PB98-916301

NTSB/RAR-98/01

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

RAILROAD ACCIDENT REPORT

DERAILMENT OF UNION PACIFIC RAILROAD UNIT

FREIGHT TRAIN 6205 WEST NEAR KELSO, CALIFORNIA

JANUARY 12, 1997

6921A
Abstract: On January 12, 1997, the Union Pacific Railroad unit freight train 6205 west derailed

on the Union Pacific Los Angeles Subdivision, milepost 238.7, near Kelso, California. While

descending Cima Hill, the engineer inadvertently activated the multiple-unit engine shutdown

switch, which shut down all the locomotive units’ diesel engines and eliminated the units’

dynamic braking capabilities. The train rapidly became a runaway, eventually reaching a speed of

72 mph, and derailed 68 of its 75 cars while exiting a siding near Kelso. No fatalities or injuries

resulted.

The safety issues discussed in this report are the placement of safety-critical locomotive

cab controls, adequate train-speed safety margins for steep-grade railroads, and the criticality of

dynamic braking systems. The report also discusses accurate car weight reporting, the power

brake rulemaking process, and the use of air brake retainers.

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

recommendations to the Federal Railroad Administration, the Association of American Railroads,

and the Union Pacific Railroad.

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, S.W.

Washington, D.C. 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) 605-6000
DERAILMENT OF UNION PACIFIC

RAILROAD UNIT FREIGHT TRAIN 6205

WEST NEAR KELSO, CALIFORNIA,

JANUARY 12, 1997

RAILROAD ACCIDENT REPORT

Adopted: February 6, 1998

Notation 6921A

NATIONAL

TRANSPORTATION

SAFETY BOARD

Washington, D.C. 20594

iii

CONTENTS

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

INVESTIGATION ........................................................................................................................ 1

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

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

Accident Sequence................................................................................................................... 1

Injuries............................................................................................................................................. 4

Damage............................................................................................................................................ 4

Personnel Information ..................................................................................................................... 4

Engineer ................................................................................................................................... 4

Conductor................................................................................................................................. 4

Track and Signal Information.......................................................................................................... 4

Track. ....................................................................................................................................... 4

Signal ....................................................................................................................................... 4

Operations ....................................................................................................................................... 4

Meteorological Information ............................................................................................................ 6

Toxicological Information............................................................................................................... 6

Train and Equipment Information................................................................................................... 6

Train Movement....................................................................................................................... 6

Car Weight ............................................................................................................................... 6

Locomotives............................................................................................................................. 7

Train Tread Braking................................................................................................................. 7

Air Brake Retainers.................................................................................................................. 8

Dynamic Brakes ....................................................................................................................... 9

Preaccident Inspections and Actions............................................................................................. 11

Postaccident Inspections, Tests, and Research.............................................................................. 11

Signals and Track................................................................................................................... 11

Locomotives........................................................................................................................... 11

Multiple-Unit Engine Stop Switch......................................................................................... 12

Event Recorders ..................................................................................................................... 17

Cars ........................................................................................................................................ 17

Train Dynamics Analyzer Simulations .................................................................................. 17

Union Pacific Braking Tests .................................................................................................. 18

Postaccident Actions ..................................................................................................................... 20

The Federal Railroad Administration..................................................................................... 20

The Union Pacific Railroad Company ................................................................................... 20

Additional Information.................................................................................................................. 20

Power Brake Regulations....................................................................................................... 20

Car Weight and Train Speed Developments.......................................................................... 21
iv

ANALYSIS................................................................................................................................... 22

General .......................................................................................................................................... 22

The Accident ................................................................................................................................. 22

Placement of Safety-Critical Locomotive Cab Controls............................................................... 23

Train-Speed Safety Margins for Steep-Grade Railroads............................................................... 24

Car Weight ............................................................................................................................. 24

Tread Braking Limits ............................................................................................................. 25

Dynamic Braking ................................................................................................................... 26

Air Brake Retainers....................................................................................................................... 29

UP Management of Safety Issues.................................................................................................. 29

CONCLUSIONS ......................................................................................................................... 31

Findings......................................................................................................................................... 31

Probable Cause.............................................................................................................................. 32

RECOMMENDATIONS............................................................................................................ 33

APPENDIXES ............................................................................................................................. 35

Appendix A -- Investigation and Sworn Testimony Proceeding................................................... 35

Appendix B -- Excerpts from Applicable Operating Rules .......................................................... 37

Appendix C -- How Air Brakes Work .......................................................................................... 39

Appendix D -- Train Dynamics Analyzer Simulations ................................................................. 41

ACRONYMS AND ABBREVIATIONS ................................................................................... 43
v

On January 12, 1997, about 11:52 a.m.

Pacific standard time, the Union Pacific

Railroad unit freight train 6205 west derailed 68

cars on the Union Pacific Railroad Los Angeles

Subdivision, milepost 238.7, near Kelso,

California. The train consisted of 3 locomotive

units and 75 loaded covered hopper cars. While

descending Cima Hill, the engineer

inadvertently activated the multiple-unit engine

shutdown switch, which shut down all the

locomotive unit diesel engines and eliminated

the train’s dynamic braking capability. The train

rapidly accelerated beyond the 20-mph

authorized speed limit despite the engineer’s

efforts to increase the train’s air braking, which

the engineer placed in emergency 1 minute and

13 seconds after dynamic braking loss. The

train’s consist weight was listed at an average of

13 tons per car less than the train actually

weighed. The train eventually reached a speed

of 72 mph and derailed 68 of its 75 cars while

exiting a siding near Kelso, California. No

fatalities, injuries, fires, or hazardous materials

releases resulted from the accident. The total

damage cost was $4,079,152.

The National Transportation Safety Board

determines that the probable cause of the

derailment was (1) a prolonged pattern of

inattention and lack of action by Union Pacific

Railroad management to protect effectively or

relocate the multiple-unit engine shutdown

switch in SD60M locomotives after the switch

had repeatedly been recognized as subject to

inadvertent activation; and (2) failure of Union

Pacific Railroad management to adequately

address critical safety issues such as dynamic

braking system operational reliance and

protection, and authorized maximum train

speeds in the event of dynamic braking failure.

Contributing to the severity of the accident was

the failure of Union Pacific Railroad

management to ensure accurate car weight

assessment and training for operating personnel

on retainer-setting procedures and effects.

The major safety issues discussed in this

report are the placement of safety-critical

locomotive cab controls, adequate train-speed

safety margins for steep-grade railroads, and the

criticality of dynamic braking systems. The

report also discusses accurate car weight

reporting, the power brake rulemaking process,

and the use of air brake retainers.

As a result of this accident investigation, the

National Transportation Safety Board makes

recommendations to the Federal Railroad

Administration, the Association of American

Railroads, and the Union Pacific Railroad.

EXECUTIVE SUMMARY

1

The Accident

Synopsis -- On January 12, 1997, the

Union Pacific Railroad (UP)1

 unit freight train

6205 west derailed on the UP Los Angeles

Subdivision, milepost (MP) 238.7, near Kelso,

California. While descending Cima Hill, the

engineer inadvertently activated the multipleunit (MU) engine shutdown switch, which shut

down all the locomotive units’ diesel engines

and eliminated the units’ dynamic braking

capabilities. The train rapidly became a

runaway, eventually reaching a speed of

72 mph, and derailed 68 of its 75 cars while

exiting a siding near Kelso. (See figure 1.) No

fatalities or injuries resulted.

Accident Sequence -- The UP unit2 freight

train 6205 west originated in Columbus,

Nebraska, on January 3, 1997. The train was

destined for a marine terminal near San

Francisco, California. Upon its arrival at Salt

Lake City, Utah, (on January 11, 1997) the train

received a Federal Railroad Administration

(FRA) 1,000-mile inspection3

 and then

continued west.

When the train reached Las Vegas, Nevada,

in the early morning of January 12, 1997, the

crew changed. The oncoming engineer went to

the lead cab and conducted a locomotive daily

inspection.4

 The oncoming conductor moved by

crew hauler to the end of the train to renew the

end-of-train (EOT) device battery.5

 

1

See the last page of this document for a list of all

acronyms and abbreviations used in this report.

2

A unit train is dedicated to transporting one

commodity from one origin to one destination, generally

over a specified route with assigned cars.

3

See 49 Code of Federal Regulations (CFR) Part

232.12(b).

4

See 49 CFR Part 229.21.

5

The EOT device is a two-part telemetry mechanism

(one part in the lead locomotive cab and one at the end of

the train) that informs the engineer of the brake pipe

pressure at the end of the train. Batteries power the rearend part of the device. The batteries are replaced regularly.

After installing the battery, the conductor

radioed the engineer to tell him that the battery

was installed, that the EOT marker was

functioning, and that the trainline air pressure at

the rear end of the train was 68 psi. The

conductor returned to the train’s head end, then

went back 10 cars to wait while the pressure in

the air brake system built up. Upon the

engineer’s application of the air brakes, the

conductor released the car hand brakes and

returned to the lead locomotive.

The train departed Las Vegas, MP 334.3, at

6:05 a.m. on January 12, 1997, with 3

locomotive units on the head end, followed by

75 cars loaded with corn. The train consist

showed that the train weighed 9,724 tons6

 and

was 4,661 feet long.

According to crew statements, the trip from

Las Vegas to Cima was routine. The engineer

carried out a running test of the dynamic brakes

from Erie, MP 309.3,7

 to Borax, MP 292. He

later testified that the dynamic brakes had

functioned appropriately. The train made one

stop at Brant, MP 263.9, where it took a siding

to clear two other trains. Three other trains en

route cleared for UP train 6205.

When approaching the crest at Cima, MP

254.6, the engineer made a gradual throttle

reduction followed by a minimum application of

the air brakes (6- to 8-pound reduction of the

brake pipe). The engineer stopped the train with

it draped symmetrically over the crest of the

grade8

 at Cima.

 

6

For reasons that are explained later in this report, the

train weight was incorrectly reported to be approximately

975 tons lighter than the train actually weighed.

7

MPs descend as the train traveled westward.

8

“Grade” is expressed in percentage of vertical

elevation change in feet for a lateral 100 feet. “Mountain,”

“heavy,” or “steep” grade for a train of 4,000 trailing tons

or less is a grade of 2 percent or more for a distance of 2 or

more miles. For a train with a trailing tonnage of more than

4,000 tons, steep grade is an average of 1 percent or more

grade for 3 or more miles.

INVESTIGATION
Figure 1—Derailed UP freight train 6205 west
3

According to the requirements of UP System

Timetable No. 2, UP train 6205’s maximum

speed down Cima Hill would have been 20 mph

and retaining valves were to have been set on all

cars before descent. The train remained at Cima

for 45 minutes, while the conductor set retainers

in preparation for the 2.2-percent grade descent

in the next 15 miles. The conductor walked

down and back up the train, setting its air brake

retainer valves to the high pressure position.9

According to the conductor, when he was about

halfway up the train on his return, he radioed the

engineer to release the brakes, which he said the

engineer did. He set about 15 remaining

retainers and returned to the lead unit.

The train started moving down Cima Hill at

about 11:18 a.m. The engineer began applying

dynamic brakes about 2 1/2 minutes later, with

the train traveling at 7 mph. Within 30 seconds,

the dynamic braking effort built to 92 amps with

the train traveling at 8 mph. Less than 2 minutes

later, the dynamic braking effort was 705 amps

at 13 mph. The engineer also made a 6- to 8-psi

minimum reduction of the brake pipe to apply

the train air brakes. The train speed and dynamic

brake amperage continued to build slowly over

the next 19 minutes, until they reached 843

amps of dynamic braking at 22 mph. The

engineer later testified that he had been using

most of his locomotive dynamic brake capability

and supplementing that braking effort

pneumatically with the train’s air brake system

as necessary to control speed.10 By about 11:42

a.m., train speed had reached 23 mph and

amperage had declined to about 820 amps. (The

speed was 3 mph above the maximum

authorized speed.)

At 11:42 a.m., the dynamic brake amperage

and effort fell to 0 amps within 13 seconds. It

later became evident that the engineer had

 

9

Each freight car is equipped with a retaining valve

that, when set in the high pressure position, retains air in

the brake cylinder at whatever pressure is dictated by one

or more brake applications. Successive applications add to

the brake cylinder pressure. From the high pressure

position, brakes may only be released by stopping the train

and pushing the release rod in or by turning the selector

handle on the retainer to another position.

10The engineer did not use all the dynamic braking

available; he retained some dynamic braking capability “to

stop on the hill or if [the train] met another train.”

unwittingly depressed the MU engine shutdown

switch, which stopped the fuel pumps on all the

locomotive units. (The switch provides a means

of shutting down the locomotive, regardless of

the number of units it comprises.) As the

accident unfolded, neither crewmember knew

the reason for the shutdown. The traincrew

members later testified that they thought only

the lead locomotive unit had shut down.

The diesel engine of the lead locomotive

stopped, and its alarm bell rang.11 The engineer

moved the dynamic brake lever to maximum

without result. He then (within 16 seconds)

reduced the brake pipe pressure by 12 to 17 psi,

in an attempt to compensate for the loss of the

dynamic brakes. The train passed the west

switch at Elora, MP 247.9, at 25 mph. Train

speed soon increased to 29 mph.12

Within the next minute, the engineer

continued to increase train air braking in

response to the rising train speed, until a fullservice application was achieved by the time

train speed reached 31 mph. The engineer then

made an emergency brake application and

notified the dispatcher that the train was a

runaway. The engineer noted that the EOT rearend cab display device showed 0 pressure,

indicating to him that the emergency had

propagated to the end of the train. The time

elapsed between the loss of the dynamic braking

until the train was put into emergency was

1 minute, 13 seconds.

For the next 9 1/2 minutes, the train

continued to increase speed despite intermittent

applications of the independent brakes.13 The

dispatcher had routed the train onto a siding at

Hayden, MP 240. The train went into the

Hayden turnout at approximately 72 mph. As

the train began to exit the Hayden siding at the

west-end turnout, MP 238.7, the drawbar

between the locomotives and the first car broke,

and the cars began to derail. The locomotives,

free of the cars, negotiated the turnout onto the

 

11The alarm bell rings when engine shutdown occurs.

12It should be noted that upon the failure of one or

more units of dynamic braking, UP rules require that

maximum authorized speed becomes 15 mph.

13Independent brakes apply braking to the locomotives

only.
4

mainline and came to rest 3 miles away. Sixtyeight of the 75 loaded cars derailed at the westend turnout at approximately 11:52 a.m. (See

figure 2 for a map of the accident site.)

Injuries

No injuries resulted from the accident.

Damage

Personnel Information

Engineer -- The 36-year-old engineer began

his employment with the UP as a brakeman on

October 5, 1990. In April 1995, he fulfilled the

necessary requirements and was certified as a

locomotive engineer. On May 5, 1995, he was

approved by the UP to operate as a locomotive

engineer. He passed his last formal examination

on the General Code of Operating Rules14

during July 1996. On December 6, 1996, the UP

approved him to operate as a conductor.

The engineer testified that he had been

rested in accordance with the Federal Hours of

Service Act and that he had felt well rested on

the day of the accident. The engineer also said

that he had not been formally trained by the UP

on setting the retainers. He said he gained his

knowledge about retainers during on-the-job

training and through experience.

Conductor -- The 54-year-old conductor

began his employment with the UP as a

brakeman on March 11, 1968. He qualified as a

conductor on August 11, 1989. He passed his

last formal examination on the General Code of

Operating Rules during June 1996.

 

14The General Code of Operating Rules governs the

operation of railroads, such as the UP, that have adopted it.

Railroads are required to file a set of operating rules with

the FRA, in accordance with 49 CFR Part 217.7.

The conductor testified that he had been

rested in accordance with the Federal Hours of

Service Act. He also stated that he had not been

formally trained by the UP on setting the

retainers. He said he gained his knowledge

about retainers during on-the-job training and

through experience.

Track and Signal Information

Track -- The track between Cima, MP

254.6, and Kelso, MP 236.5, consists of a single

main track with adjacent siding tracks at Chase,

MP 251.1; Elora, MP 247.9; Dawes, MP 243.9;

and Hayden, MP 240.0. The general derailment

occurred at the west end of the Hayden siding at

MP 238.7. The UP designated the track through

the accident area as FRA Class 4. Beginning

about MP 252, the westbound grade descends at

a steady 2.2 percent until MP 237 (15 miles),

where the grade decreases through a series of

transitions until it is level at MP 217.

Signal -- Train movements on the Los

Angeles Subdivision were controlled (in part)

by wayside single-lens colored searchlight

signals, established through a centralized traffic

control (CTC) system15 controlled from Omaha,

Nebraska.

Operations

Train operations through the accident area

were controlled by a combination of operating

rules, timetable instructions, and CTC system

signal indications. According to UP System

Timetable No. 2 (effective October 29, 1995, for

the Los Angeles Subdivision), UP engineers

must handle trains based on the trailing tons per

operative brake and the trailing tons per

operative dynamic brake. The tonnage dictates

the maximum speed and acceptable methods of

braking, including the use of the dynamic brakes

and car-retaining valves. The timetable also

establishes air brake reduction limits. (See

appendix B, “Excerpts from Applicable

Operating Rules.”)

 

15A CTC is a remotely controlled system under which

train movements are authorized by block signals whose

indicators supersede the superiority of trains.

Equipment $2,886,400

Lading 466,942

Track 236,850

Signal 300,000

Structures 40,000

Clearing and wrecking 148,960

TOTAL $4,079,152
5

Figure 2 -- Map of the accident site
6

Before departing Las Vegas, the engineer of

UP train 6205 determined, using the car-consist

weights, that he had 130 trailing tons per

operative brake and 442 trailing tons per

operative dynamic brake axle.16 These determinations dictated that the maximum speed

down Cima Hill should be 20 mph and that

retaining valves should be set on all cars before

descent.

Meteorological Information

The temperature at the time of the accident

was 33°F. A mixture of light snow and rain

affected the accident area. Both the locomotive

engineer and the conductor stated that no

significant atmospheric restrictions limited the

visibility of wayside signals and passing trains

or handicapped their train handling in any way.

Toxicological Information

Blood and urine specimens were collected

from the engineer and conductor for

postaccident toxicological testing, according to

the requirements established by the FRA in

49 CFR Part 219. The results provided by the

FRA indicated that no drugs or alcohol was

found.

Train and Equipment Information

Train Movement -- The train originated on

January 3, 1997, at Columbus, Nebraska, about

88 miles west of Omaha, Nebraska, along the

UP’s east-west mainline. The train had been

assembled from cars collected from the

surrounding UP branchline and shortline grain

elevators by local trains. Before its departure

from Columbus, the train had received an initial

terminal inspection in accordance with 49 CFR

Part 232.12. Due to track washouts and railroad

closures from heavy rains in northern California,

the train was rerouted southwest from Salt Lake

City, Utah, to Los Angeles, California, and then

northward to San Francisco, California.

 

16These figures are determined by dividing the total

trailing tonnage by the number of cars for tons per

operative brake and then by the number of traction motors

for tons per operative dynamic brake.

Car Weight -- The covered hopper cars

involved in the accident had a nominal

commodity capacity of 200,000 to 221,000

pounds (100 to 110.5 tons).17 The rated

maximum (gross) weight of each car, loaded

with commodity, was 286,000 pounds or

143 tons. According to the UP Director of

Derailment Prevention, when freight cars first

enter UP property, each is identified,18 entered

into the UP train control computer system, and

automatically assigned the maximum car-consist

weight,19 which would have been 143 tons

per car for UP train 6205.

Shortly before UP train 6205 departed

Columbus, Nebraska, a clerk mistakenly

replaced the defaulted maximum car-consist

weights of UP train 6205 with the freight-car

billing weights20 of 129, 130, or 131 tons for

each car and manually entered the billing

weights into the UP computer system. The

engineer used these weights to determine the

maximum speed down Cima Hill. (Since the

Kelso accident took place, all loaded car-consist

weights are automatically assigned maximum

capacity weights by the UP. Billing clerks

cannot change the car-consist weights.)

Railcars are generally weighed at or near

their points of loading or origin. Bulkcommodity loading points such as grain

elevators, mines, and mills usually maintain

track scales for this purpose. Railroads also have

weigh-in-motion scales near train yards.

 

17Weight and dimension data appear on the left side of

each freight car.

18This procedure is usually done electronically by an

Automatic Equipment Identification (AEI) scanner, which

reads a transponder attached to the side of the freight car.

Each AEI transponder has information formatted for that

particular vehicle, including the equipment type, owner,

and number. Car identification must match an entry in the

Association of American Railroad’s computerized

Universal Machine Language Equipment Register before

car interchange can take place.

19The car-consist weight is used by the engineer to

determine appropriate train-handling practices. Freight cars

also have a billing weight, which sometimes does not equal

the consist weight.

20The freight-car billing weight is the “per car rate”

agreement between the shipper and the railroad. In this

instance, the rate happened to correspond to a nominal

tonnage rate for a car of 129 to 131 tons.
7

Locomotives -- The first and third

locomotive units in the train were UP 6205 and

UP 6162, respectively. Both were 3,800-hp,

SD60M locomotives, built by General Motors

Electro-Motive Division (EMD) in 1989. The

second locomotive unit was a Southern Pacific

Railroad Company (SP) unit, SP 9360, which

was a 3,600-hp, SD45-2T locomotive, built by

EMD in 1975.

Train Tread Braking -- Freight train air

brake systems use compressed air to push a

piston within a cylinder that is mounted on a

freight car.21 (See appendix C for additional

information on air braking.) Usually, through a

series of rods and levers, the piston’s movement

forces a brake shoe against the tread of each

wheel to retard wheel rotation through friction.

The application of the brake shoe against the

wheel tread is called tread braking.

The effectiveness of tread braking depends

upon the resistance to sliding or friction,22

between the two surfaces. The friction between

the brake shoe and the wheel tread results in the

creation of heat. Shoe force and wheel speed

dictate the amount of friction and the resulting

heat generated between the brake shoe and the

wheel. The greater the shoe force against the

wheel and/or the greater the wheel speed, the

greater the frictional heat generated (assuming

that the wheel is turning without slipping on the

rail).

During tread breaking, the heat generated

will migrate away from the surfaces and heat up

the wheel and brake shoe. The wheel and brakeshoe temperatures will be warmest at the sliding

surfaces, where friction is creating the heat, and

progressively cooler away from the wheel tread.

At some point during braking, sufficient heat

will build in the brake-shoe material and wheel

steel to change the molecular and surface

characteristics of the materials at the rubbing

surfaces. This in turn will change their frictional

characteristics (coefficient of friction) and result

in a different braking ability. Thus the resistance

 

21Brake cylinders are usually mounted on the

underside of the car body below the floor or on the trucks.

22Mathematically, this is quantified as the coefficient

of friction.

to sliding between two surfaces changes as the

amount of generated frictional heat changes.

Tread braking is most effective soon after

initial application of the brakes and actually

improves up to some point as the brake shoe and

wheel tread surfaces warm up, but soon braking

effectiveness begins to degrade as more heat is

generated. Generally, the more frictional heat

that is generated, the less frictional resistance

and retardation or braking ability result. This

process is commonly called “heat fade.” In order

to make up for heat fade, it may become

necessary to apply greater brake-shoe force.

Although even greater brake-shoe force will

result in even greater heat fade and less

efficiency,23 the overall effect will still be more

retardation and braking ability than at a lower

shoe force.

Depending on the brake-shoe material and

the type of wheel steel, heat fade may not be

significant at low speeds. At some point during

tread braking, the generated heat, which is

absorbed by the wheel and (to a lesser extent)

the brake shoe, may increase to a certain

temperature and remain at that point until the

brakes are released. A thermal equilibrium is

reached as the wheel and brake shoe act as heat

sinks24 and dissipate the frictional heat as fast as

it is generated, resulting in a constant level of

frictional resistance and braking retardation.

At higher brake-shoe forces and wheel

speeds, heat fade becomes significant. A

buildup of heat faster than it can be dissipated

will result in diminished braking retardation at

an exponential rate. Shoe forces and/or wheel

speeds can generate temperatures higher than

the wheel and brake-shoe materials can handle,

causing their deterioration. Deterioration of

brake shoes and changes (melting) in the surface

metal of the wheel tread will diminish the

frictional resistance between the two materials.

In extreme cases, the excessive heat generated

will cause metal flow on the surface of the

wheel tread, which will act as a lubricant,

reducing braking effectiveness and speed

retardation.

 

23“Efficiency” refers to the amount of retardation or

braking for a given shoe force.

24A heat sink is an object that absorbs heat energy.
8

According to the results of brake tests

performed in 1991 by the Association of

American Railroads (AAR),25 an intermodal

freight train descending the 2.2-percent grade of

Cima Hill with an average braking ratio of 7.5

percent, an initiation speed of 23 mph, and

101.9 tons per operative brake would have been

unable to stop on the grade using the air brakes

alone. The AAR test results showed that the

coefficient of friction is a function of brake-shoe

force and wheel temperature. For shoe forces

below 1,000 pounds, the coefficient is relatively

independent of temperature. At forces above

1,500 pounds, the coefficient decreases as the

temperature rises; it decreases at a rate that

becomes greater as the shoe force rises. The

AAR found that when brake-shoe forces reach

such levels, air brake performance declines. The

coefficient is lowest when high shoe forces

combine with high wheel temperatures.

Air Brake Retainers -- The air brake control

valves apply, release, and recharge the train’s air

brake system. All train locomotives and cars

have control valves. Each locomotive control

valve receives its commands from the engineer

through the trainline, which is a pipe that

connects all of the cars to the locomotive.

Brakes are applied when air pressure is reduced

in the trainline. The degree of braking is

proportional to the amount of reduced pressure

in the air brakes; the greater the drop in trainline

air pressure, the harder the brakes apply.

Therefore, the brakes are “fail safe” and

designed to apply if the train accidentally breaks

in two or becomes uncoupled. Conversely, when

trainline air pressure increases, the control

valves cause the brakes to release.

The trainline is not perfectly sealed. The

trainline may have leaks throughout its length to

varying degrees, depending on the seals,

ambient temperature, and other factors. In steam

engine days, as long as the locomotive’s control

valve was in the release position, air would

continue to flow back through the trainline to

continuously recharge the system, making up for

any leakage. However, if the brakes were

applied, not only would air pressure be reduced

 

25See the minutes of the AAR Air Brake Association

meeting, September 16, 1991, page 36, exhibit 2 –

Summary of Double Stack Stop Distance Tests.

in the trainline to apply the brakes, but the

leakage would aid in applying the brakes and

continue to bleed the trainline pressure down

past the level of braking desired by the engineer.

Trains being braked down long grades would

bog down and stop if the engineer did not

release the brakes. Upon release, the train would

soon accelerate again and the engineer would

have to reapply the brakes. This cycle of

application and release down grades is called

“cycle braking.” If the engineer applied and

released his brakes too often, he would use the

compressed air faster than the locomotive

compressors could make it. The result would be

no brakes and a runaway train.

To overcome this problem, retainers were

installed on each car. Every freight car’s air

brake system is equipped with pressureretaining valves, technically called “releasecontrol retainers.” Retainers enabled the

engineer to retain air in each car’s brake

cylinder to brake the train while he placed his

locomotive control valve in release to recharge

the system. Thus, the retainer allowed the air

brake system to do two things at once.

Eventually, locomotive control valves were

equipped with a “pressure-maintaining” feature

that automatically made up for leakage

whenever the brakes were applied and at any

level of application. Thus, the brakes would stay

applied at any amount of trainline reduction the

engineer desired, instead of continuing to leak

down which would apply the brakes harder. The

pressure-maintaining feature rendered retainers

relatively obsolete, but they are still used by

some railroads. The development of dynamic

brakes, which increased braking capacity, also

reduced reliance on retainers.

Retainers are connected to the brake

cylinder exhaust and help control the brake

cylinder pressure. Retainers enable traincrews to

retain a portion of the air pressure in the brake

cylinder to help slow trains (particularly on

severe downgrades). When the air brakes are

applied, the piston within the brake cylinder is

forced outward by the compressed air; when the

brakes are released, the piston returns to its

original position, as release springs take effect.
9

When the retainer handle is set in position,

the retainer will exhaust brake cylinder pressure

more slowly and retain or hold a certain amount

of pressure in the brake cylinder. This system

allows an engineer to make several brake

applications and releases in a relatively short

time (cycle braking),26 while still recharging the

air brake system. The term “recharging” refers

to resupplying the air brake system with

pressurized air from the locomotive air

compressors. “Precharging” refers to applying

the brakes on a car through a set retainer value

that may be incrementally increased through

further brake applications. Precharging allows

the engineer to make more forceful brake

applications without increasing the number or

magnitude of additional brake applications.

Precharging increases the brake-shoe force and

may significantly increase wheel temperatures

and heat fade. The UP timetable rules do not

address precharging.

According to UP timetable rules, retainers

are to be set on a train if the tons per operative

brake exceed 80 and the tons per operative

dynamic brake exceed 300. Because the

engineer had determined that UP train 6205 had

130 tons per operative brake and 442 tons per

operative dynamic brake, retainers were

required to be set on UP train 6205.

Shortly before the Kelso accident, and

before descending Cima Hill, the conductor set

the retainers on each car. He also unknowingly

precharged the brake cylinders by setting most

(all but approximately 15) of the retainers while

the train brakes were still applied. Postaccident

inspection of all the freight cars by Safety Board

investigators showed that the retainers of all

cars were set in the high pressure position.27

 

26This system depends on a number of factors,

including the brake system volume, the brake pipe pressure,

and the number and magnitude of brake applications.

27Retainers have four handle positions: normal, high

pressure, low pressure, and control. Each position causes

the brake cylinder to exhaust or release differently. When

the handle is pointing straight down, it is in the normal

position and allows brake cylinder air to flow unimpeded

directly to the atmosphere. In the high pressure position,

the handle is turned up at a 45-degree angle. In the high

pressure position, both retainer springs must be compressed

and double pressure will be retained in the cylinders; the

exhaust process at high pressure is also slower than in the

Retainers have several pressure-retaining

capabilities, which depend on the strength of the

springs they contain. Common retainer-pressure

values are 10 and 20 pounds, 15 and 30 pounds,

20 and 40 pounds, and 25 and 50 pounds. The

retainer pressure values of the accident cars

were 10 and 20 pounds.

Dynamic Brakes -- Each locomotive unit

on UP train 6205 was equipped with extended

range dynamic brakes.28 Dynamic brakes apply

braking to the locomotives only, not the cars.

Dynamic brakes use the kinetic energy of the

train to generate electricity through the traction

motors, which is then run through resistor grids

and dissipated as heat. The kinetic energy used

to turn the traction motors retards the movement

of the train, causing it to slow or brake.

As long as the dynamic braking system

works, total dependence on the air brakes

(which are affected by heat fade) can be

avoided. Improvements in dynamic braking

capacity and reliability have offset the heat-fade

limitations of the tread-brake system.

The AAR and some railroads (including the

UP) have gone on record with their view that:

Dynamic brakes are not safety devices

but are economical devices and their

operation should be governed by the

railroads’ operating rules and not

Federal regulations...[They] are not the

primary brakes and are not used to stop

a train...[Dynamic brakes are] optional

features used to save fuel and reduce

wear and tear on brake equipment. 29

 

low pressure position. The low pressure position, in which

the handle is at a 90-degree angle, requires only one spring

to be compressed to open the valve to exhaust the brake

cylinder pressure. When the exhaust air flow is no longer

sufficient to compress the spring, the remainder of the air is

trapped and retained in the brake cylinder to provide some

level of braking. In the control position, the handle is

turned up 135 degrees from the normal position. The

control position allows the valves to be bypassed and

exhaust brake cylinder air to be directed through a choke to

slowly release the brakes.

28Extended range dynamic brakes are effective at

higher and lower speeds than regular dynamic brakes.

29Federal Register, Vol. 59, No. 179, September 16,

1994, page 47686.
10

Regarding dynamic braking use, the FRA

has stated30 that it:

Views as unfortunate and potentially

reckless, the increasing number of train

handling and power brake instructions

issued by freight railroads that

emphasize use of dynamic brakes

without including prominent warnings

that such systems may not be relied

upon to provide the margin of safety

necessary to stop short of obstructions

and control points or to avoid overspeed

operation. Such instructions, while not

affirmatively misleading to seasoned

locomotive engineers, threaten to

overcome the good judgment of safety

critics and regulations by leading to

excessive reliance on these systems.

In the same Federal Register entry, the FRA

stated that:

To the extent significant emphasis is

placed on dynamic brakes, [...]

engineers may in fact be encouraged to

make errors in judgment that take them

beyond prudent safety margins.

According to the AAR Director of Safety

and Operating Rules, many Class 1 railroads

emphasize the use of dynamic brakes to control

trains in moderate grade territory, to conserve

fuel and minimize brake-shoe wear. At 1994

FRA hearing sessions in Newark, New Jersey,31

several railroad employees testified that

dynamic brakes were the first brakes to be used

in controlling a train.

Many railroads have train-handling rules

that require engineers to use dynamic brakes.

The SP’s Air Brake and Train-Handling Rule

56.2, Use of Dynamic Brake to Control Train,

states that “Consistent with good train-handling

techniques, dynamic brake must be used as the

primary means of reducing and controlling train

 

30Ibid., page 47687.

31The FRA held a public hearing on November 4,

1994, in Newark, New Jersey, regarding proposed changes

in the power brake regulations, including the regulations

concerning dynamic brakes.

speed.”32 The Burlington Northern Railroad

(BN) Air Brake and Train-Handling Rule 501B

states that:

Train handling must be performed in a

manner that will be the most fuel

efficient consistent with good train

handling. Therefore, maximum use must

be made of the throttle modulation,

throttle reduction and dynamic braking

methods for slowing, controlling, and

stopping trains. Unless rules specify

otherwise, DURING PLANNED

BRAKING OPERATION, IF ONE OR

MORE DYNAMIC BRAKES ARE

AVAILABLE, THE POWER

BRAKING METHOD WILL NOT BE

USED.33 [Emphasis appears in original.]

UP rules require that, “On descending grade

from Cima to Kelso (California)... freight trains

exceeding 3,500 trailing tons must not be

controlled exclusively with dynamic brake.”

Title 49, CFR Part 229.13 states, “If a

dynamic brake or regenerative brake system is

in use, that portion of the system in use shall

respond to control from the cab of the

controlling locomotive.” No rule requires that

the operational status of the dynamic braking

system be determined before use. The FRA has

stated that:

If dynamic brakes] are available, they

should be maintained, and engineers

should be informed on their safe and

proper use and be provided with

information regarding the amount of

dynamic braking effort that they have

available.... The FRA also proposes to

require railroads to inform engineers of

the total dynamic brake retarding force

available on all outbound trains

equipped with dynamic brakes.34

 

32SP Air Brake and Train-Handling Rules, April 10,

1994.

33Although the SP and the BN had merged with other

railroads, each used its own train-handling rules until new

rules were written.

34Federal Register, Vol. 59, No. 179, September 16,

1994, page 47687.
11

Preaccident Inspections and Actions

Before departing from the Las Vegas

station, the engineer carried out an FRA

locomotive daily inspection in accordance with

49 CFR Part 229.21, checked the function of the

EOT device, and made an application and

release test of the air brakes35 with the assistance

of the conductor. The results of all the tests and

inspections were satisfactory. The engineer also

confirmed that the EOT cab display device

reflected his automatic brake pipe changes to

ensure trainline continuity.36

When the engineer performed the

locomotive daily inspection at Las Vegas, he

found two “bad order tags”37 attached to the

isolation/run switch located on the back wall of

the locomotive cab in the second locomotive

unit. One, a red SP tag (form CS78) that was

dated December 30, 1996, was torn

approximately in half. It indicated a bad order

speed indicator, malfunctioning dynamic brakes

above the 4th notch, and a bad order alerter reset

button. The other tag was a UP noncompliance

tag, also dated December 30, 1996, and it cited a

bad order speed indicator. The engineer later

testified that he noticed the tags. He did not

write any comments about them on his

engineer’s work report, as would have been

normal practice according to UP operating

procedures.38 The engineer later said that he had

assumed that the dynamic brakes on the second

unit worked, even though the bad order tags

indicated that they might not. (In fact,

postaccident inspections revealed that all the

malfunctions cited by the tags had been

 

35An air brake test entails the operation of the brake

valve to ensure that the air brake system is operating

correctly and could stop the train if necessary.

36Trainline continuity is checked (to ensure that all air

hoses are connected) by applying and releasing the brakes

and then observing, through the EOT device, a

corresponding fall and rise in the brake pipe pressure on

the last car.

37“Bad order” or nonconformance tags are small

cardboard markers placed on equipment to notify railroad

personnel that the indicated equipment is not functioning

properly and is in need of repair.

38The work report is a lined blank form that the

engineer is required to use to report equipment defects or

other problems to mechanical personnel or supervisors.

addressed and resolved.) The UP manager of

Operations Practices later testified that it was

UP policy for personnel to assume that all

equipment worked unless they were specifically

told otherwise.

According to the UP’s timetable operating

rules, the engineer was required to make a

running test of his dynamic brakes between MPs

309 and 292. The event recorder from the first

locomotive shows that the engineer tested the

dynamic brakes from Erie, MP 309.3, to Borax,

MP 292. The engineer said that the train was

traveling around 45 to 50 mph at the time, the

dynamic brakes functioned as required, and the

train handled normally. The engineer did not

have a device in the locomotive cab that could

be used to determine the real-time status of the

trailing locomotives’ dynamic braking system.39

(Such devices are not required under current

regulations.)

Postaccident Inspections, Tests, and

Research

Signals and Track -- The postaccident tests

and records review conducted by Safety Board

investigators showed that signal and traincontrol systems in the accident area functioned

as designed. Postaccident track inspections

revealed no significant track anomalies.

Locomotives -- After the accident, the

train’s locomotive consist was inspected and

tested. A UP mechanical manager from Los

Angeles, California, and a California Public

Utilities Commission (PUC) inspector found the

torn-off half of the bad order tag on the cab

floor of the second locomotive unit. Later,

during sworn testimony, the UP mechanical

manager stated that the company’s regular

procedure for handling a bad order tag was to

remove the tag from the machinery once the

repairs had been made. The tag was then to be

torn in half and one half was to be filed with the

repair report for 1 year. He could not account

for the failure to follow proper procedure in this

case. He stated that since this accident the UP

 

39At least one manufacturer (PULSE Electronics, Inc.)

has developed a device that will enable the engineer in the

lead locomotive unit to reliably monitor the dynamic

braking performance of trailing locomotive units. The

device costs about $1,500 per locomotive unit.
12

has placed greater emphasis on bad order tag

system procedures.

The radio in the lead locomotive unit was

field tested and found to work as designed. The

locomotive consist’s air brake, motive power,

and dynamic braking systems were also tested.

All systems were found to work as designed.

MU Engine Stop Switch -- During

postaccident inspections conducted on the day

of the accident, California PUC inspectors and

UP officers found the MU engine stop switch of

the lead locomotive cab (UP 6205) depressed in

the “Stop” position. According to the accident

crew, the locomotive had been shut down when

the train finally stopped. Neither the engineer

nor the conductor could account for the

locomotive’s shutdown. Neither knew that the

MU engine stop switch had been activated.

The MU engine stop switch is designed to

shut down all locomotive units in the consist

simultaneously. Switch activation shuts off

electrical power to the fuel pumps, thereby

causing engine shutdown. The switch can be

considered a safety feature, as it allows the

traincrew to shut down all units should a fire or

another emergency occur.

Depending on the locomotive make and

model, the MU engine stop switch may be

located in various places and have one of

several designs. The switch in this accident was

composed of two rectangular buttons mounted

within a 2-inch square, box-like frame that

protruded from the wall of the lead locomotive.

The top button was black with “Run” imprinted

on it in white letters; the bottom button was red

with “Stop” imprinted on it in white letters. (See

figure 3, below.) The switch was mounted on

the lower left panel of the engineer’s control

console; it was about 18 inches above the

locomotive floor and near the cab heater switch

and the “attendant call” and “ground reset”

buttons.

Figure 3 -- MU engine stop switch (undamaged)
13

The surrounding frame of the lower lefthand

corner of the MU engine stop switch on the lead

locomotive had been broken off and was

missing. The missing portion would have

extended over two-thirds of the bottom of the

switch and up about 1/2 inch of its left side. No

broken parts remained in the area surrounding

the frame, and grime was found on the broken

surfaces. (See figure 4.)

Figure 4 -- Engineer’s control console

Footwear-shaped marks, grease, and dirt

were all around the MU stop switch and the

sliding light switches located above it. The

discolored and dirty area was on the right half of

the panel that extended down from the left side

of the console. The area appeared to be one in

which engineers sitting at the console might

have rested their feet when they crossed their

legs or leaned back. (See figure 5, next page.)

UP train 6205’s lead locomotive unit, UP

6205, was an SD60M locomotive unit that the

UP had ordered from EMD in 1988. In March

1988, development work began on the design of

the console cab for the SD60M.40

 

40The console cab has a full-width, wide-body design

that is commonly called the “North American” cab. Its

This SD60M was the first EMD production

console cab built in the United States. The

console cab had been developed in Canada and

had already been in use there for some time.41

The UP requested that space for projected

electronics installations be reserved at and

above the cab console. Therefore, EMD located

the MU stop switch near the bottom of the front

left face of the engineer’s control console.

 

console is designed to function like a desk or counter for

the engineer, rather than like the older-style control stand.

41In the early 1970s, the Canadian National Railway

and the Montreal Locomotive Works collaborated on a new

locomotive cab design to enhance crew safety in case of

collision. This resulted in the “safety,” “comfort,” or

“wide” cab design, which was used on the M420-model

locomotives built between 1973 and 1977.
Figure 5 – Proximity of engineer’s control panel to seated engineer
15

A total of 231 SD60M locomotives were

built for the UP in 5 successive orders. Changes

and improvements were made in the

locomotives from order to order, as experience

was gained from the units in service. (See

details in table 1, below.)

In 1989, within the first year of service of

the SD60M locomotives, the UP became aware

of a problem with inadvertent activation of the

MU engine stop switch. Safety Board

investigators’ informal postaccident discussions

with UP locomotive engineers revealed that

inadvertent activations of the switches had been

common. The engineers told investigators that

once the MU engine stop switch had been

activated, it would take 5 to 10 minutes per

locomotive unit for a crewmember to reach and

then manually restart each engine. The UP

requested a “guard” from EMD for the switch.

On January 10, 1990, representatives of the

UP and EMD met to discuss open items

pertaining to SD60M order 886061; a second

meeting followed on January 18, 1990. A

January 18 memorandum listed discussion items

from the meeting. Item A7 of the memo stated,

“The MU engine stop switch shall remain on the

lower console but will be provided with a guard

to prevent accidental bumping.” This guard

installation became EMD modification #9133

and took the form of a U-shaped bar to be

placed over the Stop button portion of the MU

engine stop switch.

Table 1. -- SD60M locomotives built for the UP

Order Number No. of Units Remarks

886010 25 Last unit shipped February 1989. Road numbers 6085

through 6109.

886015/023/036 106 Last unit shipped September 1989. Road numbers 6110

through 6215.

886061 52 Last unit shipped November 1990. Road numbers

6216 through 6267. Guard provided for MU engine

stop switch.

896050 1 Shipped March 1991. Road number 6268. Included

WABCO EPIC air brake system.

906100 47 Last unit shipped December 1991. Road numbers 6269

through 6316. MU engine stop switch relocated to upper

console.

TOTAL 231 Of the 231 units, 184 had the MU engine stop switch

located on the bottom left portion of the engineer’s

control console.
16

On September 5, 1991, an EMD interoffice

memo referred to “Retrofit of MU engine stop

switch protective bar to first 131 SD60M

locomotives. This may also be a service

modification.” On October 22, 1991, EMD

issued the three SD60M customers — the UP,

the BN, and the Soo Line (now Canadian

Pacific) — an Engineering Service Release,

Subject: MU Engine Stop Switch Guard. The

service release stated:

Due to the location of the MU engine

stop switch on the engineer’s control

console, it is possible that it can be

accidentally activated during normal

movement by the crew within the

locomotive cab. This switch when

activated, shuts down the locomotive

consist.

The release included drawings, diagrams,

and parts numbers for ordering and installing the

bar-type guard. EMD stocked the modification

parts, which were provided free to customer

railroads upon receipt of a requisition charged to

a locomotive unit number. Installation labor was

provided and paid for by the railroad.

On November 20, 1991, EMD issued an

interorganization memo indicating that 289

locomotive units would be affected by the MU

engine stop switch bar-guard modification. Of

these units, 184 were operated by the UP, 100

by the BN, and 5 by the Soo Line.

On December 23, 1991, EMD sent the UP a

letter outlining the MU engine stop switch barguard modification and advised that the

modification kit would be available

approximately February 1, 1992. On March 10,

1992, the EMD District Engineer notified the

UP that “Mod. 9133 - MU Engine Stop Switch

Guard...has been entered into your computer

system.” While arrangements were being made

to implement the MU engine stop switch barguard modification for in-service locomotives,

EMD installed the bar guard on new-production

locomotives, beginning with the third UP order,

number 886061.

Soon after the first bar-guard units went into

service, engine crews began to complain that the

bar-guard modification was unsatisfactory.

 Crewmembers said that they hit their shins

against the bar and that its protrusion was a

safety hazard. In response to safety concerns

regarding the bar guard, EMD developed a clear

plastic slide-type guard to fit over the frame of

the MU engine stop switch. In April 1992, EMD

issued a directive to its field representatives to

replace the bar-guard modification with the new

plastic slide-type guard. EMD included a

manufacturer’s drawing of the slide installation

with the directive.

On May 24, 1993, EMD sent a letter to the

UP concerning a letter it had received from the

EMD customer service representative in North

Platte, Nebraska.42 The North Platte

representative had referred to the plastic guard

modification and had stated that:

North Platte has just received its first

mod kit 9133 since the latest revision.

The item received has no locking tabs

on it as do the current guards. This will

necessitate glue being used to hold these

things in place which will not be

acceptable to our customer. In addition,

this guard has a clear plastic “shield”

that must be raised up in order to

depress the switch. Given the abuse

these units are subjected to, I expect this

guard to last one trip before being

tossed. In addition, there are sharp

corners exposed when this guard is in

place which could possibly cause a

laceration if hit accidentally. Given

these conditions, I strongly recommend

we continue to look for other

alternatives.

EMD’s May 24, 1993, letter reported these

concerns regarding the plastic slide guard to the

UP. On May 26, 1993, the UP requested that

EMD “develop a modification... to relocate the

MU engine stop switch to the overhead console

location comparable to units 6316 through

6365.”

An EMD Modification Status Report dated

January 13, 1994, showed that material had been

ordered for eight UP units to make

 

42North Platte is a major UP yard and locomotive

maintenance facility.
17

modification #9133 (either the bar or the slide)

for the engine shutdown switch. On January 26,

1994, EMD issued an interorganization memo

that stated that modification #9133 of the MU

engine stop switch “...is now considered closed.

The UP has determined this modification to be

unsatisfactory and has discontinued its

application.”

On May 4, 1994, EMD sent the EMD

District Engineer who was serving the UP

complete information and plans for moving the

MU engine stop switch to the upper control

console. On June 9, 1994, EMD sent the UP a

detailed set of instructions on the step-by-step

procedure for relocating the MU engine stop

switch to the upper control console. The

message included drawings and material lists.

Through postaccident investigation, the

Safety Board investigators found that the UP

had completed eight switch modifications and

no relocations by the time of the accident. The

BN and the Soo Line had relocated the switches,

at an estimated cost of $5,000 per unit. Safety

Board investigators asked UP representatives

why the UP had not effected guard

modifications or relocated the MU engine stop

switches within the 7 years between the first

recognition of the switch location problem and

the accident. During postaccident interviews,

the UP Chief Mechanical Officer (CMO) –

Locomotives stated that the UP Mechanical

Department had a two-priority system for

making equipment modifications. He said that

the UP system categorized them as either

“safety or operationally critical” modifications

or “comfort or convenience” modifications. The

CMO stated that the UP would complete the

safety or operationally critical modifications on

a priority basis. He said that other (comfort or

convenience) modifications would be handled as

budget and time permitted.

The CMO stated that when the problem of

the location of the MU engine shutdown switch

was first identified by the UP, it was not

considered a safety or operationally critical

issue. Changing the location of, or making

adjustments to, the switch was therefore not

prioritized by the UP as a critical modification.

The CMO stated that, until the Kelso accident

took place, no UP manager had foreseen direct

safety implications involving the switch

location, so the switch modifications and

relocations were made by the UP as they

became convenient.

Event Recorders -- Event recorders were

recovered from all three locomotive units.

Review of the data revealed that all units had

functioned as designed. The recorded

information concerning the engineer’s train

handling was found to reflect his recollection of

the accident. Event recorder data generally

supported the postaccident statements of the

engineer and conductor.43

Cars -- After the derailment, the last six cars

of UP train 6205 were found to be both

undamaged and still on the rail. Two preceding

cars had derailed, but they remained relatively

undamaged. The UP inspected and tested these

eight almost intact cars after the accident as a

representative sample of the condition of the

cars that had been in the train. The tests and

inspections for each car included making a

single-car air brake test and air brake inspection,

performing a net brake-shoe force test, and

weighing the car. These data were later used in a

computerized train dynamics analyzer

simulation as the basis for determining the car

condition for the entire accident train. (See next

page’s table 2 for the information compiled

during the UP postaccident tests and

inspections.)

Train Dynamics Analyzer (TDA)

Simulations -- At the request of the Safety

Board, TDA simulations were conducted after

the accident by representatives of the accident

investigation parties. The simulations were

performed at the New York Air Brake Train

Dynamics Simulations Group in Fort Worth,

Texas, on February 4 and 5, 1997. They were

based on event recorder data recovered from UP

train 6205’s three locomotive units, postaccident

inspection and testing of eight cars from the

train, and postaccident interviews.

 

43Event recorder data indicated that the release of the

train’s air brakes made during the setting of the retaining

valves at Cima had taken place earlier than the conductor

had remembered.
18

The purpose of the simulations was to

determine the maximum accident train speed for

descending Cima Hill at which the engineer

might have been able to stop the train and what

would have occurred had UP train 6205’s

maximum authorized speed been 5 mph lower.

Ultimately, the group found that the TDA

simulator did not give a realistic projection of

all braking scenarios. The heavy braking and

heat fade involved in the accident were not

accurately replicated. (Information on the TDA

simulations is provided in appendix D.)

Investigators learned that computerized train

simulation programs have not yet been

developed to realistically replicate the effects of

heat fade on train tread brakes. TDA programs

cannot accurately predict when heat fade will

begin or to what extent it will affect train

performance. Statements from industry experts,

consultants, and others indicated to Safety

Board investigators that the railroad industry

considers computerized train performance

simulators valuable tools for predicting train

dynamic performance but finds their usefulness

limited to scenarios that do not involve heavy

braking with significant heat generation and

heat fade.

UP Braking Tests -- The UP conducted

braking tests on Cima Hill with a duplicate of

UP train 6205 to investigate the accident and

explore alternative operating procedures. The

UP test train was composed of 3 SD60M

locomotive units, followed by 75 loaded

covered hopper cars rated for maximum weights

of 286,000 pounds (143 tons) each.

The UP added one car to the duplicate train

to provide a means of compiling data. The 16th

car from the locomotive was a mobile laboratory

car. It was followed by a buffer car

and two instrumented cars. The instrumented

cars were equipped with ASF Ride Master

Table 2. -- UP postaccident test results

Car Number Gross Car

Weight

(lbs.)

Gross Car

Weight

(tons)

Loaded

Braking

Force

(lbs.)

Net Braking

Ratio1

(percentage)

Brake

Cylinder

Pressure2

(psi)

NDYX 515956 286,880 143.44 21,415 7.49 52.0

SIRX 515147 288,040 144.02 21,388 7.48 52.0

NAHX 70001 285,080 142.54 19,969 6.98 52.5

GACX 5657 286,300 143.15 21,277 7.44 52.0

UP 91295 286,380 143.19 21,110 7.38 50.0

UP 89336 285,980 142.69 20,434 7.14 50.0

UP 91189 286,076 143.04 20,340 7.11 50.0

UP 90754 286,134 143.07 20,945 7.32 49.0

1

The net braking ratio is calculated by using the actual brake-shoe force, thus taking into

account the rigging efficiency. The braking ratio for freight cars has been traditionally stated

at 50 psi brake cylinder pressure.

2

Brake pipe pressure of 70 psi.
19

trucks and TMX brakes. Instrumentation

consisted of transducers44 that measured brake

cylinder pressure and thermocouples that

measured wheel-tread temperatures. (The

differences in configuration from UP train 6205

did not significantly affect braking test results.

The braking effort of the four data-gathering

cars negated the effect of the additional weight

they added to the train.)

The UP made eight test runs westbound

down Cima Hill, employing various combinations of the operating parameters, such as

use of retainers, initial speed, and speed at the

time of the emergency brake application. Runs

were made replicating actions taken by the

accident crew at the same locations where the

actions occurred during the descent of Cima Hill

that resulted in the derailment.

The first run replicated the events of the

accident as closely as possible, including the use

of retainers. The use of dynamic brakes was

discontinued at 20 mph, at the same location

that this occurred during the accident. As in the

accident, an emergency brake application was

made when the train speed was 30 mph. The

emergency application did not stop the train,

and the train speed continued to increase. Wheel

temperatures rose to an average of around 650°F

during the attempt to stop the train. The train

was safely stopped, after it had reached a speed

of 36 mph, by reactivating the dynamic brakes.

Initially, wheel temperatures rose to an average

of 560°F.

Other runs showed that stopping was

possible from 25 mph after a descent at 20 mph

with some retainers set. The highest average

wheel temperature was 650°F during the stop

from 25 mph. The stopping distance was 5,700

feet. The stopping distance from 24 mph was

3,000 feet after a descent at 15 mph. Wheel

temperature was 575°F during the stop without

retainers from 24 mph. The train could be

controlled down the hill at 15 mph without

dynamic brakes.

The UP’s test results confirmed that the

effectiveness of the air brakes in controlling

 

44A transducer is a device that transforms one form of

energy into another.

train speed depended directly on the coefficient

of friction between the shoes and the wheels,

which was dependent on the brake-shoe force

and the resulting heat generated. The results also

confirmed that the heavier the freight car, the

greater the brake-shoe force necessary to control

its speed.

Brake-shoe forces averaged 1,500 pounds

during the tests conducted by the UP between

Cima and Kelso. Wheel temperatures were

roughly 500°F. Putting the train into emergency

raised the shoe forces to almost 4,000 pounds

and wheel temperatures to 700°F.

Through the tests, the UP found that heavy

cars face three operational consequences in

contrast to light cars. First, at a given speed, the

wheel temperatures of heavy cars are higher.

Second, because the coefficient of friction is

less, heavy cars require a greater brake pipe

reduction to control their speed. Third, these

factors combine to reduce the threshold speed

for a runaway train composed of heavy cars by

an amount that is more than proportional to the

weight increase.

Because the retarding force necessary to

brake a vehicle such as a freight car increases

with weight, braking horsepower must be higher

for heavy cars than for light ones. The greater

braking effort requires more brake-shoe force

and results in higher wheel temperatures. The

same wheel temperature can be maintained for

cars of different weights by reducing the speed

in proportion to the higher weight, so that the

braking horsepower remains constant. For

example, to maintain the same wheel

temperature, the speed would have to be 

8 percent lower for a 286,000-pound car than for

a 263,000-pound car. For a 315,000-pound car,

the speed would have to be 17 percent lower

than for a 263,000-pound car. Because wheel

temperatures increase as train speed rises and

resistance (the coefficient of friction) decreases,

there exists for any train on a descending grade

a threshold speed for a given car weight beyond

which the car’s brakes cannot generate enough

retarding force within the limits of the wheel

temperature to sufficiently counteract the pull of

gravity to stop the train or control its speed.
20

Postaccident Actions

The FRA -- The FRA took action within

1 week of the accident and posted Safety Bulletin

97-1 in the Federal Register on January 17, 1997.

Safety Bulletin 97-1 applied to railroads

nationwide. It issued the following safety

precautions to railroads:

1. Inspect all locomotives to determine if

the emergency MU fuel line cut-off

device is located in such a position in

the locomotive cab that it can be

inadvertently activated by the

engineer. If the device is located in

such a position, corrective action must

be initiated.

2. Relocate the cut-off device to a

location where the device cannot be

unintentionally activated, or protect

the cut-off device in a housing that

prevents unintentional activation.

3. Until the improvements are made,

these locomotives must not be

operated in the controlling or lead

position. If the locomotive cab is

occupied while being utilized in a

trailing position, the engineer’s seat

must remain unoccupied to the

greatest extent possible. If a trailing

locomotive is to be occupied, the

conductor must brief all occupants as

to the location of the cut-off device

and the need to avoid all contact with

it.

The UP -- In response to FRA Safety

Bulletin 97-1, the UP began relocating its MU

engine shutdown switches and restricted SD60M

locomotives to trailing positions until the

relocation modifications could be made. The

Safety Board understands that all modifications

were completed by August 24, 1997.

After the Kelso accident, the UP issued

General Order No. GO-97-01-18, which stated,

in part:

When operating on descending grades

between Cima and Kelso [in addition,

the UP specified another 23 steep-grade

locations], if train speed reaches 5 mph

above authorized speed, stop train

immediately, using an emergency brake

application if necessary. In all cases, use

at least a full-service brake application.

Apply a sufficient number of hand

brakes to prevent movement. Do not

move the train until authorized by a

Manager of Operating Practices.

The UP also issued General Order No. GO97-03-20, which stated, in part, “Do not exceed

a speed of 15 mph when retaining valves are set

and charged.”

At the time of the accident, the UP general

director of safety had reported to the vice

president of risk management, who reported to

the executive vice president of operations, who

then reported to the UP president and chief

operating officer. In fall 1997, the UP changed

its reporting structure such that the UP general

director of safety now reports to the executive

vice president of operations, who reports

directly to the UP president and chief operating

officer.

Additional Information

Power Brake Regulations -- The FRA

published an Advance Notice of Proposed

Rulemaking (ANPRM) concerning the possible

revision of the Power Brake Law, 49 CFR Parts

229, 231, and 232 (57 Federal Register 62546)

on December 31, 1992. The ANPRM included

several Safety Board recommendations that

were issued following railroad accident

investigations. These recommendations dealt

with a range of issues, including two-way EOT

devices, train brake and equipment inspections,

the air-flow method of testing air brakes,

monitoring dynamic brakes, and cold-weather

and steep-grade air brake testing.

Following publication of the ANPRM, the

FRA conducted 4 days of technical workshops

in early 1993 to elicit information and opinions.

The workshops were held at Kansas City,

Missouri, February 17, 1993; Chicago, Illinois,

March 2 and 3, 1993; and Newark, New Jersey,

March 9, 1993. The workshops in each location

addressed different topics.
21

On September 16, 1994, the FRA

published45 a Notice of Proposed Rulemaking

(NPRM) for updating the power brake

regulations. It set public hearing dates of

October 24 and 25, 1994, in Chicago, Illinois;

November 4, 1994, in Newark, New Jersey; and

November 9, 1994, in Sacramento, California.

During these hearings, the railroads stated that

they opposed a provision of the NPRM that

concerned the 1,000-mile inspection. The

conflict regarding this issue halted action on all

the power brake revisions and made continued

progress doubtful.

In an effort to complete the revision of the

power brake regulation, the FRA established a

Railroad Safety Advisory Committee (RSAC).

The RSAC was intended to provide a new way

of dealing with the industry to collect more

information earlier on proposed regulations, to

make the regulatory process more responsive,

and to identify conflicts before they became

entrenched. As part of the RSAC, the FRA set

up a Power Brake Working Group to develop a

new NPRM for the power brake regulations.

During a December 1996 meeting in St. Louis,

Missouri, however, the Power Brake Working

Group reached an impasse on an issue regarding

labor concerns and inspection timing. No further

progress on the power brake regulations has

since been made.

Car Weight and Train Speed

Developments -- As railroad technology has

evolved, the sizes and weights of freight cars

and the weights and speeds of trains have

increased. In the 1890s, the average train was

powered by a 1,200-hp steam locomotive

pulling a 2,000-foot, 2,000-ton train made up of

 

45Federal Register, Vol. 59, No. 179, September 16,

1994, pages 47676-47751.

20- to 30-ton-capacity freight cars. Train speeds

averaged less than 25 mph.

The most recent expansion in car and train

capacities began in the early 1960s, with the

industry’s rapid acceptance of 100-ton-capacity

cars and the introduction of the 125-ton car.

Increasing demand for coal called for larger and

faster trains. Greater use began to be made of

welded cars and rails, as well as of larger

wheels. By the 1970s, MU diesel-electric

locomotives of 10,000 to 16,000 hp were pulling

5,000- to 8,000-foot-long trains that weighed

10,000 to 15,000 tons.46

Before the Kelso accident, the UP required

that a train be stopped if an 18-psi brake pipe

reduction failed to control train speed. Most

railroads had similar requirements. Accidents at

Tennessee Pass, Colorado,47 and Cajon Pass,

California,48 in which freight trains became

runaways, caused some carriers involved in

these accidents to adopt a “plus 5 mph and stop”

rule.

The rule states that anytime train speed

exceeds by more than 5 mph the maximum

authorized speed for that track, the engineer

must stop the train immediately (with an

emergency application, if necessary). The plus

5 mph and stop rule allows the engineer to

quickly recognize when a speed problem exists.

The rule is designed to be easy for engineers to

interpret, and it can be enforced by the railroad

through reviews of information from train event

recorders. Railroads using this rule have

reported that the policy has been somewhat

successful in preventing runaways.

 

46Engineering and Design of Railway Brake Systems,

Air Brake Association, 1984.

47Railroad Accident Report -- Derailment and

Hazardous Material Release of Freight Train 1 ASRVM-18

Southern Pacific Lines near Tennessee Pass, Colorado,

February 21, 1996 (LAX96FR007).

48Railroad Accident Report -- Derailment of Freight

Train H-BALTI-31 Atchison, Topeka, and Santa Fe

Railway Company near Cajon Junction, California,

February 1, 1996 (NTSB/RAR-96/05).
22

General

No evidence found during the investigation

indicated that the weather, the signal and traincontrol systems, or the track conditions caused

or contributed to the accident. Postaccident

equipment inspections and crew statements

showed that no weather-related factors impaired

the performance of the traincrew or equipment.

Postaccident testing and review of the records

showed that signal and train-control systems

functioned as designed. Postaccident track

inspections revealed no significant track

anomalies. The Safety Board concludes that

neither the weather, the signal and train-control

systems, nor the track conditions were factors in

the accident.

No information indicated that fatigue played

a part in the accident. Train crewmembers said

they were rested in accordance with the Federal

Hours of Service Act. They were qualified to

perform their duties according to UP procedures

and accepted practice. The engineer’s work

schedule, his statement that he felt well rested,

and the event recorder data all suggest that

fatigue was not an element in this accident.

Drugs and alcohol were also excluded as

accident factors. Toxicological tests were

performed on the engineer and conductor after

the accident, and no drugs or alcohol was found.

Therefore, the Safety Board concludes that

crewmember fatigue was not a factor in the

accident, and drugs or alcohol did not cause or

contribute to the accident.

The Accident

The UP unit freight train 6205 west, with 3

locomotive units on the head end, followed by

75 cars loaded with corn, originated in

Columbus, Nebraska, on January 3, 1997,

destined for a terminal near San Francisco,

California. When the train reached Las Vegas,

Nevada, in the early morning of January 12,

1997, the crew changed. The oncoming engineer

and conductor inspected the train and made an

air brake test. The train departed Las Vegas at

6:05 a.m. on January 12, 1997.

On the approach to Cima Hill, while still

about 37 miles away, the engineer carried out a

running test of the dynamic brakes and found

that they responded appropriately. At Cima, the

engineer stopped the train with it draped

symmetrically over the crest of the grade. By

consulting the consist list, the engineer found

that the train was reported to weigh 9,724 tons.

In fact, the consist weight was incorrect; the

train actually weighed 10,699 tons — 975 tons

above the consist weight.

UP System Timetable No. 2 established the

train’s maximum speed down Cima Hill at 20

mph and required that retaining valves be set on

all cars before descent. The train remained at

Cima for 45 minutes while the conductor set the

air brake retainer valves. He set most of the

retainers while the air brakes were on, thus

precharging all but about 15 of the retainers. As

a result, initial movement down the hill required

more power to overcome the precharged applied

air brakes.

The train started moving down Cima Hill at

about 11:18 a.m. The engineer began applying

dynamic brakes about 2 1/2 minutes later, with

the train traveling at 7 mph. The engineer also

made a 6- to 8-psi minimum reduction of the

brake pipe to apply the train air brakes. By

about 11:42 a.m., the train was traveling at

23 mph and dynamic braking amperage was

about 820 amps.

Suddenly, dynamic brake amperage and

effort fell to 0 amps within 13 seconds, when

the engineer unwittingly depressed the MU

engine shutdown switch. Unaware that the

shutdown switch had been activated, the

engineer tried, without result, to increase the

dynamic brake effort. Then, to compensate for

the dynamic braking loss with air brakes, he

reduced the brake pipe pressure by 12 to 17 psi.

The engineer continued to increase train air

braking in response to the rising train speed,

until a full-service application was achieved by

the time train speed reached 31 mph. The

engineer then made an emergency brake

application and notified the dispatcher that the

ANALYSIS
23

train was a runaway. The time elapsed between

the loss of the dynamic braking until the train

was put into emergency was 1 minute,

13 seconds.

For the next 9 1/2 minutes, the train

continued to gather speed. It was routed onto a

siding and went into the Hayden east-end

turnout at approximately 72 mph. As the train

began to exit the Hayden siding at the west-end

turnout, the drawbar between the locomotives

and the first car broke, and the cars began to

derail. The locomotives negotiated the turnout

onto the mainline, but 68 of the 75 cars derailed

at approximately 11:52 a.m.

The Safety Board considered whether the

remedial actions taken by the engineer during

the accident had been timely and appropriate.

First, should the engineer have tried to restart the

engines once the MU engine stop switch had been

activated? Investigation indicated that, as the

engineer was not aware that he had activated the

stop switch, he probably did not even know if a

restart was achievable. Further, because, without

personnel stationed in each locomotive unit, it

would have taken 5 to 10 minutes per locomotive

unit to manually restart each engine, this action

would not have been feasible even if the engineer

had immediately realized what had happened. As

the accident events demonstrate, even the delay

of 1 minute and 13 seconds allowed the train to

accelerate beyond the “point of no return.”

Should the engineer have placed the train in

emergency sooner? Investigation showed that

when he had confirmed that no dynamic braking

capability was available, the engineer intuitively

applied the air brakes in an increased service

application. Seconds later, when he realized that

he had no alternative, the engineer made an

emergency brake application and notified the

dispatcher that the train was a runaway. The

Safety Board, appreciating the inherent risks

(from in-train forces that could themselves cause

a derailment) of placing a train in emergency,

found it reasonable that the engineer should have

quickly explored other options first. The Safety

Board concludes that, given the severity of the

grade and the speed of the train, the engineer’s

decision to try other options before placing the

train in emergency was reasonable.

In its investigation of the accident, the

Safety Board identified three major safety

issues: the placement of safety-critical

locomotive cab controls, adequate train-speed

safety margins for steep-grade railroads, and the

criticality of dynamic braking systems. The

Safety Board also reviewed car weight

reporting, the power brake rulemaking process,

and the use of air brake retainers.

Placement of Safety-Critical Locomotive

Cab Controls

Early in the investigation, it became apparent

that the locomotive engineer had inadvertently

activated the MU engine stop switch inside the

lead locomotive unit. The red Stop button of the

MU engine stop switch was found still depressed

after the accident. Also, the suddenness with

which the engine shutdown occurred indicated

that the switch had been struck immediately

before the accident. No other reason for the

engine shutdown was discovered.

The activation of the MU engine stop switch

precipitated the accident. The stop switch

activation shut down the diesel engines, resulting

in dynamic braking loss. The dynamic brake loss

initiated the runaway. Because neither the

engineer nor the conductor was aware of what

had caused the locomotive units to shut down,

they did not take action to reactivate the units or

immediately place the train in emergency.

(Indeed, the crew thought that only their lead

locomotive unit had shut down.) By the time the

crewmembers put the train in emergency, it was

already in runaway status.

The placement of the MU engine stop

switch on the lower left panel of the engineer’s

control console made it subject to inadvertent

activation. Investigators’ informal postaccident

discussions with locomotive engineers revealed

that such activations had been common on

locomotives equipped with switches in the same

location. Sometime after 1989, EMD, the

builder of the SD60M locomotive, became

aware that inadvertent activation of the MU

engine stop switch was a problem. EMD

attempted to work with the purchasers of the

affected locomotives to correct the poor

placement of the switch.
24

While EMD’s attempts to address the

problem evidenced some concern over the safety

implications of the switch location, the UP

management did not consider changing the

location a priority modification. Instead, the UP

categorized it as a “comfort or convenience”

modification. Consequently, the UP did not

expedite protection or relocation of the

switches. Although EMD had communicated

with the UP about this issue as early as January

1990, the UP had taken steps to modify the MU

engine stop switches on only 8 of its 184

affected SD60M locomotives by 1996. None of

the affected UP locomotives had had their

switches relocated.

Correspondence between UP representatives

and EMD revealed that some UP representatives

and EMD understood that the location of the

MU engine shutdown switch had safety

implications because crewmembers could, by

inadvertently activating the switch,

simultaneously shut down all locomotive units.

The correspondence indicated concern regarding

this possibility. Safety-conscious railroad

managers should have foreseen that an

unintentional shutdown of all motive power on

an operating train could jeopardize train control.

This danger should have been particularly

conspicuous with respect to trains that traveled

on steep grades such as Cima Hill, where

dynamic braking has become critical. The

Safety Board concludes that the failure of UP

management to recognize the MU engine

shutdown switch location as a safety hazard and

to expedite effective switch protection or

relocation created the conditions that led to the

accident. The Safety Board believes that the

FRA and the AAR should alert locomotive

manufacturers and railroad operators about the

dangers posed by improperly located safetysignificant controls and switches in locomotives.

While the Safety Board appreciates that since

the Kelso accident the UP has taken action to

relocate the MU switches on its locomotives, in

the interest of protecting the UP fleet from other

possible problems that could arise from poorly

located safety controls, the Safety Board

believes that the UP should relocate and/or

protect all safety-significant controls and

switches in its locomotives so they cannot be

inadvertently activated or deactivated.

Train-Speed Safety Margins for SteepGrade Railroads

The rapidity with which the Kelso train

engineer was overtaken by events underscores the

need for railroads to maintain realistic operating

safety margins in case an unexpected failure

occurs. Safety margins that were adequate for rail

operations 20 years ago are not necessarily

adequate today. As time has passed, railroad

equipment technology has progressed, and so

have the size and weight of freight cars and the

weight and speed of trains. These changes have

altered the ways trains operate, particularly in

steep-grade areas, and have eroded the efficacy of

braking safety margins.

Car Weight -- Engineers’ determinations of

safe maximum train speeds and train-handling

methods are made based on the weight of the

train (trailing tonnage). The train’s tonnage

dictates to the engineer the maximum speeds and

the braking methods that may be used and

indicates whether air brake retainer valves must

be set. The accuracy of the engineer’s

determinations regarding these train-handling

limits depends on the accuracy of the figures used

to report the weight of each freight car. Unless

the engineer is provided with the correct weight

or appropriate maximum weight for the train on

which to base his determinations, he may be

placed in a potentially dangerous situation.

According to the UP, train 6205’s cars were

initially assigned by computer the default

maximum car weight of 143 tons each, which was

then mistakenly changed by a clerk to

approximately 130 tons each. The engineer used

the clerk’s weights in making his train-handling

decisions. Postaccident car weights were found to

be around 143 tons. The additional train weight

of 975 tons was unknown to the engineer.

Regardless of whether the engineer knew the

actual weight of the train, the maximum

authorized train speed down Cima Hill for train

6205 west would have been 20 mph. But beyond

the fixed limit of authorized speed, engineers

control trains by making experience-based

judgments as dictated by conditions. As such, the

accident engineer would probably not have

significantly altered his braking procedure down

the grade had he known the actual train weight,

beyond increasing dynamic and pneumatic
25

braking as he felt necessary to control the train.

The unknown additional weight, however, eroded

any safety margin that had been built into the

UP’s speed requirements for bringing a train

down Cima Hill. Further, the greater weight

would have caused the train to speed down the

grade faster than it would have at a lower weight

and impelled it more quickly beyond the point of

no return. Therefore, the Safety Board concludes

that, although the unknown additional train

weight of 975 tons was not causal to the accident,

it contributed to the severity and magnitude of the

derailment. Therefore, the Safety Board believes

that the FRA should require railroads to ensure

that the actual loaded weights of cars in a train

are provided to the traincrew or, if the loaded

weights are unknown, to implement a method to

ensure that the maximum loaded weight is

assigned.

As previously noted in this report, following

the Kelso derailment, the UP established a

procedure to prevent billing clerks from altering

the consist weights of cars and trains, thereby

intending to prevent inaccurate train weights from

being transmitted to engineers. Such a procedure,

however, does not prevent cars from being

overloaded beyond their design limits.

Since the Kelso accident, the UP experienced

another incident that indicated that inaccurate car

weight reporting continues to affect the railroad.

About 4 p.m. Pacific daylight time, on August 31,

1997, the eastbound UP train CSULA-30 collided

with a BN Santa Fe train at Barstow, California.

The UP train was a unit train of 72 cars, carrying

contaminated soil (“dirty dirt”) bound for Utah.

At the request of the Safety Board, the California

PUC, and the FRA, the UP cars were weighed

during the postaccident investigation. The cars

were found to weigh, on the average, 5 tons more

than the train consist weight of 121 tons per car,

which caused the train to be 360 tons heavier than

its listed consist weight. Based on these findings,

the Safety Board concludes that the issue of

accurate car weight assignment has not been

adequately addressed by the UP. Therefore, the

Safety Board believes that the UP should

reexamine its system of car weighing and carconsist weight reporting and take action to ensure

that train consist weights reflect actual train

weights.

Tread Braking Limits -- Research has shown

that train wheels and brake shoes cannot

withstand infinite levels of friction-generated

heat. Too much heat generated during braking

causes brake shoes to wear and deteriorate

rapidly, metal to flow on the wheel tread, and

trains to lose their stopping ability. In the past, the

use of air brake retainer valves (retainers)

allowed engineers to control trains down long

grades without exceeding the limits of the brake

equipment. Then, air brake system air capacity

was the limiting factor. Retainers help preserve

compressed air capacity and the potential

capability to brake a train. Retainers, however,

still depend on the same tread-braked system that

is subject to heat limitations. With or without

retainers, excessive heat at the tread brake can

cause the air braking system to become

ineffective.

Evidence from the Kelso accident suggests

that train weights and speed levels may have

reached the physical limitations of the treadbraked freight car. The engineer was attempting

to keep the train within the 20-mph speed limit

established by the UP for a train of that weight at

that location. Retainers had been set. The train’s

air brakes were functioning properly, and the

engineer used the brakes correctly. But even after

he had placed the train’s tread-braked cars in

emergency at 30 mph, the engineer of UP train

6205 could not stop it from running away. The air

brakes alone were insufficient to keep the train

from experiencing significant acceleration in

these circumstances.

Postaccident UP brake tests conducted on

Cima Hill showed that the air brakes alone could

stop a train similar to UP train 6205 at speeds up

to 25 mph but not much beyond that speed. UP

train 6205 accelerated to 25 mph within

30 seconds of MU stop switch activation.

UP train 6205, therefore, while it was

performing as required by the UP, could not be

sufficiently slowed with air brakes alone on the

Cima Hill downgrade to ensure safe operation

much beyond the maximum authorized speed.

The data indicate that the air brakes could not

function successfully in this situation because

frictional tread-brake heat generation had reached

performance-damaging levels. The Safety Board

concludes that, due to increases in train weights

and speeds, frictional tread-brake heat generation
26

has become a limiting factor for safe train

operation, particularly in steep-grade territories.

Dynamic Braking -- While the UP in theory

considers dynamic braking a nonessential

mechanism, it has in practice relied on the

safeguard that, as long as the dynamic braking

system works, total dependence on the air

brakes (with their heat-fade weaknesses) can be

avoided. As the Kelso accident demonstrated,

once dynamic braking is lost, a train operating

on a steep downgrade can become

uncontrollable within seconds, even though the

air brake system is fully functional. The Safety

Board therefore concludes that the UP’s

operational reliance on dynamic braking for

controlling heavy and fast-moving trains on steep

grades, without acknowledging and protecting

dynamic braking as a safety-critical system, is

imprudent. The fact that the accident occurred

because dynamic braking was lost indicates that

some railroads may have allowed their margins

of safety to erode by maintaining train-handling

practices rendered obsolete by the heavier

weights and faster speeds of today’s trains. The

Safety Board therefore believes that the FRA

should require railroads to review steep-grade

train-handling practices and, if necessary, make

changes that will preserve a margin of stopping

ability should a dynamic braking system fail.

Operational speeds and train-stopping

capability have traditionally been associated with

the amount of air pressure that has been reduced

from the brake pipe (the level of air braking

required). The UP required that a train be stopped

after an 18-psi brake pipe pressure reduction

failed to control train speed. Other railroads had

similar requirements. The Safety Board does not

consider that such brake pipe reduction

requirements provide timely operational guidance

or a sufficient safety margin to traincrews. By the

time a dangerous situation is recognized, it may

already be too late for crewmembers to take

effective corrective action. In the Kelso accident,

although the engineer was attempting to abide by

the UP’s maximum train speed requirement for

the area, by the time he realized that a problem

existed and initiated a 12- to 17-psi reduction, the

train still became a runaway within 73 seconds.

The Safety Board therefore concludes that the

UP has authorized maximum train speeds that

provide insufficient safety margins in the event

of dynamic braking failure. To help alleviate

this problem, the Safety Board believes that the

FRA and the AAR should carry out research,

investigation, and analysis to determine

maximum authorized train speeds for safe

operation of trains of all weights, using speedbased margins of safety that can be easily

measured by traincrews.

According to the UP rules in effect for UP

train 6205, 20 mph was the maximum safe speed

for a train descending from Cima to Kelso with

retainers set. After the accident, the UP issued

orders that required trains on which retainers

had been set to keep speeds at 15 mph or lower.

The UP also required its crews operating in

specified steep-grade locations, including the

descent from Cima to Kelso, to stop trains

immediately if speeds rose 5 mph above the

authorized speed. While the exact speed at

which the engineer might have effectively

braked train 6205, given all the variables in this

instance, has not been determined by

investigators, the Safety Board concludes that

some speed-based safeguard might have enabled

the engineer to exercise greater control over the

Kelso accident train.

The Safety Board considers that the UP’s

decision to implement the “plus 5 mph and stop”

rule specified above is a step in the right

direction. Nevertheless, the Safety Board

considers that this narrowly defined order may

not be sufficient to address the broad range of

safety margin issues raised by this accident.

Therefore, the Safety Board believes that the UP

should reexamine its maximum authorized train

speeds for safe operation of trains of all weights

to establish new speed-based margins of safety

that can be easily used by traincrews.

The railroad industry maintains that

dynamic braking is a noncritical feature.

Railroads have claimed that dynamic brakes are

not required for safety or train control and that

the main purposes of dynamic brake use are fuel

economy and maintenance reduction. Because

regulations require that trains be safely handled

with the air brake system alone, railroads do not

acknowledge that dynamic brakes have become

an important safety and train-handling feature.

Actual railroad rules and train-handling

routines, however, indicate that, in practice,

dynamic brakes have become essential to train

handling. During the Kelso accident, the train
27

accelerated beyond its stopping speed very

rapidly (within 30 seconds) after dynamic brake

loss. Therefore, the Safety Board concludes that

railroads are operating trains in situations in

which loss of dynamic braking will result in loss

of train control.

The Safety Board has a long history of

issuing recommendations regarding dynamic

brakes. As a result of an investigation of a

runaway train accident that occurred near Kelso,

California, on November 17, 1980,49 the Safety

Board issued the following recommendation to

the UP:

R-81-92

Require that the dynamic braking

feature of the lead locomotive unit on

all westbound trains originating at Las

Vegas and which are operated west of

Cima be tested and determined to be

functional.

On December 19, 1981, the UP replied that

it had revised its Special Rule 1042 (RC) #4 to

state that, “On any westbound train, dynamic

brakes must be tested between MP 309 and MP

292.” Because this procedure met the intent of

the recommendation, the Safety Board

responded on February 16, 1983, that R-81-92

had been classified “Closed -- Acceptable

Action.”

As a result of the investigation of an

accident that took place at San Bernardino,

California, in May 1989,50 the Safety Board

recommended that the FRA:

R-90-24

Revise regulations to require that if a

locomotive unit is equipped with

 

49Railroad Accident Report — Rear End Collision of

Union Pacific Railroad Company Freight Trains Extra

3119 West and Extra 8044 West near Kelso, California,

November 17, 1980 (NTSB/RAR-81/01).

50Railroad Accident Report — Derailment of

Southern Pacific Transportation Company Freight Train

on May 12, 1989, and Subsequent Rupture of Calnev

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

(NTSB/RAR-90/02).

dynamic brakes, the dynamic brakes

function.

On November 30, 1990, the FRA responded

that it was reviewing the issue of regulations

pertaining to dynamic brakes on locomotives

and specified a range of responses available to

the agency. The FRA, however, chose not to

make a “definitive response” to the

recommendation. On February 21, 1991, the

Safety Board responded that the

recommendation would remain classified “Open

-- Await Response” because of the FRA’s lack

of commitment to a specific action. Since then,

the FRA has taken two actions in response to

Safety Recommendation R-90-24, both of which

were unsuccessful. First, the FRA issued a

proposed rulemaking under the amendment of

the Power Brake Law. The rulemaking was

ultimately withdrawn. The FRA then placed the

recommended action with its RSAC for

handling. The RSAC was also unable to develop

a satisfactory solution to the problem of

providing for functioning dynamic brakes.

Separating high-priority components of

needed rulemaking from the routine process and

proposing them independently has been a

successful strategy in the past, most recently

with respect to the two-way EOT device

recommendations resulting from the 1996

Cajon, California, derailment. (For accident

citation, see footnote 47, page 21.) Because no

progress on Safety Recommendation R-90-24

has been achieved in approximately 7 years, the

Safety Board concludes that the FRA should

separate the dynamic braking function

component from the power brake rulemaking

process and promulgate regulations to require

that, on locomotives equipped with dynamic

brakes, the dynamic brakes are functioning

properly before trains are dispatched. Therefore,

the Safety Board classifies Safety

Recommendation R-90-24 “Closed --

Unacceptable Action/Superseded” and believes

that the FRA should separate the dynamic brake

requirements from the Power Brake Law

rulemaking and immediately conclude

rulemaking to require railroads to verify that the

dynamic braking systems on all locomotives

equipped with dynamic brakes are functioning

properly before trains are dispatched. The

Safety Board also believes that the UP should

develop procedures to ensure that, before a train
28

equipped with dynamic brakes is dispatched, all

the dynamic brake systems on the locomotives

are functioning properly.

In addition, as a result of the San

Bernardino accident, the Safety Board made

recommendations to both the FRA and the AAR

that they should:

R-90-23 (to the FRA); R-90-26 (to the

AAR)

Study in conjunction with the [FRA or

AAR, respectively], the feasibility of

developing a positive method to indicate

to the operating engineer in the cab of

the controlling locomotive unit the

condition of the dynamic brakes on all

units in the train.

The FRA also considered this issue part of

the proposed revisions of the Power Brake Law,

which, as noted above, have not been

successfully advanced. Consequently, the Safety

Board classified Safety Recommendation R90-23 “Open -- Unacceptable Action.” Because

the AAR performed an independent study on

dynamic brakes (the 1991 Summary of Double

Stack Stop Distance Tests), the AAR

recommendation R-90-26 was classified

“Closed -- Acceptable Action” on August 10,

1993.

Despite these recommendations, reliable

information on the status of a train’s dynamic

braking is still not available to the engineer. The

engineer of the Kelso accident train had reason

to question whether the dynamic braking system

was operative on his train. Although he

apparently did not consider this issue, a bad

order tag indicating malfunctioning dynamic

brakes had been left on one of the train’s

locomotives. This bad order tag could have

caused the engineer to doubt the reliability of

the train’s dynamic braking system. He had (in

accordance with UP requirements) performed a

running dynamic brake test from MP 309.3 to

MP 292, and the brakes had responded as

expected, although the engineer still could not

know whether they functioned as designed.

Cima is located a considerable distance

(approximately 37 miles) past this checkpoint, at

MP 254.6. The engineer made no further

dynamic braking tests before reaching Cima and

so had no verified information on whether or

how the dynamic brakes were functioning as the

train neared this significant downgrade.

Although the engineer assumed (in

accordance with UP policy) that the brakes were

operational, he had no means of checking

whether they were, aside from conducting

additional tests. No equipment in the lead

locomotive provided information on the train’s

dynamic braking status. The Safety Board

therefore concludes that the engineer in the

Kelso accident had no practical means of

knowing if or how many of his locomotive units

were properly working in dynamic braking

immediately before the accident or when used.

In recent years, the railroad industry has

developed an effective and reliable device to

display the real-time dynamic braking

performance of trailing locomotive units. Such a

display would permit an engineer to modify his

train-handling strategy based on the information

it provided, before being surprised by the failure

of a dynamic braking system that he had

depended upon using. The Safety Board

concludes that installing a device in the cab of

each controlling locomotive to indicate the realtime condition of the dynamic brakes on each

locomotive unit in the consist would give

valuable information to the engineer on train

dynamic braking capability at any given

moment. Therefore, because no progress has

been made by the FRA on Safety

Recommendation R-90-23, which addresses

developing a positive method to indicate to the

engineer the condition of the locomotives’

dynamic brakes, the Safety Board classifies

Safety Recommendation R-90-23 “Closed --

Unacceptable Action/Superseded” and believes

the FRA should now require railroads to ensure

that all locomotives with dynamic braking be

equipped with a device in the cab of the

controlling locomotive unit to indicate to the

operating engineer the real-time condition of the

dynamic brakes on each trailing unit. Further,

because the engineer of the Kelso accident train

had no means in the lead locomotive of

determining the real-time condition of the

train’s dynamic brakes, the Safety Board

believes that the UP should equip all lead or

controlling locomotive units with real-time

displays capable of indicating to the engineer
29

the dynamic brake condition on each trailing

locomotive unit in the consist.

Air Brake Retainers

The setting of air brake pressure-retaining

valves determines how much, if any, brake

cylinder pressure is retained and, therefore, how

much braking force can be created. By setting

retainers, traincrews retain air capacity in the air

brake system. According to UP timetable rules,

retainers were to be set if the tons per operative

brake exceeded 80 and the tons per operative

dynamic brake exceeded 300. Because of its

weight and braking capabilities, retainers were

required to be set on the Kelso accident train.

Neither the conductor nor the engineer on

the Kelso accident train had had any formal

training on when or how to set the retainers,

even though the practice was common and

important to braking safety in steep areas. Both

crewmembers said they had gained all the

knowledge they had about retainers through onthe-job training and experience.

In this instance, the conductor precharged

the brake cylinders by setting most of the

retainers while the train brakes were still

applied. Investigators were unable to determine

with certainty whether this action had any effect

upon the unfolding of events in the Kelso

accident. Such a precharge may or may not be

significant, depending on conditions and future

braking actions, because any additional braking

will be added to that pressure already in the

precharged cylinders. (As previously discussed,

brake cylinder pressure directly affects brakeshoe force, frictional retardation of the tread

brakes, and braking efficiency.)

The crucial point is that neither the

conductor nor the engineer had a well-defined

plan about when the retainers should be set or

how they should be charged. Neither had a true

appreciation of the significance of uncharged or

precharged brake cylinders. Further, neither

understood the proper use of retainers in

controlling train speed through cycle braking.

Because the engineer did not release the air

brakes on UP train 6205’s descent down Cima

Hill, the retainers could not function as designed

and were rendered effectively useless.

It seems self-evident that any procedure that

is important enough to be required by a railroad

should be well understood by railroad personnel

and included in the railroad’s formal training

program. The Safety Board concludes that the

significance of retainer-setting procedures,

proper retainer use, and the various choices

involved should be understood by train

crewmembers and included in railroad training

programs. Therefore, the Safety Board believes

that the UP should implement formal training on

the proper procedures for setting and using

retainers for those traincrews that may be

required to do so. The Safety Board further

believes that the FRA should require railroads to

implement formal training on correct retainer

setting and using procedures for traincrew

members who may set or use air brake retainer

valves.

UP Management of Safety Issues

The Safety Board notes with concern that

during this investigation repeated instances of

procrastination, inattention, and ineffective

action on the part of UP management regarding

significant safety issues were uncovered. The

8 years of delay before the poorly placed MU

shutdown switches were relocated, the

operational reliance on dynamic braking without

acknowledging dynamic braking to be a safety

component of the braking system, the

establishment of maximum train speeds that did

not ensure safe operation in all situations, the

recurrent misassignment of car weights, and the

failure to train personnel responsible for setting

and using retainers in correct procedures all

indicated to the Safety Board that the UP may

not be focusing sufficient corporate attention on

operational safety.

The Safety Board understands that the UP

has a general director of safety and appreciates

that the UP has made organizational changes

since the Kelso accident to put this official on a

level closer to the UP president and chief

operating officer. While the movement of the

UP general director of safety one position closer

to the president is progressive, the UP general

director of safety still reports to, and is under

the authority of, the executive vice president of

operations. The Safety Board considers that the

lead safety officer in the UP’s management

structure should report directly to the primary
30

managerial authority to avoid possible conflicts

of interest between business operations and

safety. The potential to subordinate safety to

economically expedient operating practices may

be too great under such a corporate structure.

Subordinating the position of safety officer to an

operating officer also implies that safety is

secondary to operations. The Safety Board

therefore concludes that the UP general director

of safety should report directly to the UP

president and chief operating officer. The Safety

Board believes that the UP should review the

functions and responsibilities of the UP general

director of safety and make any organizational

changes necessary to ensure that this official:

(1) reports directly to the UP president and chief

operating officer; (2) is involved in all UP

operational issues that could affect train,

railroad, and personnel safety and; (3) has the

authority to take effective safety actions

throughout the UP.
31

Findings

1. Neither the weather, the signal and traincontrol systems, nor the track conditions

were factors in the accident.

2. Crewmember fatigue was not a factor in the

accident, and drugs or alcohol did not cause

or contribute to the accident.

3. Given the severity of the grade and the speed

of the train, the engineer’s decision to try

other options before placing the train in

emergency was reasonable.

4. The failure of Union Pacific Railroad

management to recognize the multiple-unit

engine shutdown switch location as a safety

hazard and to expedite effective switch

protection or relocation created the

conditions that led to the accident.

5. Although the unknown additional train

weight of 975 tons was not causal to the

accident, it contributed to the severity and

magnitude of the derailment.

6. The issue of accurate car weight assignment

has not been adequately addressed by the

Union Pacific Railroad.

7. Due to increases in train weights and speeds,

frictional tread-brake heat generation has

become a limiting factor for safe train

operation, particularly in steep-grade

territories.

8. The Union Pacific Railroad’s operational

reliance on dynamic braking for controlling

heavy and fast-moving trains on steep grades,

without acknowledging and protecting

dynamic braking as a safety-critical system, is

imprudent.

9. The Union Pacific Railroad has authorized

maximum train speeds that provide

insufficient safety margins in the event of

dynamic braking failure.

10. Some speed-based safeguard might have

enabled the engineer to exercise greater

control over the Kelso accident train.

11. Railroads are operating trains in situations

in which loss of dynamic braking will result

in loss of train control.

12. The Federal Railroad Administration should

separate the dynamic braking function

component from the power brake

rulemaking process and promulgate

regulations to require that, on locomotives

equipped with dynamic brakes, the dynamic

brakes are functioning properly before trains

are dispatched.

13. The engineer in the Kelso accident had no

practical means of knowing if or how many

of his locomotive units were properly

working in dynamic braking immediately

before the accident or when used.

14. Installing a device in the cab of each

controlling locomotive to indicate the realtime condition of the dynamic brakes on

each locomotive unit in the consist would

give valuable information to the engineer on

the train’s dynamic braking capability at any

given moment.

15. The significance of retainer-setting

procedures, proper retainer use, and the

various choices involved should be

understood by train crewmembers and

included in railroad training programs.

16. The Union Pacific Railroad general director

of safety should report directly to the Union

Pacific Railroad president and chief

operating officer.

CONCLUSIONS
32

Probable Cause

The National Transportation Safety Board

determines that the probable cause of the

derailment was (1) a prolonged pattern of

inattention and lack of action by Union Pacific

Railroad management to protect effectively or

relocate the multiple-unit engine shutdown

switch in SD60M locomotives after the switch

had repeatedly been recognized as subject to

inadvertent activation; and (2) failure of Union

Pacific Railroad management to adequately

address critical safety issues such as dynamic

braking system operational reliance and

protection, and authorized maximum train

speeds in the event of dynamic braking failure.

Contributing to the severity of the accident was

the failure of Union Pacific Railroad

management to ensure accurate car weight

assessment and training for operating personnel

on retainer-setting procedures and effects.
33

As a result of its investigation, the National

Transportation Safety Board makes the

following safety recommendations:

-- to the Federal Railroad Administration:

Alert locomotive manufacturers and

railroad operators about the dangers

posed by improperly located safetysignificant controls and switches in

locomotives. (R-98-1)

Require railroads to ensure that the actual

loaded weights of cars in a train are

provided to the traincrew or, if the loaded

weights are unknown, to implement a

method to ensure that the maximum

loaded weight is assigned. (R-98-2)

Require railroads to review steep-grade

train-handling practices and, if

necessary, make changes that will

preserve a margin of stopping ability

should a dynamic braking system fail.

(R-98-3)

Carry out research, investigation, and

analysis to determine maximum

authorized train speeds for safe

operation of trains of all weights, using

speed-based margins of safety that can

be easily measured by traincrews.

(R-98-4)

Separate the dynamic brake

requirements from the Power Brake

Law rulemaking and immediately

conclude rulemaking to require railroads

to verify that the dynamic braking

systems on all locomotives equipped

with dynamic brakes are functioning

properly before trains are dispatched.

(R-98-5)

Require railroads to ensure that all

locomotives with dynamic braking be

equipped with a device in the cab of the

controlling locomotive unit to indicate

to the operating engineer the real-time

condition of the dynamic brakes on each

trailing unit. (R-98-6)

Require railroads to implement formal

training on correct retainer setting and

using procedures for traincrew members

who may set or use air brake retainer

valves. (R-98-7)

-- to the Association of American Railroads:

Alert locomotive manufacturers and

railroad operators about the dangers

posed by improperly located safetysignificant controls and switches in

locomotives. (R-98-8)

Carry out research, investigation, and

analysis to determine maximum

authorized train speeds for safe

operation of trains of all weights, using

speed-based margins of safety that can

be easily measured by traincrews.

(R-98-9)

-- to the Union Pacific Railroad:

Relocate and/or protect all safetysignificant controls and switches in your

locomotives so they cannot be

inadvertently activated or deactivated.

(R-98-10)

Reexamine your system of car weighing

and car-consist weight reporting and take

action to ensure that train consist weights

reflect actual train weights. (R-98-11)

Reexamine your maximum authorized

train speeds for safe operation of trains

of all weights to establish new speedbased margins of safety that can be

easily used by traincrews. (R-98-12)

Develop procedures to ensure that,

before a train equipped with dynamic

brakes is dispatched, all the dynamic

brake systems on the locomotives are

functioning properly. (R-98-13)

RECOMMENDATIONS
34

Equip all lead or controlling locomotive

units with real-time displays capable of

indicating to the engineer the dynamic

brake condition on each trailing

locomotive unit in the consist. 

(R-98-14)

Implement formal training on the proper

procedures for setting and using

retainers for those traincrews that may

be required to do so. (R-98-15)

Review the functions and responsibilities of the Union Pacific Railroad

general director of safety and make any

organizational changes necessary to

ensure that this official: (1) reports

directly to the Union Pacific Railroad

president and chief operating officer;

(2) is involved in all Union Pacific

Railroad operational issues that could

affect train, railroad, and personnel

safety and; (3) has the authority to take

effective safety actions throughout the

Union Pacific Railroad. (R-98-16)

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

February 6, 1998
35

The Kelso railroad accident occurred about

11:52 a.m. Pacific standard time on Sunday,

January 12, 1997, and was reported to the U.S.

Coast Guard’s National Response Center (NRC)

in Washington, D.C., about 27 minutes later, at

3:19 p.m. eastern standard time. The NRC

incident report number was 372918. The

incident report was electronically sent to the

Safety Board at 3:34 p.m. the same day. The

Safety Board’s Western Region Railroad Office

was notified to launch at 2 p.m. Pacific standard

time and Safety Board investigators arrived on

the accident scene about 4 hours later, at 6 p.m.

Pacific standard time.

As part of the investigation, a 1-day sworn

testimony proceeding was held at the Hilton

Flamingo Hotel in Las Vegas, Nevada, on

March 7, 1997. Parties to the proceeding

included the Union Pacific Railroad, the

California Public Utilities Commission, the

United Transportation Union, the Brotherhood

of Locomotive Engineers, and the Federal

Railroad Administration. Five witnesses

testified during the proceeding.

APPENDIXES

Appendix A -- Investigation and Sworn Testimony Proceeding

37

Appendix B -- Excerpts from Applicable Operating Rules

This material was selected from the UP System Timetable No. 2, effective 0001 hours, October 29, 1995,

for the Los Angeles Subdivision.

• On westward trains, dynamic brakes must be tested between MP 309 and MP 292. The conductor

must advise the engineer of the number of cars in the train, the total tonnage, and the tons per

operative brake.

• Passenger trains without operative dynamic brakes must not exceed 20 mph [while traveling

from] Cima to Kelso.

• On the descending grade from Cima to Kelso, the following items A through G apply:

A. Freight trains exceeding 3,500 trailing tons must not be controlled exclusively with

dynamic brake.

B. Retaining valves must be set —

1. On any freight train exceeding 80 tons per operative brake and 300 tons per dynamic

brake axle (including helper locomotives). (See note 1.)

Note 1: The retaining valve requirement does not apply to doublestack trains not

exceeding 115 tons per operative brake, not exceeding 9,600 trailing tons, and

not exceeding 300 tons per dynamic brake axle (including helper locomotives).

These trains may contain up to 4 other intermodal cars (including 4 other multiplatform intermodal cars) if entrained in the rear 5,500 tons of the train.

2. On any freight train exceeding 500 tons per dynamic brake axle (including helper

locomotives). Such trains must not exceed 15 mph.

3. On any freight train being handled without pressure maintaining.

C. [For] All freight trains exceeding 80 tons per operative brake and operating without

retainers:

1. Anytime a train is stopped with a total brake pipe reduction exceeding 15 pounds,

sufficient hand brakes, but not less than 15 pounds, must be applied to hold the train,

and the brake system must be recharged before proceeding. (See note 2.)

2. Anytime total brake pipe reduction exceeds 15 pounds to control speed, the train

must be stopped and retainers set before releasing the train brakes. The brake system

must be recharged before proceeding. If retainers are not sufficient to hold the train

while recharging, hand brakes must also be applied. (See note 2.)

Note 2: Whenever [it is] necessary to apply hand brakes to hold the train on

grade, after the air brake system is recharged, reduce the brake pipe pressure not

less than 6 pounds to hold the train while hand brakes are released.

D. Freight trains not exceeding 85 tons per operative brake and not required to use retaining

valves may operate at a speed not to exceed 25 mph, provided speed can be controlled

with minimum brake pipe reduction (6-8 pounds). If more than minimum brake pipe

reduction is required to control speed, a speed of 20 mph must not be exceeded.
38 APPENDIX B

E. Freight trains exceeding 85 tons per operative brake must not exceed 20 mph.

EXCEPTION: Freight trains not exceeding 110 tons per operative brake may operate at a

maximum speed of 35 mph, provided the train does not exceed 200 tons per dynamic

brake axle, does not exceed 3,500 trailing tons, and is controlled exclusively with

dynamic brake.

F. Freight trains authorized to operate at a maximum speed of 35 mph when controlled

exclusively with dynamic brake must comply with the provisions of item D shown above

when train air brakes are used. These trains may operate at a maximum speed of 35 mph

after a running release, provided not more than a 12-pound reduction has been made, or

the train has been stopped and the brake system has been recharged.

G. In cases where a train is required to stop, the provisions of Air Brake Rule 31.1.3 will

govern.
39

Appendix C -- How Air Brakes Work

The air brake system on a train is designed

to slow or stop a train through the use of

compressed air. The compressed air is used to

push a piston within a cylinder. Usually, through

a series of rods and levers, the piston’s

movement forces brake shoes against car or

locomotive wheels or discs to slow their rotation

through friction. The air is compressed by an air

compressor in the locomotive and stored for use

in the main reservoirs (large tanks) on the

locomotive. (See figure A, below.)

The compressed air and the brakes are

controlled by the engineer using an automatic

brake valve handle on a locomotive control

stand. The automatic brake valve controls the

train’s brakes (including the locomotive) and

has three functions: 1) to apply the brakes, 2) to

release the brakes, and 3) to charge or recharge

the air brake system. Another valve handle,

called the independent brake valve, is used by

the engineer to independently control only the

locomotive’s brakes.

Each railroad car has one or more brake

cylinder pistons, a reservoir (storage tank),

associated piping, and a control valve. The

control valves on cars are designed to respond to

signals sent by the engineer. These signals take

the form of changes in air pressure through the

trainline. The trainline is the physical

connection of the locomotive and cars’ air brake

systems through metal pipes and connecting

flexible air hoses at the ends of each railroad

vehicle.

The air pressure within the trainline is

called the brake pipe. When brake pipe pressure

(in the trainline) is reduced by the engineer,

each car’s control valve senses the drop and

applies the brakes by sending some air stored in

the car’s reservoir to its brake cylinder(s). The

amount of air sent to the air brake cylinder is

proportional to the drop in brake pipe pressure.

Up to a point, the larger the drop in brake pipe

pressure, the more air the control valve sends

from the reservoir to the brake cylinder and the

greater the amount of braking force created.

To release the brakes, the engineer lets more

air into the trainline from the locomotive main

reservoirs, increasing the brake pipe pressure.

Each car’s control valve senses this increase in

air pressure and exhausts air from the brake

cylinder, releasing the brakes. A return spring

within the brake cylinder pushes the piston back

Figure A -- Diagram of freight car air brake system
40 APPENDIX C

into the cylinder, and the brake shoe backs away

from the wheel or disc. At the same time, the

car’s control valve takes some air from the

trainline to replenish any air that the car’s

braking system has used from its reservoir to

charge or recharge its system.

The brake pipe pressure is determined by

the engineer, who turns a knob that sets the

regulating or feed valve. The regulating valve

reduces the pressurized air from the main

reservoir to a determined amount for delivery to

the equalizing reservoir, which then dictates

brake pipe pressure. The equalizing reservoir is

a small reference volume used to control the

much larger train brake pipe or trainline volume.

The equalizing reservoir allows the engineer to

make immediate predetermined changes to the

brake pipe pressure without having to wait for

the changes to take effect and stabilize, while

remaining assured that precise changes in

pressure will be made.

Because the trainline connections through

and between cars are not perfect, some of the

compressed air leaks. To prevent the car control

valves from sensing a drop in air pressure from

leakage and inadvertently applying the brakes,

the automatic brake valve in the engineer’s

locomotive control stand has a maintaining

feature. The maintaining feature automatically

sends just the right amount of air into the brake

pipe, regardless of whether the brakes are

applied or released, to make up for any trainline

system leakage.

Because the maintaining feature is located

in the locomotive, there is usually a constant

flow of air toward the rear of the train. Trainline

leakage progressively draws off air from the

brake pipe as it travels toward the rear of the

train, reducing air pressure. This gradual drop in

brake pipe pressure is called gradient and

represents the difference in brake pipe pressure

between the front and rear of the train.
41

Appendix D -- Train Dynamics Analyzer Simulations

General -- Train dynamics analyzer

simulations were performed at the New York

Air Brake Train Dynamics Simulations Group in

Fort Worth, Texas, on February 4 and 5, 1997.

The simulations were based on event recorder

data recovered from UP train 6205’s three

locomotive units, postaccident inspection and

testing of eight cars from the train, and

postaccident interviews. The simulations were

intended to determine

• the maximum speed while descending Cima Hill at which the engineer

might have been able to stop the

train, and

• what would have occurred if UP

train 6205’s maximum authorized

speed had been 5 mph less (assuming

that the engineer reacted as he did

during the accident).

A train dynamics analyzer (TDA) is a

computer system connected to a locomotive

control stand. A television monitor that displays

the behavior of the train on a graph-like track

profile is mounted on the control stand. The

train on the monitor moves in time along the

graph-like track profile past established

mileposts (MPs). The monitor display shows

corresponding in-train buff and draft forces and

trainline air brake pressures as they occur.

Simulation Design -- Before the

simulations began, pertinent vehicle and braking

information for all the cars and locomotive units

in the Kelso accident train consist was loaded

into the computer from the Association of

American Railroads Universal Machine

Language Equipment Register and the

manufacturer’s locomotive performance data. A

complete track profile of the Cima Hill railroad

area was also programmed into the TDA.

The group performing the simulations used

the data from the lead locomotive unit’s event

recorder to develop a train-handling sequence

that ran from Cima Hill’s summit until the

engineer placed the train in emergency. The

accident engineer handled the simulation

accident train for all runs; this was an approach

designed to make the simulations as realistic as

possible by accounting for unrecorded factors,

such as the engineer’s dynamic braking routine

and technique.

Seven accident scenarios, or runs, were

performed. Each of the runs began when the

dynamic brakes and engines quit operating at

Elora, MP 247.9. Based on the car data from the

Union Pacific Railroad, each of the simulation

runs used the following parameters: 143 tons per

car; 90-psi brake pipe pressure; 100 percent

braking efficiency; and 60 (of 75) car air brake

retainers set. Starting conditions included a

preset 9-psi brake pipe reduction and retainers

precharged from a previous 11-psi brake pipe

reduction at Cima.

Results Before the Stop Switch was

Activated -- The results achieved by the TDA

simulations for the period before the engine stop

switch was activated confirmed that the nominal

braking ratio, based on the average of the actual

net braking ratios of eight accident train cars,

was not only feasible but probably duplicated

the behavior of UP train 6205. Results indicated

that two working dynamic brake units could

have kept the train speed under control as

effectively as three working units, but two units

required more amperage to control the train.

(The accident engineer said that, judging by the

amperage generated during the simulated

dynamic braking, he believed that he had three

working units, since the lower amperage

allowed him to maintain a contingency reserve,

as was his practice.)

Results After the Stop Switch was

Activated -- Although several nominal braking

ratios were found to be realistic for the

simulation train before the stop switch was

activated, no functional ratio could match UP

train 6205’s performance after the stop switch

had been activated. Nominal braking ratios,

which are based on total braking force divided

by the car-light (empty) weight, are normally in

the 28 to 30 percent range. When testers applied

such a realistic ratio, the simulation accident

train, in following the train-handling scenario as

reported by the event recorder, would stop far

short of the actual derailment site. The nominal
42 APPENDIX D

braking ratio had to be degraded far below that

actually found on most freight cars to even

approach UP train 6205’s performance as

detailed by the event recorder.

According to brake tests performed by the

AAR in 1991 and documented through a

presentation in the minutes of the Air Brake

Association Meeting, Monday Afternoon -

September 16, 1991, a train descending the 2.2-

percent grade of Cima Hill with an average

braking ratio of 7.5 percent, an initiation speed

of 23 mph, and 101.9 tons per operative brake

was unable to stop on the grade using the air

brakes alone. UP train 6205 was similar to the

AAR air brake test train in every important

aspect, except that it was 40 percent heavier, at

143 tons per operative brake.

The TDA simulator results, however,

demonstrated that UP train 6205 should have

stopped far short of the derailment site.

Considering this discrepancy and the simulator’s

inability to realistically match UP train 6205’s

event recorder speed and time performance, the

group performing the tests found that the TDA

simulator was unable to give a realistic

projection of all braking scenarios.

The group finally determined that the heavy

braking and heat fade involved in the accident

could not be accurately replicated by the TDA

simulator. Therefore, the attempt to fulfill the

purposes of the TDA simulations failed,

although the exercise provided an overall idea of

the kind of braking forces involved, since UP

train 6205 behaved on the average like one that

had only received a 15-psi brake pipe reduction.
43

ACRONYMS AND ABBREVIATIONS

AAR Association of American Railroads

AEI Automatic Equipment Identification

ANPRM Advance Notice of Proposed Rulemaking

BN Burlington Northern Railroad

CFR Code of Federal Regulations

CMO Chief Mechanical Officer

CTC centralized traffic control

EMD General Motors Electro-Motive Division

EOT end-of-train

FRA Federal Railroad Administration

MP milepost

MU multiple-unit

NPRM Notice of Proposed Rulemaking

NRC National Response Center

PUC Public Utilities Commission

RSAC Railroad Safety Advisory Committee

SP Southern Pacific Railroad Company

TDA Train Dynamics Analyzer

UP Union Pacific Railroad