PB96-916305

NTSB/RAR-96/05

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON,

RAILROAD

DC 20594

ACCIDENT REPORT

DERAILMENT OF FREIGHT TRAIN H-BALT1-31

ATCHISON, TOPEKA AND SANTA FE RAILWAY COMPANY

NEAR CAJON JUNCTION, CALIFORNIA

ON FEBRUARY 1, 1996

6675A
Abstract: On February 1, 1996, Atchison, Topeka and Santa Fe Railway Company freight train HBALT1-31 derailed at milepost 60.4 near Cajon Junction, California. The conductor and the brakeman

sustained fatal injuries; the engineer incurred serious injuries. A fire resulting from the derailment and

subsequent rail car pileup engulfed the train and adjacent areas.

The major safety issues discussed in this report are the lack of Federal and management oversight in the

use of two-way end-of-train devices, the adequacy of operating personnel training in the use of two-way

end-of-train devices, the carrier compliance with Federal regulations for event recorders, and the

adequacy of wreckage removal operations for tank cars containing hazardous materials. The report also

discusses safety issues relating to standards for brake pipe configurations, crashworthiness and occupant

survivability, and emergency response and evacuation.

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

the Burlington Northern and Santa Fe Railway Company, Federal Railroad Administration, Association of

American Railroads, International Association of Fire Chiefs, and Chemical Manufacturers Association.

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.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, SW

Washington, DC 20594

(202) 314-6551

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) 487-4600
NTSB/RAR-96/05 PB96-916305

DERAILMENT

OF ATCHISON, TOPEKA AND SANTA FE

RAILWAY COMPANY TRAIN H-BALT1-31

NEAR CAJON JUNCTION, CALIFORNIA

FEBRUARY 1, 1996

RAILROAD ACCIDENT REPORT

Adopted: December 11, 1996

Notation 6675A

NATIONAL

TRANSPORTATION

SAFETY BOARD

Washington, DC 20594

iii

CONTENTS

EXECUTIVE SUMMARY........................................................................................................... v

ACRONYMS ................................................................................................................................ vi

INVESTIGATION

Accident Narrative........................................................................................................................................ 1

Emergency Response.................................................................................................................................... 7

Injuries....................................................................................................................................................... 10

Damages ..................................................................................................................................................... 10

Traincrew Information................................................................................................................................ 10

Traincrew End-of-Train Device Training................................................................................................... 11

Train Information ....................................................................................................................................... 12

Track and Signal Information..................................................................................................................... 14

Operations Information............................................................................................................................... 15

Meteorological Information........................................................................................................................ 17

Medical, Pathological, and Toxicological Information.............................................................................. 18

Survival Aspects ......................................................................................................................................... 18

Postaccident Train Examination................................................................................................................. 18

Wheel Sets............................................................................................................................................ 18

Train Line............................................................................................................................................. 18

Tank Cars ............................................................................................................................................. 19

Tests and Research ..................................................................................................................................... 21

Signals.................................................................................................................................................. 21

Event Recorder..................................................................................................................................... 21

Train Line............................................................................................................................................. 23

End-of-Train Device ............................................................................................................................ 24

Head-End Device ................................................................................................................................. 24

Train Dynamic Analysis Simulation.................................................................................................... 25

Metallurgical ........................................................................................................................................ 25

Hazardous Materials Information............................................................................................................... 28

Chemical Release................................................................................................................................. 28

Chemical Product Descriptions............................................................................................................ 28

Local and State Emergency Response Agency Notifications.............................................................. 29

Chemical Shipper Notifications........................................................................................................... 30

Derailed Tank Car Damage Assessments ............................................................................................ 31

Butyl Acrylate Tank Car ...................................................................................................................... 34

Pipeline Information ................................................................................................................................... 35

Environmental Information ........................................................................................................................ 36

Other Information ....................................................................................................................................... 37

Federal Railroad Administration.......................................................................................................... 37

Atchison, Topeka and Santa Fe Railway Company............................................................................. 38
iv

ANALYSIS

General Factors........................................................................................................................................... 41

Accident Narrative Review ........................................................................................................................ 41

Train Line Continuity Loss ........................................................................................................................ 42

Kinked Air Hose .................................................................................................................................. 43

Closed Angle Cock .............................................................................................................................. 44

Foreign Object or Debris...................................................................................................................... 45

Two-way End-of-Train Device Operation.................................................................................................. 46

Federal Railroad Administration Oversight......................................................................................... 46

Railroad Industry Inaction.................................................................................................................... 47

Management Oversight ........................................................................................................................ 47

Operating Crew Training ..................................................................................................................... 49

End-of-Train Device and Head-End Device Operation.............................................................................. 49

Event Recorder Maintenance and Placement ............................................................................................. 50

Tank Car Performance................................................................................................................................ 54

Hazardous Materials Management ............................................................................................................. 55

Shipper Notification and Coordination................................................................................................ 55

Tank Car Identification ........................................................................................................................ 57

Derailed Tank Car Handling and Damage Assessments...................................................................... 58

Pipeline Operation ...................................................................................................................................... 60

Operator Notification ........................................................................................................................... 60

Operator Response ............................................................................................................................... 61

Environmental Impact................................................................................................................................. 61

CONCLUSIONS ......................................................................................................................... 62

PROBABLE CAUSE .................................................................................................................. 64

RECOMMENDATIONS............................................................................................................ 64

APPENDIXES

Appendix A--Investigation and Hearing .............................................................................................. 67

Appendix B--Qualifications of Hazardous Materials Response Personnel ......................................... 69

Appendix C--Train Consist .................................................................................................................. 71

Appendix D--Federal Railroad Administration Form F-6180-49A ..................................................... 73

Appendix E--Rules and Regulations for End-of-Train Device............................................................ 75

Appendix F--Train Dynamic Analysis Simulation Protocol................................................................ 79
v

EXECUTIVE SUMMARY

About 4:10 a.m. on February 1, 1996,

Atchison, Topeka and Santa Fe Railway

Company (ATSF) freight train H-BALT1-

31, en route from Barstow, California, to

Los Angeles, was traveling westbound on

the ATSF south main track when it derailed

at milepost 60.4 near Cajon Junction,

California. After the derailment and the

subsequent rail car pileup, which involved

five cars containing hazardous materials, a

fire ignited that engulfed the train and the

surrounding area. The conductor and the

brakeman sustained fatal injuries; the

engineer suffered serious injuries.

The National Transportation Safety

Board determines that the probable cause of

the derailment of freight train H-BALT1-31

was an undetermined restriction or blockage

that prevented the traincrew from achieving

and maintaining adequate train braking

force and also the lack of adequate Federal

Railroad Administration and industry,

specifically the Atchison, Topeka and Santa

Fe Railway Company, regulations, policies,

procedures, and standards to consistently

utilize two-way end-of-train devices as a

redundant braking system to protect trains

from catastrophic brake system failure.

The major safety issues discussed in this

report are the lack of Federal and

management oversight in the use of twoway end-of-train devices, the adequacy of

operating personnel training in the use of

two-way end-of-train devices, the carrier

compliance with Federal regulations for

event recorders, and the adequacy of

wreckage removal operations for tank cars

containing hazardous materials. The report

also discusses safety issues relating to

standards for brake pipe configurations,

crashworthiness and occupant survivability,

and emergency response and evacuation.

As a result of its investigation of this

accident, the National Transportation Safety

Board makes recommendations to the

Burlington Northern and Santa Fe Railway

Company, Federal Railroad Administration,

Association of American Railroads,

International Association of Fire Chiefs, and

Chemical Manufacturers Association.
vi

ACRONYMS

AAR Association of American Railroads

ATSF Atchison, Topeka and Santa Fe Railway Company

BN Burlington Northern Railroad Company

BNSF Burlington Northern and Santa Fe Railway Company

Calnev Calnev Pipe Line Company

CHEMTREC Chemical Transportation Emergency Center

CHP California Highway Patrol

CMA Chemical Manufacturers Association

COES California Office of Emergency Services

CPUC California Public Utilities Commission

DOT U.S. Department of Transportation

EPA Environmental Protection Agency

ETD end-of-train device

FRA Federal Railroad Administration

HED head-end device

IC incident commander

I-15 Interstate 15

MM milemarker

MP milepost

NPRM notice of proposed rulemaking

NRC National Response Center

POD point of derailment

ppm parts per million

psi pounds per square inch

psig pounds per square inch gauge

R&H Rohm and Haas Company

RLM receiver logic module

RSPA Research and Special Programs Administration

SBCC San Bernardino (County) Communications Center

SOC System Operations Center

SR-138 State Route 138

TRANSCAER Transportation and Community Awareness and Emergency

 Response
INVESTIGATION

Accident Narrative

About 4:10 a.m., Pacific standard time, on

February 1, 1996, westbound Atchison, Topeka

and Santa Fe Railway Company1

 (ATSF) freight

train H-BALT1-31 derailed near Cajon

Junction, California. (See figure 1.) The point of

derailment (POD) occurred at milepost (MP)

60.4 on the ATSF south main track, southern

California division, Cajon subdivision. HBALT1-31 consisted of 4 locomotives and 49

rail cars traveling from Barstow, California, en

route to Los Angeles with a traincrew of an

engineer, a conductor, and a brakeman. A fire

resulted from the derailment and the subsequent

car pileup, which involved five cars containing

hazardous materials, and the immediate area

was evacuated. The conductor and the brakeman

sustained fatal injuries; the engineer incurred

serious injuries.

Barstow and Los Angeles were the

designated away-from-home and home

terminals, respectively, for all three H-BALT1-

31 crewmembers. The traincrew, having been

off duty for 12 hours 50 minutes, had reported

for duty at the ATSF yard in Barstow at 5 p.m.

on January 31, 1996. They were instructed not

to couple the locomotive consist to the train

because a yard crew was connecting car ATSF

90033, following its repair, to the train cars. Car

ATSF 90033 was joined onto the train as the

16th car from the head end, and the crew then

coupled the locomotive consist to the

westernmost car on the track.

The engineer said that after the locomotive

consist was coupled to the train, a carman

informed the crew that the car department

needed to inspect and to test the air brakes on

 

1

The Burlington Northern Railroad Company (BN)

and the ATSF merged on October 1, 1995, and formed the

Burlington Northern and Santa Fe Railway Company

(BNSF). The BN and the ATSF operated independently

under the BNSF at the time of the derailment.

car ATSF 90033. The test of the ATSF 90033

air brakes was done in conjunction with the

initial terminal air brake test. The engineer

stated that he performed the initial terminal air

brake test with the assistance of a carman, who

was at the rear of the train. The engineer

continued that after the train line2

 was fully

charged with air, about 86 pounds per square

inch (psi), at the rear of the train, he reduced the

train line air pressure by 20 psi and noticed that

the head-end device (HED) indicated that the air

pressure reading on the end-of-train device

(ETD) had decreased accordingly.

Located in the locomotive control

compartment, the HED displays the brake pipe

pressure being transmitted from the ETD on a

digital read out and activates the red rear-end

marker light. This multipurpose receiver will

indicate whether an attempt to “arm” the twoway function on the ETD was successful. When

attempting to arm the ETD, an individual at the

rear of the train tells the engineer the ETD

number, which the engineer enters on the HED

key pad. The individual at the rear of the train

then pushes the test button, and the engineer

waits for the ready-to-arm message to then press

the arm button. The message indicates that the

ETD is armed after the link is made.

The battery-powered ETD is mounted to the

rear coupler on the last car of the train, and an

air hose connects the ETD to the brake pipe.

The one-way ETD has a pressure transducer to

monitor the brake pipe pressure and a flashing

red marker light to protect the end of the train. A

two-way ETD provides the same functions as

the one-way ETD except it additionally has the

capability of venting the brake pipe for applying

 

2

The continuous line of brake pipe extending from the

locomotives to the last car in a train with all cars and their

air hoses coupled. However, the term is often used to refer

to the brake pipe on a single car.
San Bernadino

County

o

 Junction

point of 

for 

Los Angeles

138

San Bernardino

Not to scale

Source: National Transportation Safety Board

Figure I.--Map of California and area of freight train H-BALTI-31 derailment

2
3

emergency brakes. The signal to vent the brake

pipe comes from a starter switch on the HED

controlled by the engineer. The advantage of

applying emergency brakes from the rear of the

train is that any blockage in the brake pipe

would be bypassed and braking would occur at

both the front and rear of the train

simultaneously.

The engineer had waited about 1 minute and

then did a leakage test, noting the train line

leakage was 2 pounds per minute meeting the

requirements under 49 Code of Federal

Regulations (CFR) 232.12. After the leakage

test, the engineer released the train air brakes,

and the air pressure at the rear of the train, as

indicated by the ETD, returned to 86 pounds.

The engineer then informed the carman at the

rear of the train that he intended to make an

emergency brake application to test that feature

of the train brakes. He initiated the emergency

brake application from the automatic brake

valve3

 on the locomotive, and according to the

carman, the emergency brake application

propagated through the train. The engineer

released the brakes, and the air pressure on the

ETD returned again to 86 pounds. One of two

carmen who were near car ATSF 90033 said

that he observed the brakes set and release on

the car during the first part of the air test.

During the air brake tests with the assistance

of the carman at the rear of the train, the

engineer also attempted to arm the two-way

telemetry feature on the ETD. The engineer

stated that he received a "com/test/fail" error

message on the HED on the locomotive during

the ETD arming procedure. He informed the

carman of this error message, and the carman

responded, "Okay." The engineer said that they

had no further conversation about the ETD.

 

3

Draws air from the atmosphere and stores it under

pressure. Reducing and increasing the brake pipe pressure

results in the brakes applying and releasing, respectively,

regardless of how initiated.

Because of a mudslide in the Cajon area, the

ATSF management decided to hold H-BALT1-

31 at the Barstow yard, and the traincrew was

taken off duty at 7:30 p.m. The engineer said

that before leaving the train, he had applied its

air brakes by reducing the brake pipe pressure

by approximately 20 pounds. The engineer

resided in the nearby town of Newberry Springs,

California, and went home; the other two

crewmembers returned to the motel. The

traincrew was recalled for duty at 11:45 p.m.,

and another set and release, initiated from the

head end of the train, was performed on the air

brake system. The braking system was charged

for 3 minutes 6 seconds, and then a 12 psi

reduction was made.

About 1:17 a.m. on February 1, 1996, HBALT1-31 with its 4 locomotives and 45 loaded

and 4 empty rail cars departed Barstow and

proceeded to and stopped for 30 seconds at

Hodge, California, (MP 13.6). The event

recorder data indicated that a 7-pound reduction

was made to the automatic air brakes of the

train. H-BALT1-31continued west and did not

stop until 2:30 a.m. at Victorville, California,

(MP 36.7). The event recorder registered the use

of its automatic air and dynamic brakes. The

engineer said he believed that using the air

brakes to stop at Victorville complied with the

timetable instruction requiring him to make a

"running" air brake test at that location and that

the air brakes were operating properly at that

time also. After 5 minutes 17 seconds at

Victorville, H-BALT1-31 continued on to and

arrived at Summit, California, (MP 55.9) at 3:40

a.m. (The engineer did not recall making a stop

at MP 50.1 [Lugo, California].) The engineer

stopped at Summit by using the train air brakes,

and the train remained there while the crew

waited for a permissive signal permitting them

to proceed westward. The engineer said that the

conductor and the brakeman were sitting in the

cab with him. The engineer stated that after

receiving a permissive signal, he made at least a

10-pound brake pipe reduction, as required by

timetable instruction. The engineer continued

that he moved the three-position cut-out valve

from the freight position to the passenger
4

position.4 At 3:50:08 a.m., the train brakes were

released, the train brake pipe pressure was 86

psi 1 minute 42 seconds later. The throttle went

from zero to one at 3:56 a.m. The engineer said

that both the dynamic and the train brakes

functioned as expected up to and including the

stop at Summit.

The engineer reported that H-BALT1-31

crested and began to descend the mountain and

at Cajon Pass, he applied the dynamic brakes,

“bunching”5

 the train toward the engines. He

also made a first-service brake application by

reducing the brake pipe pressure between 5 and

8 pounds. The engineer noted that the speed of

the train was increasing, and he applied more

braking. The engineer stated that when the train

reached the speed of 18 mph, he and the

conductor were aware that the train was moving

too fast. They were discussing what action to

take when the engineer realized that the speed

had reached between 20 and 21 mph, and he

said that he wanted to “plug it.”6

 The engineer

stated that the conductor said, “No, let’s not

plug it. Let’s make a full set on it, get it

stopped.” The engineer continued that he then

initiated a full-service brake application,

immediately placing the train in emergency. At

this time, the engineer noted that the HED was

reading 81 psi on the rear of the train. He said

that he put the train into emergency and the air

pressure reading did not reduce to zero. The

engineer stated that he radioed the ATSF

dispatcher to warn all traffic ahead that HBALT1-31 was a runaway train.

The engineer recalled that both

crewmembers had stood and then proceeded

down the steps in the cab to a door leading to

 

4

The passenger position is designed for a graduated air

brake release on passenger trains.

5

The rail cars pushing together that occurs when the

slack is taken out of the train.

6

Railroad jargon for placing the train into emergency

application.

the front of the locomotive and that the speed

indicator now showed 45 mph. And he felt the

wind coming through the front door. The

engineer remained in the cab and continued the

attempt to stop the train. The event recorder

registered that the brakes were charged to 40

pounds and reapplied 8 seconds later. The

engineer reversed the engines7

 about 7 seconds

later, felt the lead locomotive tilting to the right,

and then crouched down. The locomotive left

the track on the curve at MP 60.4 about 4:10

a.m. After rolling onto its right (engineer's) side

into a dry creek bed, it slid to a stop on the sand

and came to rest, (see figure 2) without striking

anything, south and west of an ATSF trestle.

(See figures 3 and 4.) The engineer, who had

sustained serious injuries, crawled out of the cab

through the window on the left (fireman's) side

of the locomotive to reach the ground. Then,

hearing someone call on the cab radio, he

climbed back into the cab to answer to the call.

Two local residents arrived at the locomotive

and then assisted the engineer from the cab.

The four locomotives and 45 of the 49 cars

derailed, and H-BALT1-31 was compressed into

a 400- to 500-foot long pileup of cars. (See

figure 5.) Five rail cars in the pileup contained

hazardous materials. (See figure 6.) In addition,

two underground pipelines, which transported

petroleum products, were near the derailment

site. A fire ignited after the derailment, and the

center of the pileup and the surrounding area

were engulfed in flames. Sand in the creek bed

around the derailed cars north of the trestle and

for 0.5 mile south of the trestle was burned. The

conductor and the brakeman, who had sustained

fatal injuries, were found, respectively, partially

buried in the sand 20 feet south and 30 feet west

of the trestle and lying in the burned sand creek

bed 30 feet south and east of the trestle.

 

7

The action in some locomotives seizes the traction

motors, locking the axles.



Formerly Southern Pacific Lines

February 1996

point of derailment If

SR

13s

now Union Pacific

double Tracks

ATSF

back

ATSF

south

track

138

Formerly Southern Pacific Lines

now Union Pacific

Not to scale double tracks

Source: National Transportation Safety Board

track

Figure 7.--Freight train H-BALT1-31 derailment site

8
9

The State forestry and fire protection

department division (service area 38) fire chief10

was dispatched from his residence, 20 miles

from the accident, at 5:15 a.m. and was on scene

at 6:14 a.m. He reestablished the SR-138/I-15

command post at the Mormon Rocks U.S. Forest

Service fire station, which was 1 mile from the

accident scene (see figure 7), at 6:47 a.m. and,

as the Incident Commander (IC), managed the

incident, using the incident command system,11

to its completion. An IC deputy, an incident

safety officer,12 an operations chief, and a

hazardous materials expert were assigned to

assist him. In addition, 33 agencies, representing

Federal, State, county, and local authorities,

with access to resources were available to assist

as consultants.

The South Coast Air Quality Management

District was also at the site of the derailment

taking air and soil samples for analysis. About

12:20 p.m., the management district air quality

test results indicated that the toxins from the

burning wreckage were no longer at a dangerous

level. The IC advised that the roads be reopened

at 2 p.m.; however, SR-138 between I-15 and

SR-2 would remain closed to the public until

noon on February 4 to allow the heavy

construction and emergency equipment to safely

enter and exit the scene for the initial

decontamination and removal of debris. At 2:30

p.m., the IC estimated that approximately 90

percent of the train had burned out and, in a

 

10For qualifications in hazardous materials response,

see appendix B.

11Combined facilities, equipment, personnel,

procedures, and communications operating in a common

organizational structure under management responsible for

assigning resources to effectively accomplish the stated

incident objectives.

12See appendix B for qualifications in hazardous

materials response.

joint decision with others, stopped fighting the

fire. The firefighters monitored the situation and

attempted to cool the rail cars with water while

the cars continued to burn between February 1

and 4.

At 10:30 p.m. on February 4, the State

forestry and fire protection department, together

with the ATSF, identified a damaged derailed

tank car (NATX 82129), containing the

flammable liquid butyl acrylate, that was found

to have an increasing internal temperature.

Because of the potential for the tank car to

explode from the overpressurization, I-15 and

SR-138 were closed again at 11:01 p.m. On

February 5 at 9:44 p.m., the tank car was

ventilated by using plastic explosives and was

no longer regarded hazardous to the public;

therefore, I-15 and SR-138 were reopened at

11:47 p.m. on February 5 to the public. On

February 5, 1996, the State forestry and fire

protection department considered the complete

incident terminated and suspended command

post activities.

The notification of and coordination between

the railroad, emergency responders, and chemical

shippers about the released hazardous materials

and the wreckage clearing operations involving

the tank cars, as well as the environmental

monitoring and impact, are addressed later in the

report.
10

Injuries*

Table 1.--Injuries incurred from accident

TYPE TRAINCREW OTHERS** TOTAL

Fatal 2 0 2

Serious 1 0 1

Minor 0 32** 32

Total 3 32 35

*Based on the injury criteria (49 CFR 830.2) of the International Civil Aviation Organization, which the National

Transportation Safety Board uses in accident reports for all transportation modes.

**21 police officers, 8 California Transportation Department personnel, and 3 civilians.

Damages

Estimates are quoted as of April 23, 1996.

Equipment $ 3,672,294

Track 71,000

Signal 3,000

Environmental 3,734,044

Other 2,017,000

Total $ 9,497,338

Traincrew Information

ATSF records indicated that each

crewmember was qualified on the physical

characteristics of the territory and the operating

rules for trains over the southern California

division. All had attended the instruction classes

in 1995 on the General Code of Operating

Rules.

The 42-year-old engineer was hired on

August 8, 1991, as a switchman and was

promoted to conductor and to engineer,

respectively, on September 18, 1992, and May

7, 1994. He attended locomotive simulator

training in May 1994 and said that during the

training, he had activated the simulator

emergency brakes on several occasions in

response to emergency situations. The ATSF

records revealed that he was administered 157

observed efficiency tests, with one failure, in

1995, and 30 observed efficiency tests, with no

failures, in 1996. The engineer, according to the

ATSF records, underwent and successfully

passed an initial comprehensive physical

examination on July 21, 1991, and his most

recent physical examination before the accident

occurred on July 11, 1994. The engineer

testified that he had not used alcohol or other

drugs, including prescription or over-the-counter

medication before the accident.

Additionally, the engineer reported that he

was not overworked when he departed the yard

at Barstow on the evening before the accident.

(He and his two crewmembers went off duty and

on duty, respectively, at 4:10 a.m. and 5 p.m. on

January 31, 1996. At the time of the accident,

the three crewmembers had been most recently

on duty for about 4 hours 30 minutes.) He said

that he had no deadline for completing the trip.

The engineer stated that with the exception of

the inability to arm the ETD, train operations

had not been affected by mechanical factors. He

reported that he had previously operated trains

over the track where the accident occurred about

200 times and had worked this particular

assignment for about 8 months before the

accident.
11

The 25-year-old conductor was hired on

October 22, 1992, as a brakeman and was

promoted to engine foreman and to engineer,

respectively, on May 27, 1994, and February 18,

1995. He was administered 108 and 20 observed

efficiency tests with no failures, respectively, in

1995 and 1996. The ATSF records also

disclosed that the conductor underwent and

successfully passed a preemployment medical

examination, which included a drug test, on

October 15, 1992.

The 38-year-old brakeman was hired as a

switchman and was promoted to conductor,

respectively, on August 2, 1993, and April 7,

1995. The ATSF administered him 155 and 35

observed efficiency tests with no failures in

1995 and 1996, respectively. According to

ATSF records, he successfully passed a

preemployment physical examination, which

included a drug test, on June 2, 1993.

Traincrew End-of-Train

Device Training

The vice president of operations for the

ATSF stated that the training department is

responsible for developing appropriate

procedures for any task and for distributing the

procedure material to the transportation

department, which provides instruction or

training. The ETD training for operating

personnel before February 1, 1996, consisted of

instructional videotapes; printed operation

procedure material, distributed separately; and

the written instructions presented in the ATSF

general orders and timetables. Round-the-clock

safety meetings also addressed ETD use.

Engineers received additional training at the

ATSF Lenexa, Kansas, training center in the use

of the HED/ETD system, which included, as

part of locomotive simulations training,

activating the emergency braking function.

The H-BALT1-31 engineer testified that he

knew how to arm a two-way ETD before the

accident. The two-way telemetry system must be

armed for two-way operation through an arming

sequence, which establishes the two-way

communications and links the HED to an ETD,

enabling the two to communicate only with each

other and not to conflict with other systems on

other trains. He further testified that his

knowledge resulted from being “verbally

instructed” in 1994 by the manager of training

operations in how the HED and the ETD

functioned as well as from reading written

material in 1995. He added that he had never

seen an ETD training video and was not aware

of any formal ETD training program offered by

the carrier.

The director of train handling and the

superintendent of field operations in San

Bernardino for the ATSF stated that before the

accident, the carrier ensured that its road

foremen understood the correct procedures for

operating a two-way ETD. The road foremen

were evaluated on their ability to instruct

employees who viewed the video that

demonstrated the proper procedures for HED

and ETD operation. Since the accident, the

ATSF has constructed a fully functional

demonstrator that allows hands-on training of

both the control HED and the ETD and requires

all operating personnel to participate in this

training. (Safety Board investigators have

observed the demonstrator at the Barstow

terminal.) This demonstrator is used in addition

to road foremen showing the instructional

videos and answering questions. Feedback and

additional training are still offered, as needed,

and the carrier has created a brochure that

outlines the correct procedures for operating

personnel to follow should further guidance be

necessary. In addition, the director of train

handling stated that since the accident, operating

crewmembers are required to successfully

demonstrate their understanding of arming

procedures in their daily operations.

One ATSF road foreman of engines recalled

asking the engineer assigned to H-BALT1-31

whether he had any problems arming the twoway ETD, and the engineer, according to the

road foreman, had no questions about the device

during that conversation. However, the road
12

foreman was unable to recall when that

conversation had occurred. In addition, the road

foreman had observed the conductor assigned to

H-BALT1-31 successfully arm a two-way ETD

on one occasion in 1995 and stated that the

conductor would have received ETD training in

the engineer training program and ETD

information with a January 1996 train brake

system class. The road foreman said that he was

unable to state whether the brakeman assigned

to H-BALT1-31 had received any training about

arming a two-way ETD or any H-BALT1-31

crewmember had seen the ETD videos.

Before February 1, 1996, the carrier lacked a

procedure to record the training class attendees.

The road foreman stated that although

crewmembers were required to attend various

training classes, they were not required before

this accident to record their attendance. The vice

president of operations said that since the

accident, the carrier has implemented a

comprehensive procedure to document

attendance at the ETD training. The director of

train handling stated that operating employees

are also required since the accident to

successfully demonstrate their understanding of

“arming” procedures in daily operations.

The Safety Board queried several class I

railroads, including the Consolidated Railroad

Corporation, the CSX Transportation Inc., and

the Southern Pacific Lines about the established

(post-March 1996) ETD training programs for

operating personnel. The training methods of

two carriers which responded included a video

presentation and written materials for the

personnel; a third carrier provided a quick

reference guide to its operating personnel. In

addition, one carrier which responded indicated

that it will incorporate arming an ETD into its

efficiency testing program.

Train Information

H-BALT1-31, which originated at Barstow,

was 3,218 feet long with 5,025 trailing tons and

had been formed from the cars of other inbound

trains. It consisted of a 4-unit locomotive, 45

rail cars loaded with miscellaneous

merchandise, and 4 empty freight cars. The

four-unit locomotive included ATSF 157; ATSF

3853; ATSF 342, which was the only unit

equipped with an event recorder; and ATSF

4031. (For a detailed consist, see appendix C.)

The locomotive units were equipped with 26L

schedule brake equipment. The train had at least

the minimum number of operative dynamic

brakes, 102.6 tons per operative brake.13 All

brakes were inspected and operative, according

to an ATSF carman, when the train left Barstow.

The lead locomotive, ATSF 157, was

equipped with a new safety control

compartment, designed in part by the ATSF,

that included a desktop control console on the

right (engineer's) side and two adjustable seats,

one behind the other, for the conductor and the

brakeman on the left (brakeman’s) side. This

control compartment design was introduced on

the ATSF in May 1990. The forward entrance of

the locomotive was a heavy metal windowless

door on the right side of the front wall. This

exterior door opened onto a small vestibule in

which an interior door and two steps led to the

control compartment. The rear entrance had a

door with a fixed upper vertical window at the

right rear of the control compartment behind the

engineer's seat.

The third locomotive unit was equipped with

a Q-tron Ltd. DATACORD 3000 model Q888208/01 event recorder. The Federal Railroad

Administration (FRA) regulations require the

lead locomotive unit on trains operating at

speeds greater than 30 mph to be equipped with

an event recording device. The event recorder

placement, however, did not violate the existing

regulation, according to the FRA, which noted

that 49 CFR 229.135(a) states, “the duty to

equip the lead locomotive may be satisfied with

an event recorder located elsewhere than the

 

13Tons per operative brake is the gross trailing tonnage

of the train divided by the total number of cars having

operative brakes.
13

lead locomotive provided that such event

recorder monitors and records the required data

as though it were located in the lead

locomotive.”

Safety Board investigators found an FRA

form F6180-49A, known as a blue card, on

locomotive unit ATSF 342. On this form is

recorded when certain parts of the engine were

inspected and by whom. (See appendix D.)

According to 49 CFR 229.135(a):

The presence of the event recorder

shall be noted on Form F6180-49A,

under the REMARKS section, except

that an event recorder designed to

allow the locomotive to assume the

lead position only if the recorder is

properly functioning is not required to

have its presence noted on Form FRA

F6180-49A.

The carrier is to note in the remarks section on

this form whether the engine is equipped with

an event recorder. No evidence of this engine

being equipped with an event recorder was on

this form.

Initially, according to the ATSF assistant

vice president for technical training and rules,

the ATSF policy was to equip all evennumbered locomotives with event recorders. An

ATSF study had previously determined that,

with 94-percent probability, at least one event

recorder-equipped locomotive would then be in

every four-unit locomotive consist. (Several

odd-numbered locomotives in the ATSF fleet

were equipped with event recorders.) Beginning

with the delivery of the ATSF class (GE CW44-

9) locomotives, all delivered locomotives were

equipped with event recorders. Both the ATSF

and the BN current policy is that all new,

delivered locomotives have event recorder

capability.

On February 1, 1996, no Federal regulation

required the use of an ETD with the two-way

feature for trains traveling westward through

Cajon Pass. H-BALT1-31 was equipped with a

two-way ETD but had no caboose, and neither

were required. (See appendix E for ETD rules

and regulations.) With the issuance of the FRA

emergency order 18, effective 12:01 a.m., on

February 8, 1996, two-way ETDs were required

for all westbound trains operated by the ATSF

traversing the Cajon Pass. The carrier was

required to ensure that it is possible for the

traincrew to effect a brake application from the

rear of the train by using one of the following

methods: a) a two-way ETD, b) an occupied

helper locomotive, c) an occupied caboose at the

rear of the train, or d) a radio-controlled

locomotive in the rear third of the train.

Three of the 14 tank cars on H-BALT1-31

were empty, and 11 tank cars contained

chemical products. Butyl acrylate (NATX

82129), trimethyl phosphite (GATX 37310),

denatured alcohol (MWSX 29654), and methyl

ethyl ketone (CELX 2374) are classified under

the U.S. Department of Transportation (DOT)

hazardous materials regulations as flammable

liquids.14 Naphtha solvents (ACFX 79907)

were shipped under DOT regulations as

combustible liquid.15 Petroleum oil (ECDX

792140) was classified as a hazardous substance

(environmentally harmful material) by the U.S.

Environmental Protection Agency (EPA) under

the provisions of the Comprehensive

Environmental Response, Compensation, and

Liability Act. Calcium chloride solutions

(ACFX 84070 and ACFX 84855), propylene

 

14As defined at 49 CFR 173.120, flammable liquids

have a flash point of not more than 141o

F or are any

material in its liquid phase with a flash point at or above

100o

F that is intentionally heated and offered for

transportation at or above its flash point in a bulk

container. The flash point is the minimum temperature at

which a liquid gives off vapor within a test vessel in

sufficient concentration to form an ignitable mixture with

the air near the surface of the liquid.

15Any liquid that does not meet the definition of any

other hazardous class and has a flash point above 141o

F

and below 200o

F. As defined at 49 CFR 173.120(b),

certain flammable liquids also may be shipped as

combustible liquids for highway and rail transport.
14

glycol (DOWX 3965), plasticizers (GATX

13571), and petroleum lubrication oil (UTLX

79897) were not regulated under the DOT

hazardous materials regulations.

Eleven of the 12 tank cars that derailed were

DOT specification 111A100W1 or 111A100W3

tank cars ranging in capacity from 8,000 gallons

to 30,000 gallons. The thickness of the tank

shells and tank heads on these tank cars was

typically 7/16 inch, and in one or two instances,

15/32 inch. Eight of these tank cars (DOWX

3965, ECDX 792140, GATX 13571, GATX

18211, GATX 37310, UTLX 41411, UTLX

41424, and UTLX 79897) were insulated and

jacketed. The insulation typically was about 4

inches thick. The steel jackets typically are

about 1/8 inch thick and hold the insulation in

place. None of the 11 DOT specification

111A100W1/3 tank cars were equipped with

head shield protection, but all were, as required,

equipped with vertical restraint couplers. The

remaining (12th) tank car that derailed, NATX

82129, was a DOT specification 105J300W tank

car operating under DOT exemption E-11184

that permitted a safety relief valve set to

discharge at 75 pounds per square inch, gauge

(psig), rather than the required 225 psig. The

tank, with a test pressure of 300 psig, had a shell

thickness of 9/16 inch and heads 19/32-inch

thick. The tank was covered by 4 inches of

fiberglass and 1⁄2 inch of ceramic fiber as

thermal protection and a 1/8-inch steel jacket.

The tank car also had 1⁄2-inch full head shield

protection and vertical restraint couplers.

Car ATSF 90033, the 16th and last car of the

train added in Barstow, was a heavy-duty flat

car, which had been loaded with steel pipe on

January 19, 1996, in East St. Louis, Missouri. It

had end-of-car cushioning devices16 rather than

conventional draft gear behind the couplers. Car

 

16Hydraulic shock absorbers designed to absorb shock

during train yard impacts.

ATSF 90033 was bad ordered17 between

January 22 and 24 in Kansas City, Kansas, for

repairs, which were made to the brake pipe on

the “A” end. The car continued on to Barstow,

where it was bad ordered for the cushioning unit

on the A end and later for damage to the brake

pipe on the “B” end.18 The cushioning unit was

determined to be serviceable by the Barstow

repair track foreman based on FRA criteria, and

a piece of the brake pipe on the B end was

replaced. The replaced brake pipe was 46.5

inches long with a kink on the inboard end. The

brake pipe connected the glad hand hose19 to the

flexible armored hose. The foreman stated that a

59-inch pipe was cut and attached in the same

manner as the hose arrangement found on the A

end of the car. When the foreman was asked

whether he had access to any reference manual

for the air hose arrangement repair on cushioned

underframe cars, he said that no such reference

was available at his facility and that the B end of

car ATSF 90033 was repaired to match its

undamaged A end.

Track and Signal Information

The tracks at the POD MP 60.4 are

designated as south and north tracks. The grade,

approaching and at the POD, is, respectively, a

3-percent and 1.73-percent descending from east

to west. At the POD is a 7-degree 40-minute 59-

second curve. Train turn-over speed was

calculated at a minimum of 70 mph. The south

track, on which the train traveled, was

constructed with 136-pound RE section

continuous welded rail and was laid in 1980 on

concrete ties with Pandrol fastenings. The ties

laid in crushed area 24 granite ballast, extending

8 or more inches below the ties, with full tie

cribs and shoulder ballast, extending 12 or more

 

17Identified by a car inspector as needing mechanical

attention or repairs.

18Rail cars are identifed as having A and B ends. The

hand brake is on the B end.

19A section of the train line system at which the hose

has a quick release coupling.
15

inches beyond the tie ends. The track had been

inspected on the day before the accident by a

qualified track inspector riding a high-rail

vehicle, and no anomalies were noted or

reported. The main track structure, not damaged

or destroyed in the accident, met or exceeded

the FRA minimum requirements for class 4

track.20

The Centralized Traffic Control System from

the computer-assisted dispatching center in

Schaumburg, Illinois, controls train movements

through the section of track at the accident site.

The signals and signal system were checked and

tested 2 days before the accident. An adjustment

was made to the switch circuit controller at MP

62.9; no other anomalies were found or noted.

Operations Information

According to the ATSF, between 70 and 90

trains in both directions pass through the Cajon

area daily. The movement of trains, controlled

by the Centralized Traffic Control System, over

the territory is governed by the ATSF timetable

instructions, operating rules, and general orders.

The ATSF system timetable no. 5, effective

12:01 a.m. April 16, 1995, was in effect at the

time of the accident. Based on the timetable, the

maximum permissible speed for H-BALT1-31

between Summit and Cajon was 15 mph and

between Cajon and San Bernardino was 20 mph.

The timetable contained the following air brake

instructions (see appendix E):

Rule 30.6, 30.7, 30.10, 30.11: All

westward trains at Barstow receiving

an Initial Terminal, Intermediate

Inspection, Application and Release or

Adding Cars Enroute Air Brake Test

must, after completion, initiate an

emergency application of the brakes

 

20At 49 CFR 213.9, maintained to accommodate

passenger and freight trains at maximum allowable speeds

of 80 and 60 mph, respectively.

and determine from end of train device

that brake pipe pressure drops rapidly

to zero.

Rule 30.13: If train is stopped at

Summit for any reason, an automatic

brake application of not less than 10

psi must be made and not released

until ready to proceed.

Rule 30.14: At Summit,

westward....freight trains operating

between Summit and Cajon must make

a running air brake test while passing

Victorville and in doing so determine

the following:

(1) Retarding force of air

brake system.

(2) If equipped with a

functioning ETD, that normal

brake pipe pressure changes

occur at rear of train.

Air brake rule 30.27, as amended, of the

timetable contained instructions for testing a

two-way ETD and verifying its operation. (See

appendix E.) Guidelines for reporting failures of

the ETDs were under rule 67 of the general

orders. The timetable contained no procedure to

follow should the two-way ETD fail the test in

the two-way mode or not be operational.

The director of train handling testified that

after the December 1994 Cajon Pass accident21

at MP 61.55 (see figure 7), the ATSF had

committed to install two-way ETDs and

receiving units on its locomotives, as the

equipment became available from

manufacturers. As a result of the Safety Board

investigation of the 1994 collision, the Safety

Board recognized the following safety

 

21Railroad Accident Report--Rear-End Collision of

Atchison, Topeka and Santa Fe Railway Freight Train

PBHLA1-10 and Union Pacific Railroad Freight Train

CUWLA-10 near Cajon, California, on December 14, 1994

(NTSB/RAR-95/04).
16

accomplishments for ATSF management

implementation:

1. Issue systemwide instructions prohibiting

the use of the feed-valve braking.

2. Expedite the installation and use of two-way

EDT devices.

3. Require an emergency brake application test

for any westbound train that receives an

initial terminal, intermediate, or

application/release test or that has cars

added at Barstow.

4. Require each westbound train operating on

the Cajon subdivision to make a running air

brake test according to the rules before

descending Cajon Pass.

5. Establish an additional assistant

superintendent of field operations position

and two additional manager of training

operations positions to ensure compliance

with the above train handling and testing

rules.

6. Inventory all rubber air brake parts for outof-date components and removed those with

expired dates.

7. Suspend temporarily the operation of fivepack double stack trains down grades of 3

percent or more.

8. Issue temporary instructions requiring

helper locomotives on train consists of fivepack double-stack cars that exceed over 100

tons per operative brake and 250 tons per

dynamic brake on the north Cajon track and

80 tons on trains on the south Cajon track.

In a letter to the Safety Board, dated October

30, 1996, the ATSF noted that the following

management processes for operations had been

implemented since December 30, 1994, and

before February 1, 1996:

1. Before departure, trains, which have been

made up or had power changes in Barstow,

are placed in emergency braking to verify

brake operation.

2. En route, between Lenwood, California,

(MP 6.7) and Lugo, running air brake tests

are made to verify that the brakes are

operational.

3. If the train is stopped at Summit, a minimum

brake pipe reduction of 10 psi is required.

4. To increase management oversight and

assist on-site training, more line supervision

(road foreman of engines) has been added.

5. On the use of ETD two-way mode, training

has been supplemented to include printed

material, increased rule promulgation,

additional road foremen to ride with crews,

and a video featuring two-way operation of

ETDs.

6. Form 1717 (evaluation for engineer

compliance with part 240 recertification)

has been revised to include a test on the

understanding of two-way ETD operation.

7. Additional two-way ETD equipment is to be

purchased, as available from manufacturers.

8. Air brake seminars conducted for engineers

in Los Angeles.

At the time rule 30.27 was amended, the

carrier had not procured enough units to equip

all trains. The director of train handling said that

a crew could, therefore, operate a train down the

grade at Cajon Pass without an operational twoway ETD or other method of initiating an

emergency brake application from the rear of

the train. According to the director of train

handling,

Generally, the operating practices—

anything that affects operations,

pertain to operating practices, we have

a—we offer it and then we propose it

and circulate it around between the

SOC staff and the training center staff,

director of rules.

He added that the executives reviewed the rules

and put their stamp of approval on them before

any one was issued.
17

The vice president of operations stated that

when ATSF began the accelerated purchasing

and installing of two-way ETDs, upper-level

managers had the “intent” to ultimately equip all

westbound trains traversing Cajon Pass with

operational devices. When the vice president of

operations was asked whether any follow-up

procedure was initiated after December 1994 to

ensure that the intent was met, he replied,

Other than the instructions that were

in place, no, there wasn't any other

formalized follow up in terms of

anything done other than what was

done here on the division itself. In

other words, there was nothing done

other than the issuing of the

instructions that we've talked about.

The vice president of operations added that

since February 1, 1996, the ATSF has initiated a

follow-up procedure that ensures front line

management is complying with the intent of

senior management, and he said,

It is mandatory that the train cannot

leave Barstow westbound over Cajon

Pass without a working two-way

device, period. If that device fails in

route prior to descending the grade at

Summit, then the device is either

repaired in route or helpers are added.

And those procedures are enforced

and followed up.

The ATSF has also contracted for a

management follow-up audit.

The operation and display of one- and twoway ETDs were not required under the CFR but

were explained in general order 126, effective

April 16, 1995. (No requirement was in effect

that the two-way feature be operational before

H-BALT1-31 departed Barstow on February 1,

1996.) General order 130, also issued on April

16, 1995, amended general order 126 and stated:

Should conditioning 2-way ETD for

emergency application capability be

unsuccessful, train may still be

operated without 2-way capability as

long as pressure comparison between

control head readout and rear unit

ETD does not exceed 3 psi.

In addition, rule 67 (B) in the general orders

states:

Engineers departing or arriving can

test their ETD display to verify proper

operation of the ETD receiver.

Improper operation must be reported

to the Train Dispatcher and Customer

Quality Support.

Also, under (D) of rule 67:

All inoperative ETDs ETMs [end of

train markers] should be reported to

the mechanical coordinator desk in the

System Operations Center,

Schaumburg, [Illinois] via radio (tone

call-in no.4) or phone (821-6800)

furnishing location, number of device,

train ID or yard engine number.

When the engineer was asked whether he was

aware in Barstow of any instruction explaining

what to do if the two-way ETD was not

operational or of any prohibition to operate a

train without an operational two-way ETD, the

engineer replied, “No, sir.” Also, when asked

whether he had taken a train out of Barstow

without an operational two-way ETD, the

engineer answered, “Yes, sir.”

Meteorological Information

Weather observations at 3:46 a.m. from the

Ontario, California, airport about 14 nautical

miles west of Cajon reported a temperature of

53°F, calm winds, cloudy skies, rain showers,

and fog with 3-mile visibility. According to the

engineer of H-BALT1-31, it was raining at the

time of the accident.
18

Medical, Pathological, and

Toxicological Information

The engineer of H-BALT1-31 was

transported after the derailment to San

Bernardino Community Hospital, admitted on

February 1, 1996, at 5:32 a.m., and released on

February 12, 1996. He suffered multiple

complex facial lacerations and a compression

fracture of the lumbar spine.

Autopsies were performed on the conductor

and the brakeman by the San Barnardino County

Office of the Medical Examiner. The conductor

suffered blunt head and torso injuries, fracture

of the left femur and upper and lower

extremities, and contusions and abrasions. No

evidence of major or blunt force trauma was

found in the autopsy of the brakeman. He

received massive burns, and soot was present in

the upper and lower airways of his lungs. The

toxicology test results for the brakeman revealed

30-percent carbon monoxide saturation.

Blood and urine specimens were taken by

6:23 a.m. on February 1 from the engineer at the

San Bernardino Community Hospital.

Specimens were taken from the conductor and

brakeman by the San Bernardino County Office

of the Medical Examiner by 2:53 p.m. on

February 3. In addition, specimens were taken

from the train dispatcher by 11:05 a.m. on

February 1. The toxicology test results for each

person were negative, with the exception of the

brakeman, whose blood tested positive for ethyl

alcohol at 0.012 w\v percent.

Survival Aspects

The control compartment windows of

locomotive ATSF 157 were broken in front of

the engineer’s seat on the right side (see figure

2), and the acoustical panel behind the seat was

missing. No intrusion was apparent underneath

the cab console, and the console appeared to be

intact and fixed squarely onto its original

mounting. Superficial damage with minor,

localized denting about 6 inches deep and also

abrasion evidence were on the right side of the

cab. The collision post right of the corridor was

bulged about 2 inches inward toward the center

line; the collision post in the rest room on the

other side was unaffected. The roof of the

passageway, although depressed about 2.5

inches, and the walls were intact.

Postaccident Train Examination

Wheel Sets--On February 5, 1996, about

70 pairs of wheels from the derailed

locomotives and cars were recovered from the

wreckage, numbered for identification, and

examined at the accident site. Most wheel sets

could not be matched to any particular car.

Investigators inspected the wheel sets for

discoloration, metal flow, or other evidence of

excessive braking. Wheels with bluing and other

distinct patterns of significant wheel

overheating were discovered during the

investigation.

Train Line--Each car control valve and

brake system responds to brake pipe pressure

changes. A blockage in the train line restricts a

pressure drop beyond the blockage, and the

brakes will not effectively apply. Brakes to the

rear of the blockage will either not apply or

apply weakly. Safety Board investigators

examined the train line for possible sources of

blockage, such as debris or objects, kinked22 air

hose, or a closed angle cock.23 No evidence of

debris or objects blocking the train line was

found because of the wreckage and fire damage,

which also hindered the investigation.

 

22Single sharp bend where interior diameter has

collapsed at bend, thus, restricting or closing passage

through hose.

23Type of a 1.25-inch valve, either ball or plug design,

at both ends of the brake pipe on locomotives and rail cars

and used to control the admission of air to the brake pipe

on individual cars. The free end is angled at 45 degrees and

threaded to receive the air hose nipple.
19

About 60 percent of the structure of car

ATSF 90033 (B end) without trucks was

removed on February 5, 1996, from the

wreckage and examined outside the

contaminated area. Safety Board investigators

found the cushioning device was burned and

still inside the sill. The bottom of the car was

cleared of all attachments including the end-ofcar air brake hose. A bent and flattened pipe

trolley was still attached. No air hoses or

attachments could be found that could be

identified as belonging to car ATSF 90033.

H-BALT1-31 had four other cars, the 5th and

11th through 13th, with some form of cushioned

underframe. Because these cars and their air

hoses were destroyed in the derailment and

subsequent fire, investigators could not

determine whether the cars had kinked air hoses

or any other condition that would have restricted

the train line.

On February 10, 1996, the EPA allowed the

ATSF contractors on site. ATSF supervisors

then notified the subcontracted wreckage

clearing personnel to recover all angle cocks

found at the scene. Two subcontractors were

shown an angle cock on a box car in the debris,

and when they returned to the wreck site

entrance, they noticed a wrecked car (ATSF

92018) along the right-of-way, which had an

attached angle cock. (See figure 8.) The

subcontractors notified the ATSF supervisors

about the angle cock. The supervisors observed

that the angle cock was closed and instructed the

subcontractors to retrieve it. This angle cock,

which was the first of six angle cocks found in

the closed position, was removed,

decontaminated, and given to the supervisors.

Two of the six angle cocks, one later matched

with the B end of car ACFX 84070 and the one

from car ATSF 92018, had sustained no major

damage.

A photograph of car ACFX 84070, taken by

Safety Board investigators on February 3, 1996,

revealed the B end of the car with the angle

cock still attached. (See figure 9.) This

photograph was enhanced at the Federal Bureau

of Investigation photography laboratory and

showed the angle cock in the open position

when the photograph was taken.

The ATSF wrote the Safety Board on

October 7, 1996, about its consultant’s findings

on the car ATSF 92018. The carrier concluded

that according to the findings, the angle cock on

car ATSF 92018 had been “closed prior to the

fire and closed prior to the derailment.” The

Safety Board laboratory noted that this angle

cock was in the closed position when the fire

reached its location.

Tank Cars--Twelve of the 14 tank cars in

the train derailed. (Of the two tank cars that did

not derail, one was empty, and one contained

methyl ethyl ketone, a DOT-regulated flammable

liquid.) Three of the derailed tank cars (ACFX

84855, ACFX 84070, and DOWX 3965) were the

3rd, 4th, and 6th cars, respectively, behind the

locomotives. The other nine derailed tank cars

were between the 26th and 41st cars trailing the

locomotives. Two of the 12 derailed tank cars

(UTLX 41411 and UTLX 41424) were empty. Of

the 10 loaded derailed tank cars, five contained

DOT-regulated hazardous materials, and five held

nonregulated products. (See table 2 for products

and classification.)

The paint and identification marks of the 12

derailed tank cars, except for ACFX 84070 and

ACFX 84855, had been completely burned

away. In addition to the fire and heat damage,

the 12 tank cars sustained extensive impact

damage, which included crushing, deformation,

denting, creases, gouges, tears in the jacket, and

punctures of the head and tank shells.

The 11 DOT class 111A tank cars,

including the seven tank cars with jackets,

collectively sustained extensive impact damage,

particularly crushing and deformation. Six of the

DOT 111A tank cars had longitudinal crushing,

deformation, and flattening that was in excess of

2 feet (between 1⁄4 and 1⁄2 tank car diameter).

One tank car was bent in half around a

circumferential plane at the middle of the tank

car. The tank heads on about six tank cars had

21

punctures and ruptures with dimensions ranging

from a 6- by 14-inch hole to a 5-foot per side

triangular hole. About half of the vertical

restraint couplers were missing, and most of the

stub sills were bent, fractured, or deformed.

Tank car NATX 82129, containing the butyl

acrylate, had indications of exposure to heat and

fire and impact damage over its entire surface.

All paint and identification marks had burned

away. The jacket had dents, tears, and punctures

over the entire surface area, and large sections

of the jacket were missing. The remaining

sections of the jacket were removed by wreckage crews to examine damage to the tank. One

tank head was dented in excess of 4 inches

between the 12 and 1 o’clock positions. The

second tank head had what appeared to be a

small dent at the 8 o’clock position, slightly

inward of the perimeter of the tank head. The

hole in the tank from one of the two shaped

charges was at the 1 o’clock position of the weld

joint between this tank head and the tank shell.

The barrel of the tank had scrape marks and

indications of exposure to heat or fire (metal

discoloration); no other damages were observed

to the barrel of the tank. Both couplers were

intact; however, both had been twisted or bent.

Tests and Research

Signals--Tests for grounds and shorts had

been performed on the signals at Summit, on the

intermediates at MPs 58 and 60, and on the

electrical signals at Cajon, respectively, on

January 12, 15, and 26, 1996. No anomalies

were found. On January 29, 1996, the signal

maintainer for the territory had inspected and

tested the switch circuit controller at Cajon,

MPs 62.8 and 62.9, and nos. 1 and 2. An

adjustment had been made on the circuit

controller at MP 62.9. No adjustments or

anomalies were found at the other locations. The

signal system was checked and tested on

February 5, 1996, after the destroyed rail was

replaced and the track placed back in service.

The system operated as designed; no anomalies

were found.

Event Recorder--The event recording

device from locomotive ATSF 342 was sent

under Safety Board supervision to the Q-tron

facility in Calgary, Alberta, Canada, where it

was tested. (The Safety Board laboratory

engineers received the event recorder and found

that not all fields were recorded.) No speed or

distance data could be calculated from the event

recorder because it had not recorded any wheel

Table 2.--Derailed tank cars with lading

TANK CARS PRODUCTS DOT CLASSIFICATION

ACFX 79907 Naphtha solvents Class 3-combustible liquid

ACFX 84070 Calcium chloride solution Not regulated

ACFX 84855 Calcium chloride solution Not regulated

DOWX 3965 Propylene glycol Not regulated

ECDX 792140 Petroleum oil Class 9-hazardous substance.

GATX 13571 Plasticizers Not regulated

GATX 37310 Trimethyl phosphite Class 3-flammable liquid

MWSX 29654 Denatured alcohol Class 3-flammable liquid

NATX 82129 Butyl acrylate Class 3-flammable liquid

UTLX 79897 Petroleum lube oil Not regulated
22

data during the accident trip. The testing of the

event recorder revealed that it was capable of

recording wheel rotations normally. The axle

generator, which is attached to an axle of the

locomotive, sends a signal to the recorder that

indicates how fast the wheel is rotating. The

generator was found to have been modified to

accommodate a nonstandard connector for the

cable that connects the generator to the event

recorder. A wire used to install the nonstandard

connector was found broken inside the axle

generator housing, and the generator was unable

to produce a signal. Q-tron contacted the carrier

that owned the locomotive as well as the

locomotive manufacturer about the

modification; however, investigators could not

determine who had performed it.

The event recorder on locomotive ATSF 342

indicated that the last download of data had

been performed on December 12, 1994, at the

Q-tron facility. No record of the memory card24

door opening or of memory card removal was

found in the recorder memory. (The opening or

removal will go undetected if occurring with no

power applied to the recorder.) Maintenance

records indicate that the recorder was sent to Qtron for maintenance, following a failed

diagnostics report that indicated a “CARD NOT

PRESENT” (event recorder memory card) flag.

According to the Q-tron maintenance records,

the battery was replaced in the memory card,

which satisfied a subsequent diagnostics test of

the event recorder. In addition, the analog

thresholds for dynamic brake control and

traction motor current at that time were 3

percent and 97 amperes, respectively. The

manufacturer-recommended settings for these

thresholds are about 3 percent and 99 amperes

or less.

 

24Stores a copy of the recorder internal memory and is

removable to facilitate convenient readout of recorded data.

After the last event recorder service at Q-tron

on December 28, 1994, the configuration of the

recorder was changed to the 146 percent and

1,782 amperes thresholds for dynamic brake

control and traction motor current, respectively.

As a result of this change, both dynamic brake

control and traction motor current were recorded

only every 8 minutes. With the manufacturerrecommended settings, the device would record

any activity from these two sources whenever

the thresholds were exceeded.25 The

configuration can be changed with the

appropriate software; however, the manufacturer

recommends that all configuration settings be

set at the factory to preclude such problems as

incorrect threshold settings. Both of these

problems exist for all data on the event recorder.

(The oldest data is dated January 17, 1996, at

11:30 a.m.)

In addition, locomotive ATSF 342 was

equipped with a microprocessor-based Q-tron

event recorder with a self-test function (a small

green light indicated when the system had no

faults). The assistant vice president for technical

training and rules told the Safety Board, “It was

the ATSF understanding with the FRA that this

type of recorder would not require downloading

at quarterly inspection intervals, but would be

required during annual inspections.” The FRA

regional administrator told the Safety Board that

“no such gentlemen’s agreement” was made

with the ATSF about this matter.

Locomotive ATSF 342, according to the

carrier, was assigned to the Corwith, Illinois,

Electro Motive Division shop, where its last

annual inspection was performed on June 12,

1995. No documentation was found in the unit

file about the event recorder for this inspection.

Under 49 CFR 229.25(e) (5),

 

25The thresholds set at the time of the accident would

never be exceeded during normal operating procedures.
23

A railroad’s event recorder periodic

maintenance shall be considered

effective if ninety percent (90%) of

the recorders inbound in any given

month for periodic inspection are still

fully functional; maintenance practices

and test intervals shall be adjusted as

necessary to yield effective periodic

maintenance.

FRA officials indicated that the FRA has no

procedure for monitoring carrier compliance

with the 90-percent rule. The ATSF could not

provide any statistical information about the

pass/fail rate of its quarterly event recorder

inspections. However, in an October 21, 1996,

letter to the Safety Board, the ATSF reported

that event recorder defects generally are

between five and 12 a day and “considering an

active fleet of 1,692 locomotives the defect rate

on October 18, 1996, would be 0.4 percent.”

Train Line--The BNSF provided a copy of

the Santa Fe Angle Cock Arrangement Manual,

revised September 22, 1995, to the Safety

Board. The manual contains over 33 different

air hose arrangements for cushioned underframe

freight cars. No other reference, except shop or

manufacturer drawings, is available as a guide

for the repair or replacement of the air hose

arrangements on the ends of cushioned

underframe freight cars.

Car ATSF 90033 was modified, which

included adding the end-of-car cushioning units,

in January 1976. According to the modification

drawings provided by the ATSF, the 15-inch

cushioning unit travel required a flexible air

hose arrangement at the end of the car to

accommodate the movement of the coupled car

as slack increased or decreased. The flexible

armored hose was bent into a question mark

shape and would curl or straighten with the

movement of the coupler slack. A 14-link, no.

20 chain supported the hose in the middle, as

built, and was attached to the underside of the

metal floor by a bracket bolted around the hose.

The flexible air hose had been moved back

about 3 feet by using two extended pipes

according to the March 1, 1976, ATSF angle

cock and air hose arrangement drawing. The

modified car had a 46.5-inch long pipe, instead

of the, as built, 1-foot pipe, connected to the

glad hand air hose, and a 16-inch long pipe used

in between, instead of the flexible hose attached

directly to, the angle cock by a 45-degree elbow.

These pipes effectively moved the flexible hose

back away from the end of the car. The 46.5-

inch pipe was attached at two locations because

of its length. The end, attached to the flexible

hose, was also attached to a welded bracket

going through a slot in the cover plate and

anchored to the movable cushioning unit. The

other end, attached to the glad hand hose, was

welded onto two loop brackets that were

supported by a bar-type hanger with 15 inches

of travel.

Safety Board investigators examined five

sister cars26 of car ATSF 90033 at San

Bernardino to determine whether 1) cushioned

car hose arrangements are common and

standard, 2) such arrangements may be more

susceptible to kinking, and 3) arrangements met

Federal, AAR, and carrier requirements. None

of the inspected five sister cars had the same

hose arrangement on both ends. Three basic

arrangements, with differences in each

arrangement, were found. Some car ends

appeared to retain the original design with

return springs; others had the modified design

when rebuilt for heavy service; and still others

had a design not identifiable. Several car ends,

such as the B end of car ATSF 90030, had a

longer pipe when compared to the other

inspected cars.

 

26ATSF 90030, 90031, 90032, 90035, and 90036,

which were 89-foot flat cars.
24

The following list compares the air brake

pipe lengths, attached to the glad hand air hose,

on the ends of the five sister cars:

ATSF 90032

B 7.0 inches Return springs

A 45.5 inches No return springs

ATSF 90031

A 22.25 inches Return springs

B 10.5 inches No return springs

ATSF 90036

A 6.5 inches No return springs

B 7.5 inches No return springs

ATSF 90035

B 11.0 inches No return springs

A 11.0 inches Return springs

ATSF 90030

B 45.0 inches No return springs

A 43.5 inches No return springs

According to the senior vice president of the

TTX company of Chicago, Illinois, which owns

and leases over 50,000 rail cars:

There are recommended arrangements

that are shown in the various AAR

manuals that should be followed.

There's -- if you look at angle cock

arrangements and hose arrangements

in cars, I think it's Rule 4 would be the

reference that you would make in the

field manual as an example. There's

probably, if memory services me,

seven or eight different figures that are

in there, depending on the type of cars

to what that configuration should be.

This provides the framework or the

guidelines for those applications. The

end-of-car cushioning units with

hydraulic draft gears typically are

either the trolley arrangement, which

is, I think, S-427, or also an

arrangement which is tied in, where

the bracket to move the hose

arrangement is actually tied into the

hydraulic draft gear itself and moves

with the draft gear.

End-of-Train Device--The ETD found on

H-BALT1-31, manufactured by Pulse

Electronics Inc., was bench tested at the Pulse

facility in Rockville, Maryland. The brake pipe

pressure accuracy; motion detection; marker,

battery, and armed/not armed status; and

emergency activation were all tested and found

to be fully functional within the Pulse

specifications.

Head-End Device--The HED components,

manufactured by Colt Technology, were tested

at the Colt facility in Lee’s Summit, Missouri.

The HED consists of two major components, the

control head (operates the system and displays

the system status) and the receiver logic module

(RLM).

The HED display window on the control

head indicates whether an arming attempt was

successful, and a momentary indication occurs

immediately after the attempt is completed. An

“emergency enabled” indicator constantly lights

when the system is armed and the two-way

communications are reliable. The HED performs

an automatic communications test every 3

minutes when the system is armed for two-way

operation. If four successive tests fail, the

emergency enabled light will flash on the

control head, indicating that two-way

communication is no longer reliable. No

indication of a transmitter failure displays on the

control head when the system is not armed for

two-way operation display. A communications

failure will be indicated on the control head

display only if no data is received from the ETD

for approximately 15 minutes. Both the display

window and the indicator light functioned as

intended during testing.
25

The control head from H-BALT1-31 had a

firmware27 version (12) dated January 16, 1995.

This version does not allow the emergency

brake function to be operated when the control

head is being used for any other function, such

as the odometer, calibrated mile, or train length

functions. Additionally, the control head

displays an “arm now” message whenever the

HED receives an arming request from any ETD,

regardless of the ID code selected armed/not

armed status. If the arming button is pressed

when this occurs, the HED will only attempt to

arm with the ETD that has the selected ID code.

Approximately 430 Colt Technologies HEDs

were in use as of October 22, 1996, as a oneway device only, according to the ATSF, and

none was operated with the “old” firmware

version installed.

The RLM contains three major modules: the

logic, the receiver, and the transmitter. During

the Safety Board testing, the transmitter module

in the RLM from H-BALT1-31 was found to

have an output power of -4 dbm (approximately

0.000350 watt). The design specification for

output power of the transmitter module is 2.0

watts.

Train Dynamic Analysis Simulation--

Safety Board investigators and representatives

from each party to the investigation conducted

28 computer simulations (27 scenarios plus 1

practice run) at Freightmaster, Inc., in Fort

Worth, Texas, on March 19 and 20, 1996. The

scenarios used in the simulations were

developed from the limited event recorder

information, from the dispatcher's Centralized

Traffic Control System signal record log

information, and from the H-BALT1-31

engineer's statements about the accident. Three

simulation scenarios more accurately matched

the actual time from Summit to the POD and the

speeds that the engineer recalled. In these

 

27Computer programming, stored on memory chips,

which can easily be replaced when computer programs are

changed.

simulations, a train line blockage occurred

between the 5th and 9th cars from the engine

consist. (See appendix F for simulation

protocol.)

The last scenario was simulated to determine

whether the train could stop if an emergency

brake was propagated through the entire train

from the automatic brake valve and the

emergency feature on the ETD. To simulate the

train brakes on the head of the train (ahead of

any blockage) being applied from the automatic

brake valve on the locomotive and the brakes on

the rear of the train (behind any blockage) being

applied from the ETD emergency feature that

simulates a single point blockage, the computer

model was set so that no train line blockage

occurred and all train brakes applied in

emergency. The train, at MP 57.82 and

completely on the downgrade, had already

attained a speed of 31.2 mph. The simulation

incorporated full dynamic brakes engaged and

emergency brake application initiated at MP

58.253 at a speed of 27.6 mph. With the

dynamic brake fully engaged, the speed

increased from 31.2 mph at MP 57.82 to 35.6

mph at MP 58.01 and then decreased to 27.6

mph at MP 58.253. At that decreased point, an

emergency brake application was initiated, and

the train stopped at MP 58.435, about 2 miles

short of the POD (MP 60.4).

Metallurgical--The Safety Board sent an

angle cock and a portion of the brake pipe from

car ATSF 92018 plus five other closed angle

cocks found at the accident site to its

Washington, DC, laboratory for examination.

The remaining three closed angle cock valves

from unknown cars were extensively damaged,

and the Safety Board considered no purposeful

information could be gained from their

examination.

The first angle cock was a Sloan model

3050A of the type found on the A end of car

ATSF 92018. (See figure 8.) The valve had a

length of flexible hose attached to the angled

inlet (hose side) with two 45-degree elbows and
26

a short length of brake pipe extended from the

straight inlet (brake pipe side). A portion of the

flexible hose was charred but not obviously

penetrated; the handle on the valve was in the

closed position oriented 90 degrees to the long

body axis; and the threaded end of the brake

pipe was fractured. The pipe fracture was later

matched to a small piece of fractured pipe

threaded into the pipe union that was part of the

brake pipe from car ATSF 92018. In addition,

the exterior paint matched the paint on the valve

and was very similar in color and appearance to

the brake pipe reportedly from the flat car found

under car ATSF 92018.

The valve handle was removed from the

valve body after the formed end of the pivot pin

was ground away and the pin driven out.

Removal of the handle uncovered fine dust and

soot deposited on the body top. The inlets were

visually inspected after the hose, elbows, and

brake pipe pieces were removed from the valve

body. On the hose side of the valve, the inlet

walls and the visible portions of the ball key

were covered in a heavy black layer of soot,

while the surfaces on the pipe side inlet showed

some corrosion products but no soot. The ball

key was removed from the valve body by

rotating the key 45 degrees past the closed stop

and pulling the key upward.

Safety Board investigators later located car

ACFX 84070 in a Fontana, California, salvage

yard. A portion of the draft gear sleeve was

removed where remnants of the angle cock weld

were attached to the car on the B end. As

received, the end fitting from a hose section was

threaded into the hose inlet, and compression

fitting hardware were attached to the brake line

side of the valve. The car attachment “L”

bracket was also attached to the valve body with

a “U” bolt and nuts. The horizontal leg of the

bracket contained a fractured weld that matched

the configuration, orientation, and surface

features found on a fractured weld on the end

sill mounting plate from car ACFX 84070.

A contact pattern and the exterior stoppage

of the painted surface on the threaded end of the

brake pipe (nearest the valve) were consistent

with the pipe being inserted into the

compression fitting on the valve to about a 4-

inch depth. Measurements found that the

threaded adapter inside the fitting was 4 inches

from the brake pipe end of the compression

fitting, which would not allow for significant

engagement of the brake pipe threads to the

adapter if the pipe were inserted to the depth

indicated by the contact pattern.

As received, the valve handle was in the

closed and down position. During manipulation,

the handle was free to lift with only minimal

force, and care had to be exercised to prevent

unwanted movement. The overall exterior of the

valve appeared intact and damage free, except

for mechanical damage in the pivot area of the

handle. Damage was also found on adjacent

areas of the handle and the socket,28 which

appeared consistent with glancing contact from

a foreign object when the handle was fully in

the down position. When this contact was made

is not known. The handle and socket were

removed from the valve by grinding away the

formed heads of the pivot, by positioning pins,

and by driving the pins partially out. The open

and closed stops on the handle, socket, and

valve body were closely examined with no

evidence of significant mechanical contact or

damage uncovered. The paint layer on many of

the stop surfaces was still intact and undamaged.

The inspection of the interior of the hose side

inlet, after removal of the hose fitting, found

corrosion products and darker areas of sooting

on the valve body surfaces. In addition, many

areas containing a light-colored granular

material were visible on top of the corrosion and

sooting, particularly near the key window and in

the female inlet threads. Under magnification,

the granular material appeared consistent with

sand particles. These sand-type particles with

 

28Mechanical fitting between the valve key and the

handle that incorporates the valve position stop lug.
27

the areas of sooting and corrosion were visible.

The surface of the closed valve key had a dark

brass appearance but did not appear to have a

significant surface deposit layer. The brake pipe

inlet side of the valve was inspected without

disassembling the compression fitting. The

surface appeared covered in corrosion products

with no sand-type particles or sooting visible.

The color and texture of the visible surface of

the key in the brake pipe inlet resembled the

visible portion of the key surface in the hose

inlet.

The disassembly of the valve continued with

removal of the threaded key cap on the bottom

of the valve body. Upon removal, a small

amount of water, estimated to be less than a

teaspoon, was found in the preload spring cavity

below the key.29 The cavity contained

significant quantities of a greasy reddish

substance containing corrosion products in the

area around the spring and of sand-type particles

inside the spring inside diameter. When the key

was extracted through the bottom of the valve

body, more moisture was found on the outer

surfaces in the areas that were previously

contacted by valve body. These areas also had a

slight turquoise coloration that faded as the

moisture evaporated. With the outer surfaces of

the key exposed, a fine line of corrosion

products and debris outlined the assembled

locations of the windows in the valve body. The

outlining debris and corrosion lightly adhered to

the surface and could be easily wiped from the

key. The underlying outer surface of the key

was scratched in a circumferential pattern

consistent with the normal rotation directions of

the key. Comparisons of the hose and brake pipe

surfaces of the key found little differences in the

surface coloration or texture between the two

areas or in the pattern of deposits. Large

quantities of light-colored particulate material

were found on the interior surfaces of the key

 

29Preloaded upward by a small coil spring assembled

between the key and the cap.

slot.30 Under magnification, the material

appeared to be clumps of sand particles that

would easily crumble when probed. Removal of

the key from the valve body also exposed

similar clumps of sand clinging to the walls of

the valve at the key slot.

A small sample of the sand material was

collected from the surface of the valve body and

prepared for energy dispersive x-ray analysis.

The spectra, acquired from an area of the sample

containing many particles, indicated that the

majority of the sample was silicon and oxygen

with distinct but much smaller peaks for iron,

potassium, and carbon. Additional spectra of

individual particles found two types of particles

based on composition. The majority of the

particles were silicon- and oxygen-based with

other minor elements consistent with silicon

dioxide sand. The other particle type was mostly

iron and oxygen consistent with iron rust.

For energy dispersive x-ray analysis of the

surface deposits on the key, an approximate

0.25-inch-tall horizontal section was cut from

the hose side of the key, as received, and

examined in a scanning electron microscope.

The section location encompasses regions of the

key that, as received, were exposed in the inlet

window and surrounding areas that were

covered by the valve body. A base metal

spectrum was acquired from a location on the

section that was scraped to remove surface

debris. The spectrum indicated that the key was

a copper alloy containing zinc, iron, tin, silicon,

and possible traces of lead. The area previously

exposed in the hose side inlet window contained

scattered surface particles and many embedded

particles. A spectrum, acquired from an area

encompassing several of the surface particles,

showed an increase in the relative heights of the

 

30Rectangular passageway through the vertical

centerline of the key that, when aligned with windows in

the hose and brake pipe inlets, allows flow through the

valve.
28

iron and oxygen peaks when compared to the

base metal spectrum. Other spectra of the

embedded particles produced significant peaks

of fluorine, iron, silicon, titanium, and

chromium, which is indicative of a Teflon-type

material. The number and size of surface

particles greatly increased in the areas of the

sample segment that were originally hidden by

the valve body. Spectra, acquired at several

locations, found that the iron, oxygen, and

silicon levels were elevated over the base metal

contents. In addition, calcium and chlorine

peaks were detected in some areas and in some

particles.

Hazardous Materials Information

Chemical Release--Of the nearly 224,000

gallons of regulated and nonregulated chemicals

in each of the derailed tank cars, about 198,000

gallons were released or consumed or both in the

fire following the derailment.31 No measurable

amount of the approximately 25,800 gallons of

butyl acrylate in tank car NATX 82129 was

known to be released as a result of the derailment

and fire. The ATSF chief environmental officer32

estimated that 500 gallons of butyl acrylate or

reacted material or both were released from tank

car NATX 82129 after explosive charges were

used to vent and release internal pressure in the

tank car. About 55 gallons of liquid butyl acrylate

were also recovered from the tank car before its

scrapping, and the remaining butyl acrylate was

left in the tank car in a nonliquid state. Nearly

1,000 gallons of propylene glycol were also

recovered from a derailed tank car.

Chemical Product Descriptions--Butyl

acrylate (shipped in tank car NATX 82129) is a

 

31The gallon number of product in each loaded tank

car was estimated as equal to the tank volume.

32See appendix B for qualifications in hazardous

materials response.

clear colorless liquid with a pungent odor used in

the manufacture of polymers and resins for textile

and leather finishes and paint formulations. It has

a flash point of 103 o

F and a flammability range

of 1.3 to 9.9 percent by volume in air. During

storage and transportation, a chemical inhibitor is

added to butyl acrylate to stabilize the material

and prevent an uncontrolled polymerization,33

which can be initiated by excessive heat. Because

polymerization also releases heat, uncontrolled

polymerization may produce a rapid release of

energy with the potential for an explosion in

unvented and closed containers. Inhalation of

vapors can cause irritation to the nose and throat.

Butyl acrylate is highly mobile if released in soil

and may leach to groundwater and will not be

absorbed to sediment or bioconcentrate in aquatic

organisms if released in water.

Trimethyl phosphite (shipped in tank car

GATX 37310) is a clear colorless liquid with a

pungent odor and used as an intermediate product

in the manufacture of pesticides and flameretardant polymers for polyurethane foams. It is

also used as a fireproofing agent in the production

of textiles. Trimethyl phosphite has a flash point

of 60 o

F. Flammability limits have not been

determined. The product is stable but can emit

toxic fumes of oxides of phosphorus when it

decomposes through heat and combustion.

According to the manufacturer34 material safety

data sheet, vapors are not irritating to the skin and

eyes. However, the U.S. Coast Guard Chemical

Hazard Response Information System indicates

that vapors cannot be tolerated “even at low

concentrations” and can cause severe irritation to

the eyes and throat and injury to the eyes and

lungs. Data about the environmental effects were

not available.

 

33A chemical reaction in which two or more relatively

simple molecules combine to form chain-like larger

molecules. It often results in an expansion of the material

and a generation of heat that can cause overpressurization

and rupture of the container.

34Albright and Wilson Americas, Inc.
29

Denatured alcohol (shipped in tank car

MWSX 29654) is a mixture of predominantly

ethyl, methyl, and isopropyl alcohols. The clear

liquid is used in the manufacture of other

chemicals, solvents, antifreeze, and brake fluids.

It has a flash point of 60 o

F and a flammability

range of 3.3 to 19 percent by volume. The

material is stable. Data about environmental

effects were not available.

Local and State Emergency Response

Agency Notifications--Immediately after the

derailment, the ATSF System Operations Center

(SOC)35 in Schaumburg, Illinois, received

telephone notification from the CHP about a train

derailment and explosion near Cajon. According

to the SOC director of service interruptions, the

CHP was notifying each railroad that operates in

the area because it was not certain which carrier’s

train had derailed. The director of service

interruptions then spoke with the director of

network operations (SOC supervisor-on-duty),

who had been with the dispatcher who had been

conversing with the H-BALT1-31 traincrew

about the train braking problems. After speaking

with the director of network operations, the

director of service interruptions realized that HBALT1-31 had derailed and that hazardous

materials likely had been released and involved in

the explosion.

Before the SOC could notify any emergency

response agency, the San Bernardino (County)

Communications Center (SBCC) and the State

forestry and fire protection department command

center had called about 4:20 a.m. to request

copies of the train consist, which included

emergency response information about the

regulated hazardous materials on the train. The

 

35The center controls and monitors all train

movements and also notifies the appropriate Federal, State,

and local emergency response agencies in the event of an

accident within the ATSF system.

ATSF immediately sent, by fax, the consist

copies to the SBCC and the State forestry and fire

protection department command center by 4:32

a.m. While en route to the accident, a State

forestry and fire protection department firefighter

received the consist copy at the department

command center and delivered it to a hazardous

materials specialist at the scene about 5:15 a.m.

The IC indicated that the consist copy and its

emergency response information was available to

him when he assumed his duties as IC. In the

meantime, the SOC had notified the California

Office of Emergency Services (COES), the

National Response Center (NRC), and the

California Public Utilities Commission (CPUC),

whose railroad operations and safety section

oversees rail transportation within the State, at

4:30, 4:38, and 4:45 a.m., respectively.

About 6:17 a.m. the COES, which is

responsible for the notification of other State and

local agencies that have responsibilities or

jurisdiction in a given emergency situation,

notified the Office of the State [California] Fire

Marshal36 pipeline safety and enforcement

division. (The two underground pipelines

adjacent to the accident site about 200 feet north

of the wreckage were owned and operated by the

Calnev Pipe Line Company [Calnev].) A pipeline

safety engineer from the State fire marshal office

was dispatched and arrived at the accident site

about 8:25 a.m. The COES also notified the

CPUC and other agencies, such as the California

EPA, California Department of Fish and Game,

State Water Resources Control Board, and the

regional air and water quality control offices that

have jurisdiction over the environment and the

public health. All of these agencies responded

and sent representatives to the accident scene.

 

36The office is within the California Department of

Forestry and Fire Protection and is the State regulatory

agency for liquid pipelines. Gas pipelines are regulated by

the CPUC utility safety branch of the safety and

enforcement division.
30

Chemical Shipper Notifications--The IC

did not notify or direct that the shippers of the

chemicals on the train be contacted to provide

technical assistance about their respective

chemicals. The IC said that the hazardous

materials specialist at the accident scene had a

technical library available and was able to

provide the needed information about each of the

chemicals involved in the derailment. The IC

stated that he also assumed that the hazardous

materials specialist would verify through the

Chemical Transportation Emergency Center37

(CHEMTREC) that the necessary contacts with

the shippers had been made.

The director of service interruptions said that

after receiving the initial notifications, he and

other on-duty personnel at the SOC discussed the

need to notify and fax CHEMTREC a copy of the

train consist. He stated that because of

miscommunication and confusion within the

SOC, the other on-duty personnel assumed that

he would notify CHEMTREC and fax the

consist; however, he had understood that he

would fax the consist only and that someone

else would make the telephone notification.

Also, he unknowingly used the fax number for

the main office of the Chemical Manufacturers

Association (CMA) instead of the fax number

for the CHEMTREC operations desk. The

director of service interruptions stated that

CHEMTREC had first contacted the SOC for an

update on the conditions at the accident site on

February 1 at 5:32 p.m. and that the CHEMTREC

telephone call provided no indication which

would cause SOC personnel to realize that the

SOC had not previously contacted CHEMTREC.

The mistake was realized between 6 and 7 a.m.

(8 and 9 a.m., central standard time) on

February 2 after the director of service

interruptions received a telephone call from a

manager in the BNSF logistics department in

 

37The center, operated by the Chemical Manufacturers

Association (CMA), was established to provide initial and

immediate information about handling hazardous materials

and other chemicals.

Fort Worth, Texas, who was responding to

customer complaints about the lack of accident

notification. (The logistic department notifies

customers, including chemical shippers, about

incidents or accidents that result in damage or

delays of their shipments. These notifications

are for operational purposes and are not

emergency response notifications.) The director

of service interruptions rechecked the SOC

telephone log, found no entries for the telephone

notification of CHEMTREC, and concluded that

the SOC had not notified CHEMTREC.

CHEMTREC logs indicate that the first report

of the accident was received at 11:01 a.m. (2:01

p.m., eastern standard time) on February 1 from

the California EPA. The California EPA

requested that CHEMTREC assist with

contacting the shippers of the trimethyl

phosphite, butyl acrylate, and the methyl ethyl

ketone.38 CHEMTREC notified the shipper of the

trimethyl phosphite about the accident at 11:08

a.m. and received a call at 11:10 a.m. from a

second California EPA representative requesting

product information on the trimethyl phosphite

and butyl acrylate as well as contacts for the

shippers of these two products.

At 11:18 a.m., the corporate office of the

Rohm and Haas Company (R&H) in

Philadelphia, Pennsylvania, notified

CHEMTREC to confirm that the R&H had two

tank cars involved in the derailment, which were

the cars NATX 82129 and UTLX 79897,

containing the butyl acrylate and the petroleum

lube oil, respectively. The corporate office had

been notified of the accident by the BNSF

logistics manager about 11 a.m. CHEMTREC

provided the contacts for the California EPA to

the R&H and, between 11:18 and 11:30 a.m., also

contacted the shipper of the methyl ethyl ketone.

From its initial notification through February 6,

 

38The three products were not specifically identified in

the CHEMTREC logs. They are presumed to be those

listed from subsequent telephone calls received from the

California EPA and made to the chemical shippers by

CHEMTREC.
31

CHEMTREC continued to provide

communication links and information as

requested by the State emergency response

agencies, chemical shippers, and ATSF.

At 11:45 a.m., the R&H corporate officer

notified the shipping manager at the company

plant, where the butyl acrylate had been

produced, in Deer Park, Texas. The R&H

shipping manager attempted to contact the ATSF

at 12:18 p.m. for information about the status of

the butyl acrylate tank car but failed to reach

anyone. After leaving a message at the ATSF, the

shipping manager contacted CHEMTREC and

was given a California EPA contact. The shipping

manager contacted the California EPA and

expressed concerns about the polymerization of

the butyl acrylate and overpressurization of the

tank car. When the California EPA contacted the

R&H shipping manager about 1:35 p.m. for

information about the butyl acrylate, a R&H

technical expert provided information about the

decomposition and polymerization of the product.

The shipping manager stated that during a

telephone call to the incident command post

about 1:40 p.m., he was told not to send a

hazardous materials response team from the

R&H. The IC, when asked about making such a

statement, indicated that he did not recall making

such a statement and would not have made such a

statement. The IC stated that during the

postaccident critique of the emergency response,

this remark was attributed to a California EPA

representative. (The IC later confirmed that the

telephone number used by the R&H for the

command post was for a mobile communications

center operated by State forestry and fire

protection department personnel at the command

post. Department personnel in the mobile

communications center would bring incoming

information to the IC.) The R&H shipping

manager contacted the command post again about

5:16 p.m. and was informed that no attempts were

being made to extinguish the fire. After repeated

efforts to contact the ATSF and the command

post, the R&H still had no information about the

condition and location of the butyl acrylate tank

car by 4:30 a.m. on February 2; neither telephone

number was answered according to the R&H. At

7:29 a.m., the shipping manager spoke with a

California EPA representative at the accident

scene who advised the shipping manager that the

R&H concerns about the butyl acrylate were

discussed at a command post planning meeting

during the evening of February 1.

A State forestry and fire protection department

hazardous materials specialist, who was

providing assistance at the command center,

contacted the R&H shipping manager about 8:50

a.m. on February 2. The hazardous materials

specialist advised him that the fire was still raging

and that the condition of the butyl acrylate tank

car was unknown, and the shipping manager

reiterated the dangers of butyl acrylate at elevated

temperatures. Following this conversation, the

R&H technical experts in Deer Park faxed to the

command post and the SOC copies of the

material safety data sheet for butyl acrylate and a

statement about the dangers of the butyl acrylate

polymerization and the potential for

overpressurization and a catastrophic tank car

rupture. The R&H statement warned that the

chemical stabilizer no longer functions if the

internal tank temperature reaches 257 °

F and that

the temperature rise in the tank car could result in

a rapid internal pressurization and catastrophic

tank car rupture if a runaway polymerization

reaction occurred. The R&H received

confirmation at 9:47 a.m. that the faxed

information had been received at the command

post. The R&H shipping manager said that he

was advised about 11:04 a. m. by the State

forestry and fire protection department hazardous

materials specialist that all tank cars had lost their

contents and the fire was still raging. The R&H

received no further information on February 2

and 3 about its tank car.

Derailed Tank Car

Damage Assessments--The damage

assessments and handling of the derailed tank

cars were primarily under the purview of three
32

individuals: the ATSF superintendent of field

operations39 for the region encompassing

California, Arizona, and part of New Mexico; the

ATSF chief environmental officer; and the State

forestry and fire protection department battalion

chief who was the incident safety officer. The

ATSF superintendent of field operations was

responsible for the wreckage clearing operation,

including the management and coordination of

equipment and personnel during the process. The

ATSF chief environmental officer is the ATSF

chief officer in areas involving both the

environment and hazardous materials, including

compliance with DOT hazardous materials

regulations. The State forestry and fire protection

department incident safety officer was

responsible for the safety and health of the

emergency response personnel assigned to the

incident and also served as the IC’s representative

at the derailment site. The ATSF superintendent

of field operations was notified of the accident

about 4:20 a.m. on February 1 and arrived at the

accident scene between 5:45 and 6:15 a.m.. The

State forestry and fire protection department

incident safety officer indicated that he also

arrived on scene about 1 hour after the

derailment. The ATSF chief environmental

officer arrived at the scene between 6 and 7 p.m.

on February 1.

After the derailment, rescue teams entered the

derailment site in search of the two missing

crewmembers. The State forestry and fire

protection department incident safety officer, who

accompanied the second rescue team into the site

about 3 or 4 hours after the derailment, observed

that a few tank cars near the locomotives were

leaking but were not involved with fire. He also

noted that four freight cars, including two tank

cars, were still on the track at the east end of the

derailment. The remaining tank cars were at

various angles and depths within the main pile of

burning wreckage.

 

39See appendix B for qualifications in hazardous

materials response.

About noon, the State forestry and fire

protection department incident safety officer and

the ATSF superintendent of field operations were

part of a team that entered from the east end of

the accident site to pull the last four freight cars,

including an empty tank car and a tank car loaded

with methyl ethyl ketone, away from the fire.

After rerailing one set of wheels for one of the

tank cars, the four freight cars were pulled away

from the burning wreckage.

Between 4 and 6 p.m. the ATSF

superintendent of field operations and the State

forestry and fire protection department incident

safety officer conducted a perimeter assessment

of the burning wreckage to ascertain any

immediate hazards and determine a plan of

action. The incident safety officer later stated that

the flames, smoke, and “steam” obstructed their

visibility and that the fire had destroyed many of

the painted numbers and identification marks on

the burning tank cars. The ATSF superintendent

of field operations and the ATSF chief

environmental officer also noted difficulties in

identifying the tank cars because the painted

markings and identification marks had been

burned away. The incident safety officer

observed that because of the massive destruction

of the tank cars, identification of the pressure and

nonpressure tank cars from configurations

specific to each type of tank car was nearly

impossible.

Fire suppression efforts were not initiated

until the evening of February 1, after the missing

crew members had been recovered. Because the

application of foam and water to the burning

wreckage pile failed to lessen the magnitude and

intensity of the fire, the IC resorted to cooling the

periphery of the burning pile, pulling one freight

car out at a time, and then cooling each freight car

down individually. With this approach,

assessment of the damage to the tank cars became

a continuous process. Over February 2 and 3, the

State forestry and fire protection department

incident safety officer, the ATSF superintendent

of field operations, and the ATSF chief

environmental officer made additional

assessments as access to and visibility of the
33

other tank cars improved and as other wreckage

was cleared away. Each of these individuals

stated that most tank cars appeared to be severely

damaged and that others were burning at ruptures

or creases in their tanks.

During the night of February 3 or early

morning of February 4, one of the tank cars that

had been removed and isolated from the

wreckage pile on the evening of February 3 began

to vent puffs of smoke at irregular intervals. The

night operations chief advised the IC of this

situation about 6:30 a.m. when he arrived at the

incident command post, and the IC ordered the

derailment site to be evacuated. The State forestry

and fire protection department hazardous

materials specialist advised the R&H technical

experts in Deer Park about the venting tank car at

8:55 a.m. and the possibility that it might be the

butyl acrylate tank car. The R&H experts faxed a

picture of the type of tank car containing the butyl

acrylate and recommended an immediate 1\2-mile

evacuation, which was ordered and in progress by

9:10 a.m. The R&H shipping manager received a

telephone call at 9:25 a.m. from an employee of

an environmental contractor for the ATSF.

According to the R&H, the environmental

contractor stated that he was at the accident scene

and confirmed that “the car” was venting and

flaming. In response to the contractor’s request

for information about the butyl acrylate, the

shipping manager stated that information had

previously been faxed to the incident command

post. At 9:30 a.m., the R&H dispatched a

hazardous materials response team to the accident

scene.

Because of the uncertain identity of the

venting tank car, the IC decided to determine the

identity of that tank car and the status of the other

tank cars. The State forestry and fire protection

department incident safety officer, the ATSF

superintendent of field operations, and the ATSF

chief environmental officer entered the

derailment site about 10 a.m. to survey the

damaged tank cars and to map the car locations.

The ATSF superintendent of field operations later

testified that they mapped the location of 13 tank

cars: 10 “low pressure” tank cars and 3

“pressure” tank cars. The incident safety officer

recognized the venting tank car as the propylene

glycol tank car, which he had seen before the tank

car was involved in fire and while the numbers

and identification marks were still readable. The

three members of the survey team determined that

the butyl acrylate tank car and the trimethyl

phosphite tank car remained on the top of the

wreckage pile. According to the incident safety

officer, the tank car later determined to contain

the butyl acrylate was in the middle of the

wreckage pile with one end pointing upwards at a

60-degree angle, and from a distance of 70 feet, a

large rupture appeared to be toward the end of the

tank pointing in the air. The incident safety

officer believed that this tank car was the same

tank car that he had seen the previous evening

burning and venting. All of the other derailed

tank cars had been removed and isolated from the

burning wreckage pile. The ATSF chief

environmental officer and the ATSF

superintendent of field operations confirmed that

those tank cars that had been removed from the

pile were breached or had severe damage.

According to the IC, the incident safety officer,

the ATSF chief environmental officer and the

ATSF superintendent of field operations

immediately reported to him that the tank cars

containing product had been breached and were

“for the most part” empty. The IC said that they

had identified the butyl acrylate tank car “with a

high degree of certainty,” but they had not been

able to reach it. According to the IC, they had

spoken with an equipment operator who

reportedly saw a hole in the side of the butyl

acrylate tank car. He added that he and the others

were not aware that the butyl acrylate tank car

was a jacketed tank car.

On the basis of this assessment, the IC lifted

the evacuation about noon and permitted the

wreckage clearing operations to continue. About

the same time, the State forestry and fire

protection department hazardous materials

specialist notified R&H personnel in Deer Park

that the butyl acrylate tank car had been located

and was ruptured. The R&H then advised the

hazardous materials specialist that a R&H

response team was en route to the accident scene.
34

Butyl Acrylate Tank Car--The ATSF

superintendent of field operations, being

responsible for the wreckage clearing operations,

was present when the butyl acrylate and the

trimethyl phosphite tank cars were pulled from

the wreckage pile shortly before dusk on

February 4. He noted that the manway on the

trimethyl phosphite tank car was open and had

smoke and fire damage around it. The

superintendent of field operations stated that the

butyl acrylate tank car was upside down when it

was pulled from the wreckage and was left in that

position. In addition, he did not inspect or direct

anyone else to inspect the butyl acrylate tank car

after it was pulled from the wreckage. The

superintendent of field operations spoke with the

equipment operators who removed the tank car,

and they told him that they were able to pull and

shove the butyl acrylate tank car easily and that it

handled as if it were empty. The superintendent

of field operations concluded on the basis of the

equipment operators’ observations and the fire

and heat damage to the tank car that it was empty.

Because he believed the tank car to be empty, the

superintendent of field operations found no need

either to inspect the tank car after it was removed

and isolated or to consult with other tank car

experts. Although the ATSF chief environmental

officer did not see the butyl acrylate tank car until

either late night on February 4 or early morning

on February 5, he too believed the tank car had to

be empty because the derailment forces were too

great for it to survive and, after being exposed to

intense fire and heat for over 2 derailment days, it

did not vent as he had expected.

After arriving at the accident scene about 5:30

p.m., the R&H response team proceeded to

inspect the butyl acrylate tank car, which they

found nearly upside down with the dome buried

in the ground. After digging dirt away from the

valves in the dome, they recognized a fitting that

was unique to the butyl acrylate tank car and

positively identified the tank car. The response

team members found no apparent holes in it and

assumed the tank was intact.

A temperature gauge was installed on the

external tank surface where the thermal

protection and jacket were missing; its initial

reading was 110 o

F. About 7:30 p.m., firefighters

began to spray the tank car with water, which

initially turned to steam. Within 15 minutes, the

temperature of the tank had fallen to 60 o

F, and

the tank car had cooled sufficiently that the water

no longer changed to steam. By the time the R&H

team briefed the firefighters on the hazards of the

tank car and cautioned them to listen for strange

noises from the tank car, the tank temperature had

increased to 85 o

F. The firefighters reported that

by 9 p.m., gurgling noises could be heard from

the tank car and the temperature gauge read 114

°F. A 0.5-mile evacuation of the derailment site,

including an I-15 and SR-138 closing, was

ordered by 9:30 p.m. (In the meantime, the R&H

dispatched a second response team that arrived at

the accident scene about 7:30 a.m. on February

5.)

About 3 a.m. on February 5, the on-scene

R&H response team members, still hearing

gurgling noises from the tank car, approached the

tank car with infrared thermal imaging equipment

and obtained a localized temperature of 178 o

F at

one end of the tank car. The infrared equipment

was then used throughout the day to monitor the

temperature of the butyl acrylate tank car from a

distance of 200 yards. From that distance, an

initial temperature of 66 o

F at 4:40 a.m.,

representing an average of the entire tank car and

the surroundings, served as a baseline. By 9:28

and 11:03 a.m. and 1:02 p.m., respectively, the

temperature was 90, maximum 104, and 78 o

F.

After the IC consulted with the ATSF, the

R&H, Calnev, and other agencies at the scene, the

IC with their consensus decided about 2:30 p.m.

to have a demolition expert detonate explosive

charges to relieve the pressure on the tank car and

to allow liquid to drain out. The demolition

expert had examined the tank car by 6:15 p.m.,

and the localized temperature had decreased from

178 to 95 o

F. The explosive charges were

successfully detonated shortly before 10 p.m., and

the evacuation was lifted.
35

Pipeline Information

Calnev owns and operates the two

underground hazardous liquid pipelines that are

almost parallel to the railroad tracks at the

accident site. The 14- and the 8-inch diameter

pipelines originate in Colton, California, and

terminate in Las Vegas, Nevada. These pipelines

are laid separately from Colton, the Calnev

operations control center, to pipeline milemarker

(MM) 19 near Cajon Creek and then together to

Las Vegas. The 14-inch pipeline transports

gasoline, diesel, and military JP-8 aircraft fuels

for Las Vegas, the U.S. Air Force, and various

commercial trucking and railroad companies. The

8-inch pipeline transports Jet-A turbine fuel for

McCarran Airport in Las Vegas. At the time of

the accident, the 14- and 8-inch diameter

pipelines each had an operating pressure of 425

psig and were transporting JP-8 aircraft and

turbine fuels, respectively.

Train H-BALT1-31 derailed between pipeline

MMs 24 and 25, and wreckage from the train was

about 200 feet south of the pipelines.

Downstream of the derailment were manually

operated main line gate valves at the Cajon pump

station at MM 25.5 and remote-controlled main

line valves at the California aqueduct at MM 35

for both pipelines. Upstream of the derailment at

MMs 1 and 7 were remotely operated line valves,

which could be opened or closed from the

operations control center, for the 14-inch

pipeline. No remotely operated valves for the 8-

inch pipeline were between Colton and the

derailment site. The elevation of the two pipelines

at the derailment site was about 2,000 feet higher

than at their origin in Colton.

A Calnev engineer learned of the train

derailment at 5:15 a.m. from a radio news

broadcast and then telephoned the incident

command post to determine whether Calnev

pipelines might be near the accident site. The

Calnev engineer notified the Calnev manager of

engineering at 6 a.m. and advised him that, based

on the description of the accident, Calnev

pipelines may be near the derailment site. The

manager of engineering proceeded to the accident

scene and informed the IC of the two Calnev

pipelines about 6:45 a.m. The IC later told Safety

Board investigators that he had been aware of the

two pipelines and knew the types of product each

transported. He stated that because the Calnev

manager of engineering had arrived as the

incident command post at the Mormon Rocks

was being established, Calnev did not need to be

contacted. He said that Calnev would have been

notified had the Calnev manager of engineering

not arrived when he did. The State fire marshal

office also indicated that it was in contact with

Calnev between the time it was notified and the

arrival of its inspector at the accident scene at

8:25 a.m.

Calnev initiated procedures to shutdown its

14- and 8-inch pipelines, respectively, at 6:15 and

6:21 a.m. The remotely operated valves at MMs 7

and 35 for the 14-inch pipeline were closed at

6:47 a.m. from the operations control center. At

same time, a remotely operated valve at MM 26.2

for the 8-inch pipeline was also closed. Calnev

closed the manually operated main line gate

valves for both pipelines at the Cajon pump

station at MM 25.5 by 9 a.m. Calnev personnel

partially marked the location of the pipelines at

the derailment site. In addition, the Calnev

general manager arrived at the accident scene and

consulted with the IC. From the arrival of the

manager of engineering at the incident command

post throughout the duration of the incident,

Calnev had personnel on scene to coordinate with

the IC and to observe and monitor wreckage

clearing operations near the two pipelines. By 4

p.m. on February 1, Calnev had established its

own command post at the Mormon Rocks

incident command post.

By 6 a.m. on February 2, Calnev had marked

the location of the pipelines closest to the

wreckage with stakes and yellow warning tape.

Calnev also checked the depth of cover over each

pipeline, which was, according to the State fire

marshal office, between 3.5 and 6.5 feet. At 1:45

p.m., Calnev began startup procedures for the two

pipelines with the concurrence of Calnev

engineers, the IC, the State fire marshal office,

and the ATSF. Both pipelines were in full

operation by 4 p.m. with operating pressures

between 425 and 500 psig.
36

On February 3, Calnev monitored the

construction of a dirt ramp that provided an

additional 3 feet of cover over the pipelines

before a bulldozer was permitted to cross over the

pipelines to build a berm in the dry creek bed to

divert water runoff from predicted rains. This

activity was completed without incident.

At 10:15 a.m. on February 4, the IC requested

the shutdown of both pipelines after the

evacuation of all personnel from the accident site

because of venting from one of the tank cars. At

the time the pipelines were shutdown, the 14-inch

diameter pipeline contained diesel fuel and the 8-

inch diameter pipeline contained turbine fuel. The

remotely operated valves at MMs 7 (upstream)

and 35 (downstream) on the 14-inch pipeline and

the remotely operated valve at MM 26.2 on the 8-

inch pipeline were closed. Operating pressure at

the Cajon pump station (MM 25.5) was 374 psig.

The manual valves at the Cajon pump station

were closed by 11:05 a.m. Calnev was given

permission about 11:57 a.m. by the IC, with the

concurrence of the State fire marshal office

inspector, to restart the two pipelines. Calnev

personnel resumed monitoring activities at the

accident site at 12:30 p.m., and both pipelines

were back in operation by 1:01 p.m.

No further incidents occurred that necessitated

the shutdown of the two pipelines. The pipelines

were not shut down during the controlled

detonations on the butyl acrylate tank car because

an engineering evaluation determined that the

pipelines could withstand any percussion

generated by the detonation. However, as a

precaution, both pipelines were operating at

reduced flow rates, and diesel fuel, which has

lower volatility and less flammability hazard than

other transported petroleum products, was

injected into the 14-inch pipeline. Calnev

personnel also continued to monitor wreckage

clearing operations until work around the

pipelines was completed.

Environmental Information

A separate incident command group to

oversee the environmental monitoring, cleanup,

and restoration and the worker safety was

established. Participating agencies included the

California Department of Fish and Game, the

State forestry and fire protection department, the

California EPA (department of toxic and

substances control and the railroad accident

prevention and immediate deployment team), the

Santa Ana Regional Water Quality Control

Board, the San Bernardino County Fire

Department (hazardous materials officer), the

California Occupational Safety and Health

Administration, the U.S. EPA, the U.S. Forest

Service, and the Coast Guard strike team. In

accordance with the California hazardous

materials incident contingency plan, the

department of fish and game was the lead State

agency to coordinate and oversee the

environmental response.

On February 1, the ATSF contracted TRC

Environmental Solutions, Inc., to develop work

plans for the environmental response and to

provide air, water, and soil monitoring and

sampling services. The ATSF also contracted

Consolidated Waste Industries to provide

removal services.

Air sampling and monitoring began when the

South Coast Air Quality Management District

had ATSF personnel obtain air bag samples from

the smoke plume at the derailment site and two

other downwind locations between 10:33 a.m.

and 12:30 p.m. on February 1. The preliminary

analysis received at 3:40 p.m. indicated the

presence of hydrocarbons in the low parts per

billion range, which was attributed to the

combustion of the diesel fuel. Two additional air

bag samples were taken at the accident site

between 9 and 9:30 a.m. on February 2. The

analysis of these samples indicated no

concentrations of phosphorus compounds were

above the minimum detection levels and all

hydrocarbon gas concentrations measured in the

range of background concentrations.

Initial field monitoring with hand-held

equipment around the perimeter of the accident

site was performed every 2 hours at four

designated locations on February 1 and 2. Levels

of volatile organic compounds ranged from 3.5 to

5.8 parts per million (ppm).
37

On February 2, three fixed stations to the

west, northeast, and southeast of the accident site

were installed to take readings at 1-minute

intervals on a continuous basis. The monitoring

was interrupted during the events involving the

butyl acrylate tank car on February 5 but was

resumed on February 6. A fourth air monitoring

station was installed on February 6 within the

exclusion zone (the wreckage area in which

personal protective equipment was required).

Rain interrupted the air monitoring at the fixed

stations from February 21 to 27. The monitoring

was resumed on February 27 and was

discontinued on March 1. The average daily

levels of volatile organic compounds at the three

perimeter stations did not exceed 5 ppm, although

individual readings above 5 ppm were recorded

on numerous occasions. The average daily level

of compounds in the exclusion zone exceeded 5

ppm on 3 days. The levels of compounds for

March 1, which provided a measure of

background levels, ranged from 0.8 to 2 ppm at

the four monitoring sites.

Beginning February 1, the ATSF constructed

four earthen dikes across the Cajon Wash

upstream (north) and two dikes downstream

(south) of the derailment site. The upstream dikes

restricted flow through the derailment site, and

the downstream dikes allowed passage of water

while trapping potential floating contaminants

behind the dikes.

Wells supplying drinking water for designated

facilities and residences were tested on February

3 and 4. The ground and the surface water in

Cajon Wash, both north and south of the

derailment, were sampled and tested between

February 3 and March 7 for total petroleum

hydrocarbons, volatile organic compounds,

phosphorus, and heavy metals. The final report of

TRC Environmental Solutions, Inc., on the

environmental response indicates that the incident

command group agreed that neither water supply

wells nor groundwater in the Cajon Wash area

was impacted.

Soil samples from the derailment site and the

areas of Cajon Wash, north and south of the

derailment, were obtained from February 3 to

March 13 and analyzed for total petroleum

hydrocarbons, volatile organic compounds,

semivolatile organic compounds, and phosphorus.

The collection and analysis of surface and

subsurface samples were ongoing as

contaminated areas were identified and excavated

and as the contaminated soil was removed. About

20,000 cubic yards (27,000 tons) of soil were

removed and transported offsite for disposal as of

March 15, when the soil removal was completed.

The wreckage and debris after decontamination

were completely removed from the accident site

by February 27.

On March 13, the incident command group

determined that further air, water, and soil

sampling and monitoring were no longer needed.

The ATSF and the State forestry and fire

protection department met on March 20 to

determine restoration requirements, which

involved the removal of emergency access roads

to the derailment site and the fertilization of the

affected areas. The restoration began and was

completed, respectively, on April 1 and 5.

Other Information

Federal Railroad Administration--

Founded in 1966, the FRA is the regulatory

agency within the DOT that promotes and

enforces safety throughout the U.S. railroad

system and consolidates Federal support for

research and development for rail transportation.

The agency also encourages policies and

investment in infrastructure and technology for

the railroad industry. The FRA mission is to

promote a safe, environmentally sound,

successful railroad transportation system and to

meet the current and future needs of all railroad

passengers.
38

The FRA and the railroad industry have long

been familiar with the technology for the twoway ETD, and before the February 1, 1996,

Cajon Pass accident, the Safety Board had

recommended its use on trains to the FRA.

Following a 1989 run-away train crash in

Helena, Montana,40 the Safety Board had asked

the FRA to require the use of two-way ETDs on

all trains without a caboose.

After its investigation of the December 1994

Cajon Pass accident, the Safety Board

recommended that the FRA separate the twoway ETD requirements from the power brake

notice of proposed rulemaking (NPRM) and

conclude the ETD rulemaking to require their

use on all cabooseless trains. On February 1,

1996, the same day of the H-BALT1-31

derailment, the FRA advised the Safety Board

that it agreed with the recommendation,

intended to separate the two-way ETD issue

from the power brake NPRM, and issue a final

rule as soon as practicable. Following the HBALT1-31 derailment, the FRA issued

emergency order 18, effective 12:01 a.m., on

February 8, 1996, requiring that all westward

trains operated by the ATSF on the Cajon

subdivision between MPs 54.9 and 59.9 have

the capability to initiate an emergency

application of the air brakes from both the head

and the rear of the train.

On February 22, 1996, the FRA met with

railroad industry representatives and obtained a

voluntary agreement from them to furnish by

December 31, 1996, two-way ETDs on all trains

traveling on mountainous grades. The railroad

industry, according to the Association of

American Railroads (AAR), has also agreed to

equip additional required trains with two-way

ETDs by a self-imposed June 1997 deadline.

Still, as of December 1, 1996, the FRA has not

issued its final rule on two-way ETDs.

 

40Railroad Accident Report--Collision and Derailment

of Montana Rail Link Freight Train with Locomotive Units

and Hazmat Release, Helena, Montana, February 2, 1989

(NTSB/RAR-89/05).

Furthermore, immediately after the HBALT1-31 dreailment, the FRA together with

the CPUC conducted an audit of the ATSF train

operations at Cajon Pass and the ATSF

mechanical inspection and repair facilities at

Barstow. The audit involved over 100 FRA and

CPUC inspectors in teams who found, according

to the FRA, process and communications

problems. The FRA worked with the CPUC,

labor unions, and ATSF management to address

the problems and to develop solutions for them.

The audit procedures included group partnership

meetings in which the FRA, CPUC, and ATSF

labor and management discussed safety and

operational concerns. The FRA and CPUC later

conducted two additional audits. The first

follow-up audit, about 5 weeks after the initial

audit, included 56 inspectors, and the second

follow-up audit, about 3 months after the initial

audit, involved more than 40 inspectors.

Atchison, Topeka and Santa Fe

Railway Company--Since the accident, the

ATSF has employed an independent contractor

to audit its management and policies and to

encourage increased feedback from operating

crews to ensure carrier rules and instructions are

being complied with. In a May 1996 letter to the

Safety Board, the ATSF assistant vice president

of technical training and rules advised that the

following actions have been implemented since

February 1, 1996:

Removal of a flange oiler, on the south

track at MP 56.9.

Required that all westbound trains have an

armed two-way ETD before leaving

Barstow. If a two-way ETD loses its

continuity after leaving Barstow,

continuity must be regained or helpers

added to the train prior to passing

Summit.
39

Required that all eastbound trains have

an armed two-way ETD before leaving

Los Angeles. If continuity is lost

between Los Angeles and San

Bernardino, continuity must be reestablished or helper added to train

before passing Baseline.

All crewmembers working the San

Bernardino or Cajon Subdivisions are

required to have “hands-on-training”

in arming and disarming two-way

ETDs.

An eight foot chain link fence with

razor wire was installed on both sides

of the right-of-way between MPs 56

and 54.2 on the Cajon Subdivision.

The fence was also gated at both ends.

Lights were installed between MP 56

and MP 54.2 on the Cajon

Subdivision.

Twenty-four hour manned security has

been provided between Hesperia and

Summit.

The flow chart in the timetable was

revised making it more restrictive, in

the form of having more axles of

dynamic brake for westbound trains

leaving Summit.

Set up a reporting procedure out of

Schaumburg to track problems

encountered with two-way ETD’s.

Also monitor any air brake problems

that develop to a train while on the

San Bernardino or Cajon

Subdivisions.

Smart repeaters [which enhance the

radio signals in remote areas] were

installed at Barstow, Victorville,

Martinez Spur, and Los Angeles to

further ensure uninterrupted

performance between the ETD and

control head on the two-way devices.

Also since the February 1996 accident, the

ATSF has had the event recorders from all

westbound trains over Cajon Pass reviewed at

the end of every trip. It additionally has

instituted a guidance program in which senior

locomotive engineers consult with the junior

engineers and counsel them on train operations

over Cajon Pass. The ATSF and Calnev have

also exchanged lists of their emergency

telephone contacts and numbers. The ATSF has

also added “pipeline operators” as a line item on

its emergency notification checklist for

accidents occurring in California.

On May 15, 1996, the ATSF asked the AAR

to consider affixing a plate, engraved with the

tank car reporting mark and identification

number, on each tank car. The ATSF stated that

an engraved plate would assist in the

identification of tank cars whose painted

markings and numbers have been destroyed by

fire. The AAR tank car committee, after a

discussion at its July 1996 meeting, concluded

that the ATSF proposal would not make a

significant improvement and voted to take no

further action.

41

ANALYSIS

General Factors

Although the H-BALT1-31 engineer

encountered rain at the time of the derailment,

he reported that the weather did not adversely

affect the operation of train. The track had been

inspected by a qualified track inspector on

January 31, 1996, and no defects were noted at

or near the derailment site. The signal system

had been inspected and tested shortly before the

accident, and no defects were indicated; the

postaccident signal testing found no

deficiencies. HBALT1-31 was operating on a

clear (proceed) signal indication, as intended,

and in accordance with the applicable rules and

regulations in effect at the time. The train

crewmembers were qualified to perform their

respective duties and met the off-duty

requirements as specified in the Hours-ofService Act. No evidence of traincrew fatigue

was indicated. The postaccident toxicological

test results for the traincrew and the dispatcher

were negative. The alcohol present in the

brakeman’s blood specimen was attributable to

postmortem microbial ethanol production and

not antemortem alcohol ingestion. Therefore,

the Safety Board concludes that neither the

weather, the track, nor the signal system either

caused or contributed to the derailment. The

train crewmembers were in compliance with the

requirements specified in the Hours-of-Service

Act and were qualified to perform their duties;

no evidence of fatigue was found. Neither drug

nor alcohol use was a factor in the derailment.

The following discussion reviews the

sequence of events leading to the derailment and

examines the lack of Federal and management

oversight in the use of two-way end-of-train

devices, the adequacy of operating personnel

training in the use of two-way end-of-train

devices, the carrier compliance with Federal

regulations for event recorders, and the

adequacy of wreckage removal operations for

tank cars containing hazardous materials. In

addition, three scenarios will discuss possible

circumstances that could have caused a blockage

in the train line of freight train H-BALT1-31.

Accident Narrative Review

ATSF freight train H-BALT1-31, operating

in accordance with the carrier timetable

instruction, was traveling westbound on the

south main track through Cajon Pass. The train

received an initial terminal air brake test at

Barstow and the braking system was functioning

as designed. The train made at least three stops

from Barstow to Summit with no anomalies

reported. The first severe grade that HBALT1-

31 encountered was at Summit. After the train

departed Summit, the engineer engaged the

dynamic braking system as the train crested

Cajon Pass, which would cause braking

concentration to occur on the head end of the

train, forcing the balance of the train to bunch

toward the engine consist. The bunching of the

train would allow the engineer more train

control by compacting its length during the

braking sequence. Allowing the train to stretch

would introduce additional forces to the train

draft gear system. The engineer stated that as he

encountered the severe grade, he felt no brake

reaction as the speed increased and told the

traincrew that he was going to make a fullservice brake application. The engineer said that

he made the full brake application, which

appeared to be futile as the train speed

continued to increase.

The conductor and the brakeman then exited

the cab out of the engineer’s sight and were

either thrown from the engine platform when

the train derailed or jumped just as the

derailment occurred. The engineer remained in

the control compartment at the control stand,

attempting to recover the air system, and he
42

reapplied the full braking system, which again

proved to be a futile attempt. The engineer

unsuccessfully employed all means at his

disposal to slow or stop H-BALT1-31. Now, 13

minutes after the train had left Summit, it

approached the curve at MP 60.4. The loss of

braking power appears to have caused the train

to reach speeds that were equal to or greater

than the rollover speed for the curve a MP 60.4;

thus, H-BALT1-31 left the track, derailing all

but its last four cars.

Locomotive ATSF 157 impacted a relatively

flat sand creek bed and did not strike any

substantial fixed objects or large rocks. This

impact resulted in low decelerative crash forces,

as evidenced by the lack of severe damage to the

exterior structure of the cab, and the control

compartment of locomotive did not sustain any

major intrusion. The structural integrity of the

cab was maintained and provided interior space

for the survivability of the engineer. The

engineer sustained his serious injuries as a result

of striking the interior surfaces of the control

cab when the locomotive rolled onto its right

side and slid along the creek bed. The conductor

suffered his fatal injuries (blunt force trauma to

the head and chest) when he contacted the

ground after jumping or being thrown from the

locomotive or was hit by flying debris from the

derailing rail cars. The brakeman also jumped or

was thrown from the locomotive, but he

received his fatal injuries from the fire. The

absence of any severe head injuries or major

blunt trauma, according to the medical

examiner, may indicate that the brakeman

crawled to the location in the creek bed where

he was found, and afterward the fire eventually

reached him. Therefore, the Safety Board

concludes that had the conductor and the

brakeman remained in the control compartment

cab of the locomotive, they likely would have

survived because the cab survival space was

adequate.

California Department of Forestry and Fire

Protection firefighting vehicles were dispatched

within 1 minute of accident notification, the

initial incident command post was established

34 minutes later, and the first fire engine arrived

on scene 1 minute after that. The forestry and

fire protection department IC responded to the

scene within 59 minutes of his notification and

employed the incident command system

throughout the incident. The seriously injured

engineer was removed by ambulance from the

derailment site within 1 hour 16 minutes. The IC

established the incident command post at the

Mormon Rocks fire station and staging areas,

assigning other forestry and fire protection

department officers and a U.S. Forest Service

chief to assist in managing the accident.

Numerous Federal, State, county and local

agencies were available to address

environmental concerns and provide resources

to the IC. Given the catastrophic size of the

overall train fire and the unknown chemical

hazards with potential risks to firefighters, the

decision not to fight the fire was prudent. The

firefighters continued to cool the burning cars

and extricate them from the pileup, thus

minimizing the risk of injury. Therefore, the

Safety Board concludes that the local emergency

response was timely and adequate, given the

remote location of the derailment, and the IC

acted effectively and managed the incident

successfully to completion without serious

injury to responders, local residents, or officials

at the scene.

Train Line Continuity Loss

The Freightmaster, Inc., train dynamics

analyzer simulation results were consistent with

a blockage or restriction in the train line

between the fifth and ninth cars. This simulation

analysis, based on the event recorder transit time

from Summit to the POD and the calculated

turnover speed of 70-plus mph at the POD,

indicated that with three or more working

dynamic brakes and a minimum of 16 cars

braking, the train would have either stopped or

negotiated the derailment curve without serious

incident. Thus, the simulation results eliminated
43

the 16th car, ATSF 90033, as causing or

contributing to the inability of the train to stop.

The simulation remains a valuable diagnostic

tool, but by itself, is not conclusive. The Safety

Board is aware that the simulations did not have

all data necessary, such as unrecorded speed, to

perform an absolute test and that a change in a

variable would change the outcome of a test.

The simulations also depended upon many

assumptions and conditions that are

uncontrolled in real operating situations. The

exact starting point of the train at Summit and

the engineer’s use of his dynamic braking were

assumed or estimated. However, using the data

that were available, the tests disclose that with

four dynamic brakes and nine cars braking, HBALT1-31 lacked sufficient braking power to

allow it to negotiate the curve at MP 60.4

(POD). Although the simulation results indicate

a blockage near the fifth through ninth cars, the

Safety Board is not convinced that a blockage

could occur only in that area.

Thus, the Safety Board considered the

possibility that one or more factors caused the

loss of continuity to the train line. Because the

evidence involving the loss of train line

continuity was inclusive, the Safety Board

developed three scenarios that might identify a

possible cause for the train line blockage or

restriction that culminated in the derailment of

H-BALT1-31. These scenarios include a kinked

air hose (on a cushioned underframe car), a

closed angle cock, and a foreign object or debris

in the system.

Kinked Air Hose--A crimp or kink in the

air brake hose could block or restrict the train

line. Such a crimp or kink will generally occur

in a worn or damaged hose or in a hose

connected to an unauthorized design or repair.

As H-BALT1-31 began its descent to Cajon, the

slack in the train couplers and draft gear

bunched together. The slack action may have

bent or crimped an air brake hose that pinched

off air flow from the engines to the rear of the

train and resulted in the loss of air brake control.

(Such a phenomenon is empirically attributed

more to cushioned underframe cars than to

conventional draft gear cars.) Because of the

train line relationship to the undercarriage on

cushioned underframe cars, these cars are more

susceptible to incur a kink in their train line.

The movement of the draft system requires that

the train line also be fluid in motion as the rail

car moves. The cushioned underframe cars have

this extra movement to buffer the forces

encountered in the moving car, which offers

more protection for the lading of the car.

Initially, the investigation had focused on the

cushioned underframe car, ATSF 90033, which

was the last car added to the train after the

repair at Barstow. The Freightmaster, Inc.,

simulation later eliminated this car as a source

of a blockage because the car was too far back

(16 cars) in the train to have prevented the

engineer from safely stopping or slowing the

train for the accident curve. The simulation also

indicated that most of the other cushioned

underframe cars (11 through 13) in the consist

were probably not involved. These cars also

were not within the five- to eight-car blockage

or restriction zone that the simulation identified

as necessary to meet the derailment speed, time,

and location.

The fifth car in the consist, SFLC 10005,

was a cushioned underframe car and within the

effective position for a blockage, as identified

by the simulation. However, the derailment

sequence, subsequent fires, and wreckage

movement prevented close inspection of car

SFLC 10005 and precluded constructing a

timely simulation. Car repair records for car

SFLC 10005 showed no history of intermittent

problems indicative of hose kinking or

restriction. Investigators were unable to find any

brake hoses that appeared to have been kinked

or crimped before the accident or that could be

identified to any particular car in the suspect

zone (cars five through eight) of the train.
44

Attempting to determine the likelihood and

frequency of kinked hoses, Safety Board

investigators, therefore, inspected other

cushioned underframe cars. The postaccident

inspection of the five sister cars to ATSF 90033

for condition and design consistency of the endof-car air hose arrangement revealed three

predominate styles of air hose arrangements and

several cars having different arrangements at

each end. Each of the three predominate styles

of air hose arrangement had several customized

subversions. Only a few of the air hose

arrangements, as found on the sister cars,

remained true to the modification drawing

arrangement or the manufacturer drawings. One

of the greater differences between arrangements

was the length of the pipe that attached to the

flexible glad-hand air hose, which varied

between 6.5 and 45.5 inches. The Safety Board,

therefore, concludes that a wide deviation of

end-of-car hose arrangements on cushioned

underframe cars from the approved end-of-car

hose arrangement design is not uncommon and

may induce an air hose to kink in operation and

block or restrict a train line. Consequently, the

Safety Board believes that the BNSF should

inspect the end-of-car hose arrangements on its

cushioned underframe cars and ensure the hose

arrangements match the intended design. In

addition, the Safety Board believes that the

AAR should inform its member carriers about

the circumstances of this accident and alert them

to inspect the end-of-car hose arrangements on

cushioned underframe cars and ensure the hose

arrangements match the intended design.

The ATSF Barstow car shop had repaired the

car ATSF 90033 but had no references or

drawings on which to base the repair of the

brake pipe and the end-of-car hose arrangement

of the car and, thus, made the repair to match

the other end of the car. If a reference of

standardized hose arrangement drawings had

been readily available to the carmen, no

confusion should have existed or questionable

repair have been made to car ATSF 90033. The

Safety Board concludes that had the Barstow car

shop made hose arrangement reference manuals

readily available, the carmen could have used

guidelines to properly repair the train line on

ATSF 90033. Therefore, the Safety Board

believes that the BNSF should provide its

carmen with readily available means to identify

the proper design or specific type of end-of-car

hose arrangement on cushioned underframe cars

to preclude a possible improper repair or

modification. The Safety Board also believes

that the AAR should ensure that its member

carriers provide carmen with readily available

means to identify the proper design or specific

type of end-of-car hose arrangement on

cushioned underframe cars to preclude a

possible improper repair or modification.

A severe grade, such as at Cajon Pass, could

induce a situation in which the bunching of the

train could cause a kink in the air system of a

cushioned underframe car. Before H-BALT1-31

reached Summit, it had operated over terrain

that could have caused the train to bunch.

However, the grades were not as steep as the

one at Cajon Pass, and according to the

engineer, the brakes were functioning as he

stopped H-BALT1-31 at Summit. In addition,

Safety Board investigators were unable to

examine the train line of either car ATSF 90033

or SFLC 10005 for any evidence of kinking

because of the damages incurred from the

derailment sequence and ensuing fire. Although

the first scenario is plausible, sufficient

evidence was not available to make a conclusive

determination.

Closed Angle Cock--The sooting on the

ball key of the Sloan angle cock valve from

ATSF 92018 indicated that the valve was in the

closed position before the fire reached and

charred the attached hose. The hose was still

intact when the valve was removed from the car.

However, other cars that were involved in the

fire sequence had their rubber hoses burned off

completely. Therefore, the rubber hose on the

angle cock from ATSF 92018 did not appear to

be as involved in the fire as did those of the
45

other cars in the train. The accident area was

open to numerous personnel before being roped

off. With this open access, someone could have

had an opportunity to close the angle cock, and

then, the fire reached the car later. Furthermore,

the bending of the handle pivot pin and lug,

which prevented unencumbered movement of

the handle, strongly suggests that the valve was

in the closed position when damaged. The most

likely time for such damage to occur was during

the derailment; however, for damage to occur

during the recovery process cannot be

discounted.

Several previous railroad derailments

investigated by the Safety Board have involved

turned angle cocks from theft and vandalism.41

However, Safety Board investigators found no

material evidence of vandalism in this accident.

The practice of stopping westbound trains at

Summit presents the opportunity for tampering

with a train brake system. During the 16-minute

stop of H-BALT1-31 at Summit, ample

opportunity existed for unknown people to

tamper with any angle cock on any car in the

train. Although the crew saw no one, the

darkness and the open terrain sufficiently

allowed for someone not to be sighted by a

crew.

No definitive physical markers or artifacts as

to the position of the angle cock valve from

ACFX 84070 at impact were uncovered. The

presence of sand inside the key slot and the hose

side inlet demonstrates that the valve was open

when the sand was introduced but does not

establish a time at which it was closed. One

possible scenario is that the valve was open at

derailment, with sand and water being

 

41Railroad Accident Report--Collision and Derailment

of Southern Pacific Train at Garnet, California, August 23,

1986 (NTSB/LAX-86-FR-015) and Railroad Accident

Report--Derailment of Burlington Northern Train at

Spokane, Washington, December 24, 1991 (NTSB/LAX92-FR-006).

introduced during the fire suppression process,

and was closed during the recovery process. In

addition, the Safety Board photograph of car

ACFX 84070 taken 2 days after the derailment

discounted tampering for its angle cock

retrieved in the closed position. This photograph

indicates that the angle cock was in the open

position 2 days after the derailment and provides

evidence that the subsequent change happened

after the accident and not before.

Because of the damage incurred to the rail

cars from the derailment sequence and the

subsequent fire, the Safety Board was unable to

examine the angle cocks on all cars in the

derailment. According to the train simulations,

the blockage would need to have occurred in the

initial 15 percent of the train. The Safety Board

was unable to match any of the other angle

cocks found in the closed position to the first

eight cars in the consist or to find any turned

angle cocks on any of the locomotives or the

first 10 cars in the consist. The evidence was

insufficient to indicate a closed angle cock was

the blockage that resulted in the loss in train line

continuity, causing the derailment. This second

scenario may also be plausible, but again,

sufficient evidence was not available to make a

conclusive determination.

Foreign Object or Debris--The derailment

sequence, ensuing fire, and postaccident activities

prevented a timely examination of the cars by the

Safety Board to find any evidence of debris in the

train line causing a blockage. However, the blockage

of a train line from a foreign object or debris is a

remote possibility, and such occurrences are

relatively rare because of the number of times cars

and trains have air brake tests. The predeparture air

brake tests on H-BALT1-31 at Barstow and the

handling of the train to Summit do not indicate any

debris blockage or restriction. Also, with the length of

time the train was in operation before the derailment

and the constant air pressure in the train line, any

significant debris that could cause a blockage

would likely have been detected by the
46

engineer, who stated that his brakes were

operating up to and including his stop at

Summit. A foreign object or debris suddenly

positioning itself to block the train line appears

very unlikely.

Water may have been introduced into the

train line from cars already contaminated by

poorly maintained air systems or from air at the

Barstow yard. Water contamination may create

local air brake problems within a train line;

however, such contamination generally is unable

to block a train line unless the air temperature is

below freezing. The ambient temperature around

Barstow was not cold enough to freeze any

water contamination in a train line. The cars that

made up H-BALT1-31 had been at Barstow

from 6 hours to several days, which is sufficient

time to melt any ice having formed on the trip

west.

After a thorough and an exhaustive

investigation effort, the Safety Board could not

identify what caused the loss of train line

continuity on freight train H-BALT1-31.

Although the three scenarios offer possible

means for such blockage to occur, no evidence

was found to give credence to one over another.

The most likely event that caused the loss of

train line continuity was an undetermined

blockage or restriction from unknown origins

somewhere in the train line. Because the

blockage origin and location is unknown, any

one possibility or combination of possibilities

could have caused the loss in train line

continuity. Therefore, the Safety Board

concludes that an unknown train line blockage

or restriction, probably between the fifth and

ninth cars, resulted in responsive brakes only on

the locomotive units and possibly the first eight

cars, and, thus, the engineer was unable to slow

or stop H-BALT1-31.

Two-way End-of-Train

Device Operation

An armed two-way ETD offers a key safety

advantage over a one-way ETD because the

two-way feature allows a traincrew to

telemetrically initiate an emergency brake

application from the rear of the train forward.

Emergency braking, employing the train brakes,

propels backward from the locomotive through

the train and is enhanced because similar

braking forces can be concurrently activated

from the rear of the train. Thus, the rapid

reduction of pressurized air from two opposite

moving directions should cause the brakes on all

cars to engage up to and including the point

where any restriction in the train line might be

located. The emergency braking action initiated

from the locomotive without the aid of an armed

two-way ETD would be effective up to the point

that air encountered a blockage in the train line.

Under such circumstances, the amount of

effective braking would be dependent upon

where the restriction occurred in the train line;

the closer the blockage was to the front or rear

of the train, the less braking effort would be

available. Inadequate or nonexistent airflow at

the blockage point would preclude the activation

of emergency brakes on all cars behind the

blockage. Armed two-way ETDs are proven

critical hardware components that can assist a

traincrew during a braking emergency and, thus,

promote a safe operational environment.

Therefore, the Safety Board concludes that had

H-BALT1-31 been equipped with a fully

functioning two-way ETD, the engineer could

have applied the brakes from the rear of train

and the derailment may have been avoided.

Federal Railroad Administration

Oversight--At the time of this accident, no

comprehensive industry guidelines were in

effect for the implementation and the usage of

two-way ETDs or any other methodology that

provides the capability to initiate an emergency

brake application from either end of a train. In

addition, no industrywide directions addressed
47

the issue of the inability to arm an ETD. After

the derailment of H-BALT1-31, the FRA issued

emergency order 18 that addressed the safety

recommendations previously issued by the

Safety Board asking the FRA to require the use

of two-way ETDs on all trains without

cabooses. Had the FRA initiated its February

1996 action after the December 1995 Safety

Board recommendation was issued, this accident

may have been avoided.

The use of two-way ETDs in mountainous

grade territory may have prevented or mitigated

the December 1994 and February 1, 1996,

accidents at Cajon Pass. The Safety Board

concludes that the FRA failure to require the

capability to initiate an emergency brake

application on either end of a train in

mountainous territory after the 1989 Helena,

Montana, accident and its failure to take

immediate action after receiving the Safety

Board recommendation resulting from the 1994

Cajon Pass accident may have contributed to the

cause of this accident in 1996.

Railroad Industry Inaction--When

freight train consists included cabooses, the

capability to apply emergency brakes from the

rear of the train was secured. The railroad

industry has long been aware of the benefits of

having that capability. Cabooses had always

been equipped with an emergency valve that

allowed the conductor to apply emergency

brakes from the rear of the train. Additionally,

they had rear-end marker lights to protect the

end of the train. The conductor and other

crewmembers in the caboose reported the rearend brake pipe pressure to the engineer so he

knew when the air brakes had been applied or

released on the last car. The caboose crew also

inspected the train for dragging equipment, hot

journals,42 or shifted loads. Then, cabooses were

eliminated, and technology replaced those duties

 

42Part of a rail car axle.

of the conductor and brakeman. Wayside defect

detectors now monitor the train for hot journals

or dragging equipment and automatically radio

the data to the engineer. The one-way ETD

provides a red marker light and transmits the

brake pipe pressure to the head-end display. The

only function lacking was the capability of

applying the emergency brakes from the rear of

the train, and the development of the two-way

ETD filled this void.

The Safety Board is pleased with the railroad

industry commitment and progress to voluntarily

install two-way ETDs on all required trains by

June 1997; however, the industry action has

come unduly late. The Safety Board first

addressed the need for two-way ETDs after its

investigation of the 1989 accident in Helena,

Montana. The December 1994 Cajon Pass

accident again highlighted the necessity for twoway ETDs on freight trains. Had the railroad

industry taken voluntary action to adopt twoway ETDs when the need was initially identified

then the H-BALT1-31 derailment might have

been avoided.

Management Oversight--ATSF rule 30.6,

30.7, 30.10, 30.11, 30.13, 30.14 was put into

effect after the December 1994 collision

between two freight trains at Cajon Pass at

almost the same location as this accident. In

March 1995, ATSF senior management wrote to

the Safety Board and agreed to change their

operating practices, which resulted in the above

cited rule. The ATSF senior management also

agreed to implement train use of two-way ETDs

on Cajon Pass as soon as the equipment became

available, which amended ATSF air brake rule

30.27 in the section of the timetable that

contained special instructions for all

subdivisions. (See appendix D.) The amendment

details how a two-way ETD is to be tested and

its operation is to be verified. However, no

instructions were in the timetable about what

actions to take should the two-way feature fail

the test or should the two-way ETD not to be

operational. In addition, the ETD was not
48

required to be operational in the two-way mode

before the train proceeded.

ATSF general orders 67 and 130 address the

usage of the ETD system with no direct

reference to the two-way system. General order

67 states that the engineer must report an

improper operation of the ETD; however,

whether this interpretation was applicable to a

two-way ETD that was still functioning properly

as a one-way device is unclear to the Safety

Board. The ETD on train H-BALT1-31 was

functioning properly as a one-way device, and

general order 130 specifically allows a train to

depart the terminal even when the crew are

unable to arm the two-way system. The engineer

of H-BALT1-31 told Safety Board investigators

that he was not aware of any requirement to

report the inability to arm a two-way ETD

system and, thus, had not reported the improper

operation of the two-way ETD on H-BALT1-31.

He said that he had often operated trains down

Cajon Pass without a functioning two-way ETD.

Other ATSF locomotive engineers who had

operated trains over Cajon Pass told Safety

Board investigators that they also had often

operated trains down the pass without

operational two-way ETDs. Departure from

Barstow with an unarmed two-way ETD was a

common practice that was accepted and

condoned by the local ATSF management. The

Safety Board therefore concludes that the

engineer of H-BALT1-31 was not aware of any

requirement to report the inability to arm a twoway ETD system and, consequently, did not

report the improper operation of the two-way

ETD on train H-BALT1-31 to the train

dispatcher and customer quality support, as

required under rule 67 (B).

Furthermore, the director of train handling

who wrote the amendment to rule 30.27 stated

that instructions for two-way ETDs that failed

the test were covered under general order 130.

He later said that subsequent to the accident that

had occurred in December 1994 on Cajon Pass,

the carrier had committed to purchasing and

installing two-way ETDs as well as installing

HED units on its locomotives as soon as the

equipment became available from the

manufacturers. At the time rule 30.27 was

amended, the carrier had not procured enough

units to equip all of its trains. The director of

train handling added that because of the

procurement circumstances, a crew could

acceptably operate a train down the grade on

Cajon Pass without a functioning two-way ETD

or another method of initiating an emergency

brake application from the rear of the train. The

rule assumed that the engineer has sufficient

braking power to stop or slow a westbound train

through Cajon Pass. Although numerous trains

were departing Barstow and descending the

grade at Cajon Pass without functioning units,

local ATSF officials took no corrective action

because the rule did not require a fully

functional device.

Because of a mudslide in the Cajon area, the

traincrew went off duty, and until they returned,

HBALT1-31 was delayed for departure and was

idle for over 4 hours in Barstow. During that

time, no measures were taken to find the cause

of the com/test fail that the engineer had

received during the arming sequence. The ATSF

took no exception with a westbound train

leaving Barstow yard with an unarmed two-way

ETD, and no procedures were in place to test for

a faulty HED or ETD should a traincrew

encounter a problem in arming an ETD.

The Safety Board understood from the stated

commitment of the ATSF senior management

after the December 1994 accident that the use of

two-way ETDs meant fully functioning devices.

The vice president of operations stated that the

ATSF intent was ultimately to have two-way

ETDs on all westbound trains through Cajon

Pass; however, the final result was a rule that

allowed trains to proceed westward without a

fully functioning two-way ETD. The practice of

allowing westbound trains to depart Barstow

without a fully functioning two-way ETD

should have been evaluated as the equipment
49

became available. In addition, the carrier failed

to assess the risks associated with trains leaving

Barstow without fully functioning two-way

ETDs, and no procedures or guidance were

made available for traincrews in the event they

were unable to arm the system or encountered a

catastrophic system failure en route. Therefore,

the Safety Board concludes that the ATSF

management failed to ensure the use of fully

functioning two-way ETDs on westbound trains

over Cajon Pass.

On December 15, 1995, in Safety

Recommendation R-95-48 to the BNSF, the

Safety Board had asked that all Class I

Railroads, pending the adoption of a formal

rule by the Federal Railroad Administration,

implement the use of Two-Way End-of-Train

devises on all cabooseless trains by March 31,

1996. The BNSF responded that because of a

shortage of two-way ETDs, the carrier is

precluded from complying with this

recommendation; however, as more of these

devices become available, it intends to equip

cabooseless trains with them. This

recommendation is classified “Open--

Acceptable Response.”

Operating Crew Training--The

H-BALT1-31 engineer knew the proper

procedures required to successfully arm a twoway ETD. The engineer stated that he had read

and understood the procedures associated with

arming the system and had received instructions

from the manager of training operations. He also

said that he had experienced a "fifty-fifty"

success in arming ETDs. The engineer acquired

the arming procedure method essentially on the

job and not in association with a comprehensive

training program. The Safety Board was unable

to document whether the other two

crewmembers had received training specifically

pertaining to two-way ETD operations or were

knowledgeable of the correct procedural

method. Their knowledge of the two-way ETD

was likely also gained through informal means.

The Safety Board, therefore, concludes that the

ATSF management failed to ensure that

operating crewmembers received comprehensive

training on the proper procedures required for

arming two-way ETD operation; although,

investigators did not find that lack of training

contributed to this accident.

The Safety Board is pleased that the ATSF

has made revisions to the ETD training program

in the aftermath of this accident and understands

that the BNSF now ensures that all operating

personnel whose duties require them to use a

two-way ETD receive comprehensive training

and demonstrate proficiency in its use.

However, the circumstances surrounding the

collision on December 14, 1994, in Cajon Pass

should have compelled the ATSF to

expeditiously establish a comprehensive ETD

training program, which also could identify

performance deficiencies and remedy them with

additional instruction. A systematic instructional

approach would promote the efficient, uniform

tracking of employees to avoid any training

duplication or omission.

End-of-Train Device and

Head-End Device Operation

The telemetry system tests revealed that the

HED could not be operated as a two-way system

before the accident since the insufficient power

from the transmitter module of the unit would

not allow a two-way emergency braking system

to arm. The crew could not arm the system for

two-way operation before H-BALT1-31

departed Barstow because of this mechanical

failure, and the system must be armed to use the

emergency brake function of two-way operation.

(The system could be operated as a one-way

system since the transmitter is not needed for

one-way operation.) Therefore, the Safety Board

concludes that the failure of the transmitter

module of the HED on locomotive ATSF 157 to

generate sufficient wattage power would not

allow the engineer of H-BALT1-31 to arm the

two-way HED/ETD system.

Unsuccessful arming attempts are indicated in a
50

multi-purpose status window on the HED, but

unless the system is already armed, a

malfunctioning transmitter will not be indicated

to the operator. An armed system performs a

communications test every 3 minutes that

evaluates both the HED and the ETD. If four

subsequent automatic tests fail, then a flashing

indicator light on the HED informs the crew that

communications are unreliable. The H-BALT1-

31 crew would have been informed that the

arming attempts were not successful; however,

they would not know why.

This particular HED has several auxiliary

functions in addition to transmitting and

receiving information from the ETD. The

telemetry system test revealed that when the

HED is being employed for auxiliary functions,

such as odometer use, mile calibration, train

length input, or setup functions, the emergency

brake function is deactivated; thus, pressing the

emergency button on the HED has no effect.

When being used only to communicate with the

ETD, the status window displays the brake pipe

pressure at the end of the train and indicates

whether the ETD is in motion. When any

auxiliary function is used, the status window

reflects information about that particular

function. During the test, the emergency brake

could be activated only when the status window

displayed the brake pipe pressure and ETD

motion status. Had the transmitter in the HED

been functioning normally and the system armed

for two-way operation, the engineer likely

would not have been able to activate the

emergency function had he been using the HED

for any function other than monitoring the brake

pipe pressure.

The engineer testified that he had received

no formal training on the operation of the twoway telemetry system, and, therefore, he was

likely unaware that the emergency brake

function is disabled when the HED is used for

other functions and that additional steps are

needed to use the emergency brake function.

Even had the crewmembers received appropriate

formal training in the operation of the system,

the additional steps required to initiate an

emergency brake application can cause

confusion and delay in, if not prevent, the

application of the emergency brake valve at the

rear of the train. After the accident, the ATSF

began phasing out these HEDs in their two-way

ETD system. Although 430 of these HEDs were

operated as a one-way device only as of October

22, 1996, none was equipped with the old

firmware, which required additional actions to

initiate the emergency braking function from the

rear of the train.

Event Recorder Maintenance

and Placement

The event recorder system installed on

locomotive ATSF 342 did not record any wheel

data, and, consequently, no speed or distance

data could be calculated. Postaccident testing at

Q-tron revealed that the axle generator was

wired and reassembled in a manner inconsistent

with the manufacturer specifications. The Safety

Board, therefore, concludes that the wheel data

were not recorded due to a broken wire in the

axle generator as a result of an improper

modification to the axle generator.

The event recorder on locomotive ATSF 342

was a microprocessor-based type equipped with

a self-test function. The ATSF stated that it had

an understanding with the FRA that this type of

recorder would require a download and

inspection on an annual verses a quarterly basis;

therefore, this event recorder was not inspected

during the December 1995 quarterly inspection.

In addition, the ATSF did not inspect or

download the recorder during the most recent

annual inspection before the derailment (June

12, 1995). However, the FRA indicated that no

such agreement existed between it and the

ATSF and that, citing the existing requirement

for event recorder maintenance, any such

agreement would not be an issue.
51

Microprocessor-based event recorders with

the self-test function are exempt from quarterly

inspections. Under 49 CFR 229.25(e)(2), “A

micro-processor based event recorder, equipped

to perform self tests, has passed the premaintenance inspection requirement if it has not

indicated a failure.” Unless indicating a failure,

microprocessor-based event recorders with the

self-test function never have to be downloaded

or tested. Thus, the Safety Board concludes that

the FRA regulations for the periodic inspection

of event recorders are inadequate.

During postaccident testing, the self-test

function indicated no faults, and the recorder

was found to be fully operational and within

manufacturer specifications. The speed had not

been recorded because of a failed axle

generator, which sends the speed data to the

event recorder. Additionally, the event recorder

on locomotive ATSF 342 was found to have

been improperly programmed, which resulted in

the recording of certain parameters only once

every 8 minutes. Because the timing was

programmed into the configuration of the event

recorder, the self-test function of the event

recorder did not identify it as a fault.

After the accident in Milford, Connecticut,

on October 3, 1995,43 involving a commuter rail

control car that had been serviced before the

accident, Safety Board investigators found the

axle generator was not adjusted properly

following the service, and as a result, no speed

data were recorded. This event recorder was

also a microprocessor-based with a self-test

function and indicator light. During the

postaccident testing, the self-test function

showed no faults, and the event recorder was

fully functional and within the manufacturer

specifications.

 

43Highway Accident Report--Highway/Railroad

Grade Crossing Accident, Metro North Commuter

Railroad, Milford, Connecticut, October 3, 1995

(NTSB/NRH-96-MH-003).

The Safety Board is investigating a grade

crossing accident which occurred in Tickfaw,

Louisiana, on May 27, 1996. Although the

investigation is still ongoing, preliminary

findings show that two of the inputs to the event

recorder were wired incorrectly, resulting in

anomalous data being sent to the event recorder.

Inspection records reveal that the event recorder

was inspected 2 days before the accident and no

problems were reported. However, because it

was a microprocessor-based and self-test event

recorder, the inspection procedure was only a

status check of the self-test indicator light on the

outside of the event recorder.

The self-test functions of existing event

recorders do not test speed and other data inputs

for validity; as a result during quarterly

inspections, failures, such as those noted above,

are unnoticed if the sole means of inspecting the

event recorder is the self-test function of the

event recorder. The Safety Board concludes that

had the entire event recorder system from

locomotive ATSF 342 been properly tested

during the December 1995 quarterly inspection,

both the broken speed sensor and the improper

configuration of the event recorder would likely

have been noticed and corrected at that time.

Therefore, the Safety Board believes that the

FRA should revise 49 CFR 229.25(e)(2) to

require that event recorders, including

microprocessor-based event recorders that are

equipped with a self-test function, be tested

during the quarterly inspections of the

locomotive in such a manner that the entire

event recording system, including sensors,

transducers, and wiring, is evaluated. Such

testing should include, at a minimum, a review

of the data recorded during actual operation of

the locomotive to verify parameter functionality

as well as cycling all required recording

parameters and determining the full range of

each parameter by reading out recorded data.

After this accident, the ATSF could not

provide any documentation that the ATSF 342

event recorder was ever tested or inspected in
52

accordance with 49 CFR 229.25(e), nor could it

provide statistical information about the

pass/fail rate of its locomotive event recorder

inspections. Title 49 CFR 229.25(e)(5) requires

that 90 percent of all event recorders inbound

for quarterly inspections be fully functional. The

Safety Board concludes that the FRA was not

monitoring the compliance of the carrier with

periodic inspections of event recorders as

prescribed under 49 CFR 229.25(e)(5).

Therefore, the Safety Board believes that the

FRA should develop and implement a program

that specifically addresses carrier compliance

with 49 CFR 229.25(e)(5).

Had this event recorder system been

inspected and tested at the most recent 92-day

periodic inspection on December 14, 1995, by

downloading the recorded data and evaluating it,

the failure in the axle generator and the

improper recorder configuration, if existing at

that time, should have been noted and corrected.

The diagnostic testing would indicate whether

the recorder was working but would not show

what, if any, type of data was being recorded by

the unit. Only by downloading the unit can the

type of data being recorded be examined.

The H-BALT1-31 consist had an event

recorder that was not fully operational. The selfdiagnostic light on the unit was insufficient to

fully examine the unit and ensure that it was

recording the data. The FRA required that the

carrier indicate whether a locomotive is

equipped with an event recorder in the remarks

section of form F6180-49A. Under 49 CFR part

229.135, “any train operated faster than 30 miles

per hour shall have an in-service event recorder

in the lead locomotive. The presence of the

event recorder shall be noted on Form FRA

F6180-49 A, under the REMARKS section.” In

so doing, the opportunity for oversight is

present: first, the carrier not listing the event

recorder for inspection on form F6180-49A, and

second, the inspector not observing the remarks

section on the back of the form. Consequently,

the Safety Board concludes that FRA form

F6180-49A is not adequate for recording the

inspection of event recorders and allows

oversights to be perpetrated during inspection

procedures. By revising this form to include the

event recorder in the other items to be inspected

section, an inspector likely would not overlook

examining the event recorder. Therefore, the

Safety Board believes that the FRA should

revise its form F6180-49A to include event

recorders in the other items to be inspected

section on the form.

In its preamble to the final rule on event

recorders (58 Federal Register 36610-11), the

FRA advised that it “has determined that the

recorder will be most helpful if it records the

events happening in the locomotive occupied by

the engineer, that is, the lead locomotive.” The

final rule stated that all trains traveling faster

than 30 mph must have an event recorder in the

lead locomotive; however, a petition for

reconsideration was filed, and as a result, a

clause was added to the final rule that allows

placement of the event recorder “elsewhere than

the lead locomotive.” Also in response to the

petition, the FRA reiterated that its “primary

concern is still as it was when the preamble was

written: to provide the best data for analysis, the

recorder must capture what the engineer sees

and does” but determined that requiring the

event recorder to be placed in the lead

locomotive was “unnecessarily geographically

strict.”44 The provision allowed that if the event

recorder monitored and recorded the required

data as though it were located in the lead

locomotive, the event recorder could be placed

elsewhere than in the lead locomotive.

The Safety Board is concerned that the result

of allowing the recorder to be placed elsewhere

than in the lead locomotive is not as the FRA

intended. One alternative practice, placing the

event recorder in any locomotive that is train

 

44Federal Register, Volume 60, Number 102, May 26,

1995.
53

lined to the lead locomotive, does not result in

monitoring and recording the required data as

though it were located in the lead locomotive.

The train line data are intended to be the same

for all locomotives in the train line so the

control inputs made by the crew in the lead unit

are carried out by the trailing locomotives as

well. In the preamble to the final rule, however,

the FRA noted:

Only the lead locomotive’s device will

record the engineer’s actions in

throttle control or in setting up the

dynamic brake – recorders in trailing

units will note the ‘message’ received,

the action they were requested to take,

but only the lead locomotive will

record the direct input of the person in

control.

Furthermore, those parameters that are

monitored locally can only reflect the condition

of the locomotive on which the event recorder is

installed and are not shared among locomotives

through the train line. Therefore, event recorders

installed on trailing locomotives are not capable

of recording any parameters that are local to the

lead locomotive.

Train speed and independent brake are two

of the locally sensed parameters required under

49 CFR 229.5(g) to be monitored and recorded.

Actual speed will be the same for a trailing

locomotive and lead locomotive; however,

speed is derived from a signal-generating

device, which is attached to the locomotive axle

generator. Should an event recorder be installed

in the third unit of a locomotive consist, it

monitors the third unit axle generator signal and

not the lead unit signal. Axle generator signals

can vary significantly from locomotive to

locomotive; consequently, an event recorder in

the third unit cannot monitor and record speed

as though it were in the lead locomotive. A

locomotive is typically configured to use the

axle generator to provide data to the speed

indicator in the cab as well as to the event

recorder. To best monitor what the engineer

sees, the speed signal in the engineer’s

locomotive unit should be recorded, as opposed

to a signal in a trailing locomotive, and could

prove important should the axle generator fail or

be improperly adjusted. As speed indicators are

required under 49 CFR 229.117 to be tested “as

soon as possible after departure,” any anomalies

in the speed sensing and recording system are

likely to be noticed in a timely manner. A

malfunction in the speed system of a trailing

locomotive could go unnoticed for extended

time, as occurred in this accident.

Independent brake is usually recorded as

either a discrete value (on or off) or as an actual

air pressure. The data come from the locomotive

on which the recorder is installed. As a result,

an event recorder in the third locomotive unit

will only monitor the status of the independent

brake in the third unit and not the status of the

independent brake in the lead unit. Failure to

monitor and record independent brake data in

the lead locomotive can result in unnoticed

independent brake activity or incorrect

indications of the time that an independent

brake application is made on the lead

locomotive.

Other parameters are also only recorded on

lead locomotives, including the horn and the

engineer-induced emergency. The horn is an

important parameter in many grade crossing

accidents, and the engineer-induced emergency

allows investigators to determine whether an

emergency brake application was the result of

engineer action. Although not required under

regulation, most event recorders monitor and

record both of these parameters if the recorder is

in the lead locomotive.

Other available data that can only be

recorded by an event recorder in the lead

locomotive are:

Cab signal information (aspect or

acknowledgment or both)
54

Crew vigilance system data (alerter data and

penalty brake)

TD data (pressure, marker, battery status,

and motion status)

Traction motor current for the lead

locomotive45

Pneumatic control switch state for the lead

locomotive45

Additional train brake data (equalizing

reservoir pressure and suppression)

Wheel slip data45

Locomotive speed limiter data

Overspeed penalty

Distributed power data

The Safety Board has demonstrated that an

event recorder in the lead locomotive can

provide more accurate and diverse data than one

in a trailing locomotive. The Safety Board,

therefore, concludes that the requirement to

monitor and record data as though it were in the

lead locomotive cannot currently be met by the

placement of an event recorder elsewhere than

in the lead locomotive. The Safety Board

believes that the FRA should inform the

industry that the placement of event recorders

other than in the lead locomotive will not record

the required data as though the event recorders

were in the lead locomotive and ensure

compliance with 49 CFR 229.135(a).

Tank Car Performance

The high speed of the train at derailment and

the relatively short length of destroyed or

damaged track in which the four locomotives and

45 freight cars stopped indicate the immense

magnitude of the impact forces acting on the 12

tank cars that derailed. In addition to the

magnitude of the impact forces acting on these 12

tank cars, the exposure to fire and heat likely

reduced their material strength and integrity. The

 

45Locally sensed parameters that can be recorded by

trailing unit event recorders but would reflect the condition

of the trailing unit itself and not the lead unit.

11 derailed DOT 111A tank cars sustained

extensive mechanical damage not limited to any

area of the tank cars as a group. Although 7 of

these 11 tank cars were jacketed, the jackets did

not provide any significant protection in this

accident. The damage and deformation to the

DOT 111A tank cars was extremely severe in

comparison to the DOT 105J tank car with butyl

acrylate that survived the derailment and the fire

intact. Although the jacket was crushed and

dented in all areas on the DOT 105J tank car,

visible damage to the tank shell was superficial

and limited to denting of one head and a puncture

that was caused by the explosive charges used to

vent the tank.

The two DOT 111A tank cars with the least

damage, ACFX 84855 and 84070, were the third

and fourth cars behind the locomotives and were

either clear of or on the edge of the main

wreckage pile following the derailment. A third

DOT 111A tank car was the sixth car behind the

locomotives. All the other DOT 111A tank cars

were between the 26th and 41st cars behind the

locomotives, and the DOT 105J tank car was the

33rd car. The positioning of the tank cars in the

train consist cannot account for the difference in

the damages observed on the DOT 111A tank

cars and the DOT 105J tank car. Because the

DOT 105J tank car and most of the DOT 111A

tank cars were positioned in the middle section of

the train, all were subjected to similar impact and

derailment forces. Therefore, the Safety Board

concludes that the superior strength of the DOT

105J tank car, as a result of its thicker tank shell

and heads and head-shield protection, accounted

for the difference in the comparative damages

between the DOT 111A tank cars and the DOT

105J tank car.

This accident again reinforces the need for the

FRA, the Research and Special Programs

Administration (RSPA), and the tank car

industry, to determine through risk assessment

which hazardous materials, including

environmentally harmful products, can be carried

with an acceptable level of risk in DOT 111A
55

tank cars and which products should be afforded

more protection in pressure tank cars, such as

DOT 105J tank cars. The Safety Board has

advocated such an approach in previous accident

reports and safety studies.46 On September 21,

1995, RSPA, with the cooperation of the FRA,

issued new regulations that require a wider

variety of hazardous materials, such an

nonflammable compressed gases, materials

designated as “poisonous by inhalation,” and

designated halogenated organic compounds that

pose environmental risks, be transported in

pressure tank cars equipped with head-shield

protection and thermal protection, as

appropriate.47 The new regulations also apply to

DOT 105 tank cars under 18,500 gallons that

were previously exempted from the requirements

for head shields and thermal protection. These

new regulations are a significant safety

improvement by requiring the transportation of

products with these hazards in better protected

and stronger tank cars.

Hazardous Materials Management

Shipper Notification and

 Coordination--Once the ATSF SOC had

confirmed that freight train H-BALT1-31 had

derailed and that hazardous materials likely had

been released and were involved in the fire, the

 

46Railroad Accident Report--Collision and Derailment

of Montana Rail Link Freight Train with Locomotive Units

and Hazardous Materials Release, Helena, Montana,

February 2, 1989 (NTSB/RAR-89/05); Safety Study--

Transport of Hazardous Materials by Rail (NTSB/SS91/01); and Hazardous Materials Accident Report--

Derailment of Burlington Northern Freight Train No. 01-

142030 and Release of Hazardous Materials in the Town

of Superior, Wisconsin, June 30, 1992 (NTSB/HZM94/01).

47Crashworthiness Protection Requirements for Tank

Cars; Detection and Repair of Cracks, Pits, Corrosion,

Lining Flaws and Other Defects of Tank Car Tanks, docket

nos. HM-175A and HM-201 at 60 Federal Register 49048

on September 21, 1995.

ATSF promptly notified the COES and the NRC.

As a result, the appropriate State and Federal

agencies were notified in a timely manner. The

SOC provided copies of the train consist in a

timely manner to the State forestry and fire

protection department and the SBCC. The IC also

had other technical resources available on the

properties and the hazards of the chemicals on the

train. Consequently, from the onset of the

emergency response operations, the first

responders to arrive at the scene and the IC had

sufficient preliminary information about the

hazardous materials on the train and which

products were in each tank car.

However, following this initial exchange of

information, no direct notification of the chemical

shippers was made because of

miscommunications between personnel at the

SOC about the notification of CHEMTREC.

Because the IC believed that he had sufficient

information about the hazardous materials

involved and assumed someone would contact

CHEMTREC, he did not direct that CHEMTREC

be notified. CHEMTREC, which can provide a

communications link between the chemical

manufacturers, shippers, and emergency response

agencies, was initially contacted by the California

EPA about 7 hours after the accident. Shippers,

including the R&H, learned that their products

were in the derailment when the BNSF logistics

department contacted them about late or lost

shipments.

Because of its concerns about the

polymerization of butyl acrylate and the potential

overpressurization of the tank car, R&H

immediately attempted to contact the ATSF and

the incident command center. The R&H technical

experts in Texas faxed guidance about the

decomposition and polymerization of the product

to the incident command center. However, the

R&H encountered difficulties obtaining accurate

information on the status of the butyl acrylate

tank car until its response team arrived and

inspected the isolated butyl acrylate tank car on

the afternoon of February 4.
56

Although the technical information faxed by

the R&H to the incident command center was

received and reviewed, emergency responders

were not able to positively identify the butyl

acrylate tank car and most of the other tank cars

because of the fire, which had burned away the

identification marks and numbers on the tank

cars. Because identification of the butyl acrylate

car now depended on identifying unique fittings

and features of the tank car, relying on the

technical resources that the R&H could provide

became imperative. Had the R&H personnel been

early on scene, they could have quickly

determined on the morning of February 4 after

the discovery of the unidentified, venting tank car

that it was not the butyl acrylate tank car, and the

subsequent evacuation and the shutdown of the

Calnev pipelines might have been averted. In

addition, the R&H personnel would have also

been available during the removal of the butyl

acrylate tank car from the wreckage to ensure that

the tank car was left upright to facilitate its

venting through its safety relief valve and to

verify the condition of the tank car. ATSF

wreckage clearing personnel and the IC would

have then known that the tank car was full and

still a danger.

The ATSF superintendent of field operations,

who was primarily responsible for wreckage

clearing operations, was unsure of the number of

pressure and nonpressure tank cars in the train.

He believed that 13 tank cars derailed and that 10

and 3 were nonpressure and pressure tank cars,

respectively. Twelve tank cars had derailed, and

only one was a pressure tank car. Although

identification of specific tank cars was extremely

difficult, the process may have been facilitated

had the tank car experts from the AAR Bureau of

Explosives or the other chemical shippers been

consulted expeditiously. The explosives bureau

or the shippers could have provided certificates of

construction, design drawings, and other

documentation and records to verify the number

of pressure tank cars (DOT classes 105 and 112)

and general service tank cars (DOT class 111A)

in the train, which tank cars were jacketed, the

capacity of each tank car, and any distinguishing

features. Had this information been obtained, the

superintendent of field operations and other

personnel, involved with identifying the tank cars

and assessing their condition, would have known

that a single pressure tank car containing butyl

acrylate was in the train. Knowing the

distinguishing features of a pressure tank car,

such as protective domes and no bottom outlet

valves, they would have been better able to

identify the butyl acrylate tank car. Neither a

carrier nor an IC are required to contact

CHEMTREC, hazardous materials shippers, or

the explosives bureau; however, these resources

can provide specialized technical assistance about

the hazardous materials and tank cars in an

accident. Chemical shippers can often assist

emergency responders in the identification,

handling, and off loading of tank cars

transporting hazardous materials. The R&H, the

other chemical shippers, and the explosives

bureau were not expeditiously contacted or

requested to provide technical support. Therefore,

the Safety Board concludes that the ATSF

officials and emergency responders failed to

effectively utilize the technical resources that

could have facilitated the identification and

condition of the butyl acrylate tank car and the

other derailed tank cars in the train.

The AAR, CMA, and several other

associations48 representing the chemical and

transportation industries jointly sponsor the

Transportation and Community Awareness and

Emergency Response (TRANSCAER) program,

a nationwide community outreach program

designed to assist communities in the

development and evaluation of their emergency

response plans for transportation incidents

involving hazardous materials. Member

 

48National Association of Chemical Distributors,

National Tank Truck Carriers, American Petroleum

Institute, Hazardous Materials Advisory Council, American

Trucking Associations, and The Chlorine Institute.
57

companies of the sponsoring associations work

with local emergency planning committees and

participate in exercises and training with local

emergency response agencies to test individual

response plans. Although TRANSCAER has

fostered greater communication and coordination

between local emergency planners, carriers, and

chemical shippers, the events in this accident

indicate that a renewed emphasis is needed for

railroad personnel and emergency responders in a

derailment involving the release of hazardous

materials to utilize available technical resources

and expertise. Therefore, the Safety Board

believes that the AAR, the CMA, and the

International Association of Fire Chiefs should

develop, in cooperation, and distribute to their

members information reemphasizing the technical

data and assistance that can be provided through

CHEMTREC, the AAR Bureau of Explosives,

and the chemical shippers when tank cars

transporting hazardous materials are involved in a

train derailment.

Tank Car Identification--The fire

destroyed the painted identification marks and

numbers on most of the derailed tank cars and

prevented emergency responders and ATSF

wreckage clearing personnel from positively

identifying individual tank cars. The AAR tank

car committee did not act on the ATSF proposal

after this accident to affix a permanent plate

engraved with the tank car identification mark

and number. An engraved plate permanently

affixed to the tank car provides a means for

emergency responders to identify a tank car when

painted markings have been destroyed; however,

other safety considerations arise. To obtain the

information on an engraved plate, an emergency

responder would, as a minimum to reach the

plate, need to be near the tank car and, more

likely, to climb onto the tank car. A tank car that

has been exposed to fire and heat, such as the

butyl acrylate tank car in this accident, has a

greatly increased potential for overpressurization

and catastrophic failure. Also, the external

temperature of the tank car may be too high or the

tank car may be precariously positioned for an

emergency responder to safely approach the tank

car and climb onto it to reach an identification

plate. The Safety Board concludes that the

potential danger to emergency response personnel

under accident conditions may outweigh the

benefit of an engraved plate to identify the mark

and number of a tank car.

In accidents where the identification and

condition of the tank cars containing hazardous

materials cannot be verified, emergency

responders typically have been trained to

evacuate to a safe distance, confer with tank car

and product experts, and reach a consensus on a

course of action. The difficulties encountered in

this accident by emergency response personnel in

identifying individual tank cars could have been

greatly alleviated through greater coordination

with the chemical shippers, the tank car owners,

and the explosives bureau personnel.

Coordination between the railroad, emergency

responders, and the appropriate experts remains

the most effective means to minimize the danger

to the public and emergency response personnel

from accidents involving tank cars that contain

hazardous materials.

The Safety Board previously addressed the

issue of tank car identification in its investigation

of the derailment of an Illinois Central Gulf

Railroad freight train in Livingston, Louisiana, on

September 28, 1982.49 The Safety Board

concluded in that accident that the difficulty in

identifying potentially dangerous tank cars and

their locations in the wreckage delayed attacking

the principal source of fire and heat, and as a

result, the source of the fire continued to

superheat two tank cars which ultimately

exploded and rocketed. Consequently, the Safety

Board asked the CMA in Safety

Recommendation R-83-92 to extend the use of

 

49Railroad Accident Report--Derailment of Illinois

Central Gulf Railroad Freight Train Extra 9629 East (GS2-28) and Release of Hazardous Materials at Livingston,

Louisiana, September 28, 1982 (NTSB/RAR-83/05).
58

color coding of tank cars or adopt some other

effective means of identifying high-risk

commodity tank cars in switching operations and

in wreck clearing operations. The CMA

responded that it did not consider color coding to

be effective and would not support the color

coding of tank cars because tank cars were

already required to have reporting marks,

numbers, and placards that served to identify the

tank car and the product carried. The CMA also

cited the practicality of color coding tank cars

because of the wide variety of chemical products

transported by tank cars and the use of individual

tank cars to carry multiple products. The CMA

indicated, however, that it was reviewing other

means to improve the identification of tank cars,

such as the use of radio transponders. Because the

CMA did not change its position on color coding

or demonstrate that other methods were seriously

being investigated, the Safety Board classified

Safety Recommendation R-83-92 “Closed--

Unacceptable Action” on February 18, 1987.

Although color coding of tank cars relies on

painted markings that may be destroyed in intense

fires, as occurred in this accident, positive

methods for identifying tank cars need further

investigation and evaluation. The FRA conducted

research in the 1980s on the use of radio

transponders to track tank cars, and the AAR is

now evaluating the use of global satellite tracking

systems to collect impact data on tank cars while

in transport. Enhancement of such technologies

may feasibly include the identification of tank

cars. Therefore, the Safety Board believes that the

AAR should investigate and evaluate means to

improve the ability of emergency response

personnel to identify tank cars involved in

accidents.

Derailed Tank Car Handling and

Damage Assessments--After the derailment,

conditions at the accident scene precluded the

ability of emergency responders and the ATSF

wreckage clearing personnel to survey and assess

the conditions of the derailed tank cars. Nine or

10 of the 12 derailed tank cars were mixed

throughout the burning wreckage pile. Fire and

smoke reduced visibility and limited tank car

observation. In addition, the efforts to extinguish

the fire with the application of water and foam on

the wreckage pile was ineffective, and a process

of cooling the perimeter of the wreckage and then

removing, isolating, and cooling individual

freight cars was implemented. Damage

assessments, therefore, could not be performed

until each tank car was isolated from the other

wreckage and fire. With this approach to

extinguishing the fire, emergency responders and

the ATSF wreckage clearing personnel indicated

that damage assessments of the tank cars were

made continuously as the visibility improved and

wreckage was cleared away. The alternative was

to let the fire burn itself out; however, the closure

of I-15 and the evacuation of the immediate area

for an undetermined time would probably have

been necessary.

After each tank car had been removed and

isolated, it should have been visually inspected to

identify the specific tank car or type of tank car

and to verify, if possible, whether the tank car had

been breached and any cargo remained in the

tank. Had a definite breach in a tank car not been

seen, the most prudent assumption was that the

tank car remained full and should be handled with

care. Furthermore, such a tank car should have

been closely monitored until its true condition

could be ascertained. Because of the severity of

the damage to most of the DOT 111A tank cars,

determining the condition of those tank cars may

have been relatively easy. Before the tank car was

removed from the wreckage, an observer who

was 70 feet away saw a hole reportedly near one

end of the butyl acrylate tank car, which was not

a reliable indicator of the tank car condition. The

lack of visual inspection of the butyl acrylate tank

car after its removal from the wreckage on

February 4 indicates that ATSF personnel did not

perform a complete and careful damage

assessment of any of the tank cars.

The ATSF superintendent of field operations

who was responsible for wreckage clearing
59

operations had the primary responsibility to

assess the derailed tank car damage and to

oversee the movement and handling of the tank

cars at the site. He was assisted by the ATSF

chief environmental officer. The determination of

the superintendent of field operations that the

butyl acrylate tank car was empty was not based

on a physical examination of the tank car after its

removal from the wreckage but on the

impressions of the equipment operators who

pulled the tank car from the wreckage and on the

lengthy exposure of the tank car to fire and heat.

Because he concluded that the tank car was

empty, he did not perform a visual inspection to

determine whether the tank car had been

breached or direct that the tank car be left

positioned upright, cooled with water, or

monitored. The chief environmental officer

resolved that the tank car could not have survived

the impact forces and the fire and heat. Although

both individuals had sufficient training and

experience about railroad tank cars to perform

their respective duties (see appendix B), they

relied on their impressions rather than verification

of the physical tank car condition. The Safety

Board, therefore, concludes that both the ATSF

superintendent of field operations and chief

environmental officer exercised poor judgment in

their assessment and handling of the butyl

acrylate tank car.

The State forestry and fire protection

department incident safety officer and IC, who

each had some knowledge and experience with

hazardous materials and tank cars, relied on the

expertise of the two ATSF officials for the

handling of the damaged tank cars. Because

firefighters and other emergency responders

typically are not experts about tank cars and

railroad operations, they depend on the railroad

officials for guidance.

Both railroad officials may have exercised

better judgment had written guidance and

recommended practices been available about the

assessment and handling of tank cars exposed to

sustained fire and heat following a derailment.

Although criteria exist to assess mechanical

damage to a tank car, guidance could not be

found on the cumulative effects from fire, heat,

and mechanical damage on the strength and

integrity of a derailed tank car. The guidance

about moving and handling loaded or partially

loaded tank cars that have sustained mechanical

or fire and heat damage or both is also lacking.

The integrity of tank cars, subjected to severe

accident forces and fire, should be adequately

assessed before moving the tanks. Awareness of

the tank car integrity minimizes the potential of a

catastrophic failure of the tank car and release of

any remaining cargo.

The Safety Board had expressed concern

about the need for written technical guidance to

help emergency response personnel assess the

severity of tank car damage and select the

appropriate means to remove the wreckage after

its investigation of a freight train derailment

involving hazardous materials near Inwood,

Indiana, on November 8, 1979.50 In Safety

Recommendation I-80-2, the Safety Board asked

the FRA to develop guidelines for handling tank

cars containing pressurized liquefied gases at

accident sites based on research and tests of a

representative sample of damaged tank cars. As a

result of various FRA-sponsored research studies

and industry-initiated reports, Safety

Recommendation I-80-2 was classified “Closed--

Acceptable Action” on May 25, 1994. These

research studies address mechanical damage but

not the effects of fire and heat. In addition, the

tank car safety courses offered at the AAR

transportation test center in Pueblo, Colorado,

and the AAR annual hazardous materials

seminars provide training and instruction on

assessing mechanical damage to tank cars, but not

the effects from fire and heat.

 

50Special Investigation Report--Tank Car Structural

Integrity after Derailment (NTSB/SIR-80/1).
60

Because many emergency responders rely on

railroad personnel to provide guidance about

handling and moving damaged tank cars, railroad

personnel involved with wreckage clearing

operations should have sufficient guidance to

assess all types of damages and the combination

of damages that can result from a derailment.

Because tank cars involved in a derailment can

sustain mechanical or fire and heat damage or

both, wreckage clearing personnel need to be

aware of the effects of each type of damage and

any combined effects. The Safety Board,

therefore, believes that the AAR should develop

written guidelines for assessing the individual and

combined effects of mechanical or fire and heat

damage or both to tank cars involved in a

derailment and for the handling and movement of

such tank cars.

Pipeline Operation

Operator Notification--Calnev became

aware of the accident when an employee heard a

radio news broadcast about the derailment and

verified that the derailment site was near two

Calnev underground pipelines. The ATSF

notification of the COES and its subsequent

notifications of the appropriate state agencies,

including the State fire marshal office and the

State forestry and fire protection department,

were timely and prompt; however, the ATSF did

not contact Calnev directly about the derailment

and potential threat to its pipelines.

In previous accident investigations,51

including a collision between two ATSF freight

 

51Railroad Accident Report--Derailment of Southern

Pacific Transportation Company Freight Train on May 12,

1989, and Subsequent Rupture of Calnev Petroleum

Pipeline on May 25, 1989, at San Bernardino, California

(NTSB/RAR-90/02); Railroad Accident Report--Atchison,

Topeka and Santa Fe Railway Company (ATSF) Freight

Trains ATSF 818 and ATSF 891 on the ATSF Railway,

Corona, California, November 8, 1990 (NTSB/RAR91/03); and Highway Accident Report--Collision of Amtrak

trains in Corona, California, on November 7,

1990, the Safety Board found that railroads have

the responsibility to notify pipeline operators

about derailments and wreckage clearing

operations that occur near pipelines that may

impact the safe operation of such pipelines. After

its investigation of the Corona accident, the

Safety Board asked in Safety Recommendation

R-91-44 that the ATSF, in cooperation with the

California Public Utilities Commission and the

California Office of the State Fire Marshal,

develop a complete list of 24-hour emergency

telephone numbers for those pipeline operators

whose transmission lines are near the ATSF

property. In its November 11, 1993, response to

the recommendation, the ATSF stated that it had

participated in the information gathering efforts

of the CPUC concerning pipelines along ATSF

rights-of-way and that ATSF distributed a listing

of pipeline operator emergency telephone

numbers provided by the State fire marshal office

to appropriate personnel in the SOC. On the basis

of this response, Safety Recommendation R-91-

44 was classified “Closed--Acceptable Action”

on February 14, 1994.

After the February 1, 1996, derailment near Cajon

Junction, the ATSF indicated that as a corrective

measure, pipeline operators had been added as a line

item on its emergency notification check list for

accidents occurring in California. This measure should

have been a logical step for the ATSF to have taken

when implementing Safety Recommendation R-91-44

rather than as a corrective action for the current

derailment. The Safety Board, consequently, concludes

that the ATSF management failed to ensure that

effective procedures to notify pipeline operators were

implemented and that its employees complied with

them. Therefore, the Safety Board believes that the

BNSF should develop and maintain a list

of 24-hour emergency telephone numbers for all

 

Train No. 88 with Rountree Transport and Rigging, Inc.,

Vehicle on CSX Transportation, Inc., Railroad Near

Intercession City, Florida, November 30, 1993

(NTSB/HAR-95/01).
61

pipeline operators that have transmission

pipelines on or adjoining any BNSF property and

distribute the list with written instructions for

notifying pipeline operators to all employees who

are responsible for completing emergency

notifications.

Operator Response--After the Calnev

engineer had verified that company pipelines

were near the derailment, Calnev initiated a

shutdown and isolation of the affected pipelines

even before determining whether the pipelines

were damaged. These actions were the proper

precautions to avoid a potential pipeline release.

The Calnev manager of engineering was

dispatched immediately and arrived at the

incident command post within minutes of the IC,

which resulted in early coordination and

communication between Calnev and the IC. The

IC was aware of the Calnev pipelines and, had the

engineering manager not arrived so promptly,

would have directed that Calnev be notified. The

establishment of a Calnev command post at the

IC post on February 1 ensured that the

communication and coordination continued

throughout the duration of the emergency. The

train wreckage was more than 200 feet from the

pipeline right-of-way, and the pipelines were

undamaged. Calnev, however, monitored the

wreckage clearing operations to ensure that no

heavy equipment would inadvertently work over

or cross the pipelines. Calnev also responded

promptly when the IC requested a pipeline

shutdown because of the venting tank car on

February 4. Therefore, the Safety Board

concludes that the Calnev response to the

derailment was appropriate and timely and the

coordination between Calnev and the IC was

effective.

Environmental Impact

The number of State and Federal agencies

monitoring the site and environmental safety

efforts necessitated the formation of an

environmental response group to fulfill all

functions. Air monitoring and water and soil

sampling were initiated and conducted in a

sufficiently timely and efficient manner. The

results of the air monitoring immediately

following the derailment indicate low levels of

volatile organic compounds and no detectable

levels of phosphorus compounds generated from

the combustion and release of the trimethyl

phosphite at the accident site. Subsequent air

monitoring results through March 1 yielded

average concentrations of volatile organic

compounds that exceeded a 5 ppm threshold only

in the immediate area of the derailment on 3 days

during the monitoring period. The results of the

water sampling indicated no impact on

groundwater or supply wells in the area. All

contaminated soil was removed, and the area was

restored. Therefore, the Safety Board concludes

that the release and combustion of hazardous

materials created no prolonged environmental

impact.
62

CONCLUSIONS

1. Neither the weather, the track, nor the signal

system either caused or contributed to the

derailment. The train crewmembers were in

compliance with the requirements specified

in the Hours-of-Service Act and were

qualified to perform their duties; no

evidence of fatigue was found. Neither drug

nor alcohol use was a factor in the

derailment.

2. Had the conductor and the brakeman

remained in the control compartment cab of

the locomotive, they likely would have

survived because the cab survival space was

adequate.

3. The local emergency response was timely

and adequate, given the remote location of

the derailment, and the incident commander

acted effectively and managed the incident

successfully to completion without serious

injury to responders, local residents, or

officials at the scene.

4. A wide deviation of end-of-car hose

arrangements on cushioned underframe cars

from the approved end-of-car hose

arrangement design is not uncommon and

may induce an air hose to kink in operation

and block or restrict a train line.

5. Had the Barstow car shop made hose

arrangement reference manuals readily

available, the carmen could have used

guidelines to properly repair the train line

on ATSF 90033.

6. An unknown train line blockage or

restriction, probably between the fifth and

ninth cars, resulted in responsive brakes

only on the locomotive units and possibly

the first eight cars, and, thus, the engineer

was unable to slow or stop H-BALT1-31.

7. Had H-BALT1-31 been equipped with a

fully functioning two-way end-of-train

device, the engineer could have applied the

brakes from the rear of train and the

derailment may have been avoided.

8. The Federal Railroad Administration failure

to require the capability to initiate an

emergency brake application on either end

of a train in mountainous territory after the

1989 Helena, Montana, accident and its

failure to take immediate action after

receiving the Safety Board recommendation

resulting from the 1994 Cajon Pass accident

may have contributed to the cause of this

accident in 1996.

9. The engineer of H-BALT1-31 was not

aware of any requirement to report the

inability to arm a two-way end-of-train

device system and, consequently, did not

report the improper operation of the twoway end-of train device on train H-BALT1-

31 to the train dispatcher and customer

quality support, as required under rule 67

(B).

10. The Atchison, Topeka and Santa Fe Railway

Company management failed to ensure the

use of fully functioning two-way end-oftrain devices on westbound trains over

Cajon Pass.

11. The Atchison, Topeka and Santa Fe Railway

Company management failed to ensure that

operating crewmembers received

comprehensive training on the proper

procedures required for arming two-way

end-of-train device operation; although,

investigators did not find that lack of

training contributed to this accident.
63

12. The failure of the transmitter module of the

head-end device on locomotive ATSF 157

to generate sufficient wattage power would

not allow the engineer of H-BALT1-31 to

arm the two-way head-end/end-of-train

device system.

13. The wheel data were not recorded due to a

broken wire in the axle generator as a result

of an improper modification to the axle

generator.

14. The Federal Railroad Administration

regulations for the periodic inspection of

event recorders are inadequate.

15. Had the entire event recorder system from

locomotive ATSF 342 been properly tested

during the December 1995 quarterly

inspection, both the broken speed sensor

and the improper configuration of the event

recorder would likely have been noticed and

corrected at that time.

16. The Federal Railroad Administration was

not monitoring the compliance of the carrier

with periodic inspections of event recorders

as prescribed under 49 Code of Federal

Regulations 229.25(e)(5).

17. The Federal Railroad Administration form

F6180-49A is not adequate for recording the

inspection of event recorders and allows

oversights to be perpetrated during

inspection procedures.

18. The requirement to monitor and record data

as though it were in the lead locomotive

cannot currently be met by the placement of

an event recorder elsewhere than in the lead

locomotive.

19. The superior strength of the U.S. Department

of Transportation class 105J tank car as a

result of its thicker tank shell and heads, and

the head shield protection accounted for the

difference in the comparative damages

between the U.S. Department of

Transportation class 111A tank cars and the

U.S. Department of Transportation class 105J

tank car.

20. The Atchison, Topeka and Santa Fe Railway

Company officials and emergency responders

failed to effectively utilize the technical

resources that could have facilitated the

identification and condition of the butyl

acrylate tank car and the other derailed tank

cars in the train.

21. The potential danger to emergency response

personnel under accident conditions may

outweigh the benefit of an engraved plate to

identify the mark and number of a tank car.

22. Both the Atchison, Topeka and Santa Fe

Railway Company superintendent of field

operations and chief environmental officer

exercised poor judgment in their assessment

and handling of the butyl acrylate tank car.

23. The Atchison, Topeka and Santa Fe Railway

Company management failed to ensure that

effective procedures to notify pipeline

operators were implemented and that its

employees complied with them.

24. The Calnev Pipe Line Company response to

the derailment was appropriate and timely

and the coordination between the Calnev

Pipe Line Company and the incident

commander was effective.

25. The release and combustion of hazardous

materials created no prolonged environmental

impact.
64

PROBABLE CAUSE

The National Transportation Safety Board

determines that the probable cause of the

derailment of freight train H-BALT1-31 was an

undetermined restriction or blockage that

prevented the traincrew from achieving and

maintaining adequate train braking force and

also the lack of adequate Federal Railroad

Administration and industry, specifically the

Atchison Topeka and Santa Fe Railway

Company, regulations, policies, procedures, and

standards to consistently utilize two-way end-oftrain devices as a redundant braking system to

protect trains from catastrophic brake system

failure.

RECOMMENDATIONS

As a result of its investigation, the

National Transportation Safety Board makes

the following recommendations:

--to the Burlington Northern and Santa

Fe Railway Company:

Inspect the end-of-car hose

arrangements on your cushioned

underframe cars and ensure the hose

arrangements match the intended

design. (R-96-67)

Provide your carmen with readily

available means to identify the proper

design or specific type of end-of-car

hose arrangement on cushioned

underframe cars to preclude a

possible improper repair or

modification. (R-96-68)

Develop and maintain a current list of

24-hour emergency telephone numbers

for all pipeline operators that have

transmission pipelines on or adjoining

any Burlington Northern and Santa Fe

Railway Company property and

periodically update, at least annually,

and distribute the list with written

instructions for notifying pipeline

operators to all employees who are

responsible for completing emergency

notifications. (R-96-69)
65

--to the Federal Railroad Administration:

Revise 49 Code of Federal

Regulations 229.25(e)(2) to require

that event recorders, including

microprocessor-based event recorders

that are equipped with a self-test

function, be tested during the

quarterly inspections of the

locomotive in such a manner that the

entire event recording system,

including sensors, transducers, and

wiring, is evaluated. Such testing

should include, at a minimum, a

review of the data recorded during

actual operation of the locomotive to

verify parameter functionality as well

as cycling all required recording

parameters and determining the full

range of each parameter by reading

out recorded data. (R-96-70)

Develop and implement a program

that specifically addresses carrier

compliance with 49 Code of Federal

Regulations 229.25(e)(5). (R-96-71)

Revise your form F6180-49A to

include event recorders in the other

items to be inspected section on the

form. (R-96-72)

Inform the industry that the

placement of event recorders other

than in the lead locomotive will not

record the required data as though the

event recorders were in the lead

locomotive and ensure compliance

with 49 Code of Federal Regulations

229.135(a). (R-96-73)

--to the Association of American Railroads:

Inform your member carriers about

the circumstances of this accident and

alert them to inspect the end-of-car

hose arrangements on cushioned

underframe cars and ensure the hose

arrangements match the intended

design. (R-96-74)

Ensure that your member carriers

provide carmen with readily available

means to identify the proper design or

specific type of end-of-car hose

arrangement on cushioned

underframe cars to preclude a

possible improper repair or

modification. (R-96-75)

Develop, in cooperation with the

Chemical Manufacturers Association

and the International Association of

Fire Chiefs, and distribute to your

carrier members information

reemphasizing the technical data and

assistance that can be provided

through the Chemical Manufacturers

Association Chemical Transportation

Emergency Center, the Association of

American Railroads Bureau of

Explosives, and the chemical shippers

when tank cars transporting hazardous

materials are involved in a train

derailment. (R-96-76)

Investigate and evaluate means to

improve the ability of emergency

response personnel to identify tank

cars involved in accidents. (R-96-77)

Develop written guidelines for

assessing the individual and combined

effects of mechanical or fire and heat

damage or both to tank cars involved

in a derailment and for the handling

and movement of such tank cars. (R96-78)
66

--to the International Association of Fire

 Chiefs:

Develop, in cooperation with the

Association of American Railroads

and the Chemical Manufacturers

Association, and distribute to your

members information reemphasizing

the technical data and assistance that

can be provided through the Chemical

Manufacturers Association Chemical

Transportation Emergency Center, the

Association of American Railroads

Bureau of Explosives, and the

chemical shippers when tank cars

transporting hazardous materials are

involved in a train derailment. (R-96-

79)

--to the Chemical Manufacturers Association:

Develop, in cooperation with the

Association of American Railroads

and the International Association of

Fire Chiefs, and distribute to your

members information reemphasizing

the technical data and assistance that

can be provided through the Chemical

Manufacturers Association Chemical

Transportation Emergency Center, the

Association of American Railroads

Bureau of Explosives, and the

chemical shippers when tank cars

transporting hazardous materials are

involved in a train derailment. (R-96-

80)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR

Member

December 11, 1996
67

APPENDIXES

APPENDIX A

INVESTIGATION AND HEARING

The National Transportation Safety Board was notified at 10 a.m., eastern standard time, on February

1, 1996, that an Atchison, Topeka and Santa Fe Railway (ATSF) freight train derailed in Cajon Pass,

California. The investigator-in-charge and other members of the Safety Board investigative team were

dispatched from the Washington, DC, headquarters and the Atlanta, Georgia, and Chicago, Illinois,

regional offices. The investigative groups studied operations, track and signals, mechanical, survival

factors, human performance, and hazardous materials.

The Federal Railroad Administration, ATSF, California Public Utilities Commission, Brotherhood of

Locomotive Engineers, Brotherhood of Carmen, and the United Transportation Union assisted in the

Safety Board investigation.

The Safety Board staff conducted a deposition proceeding as part of its investigation on April 23,

1996, in San Bernardino, California, at which eight witnesses testified.

69

APPENDIX B

QUALIFICATIONS OF HAZARDOUS MATERIALS RESPONSE PERSONNEL

The incident commander (IC) had 29 years experience as a firefighter and as a training officer. He

attended a 6-week hazardous materials course at the National Fire Academy in 1981. He estimated that 40

hours may have been dedicated to railroad tank cars. Although he has since taken refresher training in

hazardous materials, he has not received any specific training about railroad tank cars. The IC also

completed the following hazardous materials courses through the California Specialized Training Institute

under the sponsorship of the California Office of Emergency Services: First Responder Operational in

September 1991, IC/On-scene Manager in June 1992, and instructor certifications for first responders and

ICs/on-scene managers in July 1992. Before this accident, the IC had been involved in one minor

derailment.

The California Department of Forestry and Fire Protection incident safety officer had numerous courses

on hazardous materials since 1981, including 80 hours of chemistry training dating back to 1985. Since

1991, he has been teaching classes on hazardous materials operations and scene management for the

California Specialized Training Institute. During the past 10 years, he has received training at the General

American Transportation rail car repair facility in Colton, California. He had responded to approximately

nine rail car incidents in the last 12 years.

The Atchison, Topeka and Santa Fe Railway Company (ATSF) superintendent of field operations had 23

years experience and had been involved with between 20 and 25 derailments that included hazardous

materials. The superintendent stated that he was in the original group of employees that became hazardous

materials responders for the ATSF. He attended a 1-week course in hazardous materials at Texas A&M

University in 1984 and has attended the tank car safety course at the Association of American Railroad

(AAR) transportation test center in Pueblo, Colorado, annually since 1987 to maintain his certification as a

hazardous materials technician. The superintendent also cited his experience working with companies that

specialize in wreckage clearing at derailments. The superintendent was familiar with the guidelines for

assessing tank car damage that are covered in the AAR tank car safety course. (These guidelines cover

mechanical damage, such as gouges, dents, scores, and wheel burns, but do not address fire and heat

damage.)

The ATSF chief environmental officer had degrees in civil engineering with a primary emphasis on

structural engineering and a secondary emphasis on environmental engineering and had been in the

environmental department of the ATSF since 1982. He also attended the Texas A&M course in 1984 or

1985, the AAR tank car safety course in 1986 or 1987, other courses at the AAR center, and participated in

at least one symposium in the late 1980s on damage to tank cars. He had participated in four or five other

derailments involving tank cars. He too was aware of the AAR guidance for assessing tank car damage.

71

APPENDIX C

TRAIN CONSIST

According to the automatic equipment identification (AEI) reader 586 at Lenwood. California,

(milepost 6.7), train H-BALT1-31 passed the AEI reader at 1:37 a.m. on February 1, 1996 at 38 mph with

the following ordered consist.

Locomotives Unit Model Manufacturer Remarks

1 ATSF 157 GP60M EMD

2 ATSF 3853 GP50 EMD

3 ATSF 342 GP60B EMD Cabless Unit Event Recorder

4 ATSF 4031 GP60 EMD

Cars Number Type Commodity Remarks

 1 WC 28076 A63 box car fiber board

 2 WC 28125 A63 box car fiber board

 3 ACFX 84855 T5F tank car calcium chloride

 4 ACFX 84070 T5F tank car calcium chloride

 5 SFLC 10005 LB4 box car corn meal cushioned underframe

 6 DOWX 3965 T5G tank car glycol

 7 TQEX 58464 C5P covered

 hopper plastic pellets

 8 CNW 128078 GSC gondola steel shapes

 9 ACFX 66459 C5P covered

hopper plastic pellets

10 BN 249296 A23 box car fiber board

11 ATSF 45841 AB6 box car fiber board cushioned underframe

12 ATSF 45920 AB6 box car fiber board cushioned underframe

13 ATSF 46034 AB6 box car fiber board cushioned underframe

14 WC 28047 A63 box car fiber board

15 ALAX 61489 C5P covered

hopper plastic pellets

16 ATSF 90033 FP7 flat car steel pipe cushioned underframe
72

APPENDIX C

17 ABOX 52396 B24 box car lumber

18 ITTX 912296 FM7 flat car pipe

19 ATSF 45712 AB6 box car fiber board

20 ATSF 46151 AB6 box car fiber board

21 ATSF 45990 AB6 box car fiber board

22 CR 297851 D7C box car auto parts

23 CR 627150 FS flat car iron

24 CR 627333 FS flat car iron

25 IHB 1209 FS flat car iron

26 ECDX 792140 T5F tank car lube oil

27 UTLX 79897 T3D tank car lube oil

28 WC 20252 A65 box car printing paper

29 ATSF 92018 FS flat car iron

30 ATSF 73758 GSC gondola iron

31 ACFX 79907 T5I tank car petroleum distillates hazmat

32 SOU 17010 D6N box car textiles

33 NATX 82129 T5H tank car butyl acrylate hazmat

34 GATX 13571 T5G tank car ind chemical

35 ATSF 622893 LC5 box car veneer

36 ATSF 622600 LC5 box car salt

37 CSXT 496026 FS flat car iron

38 MWSX 29654 T6I tank car denatured alcohol hazmat

39 GATX 37310 T4F tank car flammable liquid hazmat

40 UTLX 41424 T5F tank car empty

41 UTLX 41411 T5F tank car empty

42 ATSF 611088 B75 box car flour

43 SP 247682 A64 box car lumber

44 SOU 525865 A23 box car tires

45 NOKL 4574 D5N box car lumber

46 CELX 2374 T6I tank car methyl ethyl ketone hazmat

47 NAHX 550724 C6 covered

 hopper empty

48 ACFX 99289 C6 covered

 hopper plastic pellets

49 GATX 18211 T4F tank car empty


75

APPENDIX E

RULES AND REGULATIONS FOR END-OF-TRAIN DEVICE

232.19 End of Train Device

(a) An end-of-train device shall be comprised of a rear-of-train unit (rear unit) located on the last car of

a train and a front-of-train (front unit) unit located in the cab of the locomotive controlling the train.

(b) Rear unit. The rear unit shall be capable of determining the rear car brake pipe pressure and

transmitting that information to the front unit for display to the locomotive engineer.

The rear unit shall be—

(1) Capable of measuring the rear car brake pipe pressure with an accuracy of +

/- 3 psig and brake

pipe pressure variations of +

/- 1 psig;

(2) Equipped with a “bleeder valve” that permits the release of any air under pressure from the rear

of train unit or the associated air hoses prior to detaching the rear unit from the brake pipe;

(3) Designed so that an internal failure will not cause an undesired emergency brake application;

(4) Equipped with either an air gauge or a means of visually displaying the rear unit’s brake pipe

pressure measurement; and

(5) Equipped with a pressure relief safety valve to prevent explosion from a high pressure air leak

inside the rear unit.

(c) Reporting rate. Multiple data transmissions from the rear unit shall occur immediately after a

variation in the rear car brake pipe pressure of +

/- 2 psig and at intervals of not greater than 70

seconds when the rear car brake pipe pressure variation over the 70-second interval is less that +

/- 2

psig.

(d) Operating environment- The rear unit shall be designed to meet the performance requirements of

paragraphs (b) and (C) of this section under the following environmental conditions:

(1) At temperatures from -40o C to 60 o C;

(2) At a relative humidity of 95% noncondensing at 50 o C;

(3) At altitudes of zero to 12,000 feet mean sea level;

(4) During vertical and lateral vibrations of 1 to 15 Hz., with 0.5 g peak to peak, an 15 to 500 Hz.,

with 5g. peak to peak;

(5) During the longitudinal vibrations of 1 to 15 Hz., with 3g. peak to peak and 15 to 500 Hz., with

5g. peak to peak; and

(6) During a shock of 10g. peak for 0.1 seconds in any axis.
76

APPENDIX E

(e) Unique code. Each rear unit will have a unique and permanent identification code that is transmitted

along with the pressure message to the front-of-train unit. A code obtained from the Association of

American Railroads, 50 F Street, NW., Washington, DC 20036 shall be deemed to be a unique code

for purposed of this section. A unique code also may be obtained from the Office of Safety

Enforcement (RRS-10), Federal Railroad Administration, Washington, DC 20590.

(f) Front unit. (1) The front unit shall be designed to receive data messages from the rear unit and shall

be capable of displaying the rear car brake pipe pressure in not more that one-pound increments.

(2) The display shall be clearly visible and legible in daylight and darkness from the engineer’s

normal operating position.

(3) The front device shall have a means for entry of the unique identification code of the rear unit

being used. The front unit shall be designed so that it will display a message only from the rear

unit with the same code as entered into the front unit.

(4) The front unit shall be designed to meet the requirements of 232.19(d) (2), (3), (4), and (5). It

shall also be designed to meet the performance requirements in this paragraph.

(i) At temperatures from 0o C to 60o C;

(ii) During a vertical or lateral shock of 2g. peak for 0.1 second; and

(iii) During a longitudinal shock of 5g. peak for 0.1 second.

(g) Radio equipment. (1) The radio transmitter in the rear unit and the radio receiver in the front unit

shall comply with the applicable regulatory requirements of the FCC and use of a transmission

format acceptable to the FCC.

(2) If power is supplied by one or more batteries, the operating life shall be a minimum of 36 hours

at 0o C.

(H) Inspection. (1) Upon installation of the end-of-train device, it shall be determined that the

identification code entered into the front unit is identical to the unique identification code on the

rear-of-train unit.

(2) The functional capability of the device shall be determined at the point of installation, after

charging the train, by comparing the quantitative value displayed on the rear unit or on an air

gauge. The end device may not be used if the difference between the two readings exceeds three

pounds.

(3) The rear unit shall be calibrated for accuracy at least every 92 days. A tag, sticker, or other

method of information storage that provides that date of the last calibration was made, and the

name of the person doing the calibration shall be affixed to the rear unit.

[51 FR 17303, May 9, 1986]


79

APPENDIX F

TRAIN DYNAMIC ANALYSIS SIMULATION PROTOCOL

Train conditions: 2 pounds leakage, braking ratio 26 percent, 90 pounds brake pipe

Time Action

 0:00 independent reduced to release

(automatic brakes already released)

 0:05 throttle 1

 1:03 throttle 2

 3:16 throttle 1

 3:29 throttle off

 4:34 dynamic brake applied

 5:00 full dynamic

 7:04 minimum reduction (6 pounds) bail off independent

 7:11 2 pounds additional reduction

 8:07 another 2 pounds additional reduction

 9:33 1 pound additional reduction (75 pounds brake pipe)

 9:41 another 2 pounds additional reduction (73 pounds brake pipe)

10:03 another 2 pounds additional reduction (71 pounds brake pipe)

10:28 full service (64 pounds brake pipe)

10:38 emergency (no bail)

10:43 knock off dynamic