U.S. Fire Administration/Technical Report Series

Amtrak Train Derailment

Nodaway, Iowa

USFA-TR-143/March 2001

Homeland

Security

U.S. Fire Administration Fire Investigations Program

T

he U.S. Fire Administration develops reports on selected major fires throughout the country. 

The fires usually involve multiple deaths or a large loss of property. But the primary criterion 

for deciding to do a report is whether it will result in significant “lessons learned.” In some 

cases these lessons bring to light new knowledge about fire--the effect of building construction or 

contents, human behavior in fire, etc. In other cases, the lessons are not new but are serious enough 

to highlight once again, with yet another fire tragedy report. In some cases, special reports are developed to discuss events, drills, or new technologies which are of interest to the fire service.

The reports are sent to fire magazines and are distributed at National and Regional fire meetings. The 

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fire service. On a continuing basis the reports are available on request from the USFA; announcements of their availability are published widely in fire journals and newsletters.

This body of work provides detailed information on the nature of the fire problem for policymakers 

who must decide on allocations of resources between fire and other pressing problems, and within 

the fire service to improve codes and code enforcement, training, public fire education, building 

technology, and other related areas.

The Fire Administration, which has no regulatory authority, sends an experienced fire investigator 

into a community after a major incident only after having conferred with the local fire authorities 

to insure that the assistance and presence of the USFA would be supportive and would in no way 

interfere with any review of the incident they are themselves conducting. The intent is not to arrive 

during the event or even immediately after, but rather after the dust settles, so that a complete and 

objective review of all the important aspects of the incident can be made. Local authorities review 

the USFA’s report while it is in draft. The USFA investigator or team is available to local authorities 

should they wish to request technical assistance for their own investigation.

This report and its recommendations were developed by USFA staff and by Varley-Campbell & 

Associates, Inc. Miami and Chicago, its staff and consultants, who are under contract to assist the 

Fire Administration in carrying out the Fire Reports Program.

The Federal Emergency Management Agency, U.S. Fire Administration gratefully acknowledges the 

cooperation of the Adams County Sheriff’s Office, Emergency Management Agency, and Emergency 

Medical Service as well as the Fire Chief and members of the Corning, Iowa Volunteer Fire Department. 

Everyone who assisted in the preparation of this report was generous with his or her time, expertise, 

and counsel.

For additional copies of this report write to the U.S. Fire Administration, 16825 South Seton Avenue, 

Emmitsburg, Maryland 21727. The report is available on the Administration’s Web site at http://

www.usfa.dhs.gov/

Amtrak Train Derailment

Nodaway, Iowa 

Investigated by: John Lee Cook, Jr.

This is Report 143 of the Major Fires Investigation Project conducted 

by Varley-Campbell and Associates, Inc./TriData Corporation under 

contract EME-97-C0-0506 to the United States Fire Administration, 

Federal Emergency Management Agency.

Homeland

Security

Department of Homeland Security

United States Fire Administration

National Fire Data Center

U.S. Fire Administration

Mission Statement

As an entity of the Department of Homeland 

Security, the mission of the USFA is to reduce life and economic losses due to fire 

and related emergencies, through leadership, advocacy, coordination, and support. 

We serve the Nation independently, in coordination with other Federal agencies, 

and in partnership with fire protection and 

emergency service communities. With a 

commitment to excellence, we provide public education, training, technology, and data 

initiatives.

Homeland

Security

Table of Contents

OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SUMMARY OF KEY ISSUES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

THE CORNING VOLUNTEER FIRE DEPARTMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

AMTRAK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

THE DERAILMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

THE INVESTIGATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

LESSONS LEARNED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

APPENDIX A: Maps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

APPENDIX B: List of Photos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

APPENDIX C: List of Participating Agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

APPENDIX D: Recent Passenger Train Derailments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1

Amtrak Tram Derailment

NODAWAY, IOWA

MARCH 17, 2001

Local Contacts: Donnie Willett, Jr., Fire Chief

Corning Iowa Volunteer Fire Department

Corning, Iowa 50841

641-322-4112

Merlin R. Dixon, Sheriff

Adams County, Iowa 50841

Corning, Iowa 50841

Brian Kannas, Emergency Management Coordinator

Adams County Iowa

P0 Box 407

Corning, Iowa 50841

641-322-3798

David Walter, Director

Adams County Emergency Medical Service

Corning, Iowa 50841

641-322-3121

OVERVIEW

On the night of March 17, 2001 Amtrak’s westbound California Zephyr passenger train derailed at 

11:40 PM between Brooks and Nodaway in Adams County, Iowa. The train was traveling along a section of track owned by the Burlington Northern Santa Fe Railway and was carrying 225 passengers 

and sixteen crewmembers. The maximum passenger capacity is 519. One passenger died as a result 

of blunt force trauma sustained during the derailment and ninety-six others required transportation 

to a medical facility. Two of the injuries were serious enough to warrant evacuation by helicopter.

The derailment occurred in a very remote area just east of the Nodaway River. Two engines and 

nine of the fifteen cars left the tracks, but did not catch fire or spill any fuel. Two of the cars came 

to rest perpendicular to the tracks and several of the rail cars overturned or came to rest on their 

sides. Many of the passengers were already asleep when the incident occurred and were disoriented 

when they awoke because of the attitude of the cars and almost total darkness due to the absence of 

electrical power.

The crew of the Zephyr contacted the BNSF dispatcher in Fort Worth, Texas and reported that the 

train had derailed. The SNSF dispatcher contacted the Adams County Sheriff’s Department and pro-
2

vided the authorities with the location of the derailment, but was unable to provide any additional 

details concerning the number and extent of the injuries or the magnitude of the incident. Local fire, 

EMS, and law enforcement agencies were immediately dispatched.

When the derailment occurred, the Corning Volunteer Fire Department was hosting its annual fundraiser at the National Guard Armory and was preparing to serve breakfast at the fire station after the 

festivities concluded. Consequently, the department was fully staffed and the response to the incident was immediate. Upon hearing the incident dispatched, other area emergency services offered 

their assistance, which was readily accepted. The spouses of the firefighters also went into action to 

assist with the potential influx of patients at the local hospital and to shelter and feed the passengers 

that had not been injured.

The scene that greeted rescuers upon their arrival was eerily similar to the movie Field of Dreams. 

As soon as the passengers spotted the lights from the emergency vehicles, they began to quietly move 

toward the light and seemed to magically appear out of the darkness. Rescuers commented that the 

victims were very calm and the incident scene was unusually quiet. Rather than panic, people had 

attended to the injured and had helped each other evacuate the wreckage.

Access to the derailment site was limited since the derailment had not occurred at a crossing. Open 

pasture and farmland bordered the site on the north and south. Originally, there had been parallel 

tracks along the section where the derailment occurred. The southern track had been abandoned, 

but the roadbed had been maintained by the railroad to provide access along the track and small 

vehicles were able to use the roadbed to reach the site of the incident from a narrow road that was 

approximately one quarter of a mile west of the incident site and from another road that was located 

three-eights of a mile east of the site. Therefore, emergency responders were able to access the 

derailment site from two directions.

Access from two points proved to be significant, because two of the derailed cars completely blocked 

both the track and the abandoned roadbed, essentially dividing the incident site in half. Terrain and 

soft ground prevented the rescuers from driving around the wreckage and the roadbed was so narrow that it was impossible to turn around. Therefore, emergency vehicles were forced to drive in to 

the site from both the east and west side of the incident and then back out to the road.

Because of the large number of passengers and crewmembers (241), many of those who had not 

been injured or had only sustained minor injuries were taken out in the back of a pick-up truck or 

in a four-wheeled drive vehicle. Ambulances were then free to transport the more seriously injured 

victims to area hospitals following triage and stabilization. The two most seriously injured were 

taken by helicopter to a trauma center.

Those that had not been injured were taken by school bus to the Nodaway Community Center, 

where a temporary shelter had been opened. The occupants of the train were re-examined at the 

Community Center to make sure that they had not been injured. Later into the incident, Amtrak 

arranged for everyone to be transferred to hotels in Omaha, Nebraska, some seventy miles away.

Approximately 200 emergency responders from a number of local and State agencies responded to 

the incident. The remoteness of the location allowed law enforcement officials to quickly establish 

a perimeter to secure the area and to prevent the curious from interfering with rescue efforts. The 

time of the day also contributed to limiting the number of curiosity seekers at the scene. Most of the 

civilians that did go to the scene used their personal vehicles (pickups, SUV’s, and van’s) to assist in 

the removal of the passengers from the derailment site.
USFA-TR-143/March 2001 3

The incident lasted approximately three hours and by the time the national and international media 

began to descend on Corning, the event was largely over. More than 519 calls from the media and 

family members were processed by the Adams County Sheriff’s Office.

More than fifty investigators from State and Federal agencies scoured the site of the derailment to 

determine the cause of the incident. The exact cause had not been determined at the time that 

this report was written, but the National Transportation Safety Board determined that the incident 

occurred at the site of a broken rail. A section of the rail had been previously removed and had been 

patched, a common practice in the railroad industry. It was not immediately determined in the 

derailment occurred because of the broken rail or if the rail broke as a result of the derailment.

SUMMARY OF KEY ISSUES

Issues Comments

Access Access was extremely limited due to the remoteness of the accident site, which made the evacuation 

of passengers and the injured very difficult. On the other hand, the remoteness of the site assisted law 

enforcement with crowd and traffic control efforts.

Communications The volume of radio traffic quickly overwhelmed the two-way communications system. The absence of 

a repeater system and the remote location hampered the use of portable radios and was not conducive 

to the use of cellular telephones. There were only five incoming 9-1-1 lines and 9-1-1 telephone lines, 

which were quickly overcome by the 519 telephone calls processed by the Adams County Communication 

Center.

Media The remote location and inaccessibility of the incident site allowed the emergency responders to seal off 

the perimeter and prepare for the arrival of the media. Nevertheless, media inquires were abundant, some 

as far away as London and Brisbane.

Pre-Incident 

Planning

While an incident of this type had not been pre-planned, the presence of an up-to-date County Emergency 

Operations Plan, which had been regularly exercised, contributed to the successful outcome of the 

incident. The Plan included an annex for tornado response, which can include multiple causalities. 

Emergency Responders successfully followed the guidelines of the tornado plan in conducting search and 

rescue operations as well as treating, transporting, and sheltering the large number of injured passengers.

The local firefighters had not been trained to rescue and extricate people from trains. Therefore, they 

relied upon their training in searching for and rescuing victims of tornadoes.

Rescue Efforts Many of the doors jammed when the derailment occurred and the train lost electrical power. The windows 

were not breakable and a number of the cars were two stories in height with narrow stairways. All of these 

factors delayed and hampered in the search and rescue effort.

The train derailment occurred at 11:40 hours and many of the passengers on the train were already asleep. 

The incident site was in an unlit area and the absence of emergency lighting on the train made and compounded the disorientation of the passengers as they attempted to find their shoes and coats and exit the 

train. Emergency responders were required to illuminate the scene to the best of their ability to conduct 

search and rescue operations.

Time of Day The temperature at the time of the incident was 28°F. Winds were calm and the sky was clear. It had 

recently snowed, but the accumulations on the roadways had already melted. The lack of a wind chill 

no doubt prevented any cold related temperatures, while the freezing temperature helped stabilize the 

unpaved roadbed. The cold weather also made it imperative to open a shelter to accommodate the large 

number of passengers that were not injured, but were exposed to the freezing temperatures.

Weather If the weather had been warmer the melting snow and ice would have led to the formation of mud on the 

unpaved access to the incident site, which would have impeded rescue efforts. Elevated conditions would 

have also contributed to the possibility of heat related injuries to passengers and emergency responders.
4

THE CORNING VOLUNTEER FIRE DEPARTMENT

Corning is located east of Omaha, Nebraska in the southwestern corner of Iowa and is seventy-one 

miles west, southwest of Des Moines, the State capital. The city is the county seat of Adams County 

and has a population of 2,000. Adams County encompasses 432 square miles and the principle 

occupation of the county’s 4,800 residents is agriculture.

The Corning Volunteer Fire Department is one of three volunteer fire departments in Adams County. 

There are no paid departments within the County. Corning VFD’s thirty members provide fire protection within the city limits of Corning and respond to a rural portion of the county as well. The 

Department operates one fire station located in downtown Corning with four pieces of apparatus. 

Operations personnel are divided into three teams of firefighters. Each team is lead by a Captain and 

a Lieutenant who is responsible for training his or her team. Average response time is three minutes 

within the city limits and the Department averages fifteen members per incident, which includes 

daytime calls. The Department’s response goal is to be able to respond with at least two units and 

eight firefighters on every call.

The Adams County EMS Service, staffed by both volunteer and career members, provides EMS transport 

service within the city and the county. The service is based at the Alegent Health Mercy Hospital in 

Corning. At least two BLS ambulances are staffed around the clock whenever it is possible to do so.

AMTRAK

The name Amtrak is the blending of the words “American” and “Track”. The railroad’s official name 

is the National Railroad Passenger Corporation. Amtrak officially began service on May 1, 1971 with 

a schedule of 184 trains, serving 314 destinations. Amtrak took over the passenger operations of all 

but three railroads that continued their own intercity passenger train service for a period of time. 

They were the Rock Island Railroad, the Southern Railway, and the Denver & Rio Grande Western 

Railroad. The Southern Railway ceased operations of its Southern Crescent in 1979. Amtrak assumed 

the route, renaming it the Crescent. The Denver & Rio Grande Western Railroad ceased passenger 

train operations in 1983. Amtrak re-routed its California Zephyr to cover the Denver & Rio Grande’s 

routes.

Since the beginning, even-numbered trains have traveled north and east. Odd numbered trains travel 

south and west. Among the exceptions are Amtrak’s Surfliners, which use the opposite numbering 

system inherited from their former operator, the Santa Fe Railroad and some Empire Corridor Trains. 

Amtrak serves more than 500 stations in forty-five States. Those not included are Alaska, Hawaii, 

Maine, South Dakota and Wyoming. Wyoming is served by Amtrak Thruway Motorcoaches and plans 

are being developed to serve Maine.

Amtrak operates over more than 22,000 route miles with 25,000 employees. It owns 730 route 

miles, about 3% of the total nationwide, primarily between Boston and Washington, DC, and in 

Michigan; eighteen tunnels, and 1,165 bridges. In other parts of the country, Amtrak trains use 

tracks owned by freight railroads. On weekdays, Amtrak operates up to 265 trains per day, excluding 

commuter trains. These trains include 100 trains in the Amtrak Intercity business unit and 48 trains 

in the Amtrak West business unit (Washington, Oregon, and California). Amtrak trains operate every 

minute of the entire year.

Amtrak operates 2,188 railroad cars including 173 sleeper cars, 743 coach cars, 66 first class/business class cars, 65 dormitory/crew cars, 65 lounge/cafe/dinette cars, and 83 dining cars. Baggage 
USFA-TR-143/March 2001 5

and Mail and Express cars make up the remainder of the fleet. Amtrak also operates 343 locomotives, 

278 diesels and 65 electric.

THE DERAILMENT

At 11:40 PM on the night of Saturday March 17, 2001, the dispatcher on duty at the Adams County 

Sheriff’s Office in Corning, Iowa received a telephone call from the Fort Worth, Texas based dispatcher of the Burlington Northern Santa Fe Railway (BNSF) advising her that Amtrak’s California 

Zephyr passenger train traveling westbound on the BNSF’s mainline had derailed between Brooks 

and Nodaway, Iowa. The BNSF dispatcher had been contacted by the train’s engineer via their radio 

system, but was unable to provide any additional details concerning the incident.

The Sheriff’s Office serves as the 9-1-1 answering point for all of Adams County and dispatches for 

all of the public safety agencies within the County. The dispatcher immediately notified the volunteer 

fire departments, the County EMS Service, and all available deputies. Given the potential magnitude 

of the incident, the dispatchers also began to recall the off-duty deputies.

Only one dispatcher was on duty at the time the call was received, but it was time for a shift change 

and the relief dispatcher was already present. The off-going dispatcher remained in the dispatch 

center through the duration of the incident to help, and as soon as the incident was dispatched offers 

of assistance from other agencies began to be received, and all were accepted. Upon hearing the call 

being dispatched, an off-duty senior reserve officer and the Corning Police Chief responded to the 

Communications Center and assisted throughout the incident. The five in-coming 9-1-1 lines and 

the five in-coming telephone lines were immediately flooded and remained busy throughout the 

incident. A total of 519 calls were processed by the dispatch center.

March 17th is also Saint Patrick’s Day and the Corning VFD was hosting its annual fund raising event, 

a Firemen’s Ball, at the local National Guard Armory. After the Ball, attendees were scheduled to 

adjourn to the fire hall for breakfast and some of the members had already retired to the fire hall to 

help prepare for the breakfast when the incident occurred. Since the temperature was below freezing, the Fire Chief had instructed members to start the apparatus, which was parked outside on the 

apron. The Chief wanted the engines to be warm and the windshields to be free of ice or frost in the 

unlikely event something were to occur during the breakfast.

The sky was clear on the night of March 17. The temperature was 28°F and the wind was calm, thus 

no wind-chill. These conditions helped prevent hypothermia and prevented emergency responders 

from becoming overheated during the incident. Had it been colder, there would have been a problem due to the large number of victims and the potential for hypothermia. Victims were awaken 

from their sleep and were unable to find their shoes or coats due to the darkness and position of 

many of the rail cars. Colder temperatures, however, might have frozen the ground, which would 

have made access easier. Nevertheless, freezing temperatures did help keep road passable and prevented them becoming muddy due to the presence of accumulated snow and ice, and the fact that 

the roads were unpaved. If the event had occurred one week earlier, the results might have been 

different due to the amount of snow that had been on the ground in the area. The incident would 

have had a snow removal problem.

Amtrak's California Zephyr, also known as the Number Five, had last stopped in Des Moines, Iowa 

and was traveling along a portion of track owned and operated by the Burlington Northern Santa Fe 

Railway (BNSF) when it derailed one and one-half miles west of Brooks and east of Nodaway. The 

Zephyr originated in Chicago and was destined for Emeryville, California, which is near Oakland. 
6

The train consisted of two locomotives and fifteen cars and its next scheduled stop was Omaha, some 

seventy miles to the west. The train was confirmed to have been traveling at fifty-two miles per hour 

on a rail section that is rated at eighty miles per hour. The slower speed was due to problems with 

the train's whistle, which is used at crossings to warn motorists.

Rescuers were unable to immediately determine the number of people on the train because the 

conductor had just begun the task of collecting tickets when the derailment occurred, which particularly made it difficult to account for the number of children on board. While the train had the 

potential to transport 519, the initial reports placed the occupant load at 210 - 195 passengers and 

fifteen crewmembers. That number was later revised upward to 241 - 225 passengers and sixteen 

crewmembers.

The first law enforcement officer on the scene was a State Trooper who approached the incident site 

from the west side. The officer placed the crew of the derailed engine in his car. Railway officials 

later took the crew to be tested for alcohol and drugs. Law enforcement agencies from throughout 

the area responded and were primarily used for traffic control. The time of day and the remoteness 

of location resulted in a very limited problem with spectators. The response by rescuers in their 

personal vehicles and that of nearby residents contributed significantly to the congestion at the site.

When the derailment occurred, a number of the cars came to rest perpendicular to the track (see 

Photo One). Two of the cars completely blocked the scene and essentially divided the incident into 

two sectors, east and west. Wreckage and debris was scattered over an area approximately 1/4 mile 

in length. Access was limited to a narrow road located 3/8th of a mile east of the wreckage and 

another road 1/4 mile to the west. Staging and triage areas were established on both sides of the 

site.

The derailment did not cause a fire and there were no hazardous materials involved. Both engines 

and a majority of the cars came off the track, however, with at least one being turned upside down 

and approximately four cars being turned on their side. The train traveled through fences as it left 

the track, but none of the affected fields contained livestock. Additionally, no utilities were disrupted 

by the derailment. There, was an old telegraph line along the track, which had been abandoned and 

it was quickly determined not to be a hazard.

The rail bed at the site of the incident had space for two parallel tracks, although only one set being 

used at time of the crash and generally ran from northeast to southwest. The section is part of the 

BNSF's mainline and carries approximately forty freight trains a (day and some 103 million tons 

of freight annually. The primary product is coal being hauled east from Wyoming. The abandoned 

roadbed proved to be the only means to each site. Ambulances and rescuers had to drive into the 

site, in single file and then back out with their patient before another vehicle could enter the site. 

This process was complicated by the presence of several trestles, which spanned small streams. The 

trestles were open between the cross ties, thus making crossing on foot very dangerous.

Ninety-six people were injured and one person was killed in the derailment. No one was ejected as 

a result of the derailment, but access to the victims was limited by the position of the cars and the 

very narrow stairways on the double-decked cars. Two of the cars came to rest perpendicular to the 

track and essentially sliced the scene into two sectors. Passenger rail cars are very sturdy and have 

unbreakable windows. The doors began jammed as a result of the impact of the derailment.

As the emergency responders began to arrive, a scene eerily reminiscent of the movie The Field of Dreams

greeted them. People began to walk toward them and their lights. The responders also reported an 
USFA-TR-143/March 2001 7

unusual sense of calm, which pervaded the incident scene. Many of the passengers directed rescuers 

to those with more severe injuries and often declined immediate transportation in order for family 

members to remain together.

The ninety-six people who were injured were transported to six area hospitals, primarily by ground 

ambulance. Two of the victims' injuries were serious enough to warrant evacuation by helicopter. A 

third person was later flown out from the Corning Hospital. The first ambulance initially responded 

from the Adams County EMS agency and assumed command of the triage efforts. The supervisor 

and the County's second EMS unit responded to the Corning hospital's emergency room to assist 

with the influx of patients because of the small capacity of the hospital and the expected patient load. 

The supervisor helped coordinate the transportation effort and directed ambulances to area hospitals 

based upon the nature and severity of the injuries.

Due to the large number of injuries, ground ambulances were required to make multiple trips 

and they began to run out of backboards and c-collars. In many cases the used duet tape to secure 

patients to stretchers and to immobilize patients. Rescuers used ambulances as well as privately 

owned vehicles, many of them four-wheel drive pickup trucks and SUV's, to transport the injured 

and non-injured alike to the staging areas, one each side of the derailment site. At staging, the occupants of the train were triaged and were sorted for transport to a medical facility. If they were not 

injured, passengers were taken by school bus to the Community Center in Nodaway, which had been 

opened to shelter the non-injured.

To assist with the rescue effort, a load of linens and blankets were taken to the scene by a vendor of 

the Mercy Hospital in Corning because of the temperature and the large number of occupants on 

the train. The number of blankets onboard the ambulances and train, however, proved to be sufficient. The hospital had been notified of the incident fifteen minutes in advance of the receipt of 

the first patient, which allowed sufficient time to mobilize its staff and kitchen. All four of the local 

physicians and the entire off-duty nursing staff responded to the emergency room to assist with the 

influx of patients. A total of 43 patients were taken to Mercy Hospital. Three patients subsequently 

transferred to metro hospitals and one remained hospitalized in Corning. The remainder were all 

treated and released.

At Iowa Methodist Medical Center in Des Moines, a 77-year-old female was hospitalized with chest 

injuries and a fractured wrist. At St. Joseph in Omaha: 54-year-old male and 50 year old female 

were hospitalized and a 47-year-old female was hospitalized with broken hip at the University of 

Nebraska Medical Center in Omaha.

As patients arrived and were treated, their names were faxed to the Dispatcher in order to keep track 

of everyone. The nature and severity of their injury and the location of their transport was noted by 

the Dispatcher as well.

The single fatality was a 69 year-old female from Colorado Springs that had traveled to Des Moines 

because her brother, a nursing home resident in Des Moines, had died on the previous Thursday. She 

was in the process of transporting his ashes to Colorado when the incident occurred. An autopsy 

was conducted by the State medical examiner and it was determined that she died at the scene from 

multiple blunt force trauma injuries. The medical examiner ruled that her death was accidental.

Approximately 200 emergency responders assisted at the scene of the incident. Twenty-one ground 

transportation ambulances, two helicopters, and an undetermined number of private vehicles were 

used to transport patients. For a complete list of the responders, see Appendix C. The Adams County 
8

Emergency Management Coordinator, which is a voluntary position, served as the incident commander. A Command Post was set up on the Westside of the incident and the Corning Fire Chief 

directed operations from that site. The Taylor County Emergency Management Coordinator reported 

to the staging area on the west side of the incident and assisted as needed.

Passengers and crewmembers that had not been injured were transported by school bus to the 

Nodaway Community Center where they were sheltered from the cold and fed. An EMS unit was 

place on standby at the Community Center to ensure no one was later discovered to have been 

injured or if there had been a medical emergency triggered by the delayed effects of the incident. 

The Emergency Management Coordinator from Union County went there to assist. As the incident 

progressed, Amtrak transferred them to hotels in Omaha where they received counseling and assistance from the Red Cross and the Salvation Army.

Approximately fourteen minutes into incident the media began to call the Adams County Sheriff's 

Dispatcher. Phone calls from as far away as London and Brisbane, Australia were answered. Once the 

news hit the Associated Press newswire, the call volume greatly increased. One local media person 

reported that the local media representative got in early and the event was really over by the time the 

big guys got interested. Most of the large agencies arrived after daylight, but by then it was all over 

except for the investigation and cleanup. Family members of the occupants of the train also began to 

call once the news of the derailment was released. A number of television stations responded to the 

area with their satellite trucks and helicopters. There was not need, however, to restrict air space.

The local emergency responders had not had any training on responding to or managing a train 

wreck and had very limited knowledge about train wrecks and the tactics and logistics necessary to 

manage such an event. Therefore, they relied upon the training that they had, which is the response 

to tornadoes that are common in the Midwest. Rescuers conducted both a primary and secondary 

search of the train and marked the cars as they went using the orange spray paint that is a part of 

their tornado response plan to mark buildings that have been searched in the event that a tornado 

hits and does serious damage.

By 07:00 hours on Saturday Morning, most of the passengers had been bused to Omaha hotels and 

by 09:00 hours only a few volunteers remained at the Community Center. The rail line was reopened 

to freight and passenger service at 01:45 hours on Monday March the 20th. The temperature and the 

nature of the rescue activities made rehab unnecessary according to local rescue officials. No injuries 

of emergency responders were reported during the incident, nor were there any injuries reported by 

the occupants of the train as a result of the rescue efforts.

THE INVESTIGATION

Approximately fifty investigators from the National Transportation Safety Board (NTSB), the Federal 

Railroad Administration, the Iowa Department of Transportation, Amtrak, the Burlington Northern 

Railway, the Brotherhood of Locomotive Engineers, and the United Transportation Union participated in an investigation of the derailment. Investigators concluded that the train left the track due to 

a broken rail, but were not immediately able to determine if the rail was broken before the incident 

occurred or if the rail broke as a result of the derailment.

The broken rail was discovered at a point where a patch had previously been made to replace a 

section of defective rail. A spokesperson from the NTSB indicated that this was standard procedure 

to put in a patch where a problem has been detected. A maintenance crew had cut a gap into the 
USFA-TR-143/March 2001 9

defective rail and bolted in another piece of rail approximately four yards in length. NTSB personnel 

collected pieces of the broken rail and sent them to Washington, DC for a metallurgical analysis to 

determine if there were any defects, which might have contributed to the derailment.

State and local law enforcement officials did not participate in the investigation because the derailment occurred on private property and did not occur at a railroad crossing. Therefore, law enforcement officials indicated that they did not have any jurisdiction in the matter because no crime had 

been committed. Their primary role at the incident was traffic and crowd control and to assist fire 

and EMS personnel.

The BNSF track had been visually inspected on the day of the accident and no irregularities had 

been detected and investigators determined that an eastbound coal train had passed over the derailment site fifty-seven minutes before the derailment without incident. The Amtrak crew was tested 

for drugs or alcohol following the incident. The results of those tests had not been released when 

this report was prepared. Repair crews placed a section of temporary track in the vacant roadbed to 

reroute trains around the derailment site in order to allow the investigators to conduct their investigation undisturbed.

The NTSB praised the local emergency crews for their response effort, as did officials from Amtrak. 

The NTSB also had praise for Amtrak for placing emergency light sticks on their trains based upon 

recommendations from the NTSB. NTSB stated that they believed the availability of a light source 

helped people survive the derailment.

No formal determination as to the exact cause of the derailment had been released at the time that this 

report was prepared. In a related note, The California Zephyr was involved in a collision with another 

train on September 13, 2001 in Wendover, Utah, which is near the Nevada line some 120 miles west of 

Salt Lake City. Only minor injuries were reported, although parts of the train did catch fire.

LESSONS LEARNED

1. An effective, functional means of communications is essential.

There were no turf issues that are so often associated with this type of event. Most of the rescuers and emergency responders knew each other, proving the value of daily verbal, face-to-face 

communications. Technology, however, was overwhelmed by an event of this magnitude. The 

Sheriff Department’s simplex VHF radio system (155.010 Mhz) was simply overloaded and 

plagued by dead areas created by the remoteness of the incident site and topography. Cellular 

telephone also proved to be ineffective because of dead areas and the lack of towers near the 

incident site.

Incident planning should include provisions for alternate means of communications. As proven 

by this incident, small rural communities are not immune to disasters that can quickly overtax 

an otherwise functional communications system.

2. Incident Command and Accountability Systems are important elements in the successful 

management of a large-scale incident.

The management of 241 victims and 200 rescuers is difficult under the best of circumstances. 

An incident command and accountability system is an essential element in the successful management of large-scale events. To be effective, everyone involved must be familiar with the system and should regularly use the system so that it will be automatic in these types of events.
10 U.S. Fire Administration/Technical Report Series

3. Access and logistics are critical to the success of a large-scare incident.

It was necessary to perform three extrications during this incident. There was a great need 

for ropes, hand lights, scene lighting and short ladders because of very limited access due to 

unbreakable windows, and the narrow stairways in the two-story cars. Prybars, backboards, and 

c-collars were also in great demand.

There was very limited access to the site. Rescuers had to drive into from two different directions and then back out. The process was complicated by the darkness of the scene and a number of railroad trestles open to the water below.

Transportation was also issue. When the number of ambulances was exhausted, school buses 

and privately owned vehicles were pressed into service in order to remove passengers and victims to safety.

Future planning for a similar event should identify the types and sources for the equipment that 

could potentially be required in a multiple casualty incident. Training for the incident should 

include driving techniques for maneuvering in tight quarters.

4. Pre-Incident Planning is an important tool in the successful management of a train derailment or other large-scale event.

Adams County had an often exercised and up-to-date Emergency Operations Plan at the time 

of the incident. The County activated its Emergency Operations Center and followed the plan. 

It worked and the incident proved the value of exercising the plan. The general comments 

received after the incident, including those from Amtrak, were very positive. In the absence of 

a contingency specific plan, emergency responders relied upon their tornado response plan, 

which proved to be effective in managing the incident. Debriefings and a critique were held at 

the community center following the incident. Officials from the Corning hospital and Amtrak 

coordinated the event.
11

APPENDIX A

Maps

Map One: Detailed Route Map for the California Zephyr

Map Two: General Route Map for the California Zephyr
12 U.S. Fire Administration/Technical Report Series

Page A-2

KANSAS CITY

Map One: Detailed Route Map for the California Zephyr

Map Two: General Route Map for the California Zephyr

Map One: Detailed Route Map for the California Zephyr

MADISON

CHICAGO

KANSAS CITY

St. Joseph HoldergeHasting

Lincoln

Omaha Osceola

Creston Ottumwa

Mt. Pleasant

Galesburg

Burlington

Princeton

Rockford

Naperville

Map One: Detailed Route Map for the California Zephyr

Map Two: Map Two: General Route Map for the California Zephyr General Route Map for the California Zephyr
13

APPENDIX B

List of Photos

Photo Description

Photo #1: Aerial view of wreckage

Photo #2: Photo of the California Zephyr

Photo #3: Photo taken after the track was reopened showing the position 

of the wrecked passenger cars and a BNSF freight train passing 

through the site

Photo #4: Investigators leaving a wrecked car

Photo #5: Photo of one of the wrecked cars (a double decker)
14 U.S. Fire Administration/Technical Report Series

1. Aerial view of wreckage

Page B-2

1. Aerial view of wreckage
USFA-TR-143/March 2001 152. Photo of the California Zephyr

Page B-3

3. Rescue workers look for victims

2. Photo of the California Zephyr
16 U.S. Fire Administration/Technical Report Series

Page B-4

3. Photo taken after the track was reopened showing the position of the wrecked passenger cars and a BNSF freight train passing through the site

4. Investigators leaving a wrecked car

3. Photo taken after the track was reopened showing the position of the wrecked 

passenger cars and a BNSF freight train passing through the site

Page B-4

3. Photo taken after the track was reopened showing the position of the wrecked passenger cars and a BNSF freight train passing through the site

4. Investigators leaving a wrecked car 4. Investigators leaving a wrecked car
USFA-TR-143/March 2001 17

5. Photo of one of the wrecked cars (a double decker)

Page B-5

5. Photo of one of the wrecked cars (a double decker)
18

APPENDIX C

List of Participating Agencies

The following agencies responded to and/or participated in a support role 

at the incident on 17 March, 2001

Fire Departments

Corning Volunteer Fire Department

Clarinda Fire and Rescue Department

Creston Fire Department

Lenex Fire and Rescue

Emergency Medical Services

Adams County Emergency Medical Service

Bedford Ambulance Service

Hamburg Rescue Service

Law Enforcement Agencies

Adams County Sheriff’s Department

Corning Police Department

Iowa State Police

Other Agencies

Adams County Office of Emergency Management

Alegent Health Mercy Hospital

Corning Community School

Greater Community Hospital

Iowa Department of Public Health/EMS

Iowa Emergency Management Agency

Life-Net

Red Cross

Salvation Army

Taylor County Emergency Management Agency

Union County Emergency Management Agency
19

APPENDIX D

Recent Passenger Train Derailments

Source: Brotherhood of Locomotive Engineers

• 5 February 2001: Amtrak train collides with a freight train on the same track in Syracuse, 

New York injuring sixty-one people

• 4 November 2000: Amtrak train derails after hitting a truck near Moorpark, California 

injuring killing the truck driver and injuring thirty people on the train

• 15 March 2000: Amtrak train derailed alongside a cornfield near Carbondale, Kansas injuring twenty-nine passengers

• 20 September 1999: Amtrak train rear-ended a freight train in a rail yard in Cumberland, 

Maryland injuring thirty-seven people

• 16 March 1999: Amtrak train collided with a truck and derailed near Bourbonnais, Illinois killing thirteen and injuring more than 100

• 9 August 1997: Amtrak train derailed while crossing a flooded stream in northwestern 

Arizona injuring 140 people

• 23 November 1996: Amtrak train jumped the track at sixty miles per hour in Secaucus, New 

Jersey sideswiping another train and injuring thirty-two

• 16 February 1996: Amtrak's Capitol limited and a MARC commuter train collide in Silver 

Spring, Maryland killing all three crew members and eight passengers on the MARC train

• 9 February 1996: Two New Jersey commuter trains collide killing two crew members and 

one passenger

• 22 September 1993: Amtrak's Sunset Limited jumped the rail on weakened bridge that had 

been rammed by a barge minutes earlier and plunges into a bayou near Mobile, Alabama 

killing forty-seven

Note: Auto accidents kill 10 times as many as train accidents according to the National Association of Railroad Passengers in 

Washington, DC. Deaths per 10 billion passenger miles are as follows: 96.2 for cars; 8.6 Amtrak; 3.6 airplane passengers; and 

1.4 for buses.