other

emergency traffic in the city. The Mohave County Emergency Management Coordinator

planned to meet with county officials to improve the county’s communications system

and to add the telephone numbers of the emergency service coordinators from Amtrak
Factual Information 35

and the BNSF to its plan. Amtrak and the BNSF were not invited to participate in the

critique.

Amtrak Passenger Train Emergency Response Training

On April 29, and 30, and May 1, 1997, a Festival of the Emergency Arts was held

at the Lake Havasu City Convention Center in Glendale, Arizona. At this festival,

Amtrak’s manager of Emergency Preparedness addressed emergency responders about

considerations that might affect emergency response procedures involving Amtrak train

emergencies, such as:

Railroad operations, equipment familiarization, passenger car

construction, railroad right-of-way safety precautions, passenger

evacuation, forcible entry, locomotive propulsion systems, train crew

orientations, electrical and pneumatic hazards, on-board emergency

equipment, use of emergency exit doors and windows, hazardous

materials, tunnels and bridges, grade crossing accidents, search and rescue,

fire suppression, derailments, and other types of incidents.

Although Kingman fire and rescue personnel were invited by a State

representative, the festival attendance sheet did not indicate that anyone from Kingman

had attended this training. No evidence was found of the Mohave County Sheriff’s

Department being invited to or attending the festival.

Fire

There was no postaccident fire.

Survival Aspects

When the accident took place, the engineer and assistant engineer were in the lead

locomotive. They stated that, upon traversing the bridge, they saw a “hump” in the track.

When the derailment occurred, they were thrown upward and back down and around

inside the cab before the engineer could hit the emergency button. The assistant engineer

broadcast “emergency” over the train radio and called the dispatcher, telling him to stop

any trains in the area and to call emergency responders. The engineer and assistant

engineer said they remained inside the locomotive cab and did not help during the

evacuation because the locomotives came to a stop about 1 mile away from the

evacuation site.

The conductor and an assistant conductor were in the diner car (8th car).

According to passenger statements, when the train went into emergency, the lights went

out and the emergency lights came on in some cars. The train began to “jerk,” causing the

conductor to grab the table in front of him as the train came to a stop. The assistant
Factual Information 36

conductor fell underneath a table. The conductor attempted to go out the forward door,

but it was jammed. The conductor, chef, and assistant conductor went into the galley to

open a window, then they tried to open the door using a crowbar. After opening the door,

the conductor used his radio to call the engineer to ascertain the condition of the train.

The conductor stated that he then assessed the condition of the train. At this time, he saw

other train crewmembers inside the train; they had light sticks and were trying to open

jammed doors.

Another assistant conductor, who was in the dormitory car (2nd car), stated that he

tumbled and bounced around inside the car. He joined the conductor and other train

crewmembers who were walking along the train, opening jammed doors and distributing

light sticks to passengers because the emergency lighting was not working in several cars.

A sledgehammer was used to open jammed doors. The conductor instructed

passengers to stay inside the train to avoid further injuries. The conductor asked some boy

scouts on board the train to pass out light sticks and help open doors and windows. The

conductor instructed train attendants to search the cars for injured passengers. The

assistant conductor told the conductor that the sleeping car (10th car) was on the collapsed

bridge; they began evacuating that car first. The conductor stated that he did not try to use

the public address system because he did not think it was working.

A sheriff’s deputy who was in the area heard noise of the derailment and was the

first responder to arrive on scene. The conductor told him that about 300 people were on

board the train and asked him to call for EMS and to provide portable lighting. The

conductor stated he had no idea how many persons were injured or if there were any

fatalities. The conductor did not have the passenger manifest with him. Subsequently,

after walking through the train, the conductor determined that there were no fatalities.

The on-board service personnel were either asleep in the dormitory car or had just

awoken to begin their normal work assignments. Several sleeping crewmembers stated

that they were awakened by the action of the derailing train and were injured in the

derailment. Those who were not injured or who were in cars other than the dormitory car

assisted in the evacuation of passengers.

One train attendant, who was in a sleeping car (10th car), reported that she went

downstairs to the vestibule area and noticed that the car had come to rest on the bridge.

She saw and heard water on both sides of the car and immediately decided to evacuate it

because she did not know whether the car would remain stable. She went upstairs and

began to evacuate the sleeping car but realized it would be difficult because of its angle.

She told passengers to stay calm. She informed them that a derailment had occurred. She

checked each room to make sure no one was dead or needed help. She told passengers to

put on their shoes, leave their luggage behind, and follow her downstairs. The lower

vestibule door was opened and passengers began leaving. She led the passengers away

from the train.
Factual Information 37

The train attendant had attended Amtrak’s P.R.E.P.A.R.E.19 training course in

1996 and told investigators that this training had taught her when to evacuate, how to

triage, how to set up a command post, and how to assist emergency personnel and injured

people. She said the training had made her “more knowledgeable, prepared, and focused

on what needed to be done.” She said that she thought that all crewmembers should take

the course at least every 2 years for refresher purposes.

The chief of on-board services said that he made sure that the train attendants in

the dormitory car were all right; he then proceeded to assist passengers. He said that he

gave a copy of the passenger manifest, which contained the number of passengers in the

sleeping cars, to a firefighter.

On September 17, 1997, the Safety Board mailed 210 surveys to the passengers of

Amtrak train 4; the Board received 41 responses by November 7, 1997. The survey

generally asked individuals to provide information such as the car they had been in, their

seat location, and their observations about the events that occurred before, during, and

after the accident. In addition, investigators interviewed nine patients in the Kingman

Regional Medical Center following the accident.

Crashworthiness

Locomotives and Fuel Tanks

The locomotive of train 4 was made of four P-42-8DC diesel electric units,

manufactured by GE.20 The units were less than 8 months old. The first three units were

positioned with the operator’s cab facing east (forward), and the fourth unit was

positioned with the operator’s cab facing west (to the back). Only the first unit, ATK 47,

was occupied. A description of the condition of each unit is provided below.

ATK 47, ATK 50, and ATK 80. These were the first three units of the four-unit

locomotive consist. These units uncoupled and separated from each other after crossing

the bridge. The lead unit, ATK 47, was occupied by an engineer and an assistant engineer.

An inspection of the operator’s cab compartment indicated no visible interior damage.

A visual inspection of the car bodies of these units made after the accident

indicated a slight localized exterior side sheet panel (wrinkle) distortion, both on the left

and right sides, in areas above the truck assemblies, as well as at the mid-section of the

car body (of the third unit only). The distortion became slightly more progressive from

the first to third units. No fuel leakage was apparent from these units.

 19 P.R.E.P.A.R.E. stands for “Passenger Railroad Emergency Preparedness And Response Education.”

20 General Electric/Transportation Systems Division, Erie, PA.
Factual Information 38

ATK 52. ATK 52 was the fourth unit of the four-unit locomotive consist. In its

passage over the bridge, this unit uncoupled from the 3rd unit but remained coupled to the

baggage car. A postaccident visual inspection indicated localized left and right exterior

side sheet panel (wrinkle) distortion in areas above the truck assemblies, as well as at the

mid-section of the car body. The forward end sill, beneath the sloping fascia panel under

the windshield, was deformed inward and wedged against the baggage car (ATK 1425).

Inspection of the operator’s cab indicated only minor damage. The locomotive frame

showed some structural damage.

A prerecovery visual examination of the underframe panels proximate to the

2,100-gallon fuel tank compartment indicated that only a small amount of diesel fuel had

leaked. The sight gauge (sight-port) of the fuel tank indicated that the tank was above

one-half, but less than three-quarters, full during the prerecovery inspection. Amtrak

estimated that the remaining fuel in the fuel tank totaled about 1,400 gallons. About 12

and 24 inches of clearance space were observed, respectively, between the ballast surface

and underframe of the locomotive, on the left and right underside surfaces of the unit.

Additional damage was sustained to this unit when an 82-foot-long piece of rail

that dislodged from the track structure during the derailment became embedded in the

unit. The rail had penetrated at the rear of the unit (which was its leading end) and

extended its entire length. The opposite end of the rail was found to be cantilevered into

the interior of the trailing baggage car. The rail segment passed through the fuel tank,

puncturing at least one interior baffle. A portion of rail was visible at the right-side fuel

filler pipe opening. (See figure 10.)

Passenger Cars and Emergency Lighting

The inspection of the passenger cars indicated that none had experienced any

significant breach of the car body, with most of the damage focused on the car body endstructure areas. An on-scene inspection of the passenger car equipment was conducted by

the members of the Safety Board’s Crashworthiness Group, with the results documented

on the carrier’s equipment inventory forms.

The emergency lighting system in each car is powered by a series of wet cell

storage batteries, which are secured in a utility rack located in an interior compartment

that is accessed from the exterior of each car. Inspectors found the electrical systems of

most cars at minimum or no power. The electrical systems were disabled because of

extensive undercarriage damage, resulting from severed wiring and related electrical

conduits located on the car undercarriage.

Postaccident inspection of the train seats found that the rotating locking devices or

mechanisms were not engaged on 18 seat assemblies. No seat assemblies were found

separated from their floor mountings.
Factual Information 39

Tests and Research

Locomotive Event Recorders

All four locomotive units were equipped with GE Integrated Function Computer

(IFC) event recorders, which were successfully downloaded on scene to PCMCIA21

memory cards.

The data from the lead locomotive (ATK 47) indicate that the train was traveling

approximately 89 to 90 mph, with the throttle in position 3 (with a change to 4 and

then 1), when the brake pipe pressure decreased from approximately 110 to 0 psi, and the

emergency parameter changed from NONE to TLEM. Within the next 2 seconds, the

pneumatic control switch (PCS)22 parameter changed from CLOSED to OPEN. Between

2 and 4 seconds after the PCS OPEN indication, the position of the air brake handle

changed from RELEASED to EMERGENCY, and the EIE parameter changed from OFF

to ON.

 21 PCMCIA refers to the Personal Computer Memory Card Industry Association. Although the memory

cards are often referred to as “PCMCIA cards,” the correct terminology is “PC cards.” The PCMCIA

defines and publishes the PC card standard.

22 The PCS automatically retards the throttle to the IDLE position when a rapid reduction in automatic

brake pipe pressure occurs.

Figure 10. Visible rail segment
Factual Information 40

Although the recorder is equipped to record end-of-train (EOT) device data, no

EOT device was installed on the accident train.

Recorded and Played Back Parameters. The GE recorder stores the recorded

data in a Permanent Core Memory (PCM) module, manufactured by Pulse Electronics,

Inc. The number and type of parameters that are recorded are determined by GE as well as

the individual railroad. GE provides a standard minimum list of parameters (which are

always recorded, for all railroads), and the particular railroad may choose to add other

parameters to that list. All the parameters in both the GE list and the customer optional

list (if one exists) are “recorded”; however, they are not necessarily “played back” when

the data are read out.

To view the recorded data, two basic but separate steps must be taken. First, all

the recorded data in the memory module are downloaded to a laptop computer file, or a

file on a PCMCIA memory card. Second, the downloaded file must be read out or played

back. The downloaded file is read out using an analysis program designed and written by

Pulse Electronics, according to the railroad’s specifications. The program is designed to

play back only those parameters specifically chosen by the individual railroad. The

Amtrak GE IFC analysis program did not extract all the available parameters because the

program was written to meet an older GE data format specification, which was not the

specification for the recorders installed on the accident locomotives.

Readout. The on-scene readout was performed using the Pulse Electronics GE

IFC Data Analysis Software program PPN 17502 v3.2.23 This program version did not

reveal any data related to emergency brake application(s), other than the PCS and brake

pipe pressure parameters.

These two parameters are sufficient to indicate whether an emergency brake

application was made; they cannot be used to determine whether the crew initiated the

emergency brake application. Subsequent to the on-scene portion of the investigation,

Amtrak informed the Safety Board that the type of emergency (“Emergency” parameter)

actually was recorded; a different type of readout software was needed to extract it.

After the Safety Board consulted the recorder manufacturer, it was determined

that six other parameters were actually recorded but not extracted by the Amtrak IFC

analysis program. These were: emergency type, EOT emergency (on or off), bell, brake

handle position, EIE (on or off), and dynamic brake derate (on or off).

Because these parameters could not be extracted from the recorded data using the

Amtrak analysis program, another analysis program had to be used to attempt to retrieve

this data. A program that is intended for use with BNSF data was used in this case (Pulse

Electronics Data Analysis Software program PPN 17463 v2.1). This program was used to

print tabular data for ATK 47 for the last 2 miles of recorded data. Because this program

 23 This is the latest Amtrak IFC analysis and readout program.
Factual Information 41

was designed for use with BNSF and not Amtrak recorders, none of the Amtrak optional

parameters could be recovered.

Signal Event Recorders

Signal event recorders are located at Griffith, CP 526.8, and at automatic signals

5052 and 5051 for eastward and westward trains, respectively. The signal event recorder

monitoring the position of signals, switches, and track occupancy at CP 526.8 indicated

that Amtrak train 4 had passed CP 526.8 at 5:24 a.m. The event recorder at eastbound

automatic signal 5052, the last signal Amtrak train 4 passed before derailing, recorded a

time of 5:56 a.m. The last train that passed signal 5052 before the derailment was

recorded at 3:36 a.m. The event recorder at westbound automatic signal 5051 indicated

trains passing at 4:15 and 5:34 a.m. on the north track.

Equipment Detectors

Track-side FEDs are located at MP 512.5 for both tracks; each FED consists of a

“hot box”24 and a dragging equipment detector that use radio communications. Amtrak

train 4 was recorded as it passed the hot box detector on the south track at MP 512.5 at

5:49 a.m., operating at 89 mph. The printout indicated 80 axles (4 locomotives and 16

cars) with a recorded length of 1,474 feet. No defects were detected.

High Water Detector

Bridge 504.1, where Amtrak train 4 derailed, had no HWD; however, an HWD

was located at bridge 505.9, which was linked to signals 5051 and 5082. (See figure 11,

which shows the HWD location.) When the HWD is activated, it causes the signals at

5051 and 5082 to display a RED aspect, which, according to BNSF operating rules,

requires the engineer to stop the train and proceed at restricted speed to the next signal.

The HWD must then be manually reset before the signals will display any other aspect.

The HWD at bridge 505.9 did not activate during the storm preceding the derailment

because the flow of water was not high enough to contact the HWD. The HWD is

mounted under the south bridge, approximately 18 inches below the bottom of the bridge

deck, or about 5 feet above the streambed. (See figure 12 for a closeup view of the

HWD.)

On August 9, 1997, the HWD at bridge 505.9 was tested by submerging it in

water. This de-energized the ZR relay that shunted or shorted the track circuit in approach

to the danger of high water. Signal 5082 displayed a RED aspect for eastbound

movements on the south track, and signal 5051 displayed a RED aspect for westbound

trains on the north track.

 24 Railroad jargon for an overheated bearing.
Factual Information 42

Figure 11. HWD on bridge 505.9

Figure 12. Closeup view of HWD
Factual Information 43

Bridges are not required to have HWDs. The BNSF does not have specific

requirements for installing an HWD. According to the BNSF, an HWD was usually

installed, with the concurrence of division level officers, at specific bridges when local

maintenance personnel were aware of previous history of high water at that location. The

BNSF informed the Safety Board that some superintendents preferred installing HWDs,

while others did not. According to the BNSF, HWDs were installed before weather

forecasting services were used.

Amtrak Locomotive Couplers

After the accident, the first three of the four locomotive units were found uncoupled

and separated from the train and dispersed up to a mile away from the point of derailment.

The front couplers on the second and third units had opened, allowing the preceding

locomotive units to separate. The abutted rear-end couplers between the third and fourth

units also had uncoupled. Each of the four GE P42-8DC locomotive units involved in the

accident was equipped with an F8306E coupler and an F514E knuckle. The couplers had

been manufactured by National Castings, Inc. They were F-type couplers made of E-grade

steel. F-type couplers interlock to prevent vertical separation by means of a tang or metal

horn on the opposite side of the knuckle, which fits into a pocket of a mate F coupler next to

the knuckle. These F couplers also had a bottom shelf to prevent a coupler from falling

between the rails and derailing a train in the event of a drawbar separation; the shelf would

hold the detached coupler in place.

Stopping Distance

At the request of the Safety Board, Amtrak calculated train 4’s stopping distance

with an emergency brake application on level, straight track with clean, dry rail from an

initial speed of 88 mph and with the variance of one to four locomotive units in the train.

For each locomotive unit consist, the calculation of the stopping distance reflects three

different modes of braking: friction (no blended/dynamic), friction with dynamic, and no

brake effort from the locomotives. The results of these tests are shown in table 5.

Table 5. Calculated braking distances for an emergency brake application with 1 to 4

locomotive units and 16 cars

Locomotive

Type

Units Total Weight

(pounds)

Train Braking Distances (feet)

Add

2,469,200

for 10 pass

and 6 MHC

Friction

Only

Blended No

Locomotive

Brake

P42-8DC 4 1,072,000 3,862 3,431 4,686

P42-8DC 3 804,000 3,705 3,365 4,306

P42-8DC 2 536,000 3,603 3,363 3,991

P42-8DC 1 268,000 3,488 3,362 3,675
Factual Information 44

Geotechnical Investigation

The Safety Board requested geotechnical and drainage area information for bridge

504.1. The BNSF contracted with HDR Engineering, Inc.,25 to develop such information.

The BNSF consultant’s work included a site reconnaissance, surface exploration, and

laboratory testing of soils from the site. Following its analysis, HDR Engineering stated

in its report26 that “Scour and undermining of shallow foundations with a loss of bearing

support and settlement was the most probable cause of the bridge failure.”

The consultant’s report also stated that “Transient subsurface groundwater and

moisture conditions ... and the vibration caused by the train passage could have possibly

liquefied or greatly reduced the shear strength of the foundation soils and caused

additional settlement under load.” The HDR Engineering report concluded that the

probability of this second failure mode was small.

HDR Engineering also performed a hydrology study to determine the drainage

basin of bridge 504.1. The study included the hydrologic and hydraulic conditions

associated with the accident bridge and other adjacent BNSF bridges. These included the

bridges numbered 503.1, 503.7, 504.1 (the accident bridge), 505.6, and 505.9. All these

bridges are located within interconnected drainage basins along the north side of the

railroad grade fill.

The bridges on the north and south tracks are of similar construction to bridges

504.1N and 504.1S, respectively. (That is, the north track bridges are timber-pilesupported and the south track bridges are on shallow foundations or mud sills.) In

addition, bridges 503.1 and 503.7 each have a concrete crosswall immediately

downstream, as did bridge 504.1.

The HDR Engineering study showed that bridge 504.1 had a 19.5-square-mile

drainage area basin within the Peacock Mountain range to a broad smooth valley

(Hualapai Valley), drained by a major wash referred to as the Hualapai Wash. Flood

flows would carry long distances overland before collecting into the washes. The

watercourse for bridge 504.1 sloped at 207 feet per mile.

With respect to scour, the study found the soils within the area highly erosive and

unstable, with flow velocities approaching 3 fps. Scour at the accident site varied

depending on its location within the basin. Graded roadways above the bridge area

provided for collection and concentration of flow. The flow at the bridge is fully

concentrated, which greatly increases the stream power potential and results in scour hole

formation. The depth was unknown because of sedimentation filling the holes on the

 25 HDR, Inc., offers a broad range of architectural and engineering services. The company employs

more than 1,800 engineers, architects, scientists, and support personnel worldwide and is based in Omaha,

Nebraska. Its subsidiary company, HDR Engineering, Inc., provides water/wastewater, transportation, and

waste/energy services.

26 HDR Engineering, Inc., under contract with the BNSF, produced an engineering report entitled

“System Analysis Seligman Subdivision Bridge No’s. 503.1-505.9.”
Factual Information 45

recession side of the flood. At all structures studied, the study found that the potential for

scour depths sufficient to undermine shallow footings is great. HDR Engineering

considered that structures supported on deep piles (such as 60-foot depths at bridge

504.1N) should be adequate.

The HDR Engineering study stated that the highway box culvert downstream from

railroad bridge 504.1 was undercapacity to carry the 50- and 100-year floods but more

than adequate to handle the 10-year flood. It further noted that the washes draining

bridges 503.1, 504.1, and 505.9 were eroded below the Route 66 structures. The channel

bed immediately downstream from these highway structures had degraded from 3 feet to

over 10 feet. The study also stated that these highway structures have the potential of

being washed out with the next major flood event. The study stated that:

At this time, based on the bed degradation which has developed below all

five of the downstream highway 66 bridge structures, the highway

structures have the potential of being washed out with the next major flood

event, with the potential for the resultant headcut (of a potential magnitude

of 5 feet) proceeding through the railway bridges (Br. 503.1, 504.1, and

505.9).

The HDR Engineering report recommended installing a replacement structure for

bridge 504.1 that would have longer spans of concrete slabs to provide a reduced risk of

debris collection at the bridge, an increased waterway opening area for reduced stream

velocities, and 60-foot piling to protect against scouring relative to the former shallow

footings.

Postaccident Actions

The BNSF

The BNSF replaced the two existing bridges at MP 504.1 with two separate

ballasted deck structures, consisting of three 20-foot concrete slabs on steel H-pile bents

with concrete caps and a concrete spreader at the ground line. The BNSF informed the

Safety Board that the new structure provides a waterway opening of about 503 square feet

with a capacity of 5,540 cubic fps. The BNSF further stated that the bridge is theoretically

capable of handling runoff from a 40-year storm event. According to the BNSF, with the

adjacent structures’ runoff capacity, a storm event of the 100-year-storm category could

be handled. In addition, the downstream side of the stream channel has been widened.

The BNSF engineering department is conducting systemwide training classes for

its track and bridge inspection personnel, signal employees, and maintenance-of-way

supervisors on how to recognize and report scouring around bridges and culverts. During

this training, the employees are provided information to allow them to make reasonable

judgments on the condition of the bridge or culvert and encouraged to call the bridge
Factual Information 46

inspector for final evaluation. Numerous pictures are shown during the training, including

those representing this accident. Since the accident, the BNSF has identified all its

bridges with similar supporting foundation structures for special inspection attention.

The track supervisor involved in the inspection of the bridge in this accident

stated, regarding his attendance at a class, that it:

...made us aware of what that entails, what—they made us aware of the

profile of downstream activity under any bridge, culvert, streambed or all

that business, which I had prior—before the incident no—no knowledge

of. The bridges with mud sill foundation or shallow foundation have been

clearly marked on my territory so that I would be able to identify their

location in any inclement weather or darkness. If I would observe water

bank to bank at any depth in these locations trains are going to stop, and

would not be allowed to proceed until [a] competent bridge inspector has

made a determination that the mud sill bridge, which is a sound structure

in itself if protected properly, is okay, and that sums that up pretty good.

On March 2, 1998, the BNSF informed the Safety Board of a revision to the

Maintenance Alert it issued following the accident at Kingman. This revised Maintenance

Alert was the result of severe storm-related conditions and traffic delays on BNSF’s

Northern California Division through the San Joaquin Valley. The revision states that

when a flash flood warning has been issued for an area by the BNSF NOC, passenger

trains are limited to 50 mph and freight trains are limited to 40 mph with the following

exception—if the limits of the designated area include bridges having been identified as

vulnerable to scour, all passenger trains and “key”27 freight trains are limited to restricted

speed—the same as the initial Maintenance Alert.28 (See appendix C.)

The FRA

On September 4, 1997, the FRA issued Safety Advisory 97-129 recommending

that railroads take certain actions to reduce the risk of train derailments that could result

from severe weather conditions, particularly undetected flash floods. (The advisory is not

regulatory but a recommended action.) The FRA determined that each railroad controlling

train operations on Class 4 or higher track, or passenger trains in commuter or intercity

service, should have programs and procedures in place to protect train operations during

severe weather, and particularly flash flooding, by the means cited below:

1. The railroad should have in place a procedure that will assure that all

notifications issued by the NWS of flash flood warnings will be received

within 15 minutes of issuance from the NWS, directly or through a contract

 27 The BNSF has defined “key” freight trains as those carrying hazardous materials.

28 The BNSF has identified 14 bridges on the Northern California Division as being vulnerable to

scour because their foundations do not have piling.

29 SA 97-1; 62 FR 46793.
Factual Information 47

weather forecasting service, by the train dispatchers or other employees

controlling the movement of trains on all track of Class 4 or higher or upon

which passenger trains operate in commuter or intercity service, within the

warning area. In the case of such track located outside of the warning area

but subject to damage from water resulting from the storm, the information

should be obtained in time to permit timely response by the railroad.

2. After the receipt of a warning of a flash flood which might damage track or

bridges, the railroad should notify train crews and limit the speed of all

freight and passenger trains to that which will permit the train to operate

safely, consistent with the potential water levels and visibility conditions,

on all track subject to damage from the flood. The limitations should

continue until a special inspection in accordance with 49 CFR 213.239 has

been performed of that track and it is determined that a hazard no longer

exists. In making that inspection and determination, the time taken for the

heaviest flow of water to reach the track should be considered.

3. Each railroad affected by this advisory should identify its bridges carrying

track of Class 4 or higher or over which passenger trains operate in

commuter or intercity service, which are vulnerable to damage from flash

floods or similar weather-related phenomena. Particular attention should be

given to bridges which incorporate piers, bents, or abutments, which are

founded on soil or degradable rock which could lose its integrity as a result

of scour by moving water, and which are commonly referred to as “mud

sills'” or “spread footings.”

4. The information developed in paragraph 3 should be compiled and made

available to each person who can be called upon to perform special

inspections on the subject track following a flash flood warning.

Consideration should be given to placing identifying marks on bridges that

need particular attention in special inspections, along with the bridge

number, to assist inspectors in locating them with certainty during

inclement weather. Consideration should also be given to the use of

automated high water detectors or similar sensing and warning systems on

specific bridges which could incur water damage that would be hidden from

or not otherwise detectible by a human inspector.

5. In addition to the bridge-specific information called for in paragraph 3, each

affected railroad should implement a training program for the persons

performing special inspections. The training should include methods to

recognize and protect the safety of railroad operations from the damaging

characteristics of flowing water in general, with particular regard to the

effects of a watercourse that takes a significant change in horizontal

direction or vertical profile near the track; the effects of drift material

accumulation on scour and the capacity of the waterway opening; and the

potential for damage by impact of heavy floating objects.
Factual Information 48

6. Refresher training of track inspectors on the subjects addressed in

paragraph 5 should be conducted at least once each calendar year. Where

practicable, that refresher training should include a joint inspection by a

track inspector and a cognizant bridge maintenance or engineering

employee over the inspector's assigned territory. During that joint

inspection they should locate the vulnerable components in the bridges

identified in paragraph 3, discuss the precautions to be taken in the event of

indications of distress in those components, observe drainage conditions on

and adjacent to the right-of-way, and note changes for inclusion in the

revisions of information called for in paragraph 9.

7. If a track inspector is assigned to perform a special inspection in accordance

with paragraph 2, and bridges identified as vulnerable are in the track

segment subject to damage from the flash flood, a cognizant bridge

maintenance or engineering employee should be readily available by

telephone or radio to assist in the interpretation of findings by the track

inspector.

8. Each affected railroad should brief all of its track and bridge inspectors on

the contents of this advisory. These briefings should occur within 14

calendar days of the date of publication of this safety advisory in the

Federal Register.

9. FRA believes that the actions described in paragraphs 3, 4, and 5 should be

completed within 60 calendar days of the date of publication of this safety

advisory in the Federal Register. During this period, each affected railroad

should complete an initial review of its bridges for vulnerability to high or

rapidly flowing water and provide that information to its inspectors. More

detailed reviews should be substantially completed and provided to

inspectors during calendar year 1998 and then maintained in a current

status.

10. FRA requests a letter within 45 calendar days of the date of publication of

this safety advisory in the Federal Register from each affected railroad

specifying the actions it has taken and will initiate to enhance the safety of

train operations in the event of a flood or a high or rapid water condition.

On November 14, 1997, the FRA issued an amendment to Safety Advisory 97-1

that permits the use of other competent commercial weather services that receive and

review warnings and weather data from the NWS as part of its procedures.

The FRA Track Safety Standards (49 CFR part 213) state, “In the event of fire,

flood, severe storm, or other occurrence which might have damaged track structure, a

special inspection must be made of the track involved as soon as possible after the

occurrence.” The advisory states that the FRA purposely made the provision general in

nature, because “It is not practicable to specify in a minimum safety standard all the

conditions which could trigger a special inspection, nor the manner in which any
Factual Information 49

particular special inspection must be conducted.” The FRA considers that, “It is more

effective to provide information and guidance to the railroad industry, which each

railroad can then adapt to its own circumstances.”

Arizona Department of Transportation

On August 12, 1997, the Arizona Department of Transportation (ADOT)

inspected the box culvert immediately downstream from BNSF bridge 504.1. ADOT

informed the Safety Board that it routinely inspects structures after major flash flood

events. The remarks and recommendations section of the ADOT inspection form for that

inspection included the following: “There were no significant culvert problems caused by

the recent flow; recommend replace minor eroded fill behind the outlet wings.”

According to 23 CFR 650.301, a structure is considered a bridge if the opening

measures 20 feet or more along the roadway centerline. ADOT inspection reports

indicated that the box culvert immediately downstream from BNSF bridge 504.1 is

32 feet long along the centerline of the roadway. As a result, the bridge (box culvert) is on

the Federal Highway Administration’s inventory and is subject to inspection every 4

years,30 in accordance with Arizona’s box culvert inspection plan. The box culvert’s last

scheduled inspection before the accident had taken place on February 26, 1997. With

respect to the waterway opening, the ADOT inspection report for this inspection stated

(in part): “3) channel openings 100 percent both ends, has 1.8 feet scour at outlet; ok,

High water mark: 1 foot below ceiling near inlet.” The report did not indicate how

recently the high water mark had been made.

According to ADOT, an inspection of a scour-critical bridge includes a

measurement of evidence of scour and scour calculations. ADOT considers a box culvert,

because of the nature of the structure’s design, to be a low-risk or scour-stable structure.

Other Information

Amtrak’s Proposed Procedures for Passenger Manifests

Amtrak’s general manager for Operations, Standards, and Compliance told the

Safety Board that Amtrak has a contract with a service to provide a satellite-based

communications system. The system is about 75-percent installed. It consists of a satellite

communications unit in the body of the train that can permit portable two-way

communications between the train and Amtrak’s national operations center.31 The

locomotive would have a laptop-type computer, and the conductors would be able to

 30 From 1971 to 1995, all box culverts over 20 feet in length on the State Highway System were

inspected every 2 years. In 1995, the frequency interval was changed to every 4 years.

31 The Amtrak national operations center has been relocated from Philadelphia, Pennsylvania, to

Wilmington, Delaware.
Factual Information 50

communicate through the locomotive’s computer and antennae. This communications

system would be independent of the locomotive radio for communicating with the host

railroad’s train dispatcher for train operations.

According to Amtrak’s general manager for Operations, Standards, and

Compliance, Amtrak will next develop a method to use the system to account for

passengers on the train. This general manager stated that it is difficult to account for

passengers on unreserved trains because tickets can be bought one day and not used for

weeks, be given to someone else, or be used to board the train at other locations by paying

the difference in fare. Amtrak compares the unreserved trains to transit and commuter

systems, which passengers get on and off frequently.

He stated that Amtrak must be able to provide a manifest to account for

passengers on its reserved trains, despite the current practice of not requiring tickets for

infants and small children. Amtrak has tried issuing nonrevenue tickets to account for

such passengers but has found the process cumbersome and ineffective.

The general manager for Operations, Standards, and Compliance also stated that,

in past accidents and incidents, Amtrak personnel have had to search for the conductor’s

pouch to count the tickets to determine the number of people on the train. This general

manager has prepared a draft policy to change those procedures, and Amtrak has

established a working group to ensure that an official passenger count is provided to the

national operations center. The official count would include ticketed revenue passengers

and nonrevenue nonticketed passengers such as infants, Amtrak employees traveling on a

pass (regardless of travel status), employee dependents, and authorized employees of a

railroad over which tracks Amtrak is operating.

According to this general manager, Amtrak will use the satellite communications

system to put a form in the computer. Each train conductor will add to the form some

information about the number of people on board each train, and the information will be

sent to the national operations center and made immediately available to other Amtrak

personnel. He also stated that when the process has been tested satisfactorily, it will be

implemented on all reserved seat trains.

Amtrak train 4 was not equipped with the new communications equipment.

According to the conductor and one assistant conductor, at the time of this accident, they

were in the dining car working on tickets. The conductor said that he did not have time to

look at the manifest because it was in the dormitory car. He also stated that the manifest

contained the number of passengers in coach sections and a complete list of passengers in

the sleeping cars. The conductor said that the manifest should have been up to date except

for tickets taken at Kingman.

On March 24, 1998, Amtrak demonstrated its new satellite communications

system for Safety Board investigators. The system included an on-board mobile

communications terminal in the locomotive, a conductor’s portable unit, and a global

positioning system locator for the locomotive. The system demonstrated that Amtrak now

has the ability to communicate, independently of a host carrier, with its own trains
Factual Information 51

anywhere in the United States (with certain exceptions, such as tunnels). The system is

programmed to accommodate 19 preformatted messages for train status and direct

communications between the train and its national operations center. These

communications are also interactive between maintenance and customer service

personnel. The system depends on accurate input by the on-board service personnel and

on such personnel updating passenger information accurately. It has no remote printing

capability. Also, if the locomotive unit loses power, the on-board computer will not work.

Amtrak’s On-Board Service Personnel Emergency Situation Training

Amtrak provides emergency situation training to its personnel through

P.R.E.P.A.R.E. training, courses on assisting disabled passengers, and videotapes

illustrating emergency procedures. In this training, emergency procedures are discussed

while crewmembers are taught how to perform their duties, depending on their positions.

Employees are taught about the classes of fires, what to do in an emergency, options to

consider when deciding whether to evacuate a train, and how emergency personnel

classify injuries during a triage. A Critical Assistance and Response for Employees

program is also available to Amtrak employees.

The Amtrak Manual for On-board Services Employees, dated February 1, 1992,

Section A-4-6, details the procedures to be followed when responding to train

emergencies involving fires, assisting in evacuations from different types of train cars,

communicating using the public address system and intercom, and providing first aid for

different types of injuries. In addition, the manual instructs train attendants to:

... Ensure that all beds are properly made before boarding passengers. All

beds will be made with the head toward the reading light. [According to an

Amtrak representative, the beds are made with their ‘feet’ toward the

engine]. Rooms with beds parallel to aisle, with a reading light at both

ends of the bed will be made up to permit passengers to sleep with their

feet toward the engine.

Amtrak’s general manager for Operations, Standards, and Compliance stated that,

in an emergency, it is the conductor’s responsibility to ensure that the appropriate entities

are notified and to evaluate the scene to determine the type of evacuation procedures to be

followed. The conductor is also responsible for providing information and assistance to

emergency responders.

This general manager also stated that Amtrak engineers usually review emergency

procedures every 3 years, and the conductors review them every 2 years. On-board

service crewmembers are scheduled for emergency situation training every 3 years. He

further stated that employees who have been relocated recently may have missed

scheduled training and that Amtrak determines which employees need training in

emergency procedures by using the computer database for training records information.

Table 6 shows Amtrak’s recorded dates of the last emergency situation training taken by

its train crew and on-board service personnel involved in this accident.
Factual Information 52

Table 6. Emergency situation training record of train 4 personnel, as provided by Amtrak

The train 4 engineer did not indicate that he had received any emergency situation

training. The assistant engineer said that he had never been trained in handling a

derailment. He further stated that the crew just developed teamwork to help each other.

The conductor stated that he had received emergency training by watching a videotape

that demonstrated how to remove windows and open doors. One assistant conductor had

received training on how to flag oncoming trains and on notification procedures. The

other assistant conductor stated that he had seen videotapes on emergency procedures and

had participated in a course on how to evacuate passengers from tunnels. He said that

Amtrak crewmembers needed more hands-on training and that, “Films every 3 years or so

just doesn’t do it.”

An Amtrak train attendant who received P.R.E.P.A.R.E. training in 1996 stated

that the training afforded her the opportunity to be “more knowledgeable, prepared, and

focused on what needed to be done” when the Kingman derailment occurred. The

attendant recommended that all crewmembers take the training and have refresher courses

every 2 years. 

Train crewmember

position

Date of last emergency

situation training

Engineer

Assistant Engineer

Conductor 1993

Assistant Conductor 1

Assistant Conductor 2

Chief On-Board Service 6/3/97

Lead Service Attendant 1 6/10/93

Lead Service Attendant 2 2/7/90

Service Attendant 1 6/24/93

Service Attendant 2

Service Attendant 3

Train Attendant 1 3/14/96

Train Attendant 2 5/2/97

Train Attendant 3

Train Attendant 4 4/24/96

Chef 4/18/90

Food Service 1

Food Service 2 4/24/96
53

Analysis

General

The BNSF’s FRA-qualified track supervisor had last inspected the track through

the accident area on August 6, 1997, and did not note any defects. Neither the track

geometry car tests nor the ultrasonic rail inspection tests noted any deficiencies. In

addition, a postaccident inspection by investigators did not reveal any deficiencies from

the BNSF-designated FRA Class 5 track safety standards. The Safety Board therefore

concludes that the track did not cause or contribute to the accident. The signal system was

thoroughly tested after the accident and no anomalies were found. All inspection and test

reports were within the prescribed requirements of the FRA’s signal regulations. The

Safety Board concludes that the signal system was not a factor in the accident.

At the time of the accident, “Warning 0004,” issued by the BNSF contract

weather service, WDI, was in effect for the accident location. The warning called for flash

flooding, thunderstorms, and heavy rain. The Safety Board concludes that the weather

warnings and alerts issued by WDI were both timely and substantially correct.

A Safety Board review of Amtrak and FRA forms documenting the required

predeparture mechanical and air brake tests and inspections revealed that all tests and

inspections were performed as required and no defects were noted. Examination and

testing of the train equipment at the accident site did not reveal any preexisting condition

that may have caused or contributed to the accident. In addition, the operating crew did

not report any anomalies with the mechanical condition of the train before the accident.

Therefore, the Safety Board concludes that the mechanical condition of the train was not

a factor in the accident.

The engineer, assistant engineer, and conductors all were in good health, well

rested, and qualified on the operating rules and physical characteristics to operate

passenger trains over this territory. Because of the darkness and the speed at which the

train was traveling, the operating crew had only a few seconds to identify and respond to

(that is, apply the brakes) the anomaly noted in the track at the bridge. The crew applied

the brakes about the time the train crossed the bridge. The Safety Board concludes that

the health, rest, and qualifications of the train crew were not factors in the accident.

On the day of the accident, the track supervisor was in good health. Although he

had been awakened earlier than he had planned, no evidence indicates that fatigue

impaired his performance. He was adequately trained to perform track inspections over

his territory, and he responded in a timely manner to the instructions to inspect the track.

However, he had not received training specific to bridge inspections; consequently, he

was not qualified to conduct the necessary inspection of the bridge structures under these

circumstances. The Safety Board therefore concludes that, although the track supervisor
Analysis 54

conducted a track inspection over his territory during the flooding, he was not qualified to

conduct bridge inspections.

Under the FRA’s regulation at 49 CFR 219.201(b), toxicological testing was not

required to be performed in the case of this accident. The Safety Board found no evidence

to indicate that the circumstances of the accident were related to fatigue or impairment.

The Accident

About 5:56 a.m. on the day of the accident, both the engineer and assistant

engineer of Amtrak train 4 saw a “hump” in the track as they approached bridge 504.1S.

They applied the train’s emergency braking but did not have sufficient time or distance to

stop the train short of the “hump.” The train derailed, and the locomotive units separated

as the train was crossing the bridge. The train came to a stop with the last occupied

passenger car spanning the failed bridge. The ground under the bridge support structure

had been washed away, and the bridge was probably collapsing while the train was

passing over it.

After receiving severe weather alerts and flash flood warnings from WDI earlier

on the morning of the accident, the BNSF NOC had notified its maintenance-of-way

operations desk of the information that applied to the Kingman area. The BNSF NOC had

the responsibility to ensure the safety of its train operations through the Kingman area

through its train dispatchers. Train operation personnel rely on the maintenance-of-way

personnel to perform the appropriate inspections to provide the necessary level of safety

for continued train operations. (This is an expected function of maintenance-of-way

personnel and not unusual in the railroad industry during severe weather conditions.)

When an unsafe condition is found, the track inspector has the responsibility to notify the

train dispatcher so that the dispatcher can alert engineers of trains operating in the

affected area to stop their trains or coordinate their trains’ movements with the track

inspector, or both.

About 1:57 a.m. on the morning of the accident, the track supervisor was ordered

by the maintenance-of-way desk to perform a track inspection for his territory. He began

his track inspection about 4:05 a.m., stopping at several bridges before bridge 504.1

without noting anything unusual. However, at bridge 504.1, the accident bridge, he did

not stop but made his observations from his hy-rail vehicle. He later stated, “That’s the

first time that I saw that volume of water under that particular bridge... [the water was]

lapping against the bottom of the bridge.” He also stated, “I knew from experience that

what—that I was looking for anything out of the ordinary—and at the time the knowledge

that I had—I took no exception to anything I observed.” He did not report any problems

to the dispatcher and continued with his inspection.

The Safety Board identified several concerns as a result of its investigation. The

most important were the circumstances that precipitated the bridge failure, the adequacy

and method of the bridge inspection process, and the injuries to passengers of the Amtrak
Analysis 55

train. Because of these concerns, the investigation focused on safety issues identified in

the following areas: safety of structures subject to damage in severe storms, passenger

safety and emergency response procedures, and protection of employees on or adjacent to

the track in the performance of their duties.

Safety of Structures Subject to Damage in Severe Storms

Failure of Bridge 504.1S

The investigation examined the adequacy of the design, maintenance, inspection,

and drainage area characteristics of bridge 504.1S in light of the severe weather and flash

flood conditions affecting the bridge and the subsequent failure of the crosswall and the

bridge supporting structure.

The south bridge, 504.1S, was supported by a shallow foundation consisting of

timber mud sills and timber blocking. BNSF records showed that the bridge supports

were susceptible to scouring and erosion as early as 1959, when it was necessary to add

stones and grout to a portion of the streambed. In the succeeding years, additional stones

and grouting were added. Records also showed that, in 1975, maintenance personnel were

still concerned about the bridge supporting structure and its water-carrying capacity. In

fact, they remained so concerned that they recommended that the bridge be placed on the

CIP list for replacement.

BNSF bridge records identifying the size of the drainage area for bridge 504.1

were inconsistent. One record showed the drainage area as encompassing 3.8 square

miles, while another showed the drainage area as totaling 19.09 square miles. The size of

the drainage area is an important element in determining the required waterway opening

for drainage structures. After the accident, the BNSF’s consultant (HDR Engineering,

Inc.) determined that the drainage area for bridge 504.1 was 19.5 square miles. The

consultant’s report cited the accepted engineering practice of using the 100-year storm

criteria to provide for drainage structures but noted that local conditions and

circumstances, such as the desert nature of the Kingman area, allowed for making an

engineering judgment resulting in higher or lower values. According to the consultant’s

report, the bridges located at MP 504.1 at the time of the accident were capable of

withstanding a 24-year storm. The storm related to this accident was determined to have

been approaching a 50-year storm event of 2 hours’ duration. (The August 9, 1997,

storm’s effect differed among the five railroad bridges in the area. Bridge 504.1

experienced an approximate 50-year storm event, while bridge 503.7, for example,

experienced an approximate 10-year storm event.) The bridge with which the BNSF

replaced bridge 504.1 following the accident is capable of withstanding a 40-year storm.
Analysis 56

In 1975, ATSF (BNSF)32 management placed bridge 504.1 on the 1977 CIP

replacement program because the results of engineering studies raised concerns about the

bridge’s ability to provide an adequate waterway opening and about recurring erosion

problems. In early 1976, however, ATSF (BNSF) bridge maintenance personnel made a

field decision to build an unreinforced concrete crosswall on the downstream side of

bridge 504.1. Bridge 504.1 was subsequently removed from the 1977 replacement

program.

Only two instances of high water were recorded for bridge 504.1 and both took

place in 1976. This was after 1971 work affecting the box culverts downstream from the

BNSF bridges had been performed by the ADOT and after bridge 504.1 had been

removed from the CIP budget list. Before the 1997 derailment at bridge 504.1S, no

accidents involving high water or bridge failure were recorded for the Kingman area.

The purpose of the unreinforced concrete crosswall was to allow silt to back up

and accumulate around the mud sills, thus acting to mitigate further scouring and erosion.

However, no engineering evaluation was performed on the design and construction of the

unreinforced concrete crosswall to determine the necessary anchorage, the appropriate

size, the need for reinforcement, or the hydrologic characteristics of the waterway.

The severe flash flooding and resultant stream flow between bridge 504.1 and

Route 66 caused severe erosion that rapidly progressed upstream. The Safety Board

cannot determine whether channel improvements made in 1971 contributed to this

development, but evidence of streambed erosion was found during the on-site

investigation. This erosion progression caused the failure of the unreinforced concrete

crosswall because it was not anchored and was only 33 inches in depth. Because it was

unreinforced, the crosswall broke into several pieces when its shallow footing was

undermined.

When the concrete crosswall failed, the rate of erosion accelerated through the

accumulated silt to the point that it quickly progressed to the shallow foundation of the

bridge. This process undermined the bridge’s mud sills and timber blocking and

compromised the bridge’s ability to support Amtrak train 4. The Safety Board therefore

concludes that the failure of the bridge 504.1S was caused by scour and erosion affecting

the inadequately protected shallow foundations that supported the bridge; the scour

resulted because a poorly designed concrete crosswall was built instead of a new and

better-engineered bridge. (See figures 13 through 16.)

 32 At this time, the October 1, 1995, merger between the ATSF and the Burlington Northern Railroad

had not yet taken place.
Analysis 57

Figure 13. Crosswall after the accident

Figure 14. Closer view of failed crosswall
Analysis 58

Figure 15. Scour and erosion at bridge 504.1

Figure 16. Another view of scour and erosion at bridge 504.1
Analysis 59

Consequently, the Safety Board believes that the BNSF should identify and

perform a risk assessment of all system bridges that have shallow foundations of similar

construction to the bridge that failed in the Kingman, Arizona, accident and replace those

bridges determined to be susceptible to undermining and loss of the supporting

foundation structure. In conjunction with the risk assessment, the BNSF should perform a

hydrology study on shallow foundation structures with questionable drainage areas to

determine their current drainage areas. The Safety Board also believes that the FRA

should require that all railroads identify and perform a one-time risk assessment of the

bridges on their systems that have shallow foundations of similar construction to the

bridge 504.1 that failed in the Kingman, Arizona, accident and require replacement of

those bridges determined to be susceptible to undermining and loss of the supporting

foundation structure. In addition, the Safety Board is concerned that similar situations

may exist on other railroad systems in the country that are subject to flash flooding.

Therefore, the Safety Board believes that the Association of American Railroads and the

American Short Line and Regional Railroad Association should provide information to

make their memberships aware of the facts and circumstances of this accident.

Risk Concern for Route 66 Concrete Box Culverts

In its report to the BNSF, HDR Engineering noted concerns regarding the concrete

box culverts under Route 66 adjacent to and downstream of the BNSF bridges in the

accident area. Results of the BNSF hydrology study revealed that the highway box culvert

downstream from railroad bridge 504.1 was apparently engineered to withstand a 25-year

flood. According to the study,

At this time, based on the bed degradation which has developed below all

five of the downstream highway 66 bridge structures, the highway

structures have the potential of being washed out with the next major flood

event, with the potential for the resultant headcut (of a potential magnitude

of 5 feet) proceeding through the railway bridges (Br. 503.1, 504.1, and

505.9).

ADOT inspectors did not find any significant problems with the bridge (box

culvert) either during the last scheduled inspection in February 1997 or the postaccident

inspection of August 12, 1997. Although scour observations and measurements were

made by the ADOT inspector, no scour calculations were made during either inspection.

ADOT did not require scour calculations.

Although the Safety Board did not request that the BNSF conduct a hydrology

study or a scour vulnerability assessment of either the highway box culvert or the railroad

bridges for the Kingman investigation, the BNSF provided this information to the Safety

Board in its report. The Safety Board is concerned about the statements made in the

BNSF report regarding the vulnerability of the box culverts and the potential effect such

culverts might have on the railroad bridges in another severe storm situation.
Analysis 60

However, the BNSF report did not include ADOT bridge inspection data or

pictures of the streambed dating back to 1971, information that would have been helpful

in determining the relationship between the box culverts and the railroad bridges. The

Safety Board therefore concludes that the relationship of the two structures and their

respective zones of influence is not fully understood. The Safety Board believes that the

ADOT should examine the “System Analysis Seligman Subdivision Bridge No.’s 503.1-

505.9” report in light of its own historical bridge inspection information and take any

action it deems appropriate. In addition, the Safety Board believes that the Federal

Highway Administration should examine the “System Analysis Seligman Subdivision

Bridge No.’s 503.1-505.9” report and the ADOT historical bridge inspection data to

determine the hydrologic relationship between the box culvert and bridge 504.1. If the

examination determines that the structures have a detrimental hydrologic effect on each

other, the Federal Highway Administration should alert the States and the FRA that

similarly related structures may be vulnerable to similar problems.

Adequacy of Inspection Procedures During Severe Weather

Events

The track supervisor inspecting the track and bridges stated that on the day of the

accident he took no exception to anything that he observed. He stated that, based on his

knowledge of bridge inspections at that time, he was, “Completely 100-percent confident

that my railroad was able to support traffic of any nature after I had made the inspection.”

He stated that if he had observed debris under the bridge, he would have become

concerned, notified the dispatcher to stop trains in that area, and requested help from a

roadmaster. He also stated that he had no knowledge that one bridge would be less able to

support train traffic than another.

On the day of the accident, the presence of water above the bridge foundation

would have prevented thorough inspection of the bridge supporting structure by anyone,

even a qualified bridge inspector. However, the high water levels could have indicated a

potential for structural failure of the bridge foundations. A track inspector with relevant

bridge inspection training could have recognized that the flooding had the potential to

cause problems with several bridges in the Kingman area—including bridge 504.1—and

taken measures to stop train traffic until a thorough inspection of the bridge supporting

structure could be conducted.

Following the accident, the BNSF developed a 1-hour training program

concerning bridge inspections for maintenance-of-way employees. The training describes

various types of bridges and their supporting structures (such as shallow-foundation and

deep-foundation bridges) and “tell-tale” signs that the structure may have been damaged.

The track supervisor who inspected bridge 504.1 on the day of the accident has since

taken the BNSF training, and, in hindsight, found that his knowledge of bridges at the

time of the derailment would not have been adequate for him to assess possible damage.
Analysis 61

For instance, before his training, the track supervisor was not alarmed by the

presence of high water under bridge 504.1. Since his training, however, he recognizes the

possibility of the bridge supporting structure being damaged as a result of any amount of

water around it. The BNSF expects that this training will provide basic insight for track

inspectors to recognize the types of bridges susceptible to damage in severe flash flooding

conditions when a qualified bridge inspector is not immediately available to perform an

inspection. Also, it will teach track inspectors to stop trains before they reach the bridge if

they have any doubt as to the bridge’s safety. The program has not been in place long

enough to evaluate its effectiveness.

Before the training program was instituted, the BNSF should not necessarily have

relied on its track inspectors to adequately assess possible bridge damage caused by

flooding conditions; rather, the BNSF should only have relied on qualified bridge

inspectors to perform these inspections. In this case, had the qualified bridge inspector for

the area been notified immediately of the flash flooding near Kingman, he would not have

arrived in time to have inspected the bridge before Amtrak train 4 derailed. When the

derailment occurred, the bridge inspector assigned to this area was at home, on vacation,

and he told investigators that it would have taken him at least 4 1/2 hours to drive to

Kingman. Therefore, additional responsibility (such as for bridge inspections) was placed

on the track supervisor, who at that time had not been trained to recognize the potential

damage flood waters could cause to bridge foundations.

Because the track supervisor was not a qualified bridge inspector and had not

received formal training in this area, he was ill prepared to complete rudimentary bridge

inspections. The BNSF understood that, during flooding conditions, a bridge inspector

could take several hours to arrive on scene. As a result, the responsibility for ensuring the

integrity of both the track and bridges was often placed on the track inspector (or, in this

case, the track supervisor). The Safety Board concludes that Amtrak train 4 derailed when

bridge 504.1S failed because the BNSF maintenance-of-way managers lacked proper

foresight and planning regarding the assignment or training or both of personnel

designated to conduct bridge inspections during severe weather. The Safety Board

believes that the BNSF should evaluate, and improve as necessary, its basic bridge

inspection training program for track inspectors to ensure that appropriate procedures are

used in emergency situations. Further, the Safety Board believes that the BNSF

management should periodically review bridge inspection training for track inspectors to

ensure that it meets program objectives.

Protection of Trains During Severe Weather Conditions

On August 10, 1997, (the day after the accident) the BNSF issued a Maintenance

Alert that stated a policy for trains operating during severe flooding. The Maintenance

Alert was subsequently updated on February 20, 1998, because of severe storm-related

conditions and traffic delays that affected the BNSF’s Northern California Division

through the San Joaquin Valley. The updated version of the alert is applicable only to that

BNSF division. Trains on all other BNSF divisions must comply with the August 10,
Analysis 62

1997, Maintenance Alert requirements of 40 mph for freight trains and “restricted speed”

for passenger trains until the weather warning expires.

In the February 20, 1998, version, the train speed restrictions for both freight and

passenger trains were relaxed from the earlier Maintenance Alert. When weather

warnings are issued for a “flash flood warning,” freight and passenger trains are restricted

to 40 mph and 50 mph, respectively, except in the areas where the 14 bridges have been

identified as being vulnerable to scour because their foundations do not have piling. In

those instances, the BNSF’s passenger trains and “key trains” (those transporting

hazardous materials) are required to operate at restricted speed, but all other freight trains

can operate at 40 mph. The Maintenance Alert stays in effect until the weather warning

expires.

The Safety Board recognizes the added safety for the train crews and passengers

provided by reducing the speed of the passenger trains to a level from which they can be

stopped in a relatively short distance in the event of an emergency. The Safety Board does

not understand, however, the safety rationale for BNSF freight train crews being

permitted to travel at speeds that may still require stopping distances of up to a mile. The

Safety Board concludes that when, because of flash flooding conditions, the integrity of

bridges has yet to be validated, it is critical that trains be operated at a reduced speed such

as “restricted speed.” Train operations at restricted speed provide a margin of safety for

the engineer to operate the train at a speed slow enough, while not exceeding 20 mph, to

be able to safely stop the train within one-half his range of vision, which could be

affected by weather conditions such as heavy rain or darkness or both. Therefore, the

Safety Board believes that the BNSF should conduct a thorough analysis to determine the

appropriate personnel, inspection, and operating policies to be used during flash flooding

conditions and establish procedures designed to ensure the safe passage of all trains. The

analysis should address the minimum training requirements for personnel responding to

emergency inspections and should evaluate current inspection procedures and response

actions to determine their adequacy during abnormal or emergency situations. In addition,

the Safety Board believes that the BNSF should change its policy regarding freight train

operating speeds so that it is consistent with the required operating speeds of other trains

during flash flooding weather warnings, as noted in the August 1997 BNSF Maintenance

Alert.

The Safety Board acknowledges the prompt action taken by the FRA in issuing its

Safety Advisory 97-1 for special inspection procedures for bridges, which resulted from

the Kingman accident. The Safety Board, however, is concerned because the items listed

in the FRA’s advisory are only recommended; they are not regulatory requirements.

When issuing the advisory, the FRA cited the Track Safety Standards (49 CFR 213),

which state in part, “In the event of fire, flood, severe storm, or other occurrence which

might have damaged track structure, a special inspection must be made of the track

involved as soon as possible after the occurrence...” as justification for the advisory. The

FRA stated that it purposely made this provision general in nature, because, “It is not

practicable to specify in a minimum safety standard all the conditions which could trigger

a special inspection, nor the manner in which any particular special inspection must be
Analysis 63

conducted.” The FRA believed, “It is more effective to provide information and guidance

to the railroad industry, which each railroad can then adapt to its own circumstances.”

Although bridge inspections during severe weather circumstances are not

mentioned in the FRA’s Track Safety Standards, it appears that the FRA assumes that the

language in 49 CFR Part 213.239 is a “catch-all” for everything that should be done but is

not specifically addressed. Had the FRA’s Safety Advisory 97-1 been in effect before the

accident, the BNSF may have: had a program in place to identify those bridges that had

specific features susceptible to damage in severe weather; analyzed the potential for

damage to those bridges; and made that information available to those responsible for

inspecting the bridges in such situations. As noted in this accident, however, the track

supervisor did not have this type of information before the accident. If he had had this

information, he should have been able to recognize the susceptibility of bridge 504.1S to

damage during the severe flash flooding and could have taken action to stop trains until

an appropriate inspection could be made by a bridge inspector; alternatively, he could

have halted train traffic until the water subsided and it could be determined that the

bridge was not in danger. The Safety Board concludes that, had the FRA issued minimum

standards for special inspection procedures for bridges that would be at risk during severe

weather, such as those standards recommended in its Safety Advisory 97-1, the BNSF

track supervisor would have had better guidance for making the special inspection.

Because the FRA issued the safety advisory as an informational guideline, it has already

taken the first step in specifying some minimum safety standards for bridge inspection.

Therefore, the Safety Board believes that the FRA should incorporate the intent of Safety

Advisory 97-1 into minimum safety standards for special inspection procedures for

bridges that would be at risk during severe weather.

Passenger Safety and Emergency Response Procedures

Passenger and Crew Accounting

During the emergency response to the Kingman accident, the Incident

Commander requested a copy of the train 4 manifest from an Amtrak employee. The

conductor told Safety Board investigators that a passenger manifest was located in the

dormitory car, but he did not have time to obtain it because he was helping passengers.

The chief of on-board services said that he gave a copy of a sleeping car manifest to a

firefighter. It took several days for Amtrak to provide an accurate passenger count of the

entire train.

A complete manifest is necessary, in addition to the counts provided by the

conductor, so that emergency responders will be able to locate people on the train as

quickly as possible and be alerted about those people who may need immediate assistance

because of injuries or disabilities. Although a complete manifest of train 4 was eventually

available, infants and small children were not included on it because Amtrak does not

require tickets for infants and small children. Because the survival of passengers or

crewmembers could depend on their timely rescue by emergency responders, the
Analysis 64

complete manifest should be provided to the Incident Commander as soon as he arrives

on scene. Although no complete manifest was available during the emergency response in

this instance, the lack of one did not appear to negatively affect the efficiency of the

emergency response.

As a result of the Safety Board’s investigation of the Amtrak train accident in

Mobile, Alabama,33 the following safety recommendation was issued to Amtrak on

September 30, 1994:

R-94-7

Develop and implement procedures to provide adequate passenger and

crew lists to local authorities with minimum delay in emergencies.

Amtrak responded to the safety recommendation on July 18, 1995, stating that a

three-phase project to provide a satellite and messaging system between long-distance

trains and the corporate entities associated with their operation would be implemented.

According to Amtrak, phase I would install the system, phase II would expand the system

to more trains, and phase III would provide nationwide voice communications. In a letter

dated October 4, 1995, the Safety Board stated that it was pleased to learn that Amtrak

was about to implement this project to provide satellite communications capability on

trains and that the new system would provide more accurate passenger manifests. Pending

implementation of the new system, the Board classified the safety recommendation

“Open—Acceptable Response.”

On October 19, 1997, an Amtrak official provided the Safety Board with an

update of Amtrak’s progress in developing the satellite system. The official stated that it

would be difficult to account for passengers on Amtrak’s unreserved trains because of the

frequent stops such trains make. He compared the unreserved trains to transit systems.

However, he said that a procedure to account for passengers on reserved Amtrak trains is

possible, and that Amtrak has a computer system in place that could do it.

The Safety Board recognizes the practical limitations concerning Amtrak’s

providing a manifest on unreserved trains because those trains are frequently commuter

trains on which passengers may board and detrain quickly, purchase tickets ranging from

a per ride to a monthly basis, and not be confined to certain cars or seating. However,

reserved trains do not have these characteristics, and the procedure currently used to

account for reserved train passengers, by counting tickets, can be improved. The Safety

Board is aware that Amtrak has taken steps to improve its means of communication and

ability to account for all occupants on board its reserved trains, and the Safety Board is

encouraged by Amtrak’s progress in this area.

The Safety Board concludes that because an accurate passenger manifest was not

provided by the Amtrak train 4 crew to the Incident Commander, the emergency response

 33 Railroad Accident Report—Derailment of Amtrak Train No. 2 on the CSXT Big Bayou Canot

Bridge Near Mobile, Alabama, September 22, 1993 (NTSB/RAR-94/01).
Analysis 65

to evacuate and account for all passengers from the train could have been delayed, thus

endangering passengers whose locations or circumstances were unknown to emergency

responders. Therefore, the Safety Board hereby reclassifies Safety Recommendation

R-94-7 to Amtrak “Closed—Reconsidered” and believes that Amtrak should expedite the

development and implementation of a passenger and crew accountability system on

reserved trains.

Adequacy of Emergency Training

Although passengers were safely evacuated, statements from the on-board service

personnel and a review of their training records indicated that the reactions of several of

them were based on instinct rather than organized emergency training. For example, one

Amtrak attendant stated, “We had no real instruction or direction. We all went on instinct

to help one another to see if there were injuries.” He stated that they needed more

emergency training. Another attendant had attended Amtrak’s P.R.E.P.A.R.E. training

course, which she said made her feel “more knowledgeable, prepared, and focused on

what needed to be done.” This attendant recommended that all Amtrak crewmembers take

the P.R.E.P.A.R.E. course on at least a 2-year cycle.

The Safety Board reviewed Amtrak’s emergency situation training records for the

18 on-board service persons and operating crewmembers involved in this accident. The

training time intervals recorded varied between employees. The most recent training that

could be identified from the employee records ranged from training taken 2 months

before the accident to training taken as much as 7 years before the accident. Eight

employees did not have any emergency situation training dates listed in their training

records. These findings are inconsistent with Amtrak’s stated policy of scheduling

emergency situation training at least every 3 years for on-board service attendants. Also,

although the operating crew participated in refresher or recertification training, their

training records indicate that the operating crew did not participate in emergency situation

training with on-board service attendants.

Train 4’s on-board service personnel did not use the public address system to

communicate evacuation information to the passengers. Although some crewmembers

believed that the public address system did not work, they did not attempt to use it even

though Amtrak’s emergency training procedures, as provided in the Amtrak training

manual, call for its use in emergency situations. Wreckage documentation showed that

the public address system was inoperable in some of the cars because of the damage

sustained by the equipment.

During emergency situations, particularly those involving passenger evacuations,

the train crew and on-board service personnel are responsible for managing and directing

the safe evacuation of passengers. Passengers rely on the training, experience, and

leadership of the on-board service personnel. Required periodic emergency situation

training should prepare the train crewmembers to confidently perform their duties when

emergency situations occur.
Analysis 66

Since 1984, the Safety Board has addressed the need for Amtrak to improve its

emergency situation training program. Over the years, the Safety Board has recognized

improvements in Amtrak’s training program.

Following its investigation of the Amtrak train accident in Lugoff, South

Carolina, on July 31, 1991,34 the Safety Board recommended that Amtrak:

R-93-23

Require that all on-board service personnel periodically take training in

emergency operating rules and first aid, cardiopulmonary resuscitation,

and the use of the public address system during train emergencies.

In a letter dated December 27, 1993, Amtrak concurred with the merit of this

recommendation. Amtrak formed a committee to develop an appropriate program to

address these issues. The Safety Board responded on February 10, 1994, that a meeting

with Amtrak would be postponed until the committee began its review of the issues. As a

result, the Safety Board classified Safety Recommendation R-93-23 “Open—Acceptable

Response.”

Based on the personnel training record data reviewed in this accident, however,

not all Amtrak employees appear to have received the necessary training or retraining in

accordance with Amtrak’s program. All employees should be provided the same level of

emergency situation training within a reasonable time period. Although the evacuation

went well in this accident, the responsibilities of train crewmembers should not be carried

out in an ad hoc manner. Amtrak employees should be trained in their emergency

responsibilities and not have to rely on instinct alone.

The lack of communication between the conductor and on-board service chief in

providing a complete passenger manifest to the Incident Commander demonstrates a need

for additional training of Amtrak personnel to emphasize their responsibilities when

receiving requests from emergency responders and coordinating the emergency response

on scene. In the Safety Board’s investigation of an accident that occurred on February 16,

1996, near Silver Spring, Maryland,35 the importance of the timely exchange of

information between train crew personnel and the Incident Commander was examined.

Coincident with the accident investigation, the FRA published, on February 24, 1997, the

Notice of Proposed Rulemaking for Passenger Train Emergency Preparedness, which

proposed requiring minimum Federal safety standards for the preparation, adoption, and

implementation of emergency preparedness plans by railroads connected with the

operation of passenger trains, including freight railroads hosting the operations of rail

passenger service. The rule also required each affected railroad to instruct its employees

 34 Railroad Accident Report—Derailment and Subsequent Collision of Amtrak Train 82 With Rail

Cars on Dupont Siding of CSX Transportation, Inc., at Lugoff, South Carolina, on July 31, 1991

(NTSB/RAR-93/02).

35 Railroad Accident Report—Collision and Derailment of Maryland Rail Commuter MARC Train

286 and National Railroad Passenger Corporation Amtrak Train 29 Near Silver Spring, Maryland, on

February 16, 1996 (NTSB/RAR-97/02).
Analysis 67

about the provisions of the plan. The FRA issued the final rule on Passenger Train

Emergency Preparedness on May 4, 1998, with an effective date of July 6, 1998.

The Safety Board concludes that Amtrak’s current system for providing

emergency training for train crews and on-board service personnel has not been effective,

which has resulted in personnel being provided differing levels of emergency situation

training. The Safety Board believes that Amtrak should implement effective controls to

monitor and ensure that all train crews and on-board service personnel receive the

necessary initial and recurrent emergency training to provide for passenger safety.

Emergency Lighting and Public Address Systems

The failure of emergency electrical systems to provide emergency power can be a

serious problem in critical situations such as derailments. The emergency electrical

system for each passenger car on train 4 was either at minimal output or at no power as a

result of the derailment. Extensive undercarriage damage resulted in severed wiring and

electrical conduits. Consequently, neither the interior emergency lights nor the public

address system was reliable for operation, and no back-up system was provided.

Passengers either had to rely on the instructions they were given by the Amtrak personnel

in their car or to evacuate the train on their own.

Following a June 15, 1982, derailment of an Amtrak train in Emerson, Iowa,36 the

Safety Board issued the following safety recommendation to Amtrak:

R-83-25

Evaluate and modify, as necessary, emergency lighting systems in

passenger-carrying cars to better protect the functioning of emergency

lights in emergency situations.

Amtrak responded in 1984 that the emergency lighting system was designed to

provide a minimum of 2 hours of acceptable illumination when the primary power source

was interrupted. Amtrak believed that this 2-hour period was a reasonable length of time

in an emergency situation. Amtrak also stated that using the existing commercial, batteryoperated, self-contained fixtures on railway cars is not feasible. The safety

recommendation was classified “Closed—Unacceptable Action” in April 1988.

On September 22, 1993, Amtrak train 2 struck a displaced railroad bridge and

derailed into the Big Bayou Canot near Mobile, Alabama,37 at about 2:53 a.m. Forty-two

passengers and 5 crewmembers were killed; 103 passengers were injured. The Safety

Board issued the following safety recommendation to Amtrak:

 36 Railroad Accident Report—Derailment of Amtrak Train No. 5 (the San Francisco Zephyr) on the

Burlington Northern Railroad, Emerson, Iowa, June 15, 1982 (NTSB/RAR-83/02).

37 NTSB/RAR-94/01.
Analysis 68

R-94-8

Equip cars with portable lighting for use by passengers in an emergency.

In July 1995, Amtrak stated that it was evaluating the use of portable chemical

light sticks for permanent installation on all Amtrak trains. Such light sticks are

weatherproof, maintenance-free, nontoxic, nonflammable, and not sources of ignition.

They provide immediate and dependable light for up to 8 hours. Amtrak placed light

sticks on all its passenger trains, and Safety Recommendation R-94-8 was classified

“Open—Acceptable Action.”

In the Kingman accident, the Amtrak light sticks provided sufficient emergency

lighting until the arrival of emergency responders. Light stick use was limited, but the

usefulness of the light sticks was well acknowledged by the passengers, and they

provided a measure of safety when the emergency lighting failed. Based on these actions

by Amtrak, the Safety Board classified Safety Recommendation R-94-8 “Closed—

Acceptable Action” on March 26, 1998.

The Safety Board is, however, concerned that not enough is being done to provide

for passenger safety when emergency power is lost. In the 1996 Silver Spring accident,38

a contributing factor to the severity of the accident and the loss of life was the lack of

appropriate regulations to ensure adequate emergency egress features on railroad

passenger cars. One of the safety recommendations issued following this investigation

called for the FRA to:

R-97-17

Require all passenger cars to contain reliable emergency lighting fixtures

that are each fitted with a self-contained independent power source and

incorporate the requirements into minimum passenger safety standards.

On February 25, 1998, the FRA responded to this safety recommendation, stating

that:

FRA findings in recent accidents support the Safety Board’s implied

concern that placement of electrical conduits and battery packs below the

floor of passenger coaches can result in damage that leads to the

unavailability of emergency lights precisely at the time they are most

needed. However, from initial investigation it is not certain whether

current ‘ballast’ technology provides illumination of sufficient light level

quality with reliable maintainability.

At a meeting in December 1997, the FRA delegated this issue to its Railroad

Safety Advisory Committee for Passenger Equipment Safety Standards Working Group

and stated that this group will aggressively pursue this option for more reliable

 38 NTSB/RAR-97/02.
Analysis 69

emergency illumination. The status of Safety Recommendation R-97-17 is “Open—

Response Received.”

The Safety Board concludes that passenger car interiors must have interior

emergency lighting because a sufficient quantity of light sticks may not always be

available, and light sticks may not be suitable for a large-scale evacuation such as the one

that occurred in this accident. In addition, while the light stick may serve adequately as a

personal emergency light source during an evacuation, it is not a self-contained

emergency lighting source. Therefore, the Safety Board believes that Amtrak should

install, in all new passenger equipment purchased after January 1, 2000, and in existing

passenger cars during their major overhaul/rebuild operations, fixtures that use a “selfcontained back-up energy reserve feature” to make the fixtures less vulnerable to the

disruption of electrical power during derailments. In addition, the Safety Board reiterates

Safety Recommendation R-97-17 to the FRA.

Seat Securement

Inspection of train 4’s seats indicated that none had become separated from their

floor mountings. However, 18 seat assemblies were found with their rotating locking

mechanisms not engaged. A disengaged seat lock can result in an uncontrolled rotation of

the seat assembly, even in cases of a minor derailment, which may result in serious

injuries to passengers. In the August 23, 1990, Batavia, Iowa,39 accident report, the Safety

Board stated its concern regarding Amtrak’s seat locks and noted that seats can become

unlocked either because the locking mechanisms are disengaged en route by passengers

or because they are defective. The Safety Board issued the following safety

recommendation to Amtrak:

R-91-71

Implement procedures for on-board-service personnel to periodically

check passenger seats en route for unlocked anti-rotational devices and

take action to ensure seats are functional.

On May 22, 1992, this safety recommendation was classified “Closed—

Acceptable Action,” based on Amtrak’s response that it was immediately issuing

instructions systemwide to check and ensure that seat locks are functional and engaged.

Absolute assurance is not always possible, however, because passengers can

readily disengage the mechanism to rotate the seat to suit their personal requirements and

may fail to ensure that the locking mechanism is again positively engaged. Further, onboard service personnel may not be able to provide the constant vigilance necessary to

ensure that the seat locking mechanisms have been properly restored, because the seat

locking mechanism is not readily visible. A simple solution may be to employ a positive

locking mechanism that requires use of a special keying feature accessible only to

 39 Railroad Accident Report—Derailment of Amtrak Train No. 6 on the Burlington Northern Railroad,

Batavia, Iowa, April 23, 1990 (NTSB/RAR-91/05).
Analysis 70

crewmembers (such as a conductor’s coach key). This procedure could provide for seat

locking security and effectively eliminate manipulation by passengers.

The Safety Board concludes that the current procedures used to check and ensure

that passenger car seat locks are functional and engaged are inadequate. The Safety Board

believes that Amtrak should install a positive seat securement system to prevent

disengagement and undesired rotation in all new passenger cars purchased after

January 1, 2000, and incorporate such a system into existing passenger cars when they are

scheduled for overhaul. Furthermore, the Safety Board believes that the FRA should

include in the passenger car safety standards a requirement for positive seat securement

systems to provide against the disengagement and undesired rotation of seats in all new

passenger cars purchased after January 1, 2000, and require the incorporation of such a

system into existing passenger cars when they are scheduled for overhaul.

Emergency Response

General

The Mohave County sheriff’s deputies who were in the vicinity of the derailment

responded within minutes. The Kingman Fire Department and other mutual aid agencies

responded to help with the search and rescue efforts and to transport the train crew and

passengers. Emergency responders carried out triage on survivors and transported them to

hospitals by helicopter, bus, and ambulance in a timely manner. Adequate resources and

personnel were available to effectively manage the response. The Safety Board concludes

that the emergency response was timely, and the resources provided for the emergency

response were adequate.

Unverified Notification Information

During the initial communication of on-site information by local agencies, some

confusion resulted in the erroneous reporting of 8 to 13 fatalities, when no fatalities had

actually occurred. A BNSF special agent called the Mohave County Sheriff’s Department

to inquire about the accident and was told that two persons in the upper level of the

dormitory car were seriously injured and that those injured would probably be DOA. The

BNSF relayed this information to other BNSF employees and, in some cases, stated that

two DOAs were reported. In subsequent conversations with the Mohave dispatcher and a

sergeant, the BNSF special agent overheard the dispatcher talking to someone on scene

over the radio referring to “six downstairs.” The special agent asked if she had heard that

there were two DOAs upstairs and six DOAs downstairs in the dormitory car; the

sergeant replied, “Yes.” The initial speculation by the Mohave dispatcher that those

persons with serious injuries would become DOAs apparently caused others to use that

same terminology. This incorrect information was subsequently relayed to various,

including Federal, organizations. The Safety Board recognizes that conflicting reports of

the circumstances of an accident often are communicated initially, and that in the early
Analysis 71

stages of the response, emergency responders must speculate and evaluate the situation to

ensure that adequate resources are available for the worst-case scenario; but speculation is

not fact.

The information that is relayed to responding agencies must be as accurate as

possible, and information that is relayed to other parties must either be confirmed as

factual or clearly characterized as unverified. The Safety Board concludes that the

inaccurate reporting of fatalities that took place during the accident notification process

was a result of unconfirmed information being relayed to Federal agencies by local

organizations. Therefore, the Safety Board believes that the Mohave County Sheriff’s

Department, the International Association of Chiefs of Police, and the National Sheriffs’

Association should review the circumstances of this accident with their dispatchers and

emphasize the importance of relaying verified factual information when communicating

with other agencies.

Protection for Employees on or Adjacent to Track in

Performance of Their Duties

The FRA was required by the Rail Safety Enforcement and Review Act of

September 3, 1992, to review the Track Safety Standards and revise them based on

information derived from that review. One of the issues identified to be addressed was the

safety of maintenance-of-way employees working on or along the railroad right-of-way.

This issue was separated from the ongoing review of the Track Safety Standards and

assigned to a separate Railroad Safety Advisory Committee, which was to study the issue

and develop recommendations.

As part of this study, FRA records identified 22 fatalities that occurred in the

period between 1989 and 1993. An independent labor-management task force focused on

43 accidents that resulted in 46 fatalities and 150 injuries from 1986 through 1994. Most

of the fatalities occurred while some form of protection system was available or in use.

Through this process, the FRA initiated rulemaking activity, which resulted in the

Roadway Worker Protection (RWP) regulations (found in 49 CFR 214) that became

effective January 15, 1997.

The track supervisor involved in the Kingman accident was, while inspecting the

main track, operating with a track car operator informational line-up. This practice was

permissible under the requirements of the FRA RWP regulations.

Class I railroads, including the BNSF, were required to be in compliance with the

new regulations as of March 15, 1997. The regulations also provided that carriers each

prepare a plan for compliance and notify the FRA, at least 1 month before March 15,

1997, that its plan was prepared and available for FRA review.

The RWP regulations permitted railroads that used informational line-ups as of

March 14, 1996, to continue using them. However, the RWP regulations also required
Analysis 72

that the carrier’s plan for compliance with the regulations contain a schedule for the

discontinuance of the informational line-up procedure by a definite date.

The BNSF developed a plan as required by the regulations and notified the FRA

before March 15, 1997. The plan called for the use of both train location line-ups and

track car operator line-ups to be discontinued by August 1, 2016. The FRA reviewed this

plan with the BNSF on April 9, 1997, at BNSF headquarters in Fort Worth, Texas. As of

July 14, 1998, the FRA had not approved the BNSF plan.

An internal BNSF memorandum, dated February 13, 1998, stated that, as of

January 29, 1998, train location/track car operator line-ups were still in use on 14 branch

lines and 4 main line subdivisions. The memo further stated that, although the BNSF had

committed to discontinue the use of these line-ups by August 1, 2016, ongoing efforts

were underway to employ alternate methods wherever possible, given communications

constraints. The BNSF timeline for eliminating the use of line-ups was tied to expansion

of cellular telephone coverage on remote territories and implementation of emerging

control and voice communications technologies.

Although the operational practices that the track supervisor used during his

special inspection were not factors in the derailment of Amtrak train 4, the Safety Board

is concerned about the potential risk to employees engaged in special inspections while

located on or adjacent to the railroad tracks. In this accident, the track supervisor

confirmed that no mechanism was in place to protect him or other track inspectors if they

could not contact the dispatcher for any reason. He considered it the employee’s

responsibility to get out of the way of trains. Track inspectors believe that their protection

lies in the informational line-up, even though they know that the line-up is only valid for

about 4 hours and that the dispatcher would not try to locate them. This practice places

the responsibility on the employee to protect himself, and generally he can. If, however,

the track inspector becomes incapacitated, or the communications equipment fails, or the

dispatcher does not stop trains from entering the area occupied by the inspector, the

inspector could be put in jeopardy.

The RWP regulations were intended to provide protection and safety for on-track

workers. They specifically address the need to discontinue the use of informational lineups as the sole protection for track inspectors. The Safety Board concludes that the

BNSF’s 18-year timeframe for discontinuing the practice of using informational line-ups

to ensure worker safety is too long and, until eliminated, the practice has the potential to

place railroad workers in danger. The Safety Board therefore believes that the BNSF

should immediately discontinue the use of informational line-ups. The Safety Board is

disappointed by the FRA’s lack of aggressive action to ensure that railroads become more

responsive to the issue of roadway worker protection in a timely manner.
Analysis 73

Locomotive Event Recorders

The problem of mismatched software readout programs being used to read event

recorder information is not new to the Safety Board. Hundreds of software readout

programs and versions of those programs are used to read out today’s solid-state event

recorders. The Safety Board laboratory is constantly updating its readout programs to

keep current with the many programs and software revisions as they evolve. Unlike

magnetic tape recorders, solid-state event recorders can only be read out using a computer

and appropriate software. Therefore, it is imperative that event recorder data be read out

using the correct software, to ensure that all the recorded data are extracted and that the

data are accurate.

In this particular accident, however, Amtrak did not have the capability to read out

all the data on its own recorders. Amtrak was unaware that valuable additional data had

been recorded on its event recorders; six more parameters were actually recorded but not

extracted by the Amtrak IFC analysis program. These parameters—emergency type, EOT

emergency (on or off), bell, brake handle position, EIE (on or off), and dynamic brake

derate (on or off)—provide data about the operational characteristics of the train

important for performing an accurate accident investigation. The Safety Board therefore

concludes that, had Amtrak been more familiar with the specifications of the event

recorders on train 4, it could have obtained additional information from them that would

have been useful.

The FRA, in conjunction with the railroads and recorder/software manufacturers,

is responsible for ensuring that all recorded data can be accurately and reliably retrieved

after any train accident. No industry-wide procedures or Federal regulations address

documentation of locomotive event recorders or readout system specifications. These

specifications are necessary to conduct accurate readouts of event recorders. Physical

inspections of the locomotive to determine the recording system specifications can be

impractical or, in the case of severe accidents, impossible, because of component damage.

Therefore, the Safety Board believes that the FRA should require that event

recorder system specifications be kept as part of the locomotive’s records. These records

should be readily accessible for FRA or Safety Board inspection and must be kept up to

date. These records should include, at a minimum: (1) the name, version, and date of the

readout program intended for use with the recorder currently installed on the locomotive;

(2) the manufacturer, model number, and serial number of the event recording device and

its associated components (to include the air brake manifold, axle generator or equivalent,

and signal conditioning devices) currently installed on the locomotive; (3) a complete list

of parameters that the recording system is currently configured to record; and, (4) the

recording system’s manufacturer-prescribed modification, revision, and softwarehardware version numbers.
Analysis 74

Locomotive Fuel Tank Crashworthiness

All four units in the train 4 locomotive power consist were GE model P-42

locomotives, which is a relatively new locomotive design having a monocoque body

incorporating a relatively high undercarriage clearance (to the top of the rails) and an

integrated fuel tank. The fourth unit in the consist sustained noteworthy damage, being

impaled by a length of rail that had dislodged from the track structure during the

derailment. The rail punctured the end panels of the fuel tank and inflicted other serious

structural damage, yet it caused no catastrophic rupture of the fuel tank or fire and only a

minor amount of fuel spillage. Contributory to this lack of fuel tank damage was the

ample undercarriage clearance available in this unit, as compared to other locomotives

with conventional frame-suspended fuel tanks.

Only performance in future accidents will prove whether the high ground

clearance and integrated fuel tank design found in this type of unit will permit such tanks

to continue to resist catastrophic rupture or breach, but the Safety Board acknowledges

the crashworthiness performance of the advanced fuel tank design of the locomotives in

this accident. The P-42 locomotive fuel tank of the fourth locomotive in the consist, with

its relatively high ground clearance, integral location, and internal baffle system,

demonstrated its ruggedness and ability to withstand the rigors of a serious derailment, as

compared to a conventional, frame-suspended locomotive fuel tank, which in past

derailments has been shown to be vulnerable to catastrophic puncture and potential fire.

The Safety Board concludes that, in this accident, the new Amtrak P-42 locomotive fuel

tanks demonstrated a level of crashworthiness that has not been shown by conventional,

frame-suspended locomotive fuel tanks that have been vulnerable to catastrophic

puncture and fire.

The Safety Board has previously expressed its concern to the FRA about other

locomotives built before the effective date of September 1, 1995, noting that many of

these locomotives will remain in service for several years, and this accident demonstrates

that new designs can improve the crashworthiness performance of locomotive fuel tanks.

The Safety Board will continue to address the crashworthiness issue in future accident

investigations and to monitor FRA progress in improving locomotive fuel tank

crashworthiness.
75

Conclusions

Findings

1. The track did not cause or contribute to the accident.

2. The signal system was not a factor in the accident.

3. The weather warnings and alerts issued by WeatherData, Inc., were both timely and

substantially correct.

4. The mechanical condition of the train was not a factor in the accident.

5. The health, rest, and qualifications of the train crew were not factors in the accident.

6. Although the track supervisor conducted a track inspection over his territory during

the flooding, he was not qualified to conduct bridge inspections.

7. The failure of bridge 504.1S was caused by scour and erosion affecting the

inadequately protected shallow foundations that supported the bridge; the scour

resulted because a poorly designed concrete crosswall was built instead of a new and

better-engineered bridge.

8. The relationship of the highway box culverts and the railroad bridges and their

respective zones of influence is not fully understood.

9. Amtrak train 4 derailed when bridge 504.1S failed because the Burlington Northern

Santa Fe maintenance-of-way managers lacked proper foresight and planning

regarding the assignment or training or both of personnel designated to conduct bridge

inspections during severe weather.

10. When, because of flash flooding conditions, the integrity of bridges has yet to be

validated, it is critical that trains be operated at a reduced speed such as “restricted

speed.”

11. Had the Federal Railroad Administration issued minimum standards for special

inspection procedures for bridges that would be at risk during severe weather, such as

those standards recommended in its Safety Advisory 97-1, the Burlington Northern

Santa Fe track supervisor would have had better guidance for making the special

inspection.

12. Because an accurate passenger manifest was not provided by the Amtrak train 4 crew

to the Incident Commander, the emergency response to evacuate and account for all
Conclusions 76

passengers from the train could have been delayed, thus endangering passengers

whose locations or circumstances were unknown to emergency responders.

13. Amtrak’s current system for providing emergency training for train crews and onboard service personnel has not been effective, which has resulted in personnel being

provided differing levels of emergency situation training.

14. Passenger car interiors must have interior emergency lighting because a sufficient

quantity of light sticks may not always be available, and light sticks may not be

suitable for a large-scale evacuation such as the one that occurred in this accident.

15. The current procedures used to check and ensure that passenger car seat locks are

functional and engaged are inadequate.

16. The emergency response was timely, and the resources provided for the emergency

response were adequate.

17. The inaccurate reporting of fatalities that took place during the accident notification

process was a result of unconfirmed information being relayed to Federal agencies by

local organizations.

18. The Burlington Northern Santa Fe’s 18-year timeframe for discontinuing the practice

of using informational line-ups to ensure worker safety is too long and, until

eliminated, the practice has the potential to place railroad workers in danger.

19. Had Amtrak been more familiar with the specifications of the event recorders on

train 4, it could have obtained additional information from them that would have been

useful.

20. In this accident, the new Amtrak P-42 locomotive fuel tanks demonstrated a level of

crashworthiness that has not been shown by conventional, frame-suspended

locomotive fuel tanks that have been vulnerable to catastrophic puncture and fire.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was displacement of the track due to the erosion and scouring of the

inadequately protected shallow foundations supporting bridge 504.1S during a severe

flash flood because the Burlington Northern Santa Fe management had not provided

adequate protection, either by inspection or altering train speeds to fit conditions.

Contributing to the accident was the failure of the Burlington Northern Santa Fe

management to adequately address the erosion problems at bridge 504.1S.
77

Recommendations

As a result of its investigation, the National Transportation Safety Board makes

the following safety recommendations:

—to the Burlington Northern Santa Fe Corporation:

Identify and perform a risk assessment of all system bridges that have

shallow foundations of similar construction to the bridge that failed in the

Kingman, Arizona, accident, and replace those bridges determined to be

susceptible to undermining and loss of the supporting foundation structure.

In conjunction with the risk assessment, perform a hydrology study on

shallow foundation structures with questionable drainage areas to

determine their current drainage areas. (R-98-48)

Evaluate, and improve as necessary, your basic bridge inspection training

program for track inspectors to ensure that appropriate procedures are used

in emergency situations. (R-98-49)

Require your management to periodically review bridge inspection

training for track inspectors to ensure that it meets program objectives.

(R-98-50)

Conduct a thorough analysis to determine the appropriate personnel,

inspection, and operating policies to be used during flash flooding

conditions, and establish procedures designed to ensure the safe passage of

all trains. The analysis should address the minimum training requirements

for personnel responding to emergency inspections and evaluate current

inspection procedures and response actions to determine their adequacy

during abnormal or emergency situations. (R-98-51)

Change your policy regarding freight train operating speeds so that it is

consistent with the required operating speeds of other trains during flash

flooding weather warnings, as noted in the August 1997 Burlington

Northern Santa Fe Maintenance Alert. (R-98-52)

Immediately discontinue the use of informational line-ups. (R-98-53)

—to the Federal Railroad Administration:

Require that all railroads identify and perform a one-time risk assessment

of the bridges on their systems that have shallow foundations of similar

construction to the bridge 504.1 that failed in the Kingman, Arizona,

accident, and require replacement of those bridges determined to be
Recommendations 78

susceptible to undermining and loss of the supporting foundation structure.

(R-98-54)

Incorporate the intent of Safety Advisory 97-1 into minimum safety

standards for special inspection procedures for bridges that would be at

risk during severe weather. (R-98-55)

Include in the passenger car safety standards a requirement for positive

seat securement systems to provide against the disengagement and

undesired rotation of seats in all new passenger cars purchased after

January 1, 2000, and require the incorporation of such a system into

existing passenger cars when they are scheduled for overhaul. (R-98-56)

Require that event recorder system specifications be kept as part of the

locomotive’s records. (R-98-57)

—to the Federal Highway Administration:

Examine the “System Analysis Seligman Subdivision Bridge No.’s 503.1-

505.9” report and the Arizona Department of Transportation’s historical

bridge inspection data to determine the hydrologic relationship between

the box culvert and bridge 504.1. If the examination determines that the

structures have a detrimental hydrologic effect on each other, alert the

States and the Federal Railroad Administration that similarly related

structures may be vulnerable to similar problems. (H-98-41)

—to the Arizona Department of Transportation:

Examine the “System Analysis Seligman Subdivision Bridge No.’s 503.1-

505.9” report in light of your own historical bridge inspection information

and take any action you deem appropriate. (H-98-42)

—to the National Railroad Passenger Corporation (Amtrak):

Expedite the development and implementation of a passenger and crew

accountability system on reserved trains. (R-98-58)

Implement effective controls to monitor and ensure that all train crews and

on-board service personnel receive the necessary initial and recurrent

emergency training to provide for passenger safety. (R-98-59)

Install, in all new passenger equipment purchased after January 1, 2000,

and in existing passenger cars during their major overhaul/rebuild

operations, fixtures that use a “self-contained back-up energy reserve

feature” to make the fixtures less vulnerable to the disruption of electrical

power during derailments. (R-98-60)
Recommendations 79

Install a positive seat securement system to prevent disengagement and

undesired rotation in all new passenger cars purchased after January 1,

2000, and incorporate such a system into existing passenger cars when

they are scheduled for overhaul. (R-98-61)

—to the Mohave County Sheriff’s Department (R-98-62):

—to the International Association of Chiefs of Police (R-98-63):

—to the National Sheriffs’ Association (R-98-64):

Review the circumstances of the derailment accident that occurred at

Kingman, Arizona, on August 9, 1997, with your dispatchers and

emphasize the importance of relaying verified factual information when

communicating with other agencies.

—to the Association of American Railroads (R-98-65):

—to the American Short Line and Regional Railroad Association (R-98-66):

Make your membership aware of the facts and circumstances of the

derailment accident that occurred at Kingman, Arizona, on August 9,

1997.

Also as a result of its investigation of this accident, the National Transportation

Safety Board reiterates the following safety recommendation:

—to the Federal Railroad Administration:

R-97-17

Require all passenger cars to contain reliable emergency lighting fixtures

that are each fitted with a self-contained independent power source and

incorporate the requirements into minimum passenger safety standards.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

JOHN A. HAMMERSCHMIDT

Member

ROBERT T. FRANCIS II

Vice Chairman

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

August 31, 1998

81

Appendix A—Investigation

The Safety Board was notified of this accident about 8:30 a.m., eastern standard

time, on August 9, 1997, and dispatched a major railroad accident investigation team.

Investigative groups examined the operation, track, structures, signals, mechanical,

survival factors, and human performance aspects of the accident.

The Burlington Northern Santa Fe Corporation, the National Railroad Passenger

Corporation, the Federal Railroad Administration, the United Transportation Union, the

Brotherhood of Locomotive Engineers, the Brotherhood of Maintenance of Way

Employes, the Mohave County Sheriff’s Department, and the Arizona Corporation

Commission assisted in the Safety Board investigation.

As part of its investigation, the Safety Board conducted a 1-day deposition

proceeding in Fort Worth, Texas, on October 15, 1997, at which 11 witnesses testified.

83

Appendix B—Event Chronology and Layout

of Seligman Subdivision

EVENT CHRONOLOGY

(Times are in mountain daylight time unless noted.)

8/8/97 FRIDAY

9 p.m. to 5 a.m. (10 p.m. to 6 a.m. CDT) Third-shift dispatcher is on duty.

8/9/97 SATURDAY

12:06 a.m. The first alert of potential severe weather is issued by the Burlington

Northern Santa Fe (BNSF) contract weather service, WeatherData, Inc.

(WDI). The alert is for thunderstorms and heavy rain on the Seligman

subdivision, and its text read, “Strong thunderstorms are rapidly

developing just southeast of, is that Pica, Pica, Arizona, moving east at

15 miles per hour. Radar estimates moderate rainfall over track with up

[to] 0.7 inches per hour rainfall rates. Expect from 0.4 to 0.6 inch of

rain in the next 40 minutes, will monitor for flash flooding.”

12:30 a.m. The National Weather Service (NWS) office in Las Vegas issues a

severe thunderstorm warning until 1:30 a.m. Saturday for Mohave

County.

12:52 a.m. The BNSF receives an update from WDI (alert 0000). “Strong to

severe thunderstorms producing heavy rain with up to 1 inch an hour

and gust wind continues to redevelop over this stretch of track.

Kingman, Arizona, has reported a gust to 50 miles per hour in the last

45 minutes. Therefore, we are extending the previous warning. To

expire at 2:30 a.m.”

1:29 a.m. The NWS issues a Severe Thunderstorm and Flash Flood Warning

effective until 2:30 a.m. for central Mohave County.

1:43 a.m. The BNSF is warned of flash floods by WDI (warning 0001).

“Thunderstorms continue to move to the east at 20 miles per hour.

Radar estimates that nearly 2 inches of rain has fallen over this stretch

of track with hourly rates of 1 inch an hour still falling. Watch for flash

flooding! To expire at 2:30 a.m.” (This warning initiated the track

inspection.)
Appendix B 84

1:57 a.m. The track supervisor is called by the dispatcher.

2:21 a.m. The BNSF receives an update from WDI (warning 0002). “Strong

thunderstorms continue to redevelop and move over this stretch of

track this morning. Movement of these storms is to the east-southeast

at 10 miles per hour. Rainfall amounts of 1 to 2 inches is likely, as well

as peak wind gusts less than 60 miles per hour. Watch for Flash

Flooding. To expire at 4:30 a.m.”

2:24 a.m. The NWS issues a Severe Thunderstorm and Flash Flood Warning

effective until 3:30 a.m. for central Mohave County.

2:32 a.m. The BNSF receives an update from WDI (alert 0003). “Strong

thunderstorms continue to redevelop and move over this stretch of

track this morning. Movement of these storms is to the east-southeast

at 10 miles per hour. Rainfall amounts of 1/2 to 1 inch is likely over

this stretch of track, as well as peak wind gusts less than 60 miles per

hour. To expire at 4:30 a.m.”

3:00-4:30 a.m. The track supervisor calls his personnel. By this time, the rain had

begun to diminish.

3:30 a.m. The track supervisor talks to the dispatcher; he obtains the eastbound

train line-up and learns that no trains are east of Cadiz. Also, the NWS

Severe Thunderstorm and Flash Flood Warning expires.

3:39 a.m. Train EB Q-LACMEM1-08 is at Walapai (MP 501.3)—on adjacent

track—and notes water in culverts and rain letting up.

3:56 a.m. Train EB Q-LACMEM1-08 is at MP 489.7—on adjacent track—and

reports no water on the ground.

4:01 a.m. The dispatcher informs the track supervisor of the report of train EB

Q-LACMEM1-08.

4:05 a.m. The track supervisor begins the track inspection at MP 516.5.

4:12 a.m. The dispatcher informs the track supervisor of EB Q-LACMEM1-08’s

report of no water on the ground between Truxton (MP 477.3) and

Hackberry (MP 509.4).
Appendix B 85

4:15 a.m. The track supervisor stops at MP 515.2 and MP 515.4, noting slight

water movement. He talks to a westbound train at Getz (MP 513.9),

reporting no high water near rails.

4:25 a.m. The track supervisor stops at bridge 507.4.

4:28 a.m. The BNSF receives an update from WDI (warning 0004) for the area

between Truxton (MP 477.3) and Harris (MP 521.4). “Thunderstorms

producing heavy rain continue to remain nearly stationary around the

Kingman, Arizona, area this morning. Radar estimates that nearly 3 to

3.5 inches of rain has fallen near this stretch of track with hourly rates

of 1 inch an hour still falling. Watch for flash flooding! The threat for

high wind has diminished; however, a gust to 45 miles per hour is still

possible. To expire at 6 a.m.”

4:30-4:45 a.m. The track supervisor reports from Hackberry (MP 509.4) and makes no

report of high water. He stops at bridges 507.3 and 505.9. He inspects

bridge 504.1.

5:00 a.m. The first-shift dispatcher comes on duty. (Serves till 1 p.m.)

5:07 a.m. The dispatcher informs the track supervisor near Truxton (MP 477.3)

that Amtrak train 4 is leaving Franconia (west of Kingman).

5:24 a.m. Amtrak train 4 departs Griffith (MP 526.8).

5:35 a.m. Train WB B-CHCLAC1-05 passes Walapai (MP 501.3) and, shortly

after, passes bridge 504.1.

5:40 a.m. The first-shift dispatcher and the third-shift dispatcher begin their

changeover.

5:46 a.m. The track supervisor reports from Peach Springs (MP 465.8) that he

will shortly clear for Amtrak train 4. He does not report any high

water.

5:56 a.m. The derailment occurs. The BNSF Operations Center is notified by the

crew of Amtrak train 4. The BNSF first-shift dispatcher notifies the

BNSF Resource Operations Center (ROC) of the accident.

6:00 a.m. (7 a.m. CDT) The BNSF police department is notified of the accident

by the BNSF operations desk. (8 a.m. EDT) The Safety Board

Communications Center notifies the Rail Division duty officer.
Appendix B 86

6:01 a.m. The track supervisor gets off the track at Peach Springs (MP 465.8).

The BNSF Operations Center notifies the Mohave County Sheriff’s

Department of the accident.

6:06 a.m. The Kingman Fire Department responds to a request for aid from the

Mohave County Sheriff’s Department.

6:15 a.m. The Kingman Regional Medical Center is notified of the accident. The

first emergency response personnel arrive on scene. The BNSF notifies

the U.S. Coast Guard National Response Center of the accident.

6:16 a.m. The command post is established.

6:17 a.m. The Kingman Fire Department requests mutual aid.

6:18 a.m. The fire department notes multiple injuries and no trapped victims.

6:19 a.m. The BNSF reports the accident as noted to the U.S. Coast Guard

National Response Center.

6:20 a.m. The first reports cite up to 300 injured. The Mohave County Sheriff’s

Department reports two unconfirmed fatalities to the BNSF ROC.

6:45 a.m. The Mohave County Sheriff’s Department reports two fatalities on the

top deck of the first car and six fatalities on the lower deck to the

BNSF ROC. The fatality situation is reported by the BNSF to the

Federal Railroad Administration and the Safety Board.

6:56 a.m. Passengers begin to arrive at the hospital.

7:00 a.m. (9 a.m. EDT) The Safety Board Investigator-In-Charge is notified by

the chief of the Railroad Division of the accident and of the 8 to 13

fatalities. Launch procedures are enacted.

9:10 a.m. The last passenger is transported from the scene.

10:00 a.m. (12 p.m. EDT) The Safety Board is informed that the news media is

reporting no fatalities.

11:00 a.m. The last passenger is admitted to the Kingman hospital.

4:20 p.m. The Safety Board team from the D.C. office arrives on site (time

approximate).
Appendix B 87

LAYOUT OF THE SELIGMAN SUBDIVISION

89

Appendix C—Applicable BNSF Instructions

Excerpt from BNSF System Special Instructions for All Subdivisions No. 2 in Effect at

0001 Central, Mountain, and Pacific Continental Time, Saturday, March 1, 1997

35. Excessive Wind, Tornado, and Earthquake Instructions

Excessive Wind Instructions:

When weather bulletins forecasting high winds are received in the Network Operations

Center, the train dispatcher will notify all trains in the area, giving the time and limits of the

expected high winds.

When notified that winds are forecast to be in excess of 60 MPH in the area, all trains

except loaded unit coal and grain trains must stop during the time and within the limits

stated.

Tornado Watch and Warning Instruction

Tornadoes are the most violent of all storms. Paths of destruction range from a few hundred

feat in width to more than a mile and extend the length of a city block to 300 miles. The

greatest potential for such storms exist usually from April through September.

A "tornado watch" means atmospheric conditions are such that tornadoes may develop.

A tornado watch is generally issued 4-6 hours before the conditions may occur.

During a tornado watch, all train movements and yard activities will continue, keeping alert

for any signs of weather change. The danger signs to look for are severe thunderstorms,

hail, roaring noise, a funnel cloud or combination of the above. The radio on a locomotive

or a pakset should be used to monitor instructions and information to and from the train

dispatcher. In the want a crew spots a funnel cloud, the train dispatcher should be

immediately notified, consistent with the crew’s safety.

If a train or yard assignment has an occupied caboose, upon being notified of a tornado

watch, the occupants of the caboose should immediately move to the locomotive consist.

While in the process of moving to the locomotive, if the tornado watch turns into a "tornado

warning”, or a funnel cloud is spotted, those affected should seek shelter in a nearby ditch,

ravine, culvert, under abridge or in a depression. If none of these are available, lie face

down on the ground with hands over the head away from the caboose or cars in the train.

A "tornado warning" means a tornado has been sighted or verified by the National Weather

Service or by persons associated with official weather spotters. The train dispatcher will

keep trains and crews appraised of limits of tornado warnings. Train crews are to follow

instructions as follows:

During a tornado warning, all train movements and yard activities must stop. Any train

enroute will stop and employees should seek appropriate shelter consistent with the safety

of all involved, avoiding the stopping of strain on a high bridge, across railroad and highway

crossing at grade, or anywhere the presence of a train could be a hindrance.

After the tornado warning has been cleared and such information has reached the train

crews, if the path of the tornado crossed the tracks at their location or in the immediate

vicinity, crew members must inspect their train before moving to determine if any damage

or derailment has occurred to the train or if the track structure has been damaged. After

inspecting the train and track, and the train dispatcher has relayed the limits of the tornado's

path, the train may proceed, prepared to stop when approaching bridges, culverts, or other

points likely to be affected. The train dispatcher must be advised immediately of such

conditions.

(Continued next page.)
Appendix C 90

Excerpt from BNSF System Special Instructions for All Subdivisions No. 2 in Effect at

0001 Central, Mountain, and Pacific Continental Time, Saturday, March 1, 1997

(Continued from page 89.)

Earthquake Instructions:

When an earthquake is reported, the train dispatcher will do the following:

1. Instruct all trains within 150 miles of the reporting location to “proceed at restricted

speed due to earthquake conditions.” An acknowledgement must be obtained from

each train or engine receiving these instructions.

2. Once magnitude and epicenter are known, the following inspection criteria apply:

If magitude is less than 5.0: - no inspection is required.

If magnitude is 5.0 or greater:

-Response will depend on the group of states and provinces within which the

epicenter is located and the following criteria will apply within the designated radius

from the epicenter:

Group 1: California and Baja California, Mexico

Group 2: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah and

Wyoming; Alberta, Canada and Chihuahua, Mexico

Group 3: All other states (includes area east of Group 2, Oregon, Washington and

British Columbia)

Magnitude Criteria for Response Group 1 Group 2 Group 3

Range Radius Radius Radius

5.0 to 5.49 Trains proceed at restricted speed until signals 30 miles 40 miles 70 miles

have been inspected

5.5 to 5.99 Trains proceed at restricted speed until signals, 30 miles 40 miles 70 miles

track and bridges have been inspected

6.0 to 6.49 Trains stop until signals, track and bridges 50 miles 80 miles 150 miles

have ben inspected

6.5 to 6.99 Trains stop until signals, track and bridges 70 miles 140 miles 220 miles

have been inspected

7.0 to 7.49 Trains stop until signals, track and bridges 100 miles 300 miles 400 miles

have been inspected

7.5 and Trains stop until instructed to proceed after inspection As As As

Above of track, signals and bridges completed directed * directed * directed *

* Radius at discretion of the command center but not less than for magnitude 7.0 to 7.49
Appendix C 91

BNSF Maintenance Alert procedures relating to possible flash floods,

issued August 10, 1997
Appendix C 92

BNSF Maintenance Alert procedures relating to possible flash floods,

issued February 20, 1998
93

Amtrak -- National Railroad Passenger Corporation, v

ATS -- automatic train stop, 22

ATSF -- Atchison, Topeka and Santa Fe Railway, 12

BNSF -- Burlington Northern Santa Fe Railway, 1

CFR -- Code of Federal Regulations, 13

CIP Capital Improvement Program, 19

CP -- control point, 22

CTC -- Centralized Traffic Control, 24

CWR -- continuous welded rail, 9

EIE -- engineer-induced emergency, 24

EMS -- Emergency Medical Services, 36

EOT -- end-of-train, 40

FED -- failed equipment detector, 22

FRA -- Federal Railroad Administration, 9

GE -- General Electric, 14

HWD -- high water detector, 22

IFC -- Integrated Function Computer, 39

MDT -- mountain daylight time, 1

MHC -- material handling car, 1

MP -- milepost, 5

NOC -- BNSF Network Operations Center, 5

NWS -- National Weather Service, 30

P.R.E.P.A.R.E. -- Passenger Railroad Emergency Preparedness And Response

Education., 37

PCM -- Permanent Core Memory, 40

PCMCIA -- Personal Computer Memory Card Industry Association, 39

PCS -- pneumatic control switch, 39

ROC -- BNSF Resource Operations Center, 5

Route 66 -- Arizona State Route 66, 15

RWP -- Roadway Worker Protection, 71

TLEM -- trainline-induced emergency, 24

WDI -- WeatherData, Inc., 27