PB96-917008

NTSB/SIR-96/05

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, DC 20594

SPECIAL INVESTIGATION REPORT

STEAM LOCOMOTIVE FIREBOX EXPLOSION

ON THE GETTYSBURG RAILROAD

NEAR GARDNERS, PENNSYLVANIA

JUNE 16, 1995

Illlr.

6768
Abstract: On June 16, 1995, the firebox crownsheet of Gettysburg Passenger Services, Inc.,

steam locomotive 1278 failed while the locomotive was pulling a six-car excursion train about

15 mph near Gardners, Pennsylvania. The failure resulted in an instantaneous release (explosion)

of steam through the firebox door and into the locomotive cab, seriously burning the engineer

and the two firemen.

This accident illustrates the hazards that are always present in the operation of steam

locomotives. The Safety Board is concerned that these hazards may be becoming more

significant because Federal regulatory controls are outdated and because expertise in operating

and maintaining steam locomotives is diminishing steadily.

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

recommendations to the Federal Railroad Administration, the National Board of Boiler and

Pressure Vessel Inspectors, and the Tourist Railway Association, Inc.

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

aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967,

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

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

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

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

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

recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, SW

Washington, DC 20594

(202) 314-6551

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

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
STEAM LOCOMOTIVE FIREBOX

EXPLOSION

ON THE GETTYSBURG RAILROAD

NEAR GARDNERS, PENNSYLVANIA

JUNE 16, 1995

SPECIAL INVESTIGATION REPORT

Adopted: November 15, 1996

Notation 6768

NATIONAL

TRANSPORTATION

SAFETY BOARD

	
 
 

iii

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

INTRODUCTION......................................................................................................................... 1

INVESTIGATION

Accident .......................................................................................................................................... 3

Train Damage.................................................................................................................................. 6

Gettysburg Passenger Services........................................................................................................ 9

Personnel Information ................................................................................................................... 10

Engineer ................................................................................................................................. 10

First Fireman .......................................................................................................................... 10

Second Fireman...................................................................................................................... 11

Helper Engineer ..................................................................................................................... 11

Training.................................................................................................................................. 11

Delineation of Duties ............................................................................................................. 12

Train and Equipment Information................................................................................................. 12

Locomotive 1278 ................................................................................................................... 12

Boiler Information.................................................................................................................. 13

Cab Equipment and Arrangement.......................................................................................... 14

Locomotive Maintenance Records......................................................................................... 18

Postaccident Inspections, Tests, and Research.............................................................................. 19

Crownsheet Failure ................................................................................................................ 19

Water Glass............................................................................................................................ 19

Water-Glass Blowdown ......................................................................................................... 24

Gage Cocks ............................................................................................................................ 26

Boiler-Water Behavior........................................................................................................... 26

Boiler-Water Supply System.................................................................................................. 29

Water Treatment .................................................................................................................... 30

Boiler Washing ...................................................................................................................... 31

Low-Water Devices ............................................................................................................... 32

Oversight and Regulation of Steam Locomotives......................................................................... 33

Regulation and Oversight....................................................................................................... 35

Industry Efforts ...................................................................................................................... 37

CONTENTS
iv

ANALYSIS

General .......................................................................................................................................... 39

Investigation .................................................................................................................................. 40

Water-Monitoring Devices..................................................................................................... 40

Water-Glass Lighting and Conspicuity.................................................................................. 41

Water Treatment .................................................................................................................... 42

Boiler Washing ...................................................................................................................... 42

Feed Pump and Gage ............................................................................................................. 43

Malfunctioning Check Valve ................................................................................................. 43

Injector ................................................................................................................................... 44

Water-Glass and Gage-Cock Testing..................................................................................... 44

Delineation of Responsibilities .............................................................................................. 44

Hours of Service..................................................................................................................... 45

Training.................................................................................................................................. 45

Progressive Crown-Stay Failure............................................................................................. 46

Steam-Locomotive Maintenance Expertise ........................................................................... 46

CONCLUSIONS ......................................................................................................................... 48

PROBABLE CAUSE .................................................................................................................. 49

RECOMMENDATIONS............................................................................................................ 50

APPENDIXES

Appendix A—Investigation and Sworn Testimony Proceeding ................................................... 53

Appendix B—Abbreviations Used in this Publication ................................................................. 55
v

About 7:20 p.m. on June 16, 1995, the

firebox crownsheet of Gettysburg Passenger

Services, Inc., steam locomotive 1278 failed

while the locomotive was pulling a six-car

excursion train about 15 mph near Gardners,

Pennsylvania. The failure resulted in an

instantaneous release (explosion) of steam

through the firebox door and into the

locomotive cab, seriously burning the

engineer and the two firemen. The firemen

were taken by ambulance to area hospitals.

The engineer, who had third-degree burns

over 65 percent of his body, was airlifted to

a burn center near Philadelphia. None of the

310 passengers or other crewmembers were

injured. Locomotive damage was limited to

the firebox grates and crownsheet, with

some ancillary smoke and debris damage to

the locomotive cab.

Investigators found that the crownsheet

failed from overheating because the traincrew had allowed the water in the

locomotive boiler to drop to a level that was

insufficient to cover the crownsheet. When

the investigators examined the locomotive

components closely, they found that the

boiler and its associated equipment had not

been maintained well enough to ensure safe

operation and that some repairs had been

done incorrectly. Investigators determined

that the deficiencies were the result of a lack

of the specialized knowledge, skills, and

training necessary to properly maintain a

steam locomotive. It was further determined

that those operating the locomotive did not

understand the full scope of their duties and

did not coordinate their efforts to ensure the

highest degree of safety.

The National Transportation Safety

Board determines that the probable cause of

the firebox explosion on steam locomotive

1278 was the failure of Gettysburg

Passenger Services, Inc., management to

ensure that the boiler and its appurtenances

were properly maintained and that the crew

was properly trained.

Because the Safety Board believes the

circumstances surrounding this accident are

not unique but reflect an ongoing attrition of

specialized knowledge and skills within the

tourist steam-excursion industry, the Board

did a special investigation of the accident.

As a result of its investigation, the Safety

Board makes seven recommendations to the

Federal Railroad Administration, three

recommendations to the National Board of

Boiler and Pressure Vessel Inspectors, and

four recommendations to the Tourist

Railway Association, Inc.

EXECUTIVE SUMMARY

1

At about 7:20 p.m. on June 16, 1995, the

crownsheet of Gettysburg Passenger Services, Inc., steam locomotive 1278 failed

while the train was pulling a six-car excursion train about 15 mph near Gardners,

Pennsylvania. The failure caused fire and

steam to be explosively released through the

firebox door into the locomotive cab, seriously burning the engineer and two firemen.

The engineer suffered third-degree burns

over 65 percent of his body. None of the 310

passengers or the other crewmembers were

injured.

The cause of this accident was determined to be the failure of the train operating

crew to maintain a water level in the locomotive boiler that was sufficient to cover the

crownsheet. Because of the inadequate water

level, the crownsheet overheated and weakened. When it weakened, it could no longer

withstand the pressure of the steam above it.

The pressure forced a section of the crownsheet to pull away from its staybolts and

collapse inward; the staybolt holes in the

collapsed section then exposed superheated

water and steam in the boiler to the atmospheric pressure of the firebox. With the sudden reduction of pressure in the boiler, the

superheated water flashed instantaneously

and explosively into steam. The investigation of this accident revealed that those responsible for maintaining, repairing, and

operating locomotive 1278 lacked the specialized training and experience that have

long been judged to be prerequisites for the

safe operation of steam-locomotive equipment.

Approximately 150 steam locomotives

are still operated in the United States by

more than 82 organizations. Virtually all of

them are used by tourist railroads, museums,

historical groups, and steam-excursion

groups. Although there are no exact figures

about how many people ride steam-locomotive trains each year, the Tourist Railway

Association, Inc., (TRAIN) estimates that

approximately 4.8 million people, or the

equivalent of 12 percent of Amtrak’s annual

intercity ridership for 1995, visit tourist

railways, museums, and excursion operations annually. A significant number of these

people ride trains pulled by steam locomotives. According to Gettysburg Passenger Services officials, about 50,000 people rode Gettysburg Passenger Services

steam trains in 1994—and this is only one of

more than 80 organizations belonging to

TRAIN that use steam-excursion trains.

This accident illustrates the hazards that

are always present in the operation of steam

locomotives. The Safety Board is concerned

that these hazards may be becoming more

significant because Federal regulatory controls are outdated and because expertise in

operating and maintaining steam locomotives is diminishing steadily. The Safety

Board believes that the reasons for the explosion on locomotive 1278, especially

those reasons having to do with deficiencies

in steam-locomotive maintenance and operations, may not be unique.

INTRODUCTION
2

Because of its concern about the safety of

passengers and crews on steam trains, the

Safety Board conducted a special investigation of the Gettysburg Passenger Services,

Inc., accident and developed recommendations to address inadequacies it found in

regulations, standards, and certification requirements regarding steam-locomotive inspection, maintenance, and operation.
3

Accident

On the day of the accident, steam locomotive 1278 with a train of six passenger

cars made two 16-mile round trips from

Gettysburg to Biglerville, Pennsylvania.

About 6:00 p.m., as a “dinner train,” it

started its third and last trip of the day. It left

Gettysburg with 310 passengers for a round

trip to Mount Holly Springs, Pennsylvania,

where the passengers were to have a catered

2-hour dinner in local restaurants before they

returned to Gettysburg.

After the train left Gettysburg, the coowner and operator of Gettysburg Passenger

Services, Inc., (Gettysburg Passenger Services) closed the Gettysburg station and followed the excursion train. The purpose of

her “chase” by automobile (she would meet

the train at road crossings) was to provide a

contingency service to the train and, if necessary, limited emergency transportation.

She carried a cellular telephone and a twoway radio that she used to monitor and talk

to the crew. Her husband, the locomotive

engineer, also carried a radio and cellular

phone. The conductors and passenger-service personnel on the train had two-way radios.

When the dinner train left Gettysburg, it

passed a Gettysburg Railroad freight train.1

It was routine procedure for the Gettysburg

Railroad freight-train locomotive to act as a

helper.

 

1

All the equipment used by Gettysburg Passenger

Services, Inc., (Gettysburg Passenger Services) is

leased from Gettysburg Railroad.

Near Aspers, Pennsylvania (MP 15, “the

Wolf Pit”), the dinner train stopped and

waited to receive the helper train, which

consisted of a diesel-electric locomotive

pulling four freight cars. It took several

minutes to couple the helper to the rear of

the dinner train, after which the combined

consist proceeded. (See figure 1.)

According to testimony, a check valve (a

one-way valve) between the feed-water

heater pump (feed pump)2

 and the boiler had

been leaking all day, even though the valve

had recently been repaired. On a previous

trip that day, when locomotive 1278 was

running backward next to a double-tiered,

open-air observation passenger car, the spray

from the leaking check valve necessitated

clearing the first half of the car.

Consequently, according to the first

fireman,3 when the train left Wolf Pit the

feed pump was shut off. He said,

We shut [the feed pump] off whenever

we started up Wolf Pit because [the

check valve] was putting water on the

track and [the locomotive drivers4]

slipped. But as soon as we were

moving, [the feed pump] was turned

back on.

 

2

The feed-water heater is a heat exchanger located in

the front of the steam locomotive, usually in the

smokebox. Cylinder exhaust steam is used to pre-heat

water from the tender before the water is pumped into

the boiler. This boosts energy efficiency and lowers

fuel usage.

3

The fireman tends and stokes the fire in the boiler’s

firebox.

4

The drivers are the wheels that propel the locomotive.

INVESTIGATION
4

The second fireman5 testified that when

he relieved the first fireman at Gardners,6

the feed pump was still turned off. The

second fireman said he then turned the feed

pump on “all the way.” When the firemen

were later asked how they could tell whether

the feed pump was working, they both indicated that the sound and visual movement of

the feed-pump rod told them the feed pump

 

5

It was the policy of Gettysburg Passenger Services to

have two firemen on the dinner train trip because the

trip was an extended one.

6

The firemen did not agree in their testimony about

where the transfer of responsibility took place. There

was no clear transfer of duty. To some extent, each

was acting in the capacity of fireman between Pond

Road and Gardners.

was working. Both firemen felt such cues

were sufficient to ensure that water was

flowing into the boiler. Safety Board

investigators agreed that the feed pump can

continue to move with little or no water

flow.

Both firemen stated that they checked the

water glass7 frequently during the trip. The

 

7

The water glass, also called the “sight glass” and

“water gage,” is a device that enables an engineman

or fireman to observe the height of the water in a

locomotive boiler. It consists of two brass fittings

screwed into the back head, one above the other, and

connected by a stout glass tube or a metal frame in

which a glass is inserted which communicates,

through the fittings, with the water and steam in the

boiler. The water level showing in the glass is the

same as that water level inside the boiler.

Figure 1. Key locations.
5

first fireman stated that he “always” watched

the water glass. The second fireman said he

checked it “once every 5 minutes or so.” He

also said the engineer leaned back in his seat

to check the glass about three times during

the trip. Neither fireman noted anything unusual about the level of water in the glass.

They said that the level appeared to be

normal and that it appeared to fluctuate

about a half to a full inch, a fluctuation they

considered normal, considering the grade of

the track and the vibrations.

At Pond Road, MP 18, the second

fireman relieved the first. About a mile later,

at Gardners, while the train was moving

about 15 mph, the firebox explosion

occurred. According to the first fireman:

We got to the top of the grade and leveled off and...we had a normal water

reading, had plenty of steam.8

 I got up

about 30 seconds before the crownsheet9

 failed. I got up to put coal in the

corners, because it’s an automatic

stoker,10 and it fans [the coal] so it

won’t hit the corners, and I decided to

wait until we got across the crossing

 

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and up around the bend before we

started up the next grade. [The second

fireman] took the fireman’s seat, and I

decided against...putting coal in. So, I

went to the door and waved to all the

people at the crossing. And about 5

seconds later is when we had the accident.

Well, [when] the crownsheet

failed...it just sounded like a muffled

.22 [rifle] pop. I instinctively turned

towards the noise....I remember

getting hit with—it just got dark

because of all the soot and the smoke

in the cab. And I remember feeling

intense heat and thinking...I’ve got to

get out of here. I jumped out

and...yelled at [the engineer’s wife] to

call 911. And then I thought about [the

engineer], and I started back up just

past [the other fireman]. I knew he

[the second fireman] was all right

then, because I saw him. He was

limping, but I knew he was all right.

Then I went up to find [the engineer]

and found him on the other side of the

train lying there. And he asked for [his

wife]. So I ran back and got [her]. And

she handed me the phone, and I

finished the 911 call.

The second fireman testified:

[The first fireman] stepped down to

fire the back corners of the firebox,

and I told him to take a break and I’d

take over firing, which, I guess, gave a

time span of about 5 minutes from that

point until the explosion. There was

like an initial poof sound, but then

there was like a second explosion,

which is what jarred the fire doors

open and dumped everything back into

the cab. All the steam and a lot of the

coal just blew back into the cab. We

had the feed pump on and had the
6

stoker on. I shut the stoker and the

feed pump down. And at first, just not

knowing where everything was

coming from, I jumped forward in the

cab between the boiler and the outside

wall of the cab to try to get away from

it. After about 10 or 15 seconds, I

realized it wasn’t getting any better,

and that’s when I came back to the

seat. And you couldn’t see anything as

far as the doorway or anything. So,

that’s when I climbed up on the seat

and jumped out the window. Almost

immediately after the explosion, [the

first fireman] went out the doorway.

And to my knowledge...[the engineer]

apparently stayed on until it stopped.

According to the helper engineer, the

engineer applied the air brakes. A conductor

announced on the radio, “Emergency! Stop!

Stop! Stop!” When the train stopped, the

engineer managed to get down out of the

locomotive cab by himself and lie on the

ground. He was then helped by the firemen

and other members of the traincrew.

Ambulances arrived minutes later.

The firemen were taken by ambulance to

area hospitals. The first fireman, who had

immediately left the locomotive cab by the

doorway, had second- and third-degree

burns over 10 percent of his body. He was

initially taken to the hospital in Gettysburg

and was later transferred to York,

Pennsylvania, for a week. His recovery took

about 1 1/2 months.

The second fireman also had second- and

third-degree burns on his legs, arms, and

chest and had fractured his legs when he

jumped through the locomotive cab window.

He was hospitalized for several weeks and

had extensive therapy for his shoulder.

The engineer was airlifted to CrozerChester Medical Center, a burn center near

Philadelphia. He had third-degree burns over

65 percent of his body. He spent the next 6

months undergoing multiple surgeries and

extensive therapy and was still undergoing

therapy and follow-up surgery 9 months

later. None of the passengers or other

crewmembers were injured.

Train Damage

A postaccident inspection of locomotive

1278 revealed that the firebox was the only

area to sustain major damage. (See figures 2,

3, and 4.) The crownsheet toward the front

of the locomotive next to the rear tube-sheet

knuckle11 had bulged downward a maximum

of about a foot in a “bag” shape that covered

an area encompassing about 60 crown stays.

The crownsheet holes around the crown

stays had been deformed and elongated,

creating gaps about the crown-stay heads.

The crownsheet knuckle next to the flue

sheet had a 6-inch tear. Also, two front (near

the flue sheet) right firebox grate panels of

the firebox floor had broken and fallen onto

the ashpan below.

It is not possible to estimate the monetary

cost of the accident. Because each steam

locomotive is unique and because very few

facilities can do major repairs for a steam

locomotive, there are no flat rates for

repairs. Instead, the repair facility estimates

the price of each repair on a cost plus basis.

 

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7
8
Figure 4. Bag in crownsheet.

Costs vary extensively from facility to

facility.

Gettysburg Passenger Services

Gettysburg Passenger Services is an

outgrowth of the steam-powered excursion

services begun on the Gettysburg Railroad

in June 1978. The Gettysburg Railroad is a

shortline freight railroad that connects CSX

at Gettysburg with Conrail at Carlisle

Junction, a distance of 23.7 statute miles. In

1986, the owner of Gettysburg Railroad

formed Gettysburg Passenger Services to

run the excursion service of Gettysburg

Railroad, and he transferred ownership of

Gettysburg Passenger Services to his son

and daughter-in-law.

The son and his wife were responsible for

hiring and supervising the company’s employees, and the son was also primarily, if

not solely, responsible for the care and operation of the excursion equipment—including the steam locomotives. His responsibilities included maintaining and testing

steam locomotive 1278 in accordance with

the Federal Railroad Administration’s

(FRA’s) regulations. (The FRA’s regulations are recorded in 49 Code of Federal

Regulations [CFR] Part 230). He was also

the primary engineer of locomotive 1278,

and he was operating the locomotive at the

time of the accident.

In 1994, Gettysburg Passenger Services

carried about 50,000 passengers. It leased

track and equipment, including steam locomotives and passenger cars, from Gettysburg Railroad. Gettysburg Passenger Services and Gettysburg Railroad shared locomotive-maintenance facilities and some

traincrew personnel. Gettysburg Railroad

diesel-electric locomotives frequently dou9
10

bled as helpers or backup relief for the excursion service. The two companies accounted separately for labor, services, equipment, and supplies.

Personnel Information

Engineer--At the time of the accident, the

engineer was 48 years old. He had obtained

most of his knowledge of railroad and

steam-locomotive operation while growing

up. He said he had been surreptitiously

allowed to be the fireman on Pennsylvania

Railroad locomotives near his home starting

when he was about 15 years old. His father

began developing a steam tourist railroad in

Blairsville, Pennsylvania, in 1959, which

became fully operational in 1964. The father

testified that his son had first officially

started running a steam locomotive when he

was 18 years old, receiving instruction from

professional railroaders. The engineer told

Safety Board investigators that he had had

no formal railroad or steam-locomotive

training.12

Between 1978, when Gettysburg Railroad

had started its steam-powered excursion

service, and the time of the accident, the

engineer had been the primary operator of

the steam locomotives. He was also the

primary servicer, maintainer, and repairer of

the locomotives and cars; however, he

contracted out work that required specialized

skills and/or tools or was beyond routine

maintenance or the capability of one or two

people. He did many of the jobs himself

with little or no assistance. The FRA

requires that a form No. 1 be signed after

routine maintenance, such as washing the

 

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boiler and cleaning the spindles,13 has been

done on a locomotive. The person who signs

the form is certifying the work has been

done. The owner must keep the forms on file

for FRA review. The engineer signed all the

forms having to do with the accident locomotive.

According to his wife, the engineer had

had a routine day up until the time of the

accident. He had started work at 6:45 a.m.,

done the necessary pre-trip work, made

excursion trips at 11:00 a.m. and 1:00 p.m.,

and finished about 3:00 p.m., more than 8

hours after he had started. After a 2-hour

break, he reported back for the dinner train,

about 5:00 p.m.

First Fireman--The first fireman, age 18,

who fired the locomotive from the time the

dinner train left Gettysburg until the crossing

at Gardners, had been employed by

Gettysburg Passenger Services since 1992.

At the time of the accident, he was a student

working full time for the excursion service

while on summer break.

He had had no prior railroad experience,

and his training as a steam-locomotive

fireman had been on the job (OJT). He had

been trained by the engineer, by one other

full-time employee, and, to some extent, by

the fireman with whom he was working at

the time of the accident. He described his

training as consisting of observation,

demonstration, and then performance.

He said he was well rested on the day of

the accident. From 7:30 a.m. to 3:30 p.m., or

for about 8 hours, he had worked on

 

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11

building an earthen ramp with a backhoe.

After 3:30, he took a break until about 5:00

p.m., when he reported for the dinner train.

Second Fireman--The second fireman, 32,

was a full-time supervisor at a local industry.

He had worked for Gettysburg Passenger

Services for 5 years as a part-time fireman.

Like the first fireman, he had had no

previous railroad experience and was given

OJT, principally by the engineer. As a

fireman, he had made about 50 trips each

season during his first 3 years and about

“two dozen” in the 2 years preceding the

accident.

On the day of the accident, he arrived at

the engine house at about 5:00 p.m., after

working a full day at his regular job.

Helper Engineer--The helper engineer, 21,

started railroading in 1989 as a part-time

summer employee with Gettysburg Passenger Services, firing locomotive 1278. He had

had no previous railroad experience and

took OJT from the engineer. After graduating from high school, he became the only

full-time train crewmember with Gettysburg

Passenger Services other than the engineer.

When the helper engineer was 18, the engineer taught him how to operate diesel-electric locomotives, as well as steam locomotives. During the off season, when the tourist

train did not make excursions, he helped the

engineer maintain the locomotives and cars.

He testified that his normal hours were

7:30 a.m. to 4:00 p.m. On the day of the

accident, he said, he came to work at the

regular time, “worked freight” from 7:30

a.m. to 12:30 p.m., and worked in the train

yard from 12:30 p.m. to 3:30 p.m., for a total

of about 8 hours. He then went home for a

break, reporting back for helper duty at 5:30

p.m. He said he followed the excursion train

“about 15 or 20 minutes behind” until Wolf

Pit.

Training--According to the engineer’s

wife, the company had started a formal

training program “2 years ago.” The training

consisted of classroom and hands-on training and included showing a safety film from

Tourist Railway Association, Inc., (TRAIN),

followed by a question-and-answer period.

The engineer taught the course, which lasted

4 or 5 hours, once a year, before the start of

the tourist season. Although the company

did not keep attendance records, all the employees attended the course. Employees interviewed by Safety Board investigators

stated that they had a training session some

time in April 1995.

Gettysburg Passenger Services did not

have a formal program for training or

certifying an engineer as qualified, nor was

it required to have one. The company was

able to meet the FRA’s definition of

certifying an engineer (49 CFR 2430.101) by

filling out a generic, American Short Line

Association, fill-in-the-blank document and

sending it to the FRA.

Beyond the recent pre-season training

described above, each Gettysburg Passenger

Services employee described his or her

training as being OJT typified by watching

others do the work, demonstrating the ability

to do the work, and then performing the

work in the context of day-to-day operations.

The company did not use training records,

task lists, tests, or other training organization

or documentation papers. Training was

random, based on the day’s operations. The

employees were not taught regulatory

requirements, standardized industry

practices, or the theory of steam-boiler

operation. Such training is not required.
12

Delineation of Duties.--The following exchange with the first fireman took place

during his testimony:

Q: Who was operating the feed pump

most of the time during the trip?

A: That would have been me.

Q: Would you say you were the one

running the feed pump all the time on

that trip?

A: Not all the time. We had two

firemen. Two firemen.

Q: But was your role the lead fireman

that day?

A: I would not—we don’t have a lead

fireman. We have [others] here to

back everyone up.

Q: What I meant by that was, was

there an agreement between you and

[the second fireman] that you would

do most of the duties and he would

back you up, or vice versa?

A: No.

Q: So you had a kind of division in

responsibilities, but it wasn’t clear

who exactly was in charge of the

fireman’s duties?

A: Well, no. There’s—we both are

competent firemen. We both know

what we are doing.

The second fireman, referring to

operation of the feed pump, testified as

follows:

Q: When you and [the first fireman]

were sharing the duties, had you

actually turned the feed pump on

yourself in the few minutes—I mean,

on that leg of the trip just before the

incident, you had relieved [the first

fireman], more or less?

A: Yes.

Q: So you were acting as kind of the

fireman—

A: Yes.

Q:—in charge?

A: (Shrugs shoulders)

Q: So, when the two of you were

working together, you had a clear

understanding of who would do what,

who would be responsible for what?

A: Pretty much. But I basically left it

up to him. I was there to give him a

break and such.

Train and Equipment Information

Locomotive 1278--Canadian Locomotive

Company, Ltd., in Kingston, Ontario,

Canada, built locomotive 1278 for the

Canadian Pacific Railway in April 1948.

The locomotive had a 4-6-214 “Pacific”

wheel arrangement15 and was designed for

passenger service. Its cylinders were 20 by

28 inches; boiler pressure was 250 psi; and

driver diameter was 70 inches. It weighed

234,000 pounds, with 151,000 pounds on

drivers, and had 34,000 pounds of tractive

effort. Its cab had side doors and was an

enclosed all-weather, or winter-type, cab.

(See figure 5.)

 

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Figure 5. Locomotive 1278.

The locomotive had had a variety of

owners and operators. In May 1965, the

Canadian Pacific Railway sold the locomotive to a man in New Hampshire. In

1969, he donated it to Steamtown, a railroad

museum then located at Bellows Falls,

Vermont, and it was renumbered 127. From

June 1970 to August 1971, it was leased to

the Cadillac & Lake City Railroad in Lake

City, Michigan, as locomotive 127. In

September 1971, it was returned to Bellows

Falls and renumbered 1278. In 1984, it was

moved, along with Steamtown, to Scranton,

Pennsylvania. In June 1987, Gettysburg

Railroad bought the locomotive and leased it

to Gettysburg Passenger Services.

Boiler lnformation-According to form No.

4, locomotive 1278 had a radial-stay,

straight-bottom, wagon-top boiler with three

courses, or diameters. 16 The boiler was

constructed of three connected rings or

courses of different diameters. The lowest

tensile strength of the steel was 72,100 psi

for the first course, 80,030 for the second

course, and 70,840 for the third course. The

crownsheet was 3/8 inch thick when new.

The water space at the firebox back was 3

1/2 inches. The firebox grate was 45.6 feet

square. The lowest level of water in the

boiler that the water glass could indicate was

a level 3 1/8 inches above the highest point

of the crownsheet. The height of the lowest

16Form No. 4 is a steam-locomotive boiler specification document required by the FRA in 49 CFR

230.54. Gettysburg Railroad had only one form No.

4, the one that had been filed by the Cadillac &

Lake City Railroad, a lessee of the locomotive. The

FRA does not require a form No. 4 to reflect the

actual condition of the boiler in its present configuration or to be completed or submitted by a qualified

person.

13
14

gage cock17 above the crownsheet was 3 1/4

inches.18

In accordance with Canadian Pacific

policy, the crown stays, which supported the

crownsheet from the boiler roof sheet,19

were alternating rows of straight-thread and

button-head crown stays. (See figures 6 and

7.) The first five rows from the rear tubesheet knuckle (next to the tubes and flues)

were straight-thread crown stays followed by

rows of button-head crown stays. The boiler

had been made that way so that if the

crownsheet failed because it was not covered

by water, it would be pushed off the straightthread crown stays first. Consequently, although the crownsheet would buckle, it

would be retained for a time by the buttonhead crown stays. Thus, if the crownsheet

failed because of too little water, the failure

would occur progressively and in stages,

rather than instantaneously and catastrophically.

20 Other than being designed to make a

failure a progressive, rather than an instantaneous, event, the boiler did not have any

low-water protection devices.

Cab Equipment and Arrangement--The cab

of locomotive 1278 surrounded the backhead

 

17Gage cocks are used as a backup system for the

water glass.

18The gages are positioned so that the lowest reading

on the gage will indicate more than 3 inches of water

over the crownsheet, which is the minimum as

required by 49 CFR 230.37.

19The outer boiler shell above the crownsheet. 20Note that (1) such a failure will still, as in this

accident, be very sudden and “explosive” and (2) no

construction method will prevent a catastrophic

failure, although it may attenuate the damage.

of the boiler.21 (See figure 8.) A number of

devices, including gages and the water glass,

were mounted on the backhead. The backhead was also the location of the back of the

firebox and the firebox door. Below the

firebox door was the automatic stoker-auger

entrance used to deliver coal to the firebox.

The backhead had a number of washout

plugs.22 The engineer’s seat was to the right

side of the boiler and slightly to the rear of

the backhead. Similarly, the fireman’s seat

was along the left side of the boiler.

On the engineer’s side of the cab were the

air-brake controls and gages, throttle lever,

reverser (valve cut-off control), boiler-pressure gage, injector operating lever,23 the

three gage-cock operating handles, and a

number of other accessory controls, handles,

and levers. On the fireman’s side of the locomotive cab were a number of gages and

controls for managing the boiler and steam

production. Three gages—stoker jet-pressure

gage, steam-heat pressure gage, and feedpump pressure gage—had been removed

from a mounting plate on the fireman’s

side,24 leaving only a stoker-engine steampressure gage and a boiler-pressure gage.

(See figure 9.)

 

21The backhead is the rearmost boiler sheet, which is

located in the cab.

22Boiler designers incorporate a minimal but

necessary number of washout plugs in a boiler to

ensure that it can be thoroughly washed and cleaned

of the sediment that contributes to scale. 23The injector is a device for forcing water into a

steam boiler. A jet of steam imparts its velocity to the

water and thus forces it into the boiler against the

boiler pressure. The injector on locomotive 1278 was

of the lifting type, which is generally used when the

locomotive is standing still. 24The missing gages were identified from a

photograph of locomotive 1278 taken several years

before this accident.
Radial

ater

Section

I

Button Head Crown Stay

Water

Figure 6. Radical stay boilers and stays. 15
Roof Sheet of Boiler

/ —“-—- —-— -—— .~- —

Firebox

—-—-

Knuckle

/

---

—.

I

I

I

1

Figure 7. Alternating pattern of stays.
Figure 8. Backhead.

The engineer told Safety Board like the injector, could be adjusted to allow a

investigators that he removed the original variable amount of water into the boiler, or

feed-pump gage after it failed and that when none when the feed pump was turned off.

the replacement also failed, he had decided

not to replace it. The turret also provided steam to a

number of other auxiliary devices, including

A fireman uses the feed-pump pressure the dynamo. The dynamo was a steamgage to ensure that heated feed water is turbine-powered generator for the

overcoming boiler pressure and is flowing locomotive headlight, cab lights, and waterinto the boiler. The gage provides a direct glass light. At the time of the accident, the

indication that water is entering the boiler dynamo was connected to the turret, but the

without the fireman looking at the water dynamo governor and the governor cap were

glass. At the time of the accident, a missing, rendering the dynamo inoperative.

distinctive pentagon-shaped brass control A portable gasoline-powered generator that

knob with “feed-water pump” cast into it sat on the tender provided the power for the

controlled the feed pump. Steam was headlight. In violation of the FRA’s redelivered from the boiler through the left quirements (49 CFR 230.42), the water glass

turret, or distributing valve, to the feed did not have a working light. There were no

pump via the control knob. The feed pump, working cab lights.

17

19

of service for 6 months, from November 1,

1994, to May 1, 1995.

Postaccident Inspections, Tests, and

Research

Crownsheet Failure--The following, taken

from the October 1943 Railway Mechanical

Engineer, a respected industrial publication

of the time, describes what happens when

the crownsheet is not sufficiently covered by

water:

The flames and hot gases in a locomotive firebox at a temperature of

from 1500 °F to 2500 °F heat the firebox sheets27 which, while covered by

water, remain at about the temperature

of the water. This temperature is dependent on the steam pressure in the

boiler, and is in the neighborhood of

400 °F. If, however, sufficient water is

not at all times present to keep the

firebox sheets at the proper temperature, the sheets become overheated.

Firebox steel when heated becomes

slightly stronger until about 500 °F is

reached, after which the strength falls

off very rapidly until at 1600 °F the

steel has lost about 85 percent of its

strength at normal temperatures. At

some stage during this overheating,

the strength of some part of the boiler,

usually the crownsheet,28 becomes less

than that required to withstand the

load of steam pressure, and rupture

 

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occurs. The force of the resulting explosion is in proportion to the size and

the suddenness of the rupture, and the

temperature and amount of water in

the boiler. At the instant the steam is

released from the boiler, the water in

the boiler flashes into steam until a

heat balance is effected. This steam,

generated so instantaneously, occupies

a space vastly greater than that occupied by the water in the boiler—perhaps 1500 or 2000 times as great. The

terrific rush of the steam to occupy

this greater space often tears the boiler

off the locomotive frame and results in

rocket-like behavior of the boiler.

The FRA requires that “every boiler be

equipped with at least one water glass and

three gage cocks” (49 CFR 230.37). In other

words, each steam locomotive is required to

have two independent systems to monitor

the level of water in the boiler. The rationale

for having redundant systems is that if one

fails, there will be another to prevent low

water and a resulting explosion. The two

systems for monitoring boiler water are the

water glass and the gage cocks. The FRA

also requires that every steam locomotive

have two independent and redundant

systems for supplying the boiler with water:

the injector system and the feed-pump

system.

Water Glass--The water glass is the primary means for the engineer and fireman to

monitor the water level in the boiler. (See

figure 10.) Mounted on the backhead of the

boiler, the water glass is a vertical glass tube

that shows the level of water in the boiler.
Toward front of B

and Steam loco

I

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motive

Top

Water Glass !

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—_._— ————=-———_—_ —

———’==————-- —.———————_—

——.’=-’==-==

! Drain Valve

*

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Figure 10. Typical water glass.

20
21

The FRA requires that “the lowest

reading that the water glass shows shall not

be less than 3 inches above the highest part

of the crownsheet” (49 CFR 230.37). Consequently, as long as the water glass shows a

water level, the crownsheet is covered by at

least 3 inches of water at all times if the

locomotive is on level terrain, and somewhat

less if the locomotive is going downhill.

According to form No. 4 for locomotive

1278, the lowest level of water in the boiler

that the water glass could indicate was at

least 3 1/8 inches above the highest part of

the crownsheet.

The water level in the water glass will

fluctuate somewhat in response to track

conditions, vibrations, and such conditions

as a surge of water in the boiler caused by

starting or stopping the train. An experienced enginecrew can still accurately estimate the level of water in the boiler by noting the midpoint between the maximum and

minimum changes in the indicated water

level in the water glass. Some steam locomotives are equipped with dampeners that

smooth out the water-level movement in the

water glass in an attempt to provide a more

accurate, if not instantaneous, indication of

the boiler’s true water level. The accident

locomotive did not have a dampener.

The accident firemen testified that the

fluctuation in the water glass was about 1/2

inch up or down. Neither fireman took

exception to this amount of movement, and

both indicated that such movement was

normal. One industry expert29 stated that

 

29Several steam-locomotive experts were involved in

the investigation. Two, the chief mechanical officers

of the Strasburg Railroad and The Valley Railroad

Company, were brought into the investigation by

Gettysburg Passenger Services. Two others, the curator of transportation for the Smithsonian Institution

and a representative of Combustion Engineering of

Teaneck, New Jersey, are recognized authorities in

such limited fluctuation “clearly indicates a

problem with the glass” and that normal

fluctuation is as much as 4 inches ± 2

inches. The expert further said he believed

that a water-level movement of only 1/2 inch

“is a serious indication of an obstructed

glass.”

The locomotive cab was covered in ash,

dust, and small cinders from the explosion.

Therefore, it was not possible to determine

the conspicuity of the water glass before the

accident. The light for the water glass was

inoperative; the wiring appeared to have

been grounded for some time. According to

FRA regulations (49 CFR 230.42, “Water

Glass Lamps”), all water glasses must have a

lamp that is located in such a way that the

engineer can easily see the water in the

glass. The firemen indicated that they carried

no light source, such as a flashlight, with

which to check the water glass. The second

fireman said that at night the crew used the

cab lights powered by the gasoline generator

on the tender and that they had an electric

lantern that sat on the floor by either the

engineer’s or the fireman’s seat.

The water glass had a protective glass

covering, or shield, as the FRA required (49

CFR 230.41), to stop pieces of flying glass if

the water glass broke; however, the covering

was also covered with debris from the

firebox explosion, making it difficult to read

the water glass with any accuracy. The

shield was subsequently removed for further

tests. The water-glass system was disassembled and inspected. (See figure 11.)

 

the field of steam-locomotive boilers and mechanics.

All four are referred to as experts for the purposes of

this report.

Figure 12. End view of plugged spindle.

According to the regulations, the boiler

must be washed once a month and the

spindles must be reamed. When asked if the

amount of scale found in the spindles could

have accumulated between monthly

cleanings, one steam-locomotive expert said,

“No, no possible way.” Another said, “I

have never seen a locomotive that had as

much scale inside the water-glass spindle as

the 1278. I worked on a lot of locomotives

all over the country and never saw anything

like this.” The chief mechanical officer

(CMO) of the Strasburg Railroad speculated

that in such a restricted condition, the

spindles would be much more susceptible to

being blocked by floating material or scale

flake. The investigators were unanimous in

their conviction that the amount of scale

found in the spindles could not possibly

have accumulated within the relatively short

time between monthly boiler washings,

regardless of the condition of the water used.

(See figure 13.)

The water glass itself was a glass tube

about 12 inches long and 1/2 inch in diameter. Running the length of the glass was

a 1/4-inch-wide faded red background line

that was barely visible. The diameter of the

bore (about 1/8 inch) appeared smaller than

the 3/8-inch bore with which the inspectors

were more familiar. They considered

whether a smaller bore would be more

susceptible to some form of capillary action

or to being plugged by lose scale (either of

which could yield a false reading). However,

after they examined and tested the glass,

they decided the diameter of the bore was

acceptable. (See figure 14.)

Safety Board investigators used a flexible

clear plastic hose to measure the response of

23
Figure 13. Plugged spindle after removal.

the water in the water glass to changes in the

level of water in the boiler and to determine

how visible the water level in the water glass

was to the cab’s occupants. The water-glass

system was reassembled in order to conduct

this test. The water level was changed by

moving the hose attached to the boiler tap,

thus simulating water-level changes in the

boiler. The changes appeared immediately in

the water glass, and the water-glass system

appeared to function as designed under these

non-pressure, non-operating conditions.

Wafer-Glass Blowdown-One of the basic

tasks an engineer and fireman must be able

to perform is to “blow down,” or verify that

the water glass and the spindles are not

blocked or restricted. According to the FRA

(49 CFR 230.40), “All water glasses must be

blown out and gage cocks tested before each

trip.” However the regulations do not

prescribe the blow-down procedure.

The National Board Inspection Code of

the National Board of Boiler and Pressure

Vessel Inspectors (NBBPVI) is recognized

nationally by the CFR as an American

National Standard and internationally as

ANSI/NB-23. According to that code, the

proper method of blowing down a water

glass is as follows (from Chapter II part I204.3, “Water Level Gage [Steam

Boilers]”):

The inspector should ensure that the

water level indicated is correct by

having the gage tested as follows:

a. Close the lower gage glass valve,

then open the drain cock and blow the

glass clear.

24
Figure 14. Water-glass tube.

b. Close the drain cock and open the

lower gage glass valve. Water should

return to the gage glass immediately.

c. Close the upper gage glass valve,

then open the drain cock and allow the

water to flow until it runs clear.

d. Close the drain cock and open the

upper gage glass valve. Water should

return to the gage glass immediately.

If the water return is sluggish, the

operation should be repeated. A

sluggish response could indicate an

obstruction in the pipe connections to

the boiler. Any leakage at these

fittings should be corrected to avoid

damage to the fittings or a false

waterline indication.

Although 49 CFR 230.40 requires that

water glasses be blown down, the procedure

for doing so is not given or specified in any

applicable Federal rules. Nor are any other

rules of the National Board Inspection Code

applicable by law or regulation to steam

locomotives not governed by the National

Board Inspection Code. The Gettysburg

Passenger Services employees did not have

any reference materials that explained the

proper method of blowing down a water

glass,

When Safety Board investigators asked

the first fireman to demonstrate the proper

method of blowing down the water glass, he

failed to demonstrate the correct method.

Similarly, the second fireman failed to show

and explain the proper method. He said he

had had no formal training on blowing down

the water glass, but that he had been shown

how to do it. When the helper engineer was

asked to describe the blow-down procedure,

25
26

he said, “Open the bottom valves on the

sight glass, and it blows steam through the

glass to clean it.” He also said this was not

to check the validity of the glass but “just

the drain.” No crewmember was officially

responsible for knowing the approved

method of blowing down the water glass.

The owner of Gettysburg Railroad (the engineer’s father) and a Gettysburg Passenger

Services employee who was qualified as

both a steam-locomotive fireman and an engineer were each asked to explain and

demonstrate how they would go about

blowing down and verifying the water glass.

Only the owner demonstrated the correct

method. Neither the accident engineer nor

the firemen knew how to properly validate

the water glass.

Gage Cocks--Mounted near the engineer’s

seat are three gage cocks that tap into the

backhead of the boiler at various levels. The

cocks are a backup system for the water

glass and help ensure that water is

maintained over the crownsheet. To check

the water level, the engineer opens one of

the gage cocks. Theoretically, if water drains

from the valve, the engineer is assured that

the level of water over the crownsheet is at

least as high as the gage cock is. This may

not always be the case if there is a false

head, which will be explained later. As with

the water glass, the lowest gage cock is

mounted at least 3 inches above the highest

point of the crownsheet. The height of the

lowest gage cock on locomotive 1278 was 3

1/4 inches above the crownsheet.

Removing the three gage cocks revealed

that the lowest cock was totally obstructed

by deposits and that the middle cock was

half obstructed. Only the highest cock was

clear of restrictions. The accident firemen

stated that they did not test the gage cocks

and did not know whether the engineer ever

did.

Boiler-Water Behavior--Since the water

glass and gage cocks are redundant, they

should indicate the same water level.

However, depending on the arrangement and

maintenance of the boiler-water-monitoring

equip-ment, this may not be the case.

In the early part of the century, a number

of locomotive boilers exploded in locomotives that had only gage-cock monitoring

systems. Consequently, the Bureau of Locomotive Inspection of the Interstate Commerce Commission (ICC) launched an investigation in 1919. The Bureau conducted a

number of tests and documented the movement of boiler water around the firebox, as

discussed below.30

Upon entering the boiler, water from the

tender is relatively cool and dense. The

water moves from the front and lower parts

of the boiler, which are “colder,” to the

“hot” rear and top of the boiler, which are

warmer because they are around the firebox,

where the heat is generated and where the

greatest exchange of heat takes place. When

the water is heated, it rises as its density

decreases. As the water finally migrates

around the sides and back of the firebox,

water heating and movement are greatly

accelerated, and steam bubbles begin to

form and rise to the surface. This rapid

movement upward creates momentum and

an upwelling of water above and along the

outside of the crownsheet. The upwelling of

water is most rapid at the firebox rear,

especially between the door sheet and the

backhead, creating a standing head of water

 

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27

(a false head) above the crownsheet rear

where the gage cocks are installed.

Depending upon the placement and

length of the pipes leading from the gage

cocks into the boiler, the false head may

cause the gage cocks to indicate that the

water level over the crownsheet is higher

than it actually is. Thus, while the gage

cocks may indicate plenty of water, in reality

there may be little or no water over the

crownsheet. Consequently, gage cocks are

problematic when used by themselves and

questionable as long-term redundant devices

for a water glass. Because of this

documented phenomenon, the United States

Railroad Administration’s Committee on

Standards adopted the water column as a

recommended practice in February 1920.

The water column is a small cylindrical

device that is connected to the boiler in

much the same fashion as a water glass;

however, the water column is really a

platform on which to mount a water glass

and three gage cocks. (See figures 15 and

16.) The water column has a limited

dampening effect and prevents the high level

of water (false head) in the back of the boiler

from being falsely indicated by the gage

cocks as the true water level. This

arrangement ensures that the water glass and

the gage cocks indicate the same and a true

water level.

Steam-locomotive maintenance literature

states that maintenance has a significant effect on water-monitoring devices, particularly the water glass. If the spindles that lead

from the boiler to the water-monitoring devices are not clean, the water-level indication may be false. When steam locomotives

were in common use, the standard practice

was to clean the interior of the spindles,

water glass/water column body, gage cocks,

and associated piping of scale with a reamer

or drill sized to fit the interior diameter of

the pipe or component. The reaming restored

the parts to their original condition.

FRA regulations imply that unless the

gage-cock pipes are periodically cleaned, the

pipes may become so plugged by scale that

water is unable to pass through them and the

gage cocks, as a result, might inaccurately

indicate a low level of water in the boiler. At

first, it might seem that indicating that the

water level is lower than it actually is would

not be a problem. If the enginecrew thought

that there was less water in the boiler than

there actually was, they might increase the

water flow to a boiler that already had

enough water. Raising the level of water in

the boiler unnecessarily is not necessarily

dangerous, but it is not efficient and could

increase the chance of incompressible water

entering a cylinder (called “working water”31) and causing a cylinder head to be

blown off.

When water-glass spindles become

progressively encrusted with scale, unpredictable and unreliable indications may

result. As moving water at the boiler

backhead moves past one or both spindle

orifices of the water glass, a slight pressure

drop is created. Normally, this has little or

no effect on the height of the column of

water in the water glass; however, should

one or both spindle orifices become partially

closed off by the gradual buildup of scale,

the height of the column of water in the

water glass may be affected, depending on

the location and extent of the buildup.

 

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28
valves at the top or bottom of the water glass

are not completely open, the result again

may be a falsely high water-level indication.

According to a leading mechanical engineer and recognized boiler expert with ABB

Combustion Engineering, several crownsheet failures occurred in England during

World War II because the water-glass spindle valves were only partially open. The

English crews of U.S. Army 2-8-O locomotives were unaware that the top valve of the

water glass had to be completely

open. Partially opened valves resulted in the water glass showing a

water level that was higher than the

actual water level in the boiler. The

crownsheets became overheated,

and explosions occurred. Those

locomotives, like the accident

locomotive, had one water glass

and one set of gage cocks.

Boiler- Water Supply System-The

investigators also examined the

devices used to supply water to the

boiler. Two types of water-supply

s ystems are used on steam

locomotives: the injector system

and the feed-water system. Most

steam locomotives have both systems, but older steam locomotives

may have two injector systems instead. Locomotive 1278 had both

systems. The injector and feedwater systems can be used

separately or together and can act

as backups for each other; however, the injector system functions

more efficiently when the locomotive is standing, while the feedwater system functions more efficiently when the locomotive is

The boiler-water supply system consists

of (in order of flow) treated or untreated

water from the tender, strainers in the tender

and delivery hose, the feed-water heater (if

the locomotive has one), the feed pump or

the injector(s) with their respective check

valves to prevent pressure backup, and two

stop valves to shut off leaking check valves.

The injector pumps unheated water

directly from the tender into the boiler,

heating it in the process. The feed pump

29
30

supplies water to the boiler indirectly

through the feed-water heater. The feedwater heater is a heat exchanger that absorbs

heat from used cylinder exhaust steam that is

otherwise lost up the exhaust stack. The

feed-water heater is more efficient when the

locomotive is moving because there is more

exhaust heat and steam.

The engineer controls the injector with a

knob on his side of the cab. The fireman

controls the feed-water system with a pumpcontrol valve that is on his side of the cab.

After the accident, the injector was found

closed, and the feed-pump control valve was

found open 1 1/2 turns. The amount of water

these devices supply to the boiler depends

on boiler demand, so their valve control or

knob positions do not indicate whether a

sufficient amount of water is being provided.

It is therefore critical for the fireman to

closely monitor the water glass and/or gage

cocks.

After the accident, the CMO of the

Valley Railroad at Essex, Connecticut,

examined the injector of locomotive 1278

and reported:

Upon entering the cab of the

locomotive...I found that the turret

valve for the injector was shut off.

Later on the next day, the steam valve

of the injector itself was disassembled

to see if any problem could be found.

Upon disassembly, it was found that

the steam valve disk inside the injector

was not the correct steam valve disk

for that model injector. The Edna Type

L lifting injector has to prime to get

water up into the body of the injector.

To do that, the steam valve disk has a

protrusion on the end of it which

allows when opened just a little bit of

steam to come by that protrusion and

enter the annular nozzle, which creates

a vacuum which raises the water. The

disk that we found inside the 1278’s

injector did not have that protrusion.

Therefore, when the steam valve was

opened, it would be very difficult to

prime the injector. If a lifting injector

cannot prime, it cannot operate. Now,

it’s possible that the injector might

function, but only with some

difficulty.

According to their testimony, none of the

train crewmembers were aware of the need

for a specific disk type in the injector.

Water Treatment--Water used in boilers is

frequently treated with chemicals and

processes to minimize the buildup of scale

inside the boiler and inside all the other

devices that come in contact with the steam

and boiler water. Treating the water also

reduces corrosion and maximizes heat

transfer. Water-monitoring and -supply

systems are dependent on the free flow of

water and do not work correctly if the

boilers and their attached devices are not

free of scale. Thus the cleanliness of the

boilers and devices has safety implications.

Depending on the source of the water, it

can be softened shortly before it is put into

the tender, or it can be treated while it is in

reservoirs and holding tanks. Safety Board

investigators explored the nature of water

treatment used by Gettysburg Passenger

Services.

During testimony, the investigator from

Gettysburg Passenger Services was asked if

the company had water-treatment facilities.

He replied:

Well, I saw some evidence of water

treatment. There were some empty

containers around. But we saw no
31

evidence of a regular program in

place. And by a regular program, I

mean a written procedure for doing an

analysis of the boiler water every day,

recording, testing the water every day

for the presence of oxygen, pH, how

much hardness is in the water, the

conductivity of the water, how much

stuff is in there. Typically, what

people do is they test for these things

every day, they record it on a chart and

then make a determination of the

chemicals based on what’s in the

boiler that day to correct whatever

deficiency there is in the water. And

we found no evidence of that

whatsoever.

The owner of Gettysburg Railroad said:

I noticed that [the accident engineer]

had put a water softener in several

years ago to soften the water due to

[the fact] that Gettysburg has very,

very hard water to work with. I will go

a little further. When we first come to

Gettysburg, we were foolish enough to

leave water sit in that engine about 2

months. It cost us to have the boiler

acid cleaned. So, he put the water

softener in.

According to testimony, the accident

engineer sent boiler and/or supply water

samples to the Water Chemical Services

(Water Chem) of Aberdeen, Maryland32 for

testing. However, Water Chem has no

record of dealing with Gettysburg Passenger

Services except for filling an order for 100

pounds of sodium tri-phosphate, a

suspension agent that was delivered May 19,

1995, less than a month before the accident.

 

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The engineer told Safety Board investigators

in a postaccident interview that he

performed his own water testing with a kit,

much like that used for swimming pools. He

stated that he kept a journal of the water

testing that he performed. No test results

were found or provided.

Boiler Washing--The interior of a boiler is

washed to minimize scale buildup in order

to ensure that the boiler and its devices

operate safely and efficiently. According to

FRA regulations (49 CFR Part 230.45,

“Time of Washing”):

All boilers shall be thoroughly washed

as often as the water conditions

require, but not less frequently than

once each month. All boilers shall be

considered as having been in

continuous service between washouts

unless the dates of the days that the

boiler was out of service are properly

certified on washout reports and the

report of inspection.

Locomotive 1278 had 29 washout plugs,

and the FRA regulations (49 CFR 230)

require that all washout plugs be removed

when a boiler is washed. The regulations

also require that special attention be given to

removing scale on arch and water bar tubes

and that a record be kept of all washing (49

CFR 230.46 and .230. 48, respectively).

Since a boiler wash and inspection are both

required monthly, they are usually recorded

and filed together on a form No. 1.

The FRA regulations do not specify what

constitutes a proper washing. The railroad

industry has long had detailed methods and

special equipment for boiler washing. In

1915, the American Railroad Administration

(ARA) adopted a recommended practice for

boiler washing that included a number of

recommended designs for boiler wash
32

nozzles. The Advisory Mechanical Committee, Equipment Engineering Department,

of the C&O Railway, the Erie Railroad, the

Nickel Plate, and the Pere Marquette Railway issued Standard Maintenance Equipment Instructions #105 on August 3, 1936,

for boiler washing and blow down. In

November 1995, the members of TRAIN, in

an effort to promote safe steam-locomotive

operation, sponsored seminars on the proper

method of boiler washing.

During his testimony, the first fireman

described how he washed the boiler of

locomotive 1278 by himself:

You take the four plugs out. In the

boiler under—by the firebox, there’s a

plug in the right-hand side and on the

left-hand side up front, and there’s two

in the back, both sides. You take those

out. There’s three plugs along the top

in the cab right above the firebox

doors. You take them out and then you

wash the boiler out. You run—we

have, I believe it’s a 2-inch hose that

we run through it. We wash it to the

point where we get no sediment out

anymore and the water is clear.

The CMO of the Strasburg Railroad in

Pennsylvania summarized how a steamlocomotive boiler should be washed out:

Take out all the washout plugs, and

essentially that’s any plug in the boiler

that allows access into the boiler. And

when you do that, then basically we

use a hose to try and get the highest

pressure we can. And we go to each

washout hole, and we attempt to wash

all surfaces, the interior surfaces of the

boiler. And that’s more or less difficult depending upon the design of the

locomotives. Our little locomotive has

34 washout plugs on it. Our biggest

locomotive has 17. It was just the way

the locomotive was built according to

the railroad specifications. So you just

wash it as thoroughly as you can and

wash the stuff basically from the top

down, from the front [to] back, collect

everything in the mud ring, then use

your four corner plugs to wash that

stuff out of there. And you make a

special attempt to rattle your arch

tubes, which is a mechanical cleaning

process.

The CMO was asked whether he thought

the boiler in locomotive 1278 had been

recently washed out. He replied:

It could have been; I don’t know. I

have never seen a locomotive that

blew up before, so I don’t know what

effect that had on things. It had a lot of

scale in it. It had a lot more scale than

I would like to see in a boiler if that

boiler was in service at Strasburg.

Low-Water Devices--During the investigation, the Safety Board explored the

availability of devices that can prevent or

warn of low water or mitigate the effects of

such a condition. Research revealed that the

railroad industry has over the years

developed several such devices.

Low–Water Alarms-–Railroad industry

manufacturers and suppliers developed a variety of devices that warned that the level of

water in the boiler was too low. The devices

warned engine crewmembers before the

boiler exploded or the crownsheet burned.

Low-water alarms were made by the Nathan

Manufacturing Company of New York, the

Ohio Injector Company of Illinois, and the

Barco Manufacturing Company, Inc. Some

of the alarms used floats while others detected abnormal expansion and/or temperature. Once activated, the alarm signaled the
33

cab crew, using a warning whistle that continued to blow until the level of water in the

boiler rose or a crewmember reduced the

heat of the crownsheet by releasing the fire

in the firebox into the ashpan.

There was and is no Federal requirement

that steam locomotives have low-water

alarms. Opinions about the effectiveness of

low-water alarms do and did vary widely

among steam-locomotive experts of today

and railroad officials from the days of steam.

Depending on the sensitivity of the alarm,

locomotive crews were known to treat the

alarm as a nuisance and muffle the whistle.

Mechanical employees found the alarms to

be an additional burden and expense to

maintain. Some railroads favored low-water

alarms; others did not. Some steam

locomotives still operating are equipped

with low-water alarms.33 Locomotive 1278

had no low-water alarm.

Fusible Plugs--The crewmembers cannot

tamper with fusible plugs, also called “drop”

plugs, as they can with low-water alarms.

Fusible plugs consist of a short, pipe-shaped

brass body that is screwed into the crownsheet at specified locations. (See figure 17.)

Within the brass body is a brass plug held in

place by a ring of fusible alloy metal that

softens or melts at temperatures between

500 and 575 °F. Once the crownsheet

reaches the critical temperature, the ring

melts and allows the brass plug to fall into

the firebox, allowing steam to spray the fire,

attracting the crew’s attention, and relieving

steam pressure. Depending on the number

 

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and placement of the plugs, the activation

may continue, effectively preventing permanent damage or an explosion, but at the same

time disabling the locomotive. Once fusible

plugs have been activated, the locomotive

must be taken to a maintenance facility for

repair. This disadvantage makes fusible

plugs, like low-water alarms, controversial.

As with low-water alarms, the use of fusible

plugs varied widely, depending on the railroad.

Federal regulations do not require the use

of fusible plugs but do require that if the

plugs are used, they must be maintained.

According to the FRA’s regulations (49

CFR 230.14, “Fusible Plugs”):

If boilers are equipped with fusible

plugs they shall be removed and

cleaned of scale at least once every

month. Their removal must be noted

on the report of inspection.

Locomotive 1278 did not have fusible

plugs.

Oversight and Regulation of Steam

Locomotives

Observers have long recognized the

dangers inherent in employing steam to

power industry and transportation. In 1863,

British Royal Astronomer George B. Airy

calculated that at a pressure of only 60 psi,

every cubic foot of boiler water has the same

destructive energy as a pound of (black)

gunpowder.34

 

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The first steam-locomotive boiler explosion occurred on June 17, 1831, when the

South Carolina Railroad’s Best Friend of

Charleston blew up because a man annoyed

by the sound of the safety valve sat on it to

prevent it from hissing. Boilers continued to

blow up or fail for a variety of reasons,

including poor construction and/or design.

With the introduction of the firebox into the

boiler, however, the most spectacular and

deadly forms of failures have been those that

have resulted from a crownsheet that has

been overheated and weakened because of a

low level of water in the boiler—as in this

accident.35

Regulation and Oversight--The types of

boil-er explosions that could affect the

public were regulated quickly and early.

Congress passed a steamboat inspection law

in 1838 after the steamboat Moselle blew up,

killing 300 people. The first State boilerinspection law went into effect in 1867 in

New York after stationary boiler explosions

in the 1850s killed scores of people.

Historically, the public risk from steamlocomotive boiler explosions has been

minimal. Unlike steamboat- and stationaryboiler explosions, generally the only people

affected by steam-locomotive boiler explosions have been, as in this accident, the

trainmen and enginecrew. Consequently, it

was not until 1909 that the first bills to

regulate locomotive safety were introduced

in Congress.36

Specifics of the locomotive safety bill,

such as the provision requiring water

glasses, were supported by labor and

 

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opposed by the railroads. The railroads’

greatest objections were to provisions that

required government inspection but left

responsibility for safety and accountability

for accidents solely with the carrier railroad.

Finally, a compromise was reached. An

amended version of locomotive inspection

dropped requirements for specific safety

devices and no longer required direct

government inspection. Instead, the carriers

were required to file inspection rules with

the ICC and to do their own inspections. The

government inspectors only spot checked

and oversaw the process and investigated

accidents. Essentially, this level of oversight

remains in effect today, with the FRA, rather

than the ICC, taking the regulatory role. The

bill that required “Railroads to equip their

locomotives with safe and suitable boilers

and appurtenances thereon” was passed on

February 17, 1911, and became law 4

months later. Federal inspection started with

fiscal year 1912.37

There are now three sources of boiler

regulation and oversight in the United

States, one of them private and the other two

governmental. Insurance companies are the

private source. The insurers, such as the

Hartford Steam Boiler Inspection &

Insurance Company, the insurer in this

accident, will generally inspect a boiler to

determine whether it is safe enough to be

insured and, if so, at what risk level.

However, the insurer is not required to

inspect. Although the Hartford Steam Boiler

Inspection & Insurance Company insured

 

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36

the accident locomotive, it never inspected

it.

Some local and most State governments

regulate, inspect, and license the operation

of stationary boilers, such as those used in

heating and power plants, but generally not

steam-locomotive boilers. This is primarily

because the FRA already has regulatory

authority over steam locomotives. State

boiler inspectors may, however, be responsible for steam-locomotive boilers operated

on railroads that do not fall under FRA

jurisdiction, such as small tourist lines not

connected to the railroad interchange system. Steam railroads that are not regulated

by the FRA are not required to file a form

No. 4. The FRA has discussed bringing

these lines under its jurisdiction.

As discussed above, the Federal

regulations involving steam locomotives are

found in 49 CFR Part 230. This title is no

longer published each year as the rest of the

CFR is, but must be requested separately

from the FRA or other sources. Most of the

standards, specifications, and procedures in

49 CFR Part 230 are from earlier railroad

industry standards or early regulations of the

ICC and date from between 1912 and 1916.

The last major revision of the material was

in 1946, long before the FRA was created

(1966) and the Rail Safety Act of 1970 was

passed.

FRA Responsibility--Generally, FRA

motive power and equipment (MP&E)

inspectors inspect a steam-locomotive boiler

only if the locomotive’s owner files for an

extension of the 4-year boiler-and-flue-tube

inspection required by 49 CFR Part 230.10.

At that time, the FRA inspector must inspect

the boiler; but otherwise, boiler inspection is

largely a self-certifying process, with the

FRA checking to make sure that required

inspection forms are filed according to the

regulations--in the 1912 tradition set by the

ICC. The FRA is not required to inspect a

steam-locomotive boiler unless an extension

of the 4-year boiler-and-flue-tube inspection

is requested, nor is such an inspection

possible without the cooperation of the

steam-locomotive maintenance personnel,

since a hot pressurized boiler cannot be

inspected on short notice because it may

require several days to cool down. The rest

of the steam locomotive is subject to FRA

inspection at any time, as is most other

railroad equipment. However, given the

limited number of FRA inspectors, not to

mention the limited number of inspectors

with steam-locomotive expertise, and the

high demands of commercial interchange

railroad inspection, FRA inspectors are able

to inspect steam locomotives only infrequently at best.

Steam locomotives for commercialrailroad motive power had all but

disappeared by the early 1960s because most

major carriers had finished converting to

diesel-electric locomotive power. The last

common carrier railroad steam locomotive38

was replaced by a diesel-electric locomotive

in September 1970. Consequently there are

no FRA and few railroad inspectors whose

expertise is based on first-hand knowledge

of steam locomotives; FRA inspectors now

gain their expertise from limited classroom

instruction. Unfortunately, many of the

FRA’s regulations are written in such a way

that the inspector’s ability to adhere to them

depends heavily on his subjective experience

and practical expertise. Testing for broken

crown stays by tapping and listening for

broken crown stays as required by 49 CFR

230.21 through .24 is one example of a

 

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37

procedure that requires an inspector who can

rely on some level of continuous daily

experience.

The regulations in 49 CFR 230.102 and

103 assign the responsibility for inspection

and repairs and define the term “inspector.”

230.102 Responsibility for inspection

and repairs.

The mechanical officer in charge, at

each point where repairs are made,

will be held responsible for the

inspection and repair of all parts of

locomotives and tenders under his

jurisdiction. He must know that

inspections are made as required and

that defects are properly repaired

before the locomotive is returned to

service.

230.103 Term “inspector.”

The term inspector as used in the rules

and instructions in this subpart means

unless otherwise specified, the railroad

company’s inspector.

The regulations do not specify the level

of education or experience needed by

someone who inspects steam locomotives or

repairs and maintains them. The regulations

assume that an individual with extensive

practical experience in boiler construction

and maintenance will be available to do the

work.

According to the FRA, the agency has

attempted to maintain some level of inspection proficiency by organizing two 1-week

seminars, which are taught by industry and

operating museum experts on boilers and

steam locomotives, about steam locomotives

and boilers, including maintenance and inspection. The FRA gives priority for steamlocomotive seminars to those MP&E

inspectors who have steam-locomotive

operations in their territory.

Industry Efforts--In 1990, members of the

tourist-railroad industry who owned and operated steam locomotives became concerned

that steam-locomotive inspection and safety

standards were slowly degenerating. Twelve

representatives formed an unofficial, ad hoc

group to formalize some type of recommended practice for the repair of steam-locomotive boilers. (The 12 representatives

included people from tourist-railroad

mechanical departments and insurance inspectors, Class I railroad steam operators,

and experts knowledgeable in the theory and

practice of steam-locomotive boiler construction.) The group contacted the

NBBPVI, the private agency that publishes

and administers the National Boiler Inspection Code applicable to all boilers used in

industry other than railroads. In 1990, the

group of 12 representatives began as the

Engineering Standards Committee for Steam

Locomotives (ESC) to develop standards for

the repair and alteration of steam-locomotive

boilers. Guidance was provided by NBBPVI

as to modern engineering practices for

boilers.

In 1995, the National Board Inspection

Code Committee adopted the standards

developed by the ESC as an American

National Standard for the repair and

alteration of steam-locomotive boilers that

are repaired or altered by NBBPVI-certified

boiler engineering firms.39 In 1995, the ESC

also became an official task group of the

NBBPVI. Appendix 3 of the 1995 National

Boiler Inspection Code contains the

NBBVPI rules for steam-locomotive boiler

 

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38

repair. These rules, however, are only

voluntary for railroads under FRA

jurisdiction, since 49 CFR Part 230 makes

no reference to any national standard or the

NBBVPI Code. In lieu of Federal standards,

the ESC and the NBBVPI have volunteered

to provide a tailored training program on

steam-locomotive boiler inspection and

repair to the tourist-railroad industry.

Since the accident, the FRA has formed a

Steam-Locomotive Safety Improvement

Committee, which began meeting in

September 1995. The ESC became a part of

the committee and has met with the FRA in

an initial step to update 49 CFR Part 230.

The ESC also has a representative on a

larger FRA committee looking into all

aspects of rail safety.
39

General

The phenomenon of crownsheet failure

has been well known and understood for

many years. That such a failure had occurred

in this accident was evident from the start of

the investigation. All parties to the

investigation agreed that the nature of the

damage, the statements of the locomotive

crew, and the postaccident examination of

the boiler confirmed that the crownsheet

failure was due to low water. The Safety

Board therefore concludes that the explosion

in locomotive 1278 resulted from crownsheet failure caused by having too little

water in the boiler.

The investigators found that it was not a

single event or condition that caused the

water to be too low. It was too low because

of the cumulative result of a number of

steam-locomotive boiler-maintenance and

operational factors that resulted from a lack

of training, knowledge, and application. The

following is a brief synopsis of the accident

chronology and the inherent factors

involved. Each of these factors will be

explained in greater detail in the rest of the

analysis.

The events leading to the crownsheet

failure began when the locomotive stopped

at Wolf Pit to pick up the helper. There, the

first fireman shut off the feed pump, thus

preventing any water from entering the

boiler. He turned off the feed pump because

a one-way check valve between the feed

pump and the boiler was leaking to the

extent that he believed that the locomotive’s

drivers (wheels) might slip on the rail. The

feed pump remained off for about the next

10 minutes as the train climbed the grade

until the second fireman took over at the top

of the grade, near Gardners. The distance

between the start of the grade and Gardners

was about 2 miles; and according to the

engineer, while the train was going up the

grade, it was “working hard,” using more

steam and, consequently, more water than

usual. The first fireman said that as steam

was used during the ascent, the pressure in

the boiler dropped from about 230 psi to 175

psi. The firemen were unconcerned about

the drop in pressure because they assumed

that the water glass would warn them if the

level of water in the boiler became

dangerously low, thus allowing them to

correct the problem.

Even before the water was cut off, its

level had been purposely kept low as a

matter of standard operating procedure. The

engineer told Safety Board investigators that

he normally kept the level of water so low

that the water glass was only 1/3 to 1/2 full

even while the train ascended the grade to

Gardners. The second fireman testified that

the highest water-glass level that he

remembered was “3/4 at most with

fluctuation.” The engineer said that keeping

the water low in the boiler was a way of

minimizing the chance of water entering the

cylinders (working water). He also said that

having less water in the boiler made for

“good steaming,” or the rapid creation of the

steam that the train needed to climb the

grade to Gardners. However, keeping the

water so low reduced the layer of safety over

the vulnerable crownsheet, particularly as

the water level changed with changes in

grade and terrain.

ANALYSIS
40

As the locomotive moved uphill, the

water maintained its level, moving to the

back of the boiler, which was tilted up

grade. Since the crownsheet was at the back

of the boiler, the water should have covered

it even more deeply than when the train was

on level track. Accordingly, the water glass,

which was on the back of the boiler, should

have shown the level of water as higher than

it was when the train was on level terrain.

However, according to the crew, when

the locomotive tilted up grade, the water

glass was still only 1/2 full (unchanged from

the start at Wolf Pit), which should have

warned the firemen that either the boiler

held very little water or that the water glass

was inaccurate. With the feed pump shut

down and the locomotive working hard and

using steam, the water level continued to

drop. At some point, the boiler held so little

water that the highest point of the crownsheet became uncovered and, as a result,

failed. By the time the locomotive crested

the grade at Gardners, where the second

fireman turned the feed pump back on, it

was already too late to prevent the inevitable

failure.

The firemen should have seen a

progressive drop in the water-glass level but

did not. The restricted condition of the

spindles leading to the water glass was

affected by one or both of the following

circumstances: a higher-than-normal water

head (a false head) at the back of the boiler

and/or free floating scale. A false head may

have been created by the increased

momentum of water moving upward as the

formation of steam became progressively

more violent because the level of water was

dropping. The more violent formation of

steam and water flow may also have freed

and/or picked up scale from the encrusted

boiler deposits, which then partially or

totally blocked the already restricted orifices

of the water-glass spindles. The firemen’s

statements that the water-level movement in

the water glass was 1/2 to 1 inch, rather than

the 4 to 5 inches that the engineer said was

normal, show that there was some form of

restriction, or blockage, probably from scale,

in the already restricted spindles.

The Safety Board investigation focused

on why the water in the boiler had been

allowed to drop to such a low level. The

investigation found locomotive mechanical

conditions, maintenance practices, and crew

training practices and procedures that

individually or in combination allowed the

low-water condition to develop.

Investigation

Water-Monitoring Devices--Since the water

glass was the primary tool that the engineer

and firemen had to monitor the level of

water in the boiler, the investigators

examined the glass and its related valves and

spindles to determine their condition at the

time of the accident. The passages of the

valves had significant deposits. Hard scale

plugged about 75 to 85 percent of the

spindles. It could not be determined how

much, if any, soft deposit or scale had been

blown out during the explosion, but steamlocomotive experts agreed that it is

reasonable to believe that soft scale and/or

scale flakes further restricted or blocked the

spindle passages. The Safety Board concludes that because the water-glass spindles

were restricted, the water glass could not

accurately represent the water level in the

boiler.

The lowest gage cock was totally plugged

by deposits; the middle gage cock was half

plugged; and the highest gage cock was

clear. Again, steam-locomotive experts who
41

participated as investigators were convinced

that such a large amount of scale could not

possibly have accumulated between monthly

boiler washings. The pattern of deposits in

the gage cocks also suggested that the

engineer was accurate when he said that the

level of water in the boiler was routinely

low. The amount of scale in each gage cock

appeared to correlate with the amount of

time it spent in the boiler water: the bottom

gage cock was always covered with water,

the middle gage cock about half the time,

and the highest gage cock almost never.

Both the first fireman and the engineer

acknowledged that their method of washing

the boiler was not thorough and that the

spindles were not cleaned and reamed out on

a monthly basis as, according to the FRA’s

regulations, they were supposed to be. The

gage cocks were also not cleaned and

reamed. The amount of scale and mineral

deposit found in the spindles and the gage

cocks supported the engineer’s admissions

that he did not follow the monthly cleaning

requirements. The Safety Board concludes

that although the engineer had signed the

FRA’s forms No. 1, certifying that the work

had been done, the spindles and gage cocks

were not cleaned on a monthly basis.

Investigators also examined the adequacy

of the water-monitoring systems (water glass

and gage cocks) in this accident since the

systems would have been crucial in

detecting the level of the water before the

crownsheet failed. At the turn of the century,

both the government and the railroad

industry had recognized the shortcomings of

gage cocks by requiring the use of a water

glass, thus relegating gage cocks to the

status of a redundant back-up system.

Government and industry knew that gage

cocks were particularly subject to the falsehead phenomenon and did not present a

readily apparent indication of the level of the

boiler water as the water glass did. Government and industry knew that the water column was the optimal solution but did not require the use of a water column. Instead, the

CFR said, “Every boiler [must] be equipped

with at least one water glass and three gage

cocks.” In 1920, the U.S. Railroad Administration’s Committee on Standards recommended the adoption of the water column as

a recommended practice. The Safety Board

believes that the FRA now should require

that, at a minimum, each operating steam locomotive have in addition to the required

water glass and three gage cocks, either

another water glass or a water column.

While it can be argued that inadequate

maintenance, as in this accident, would

eventually allow any and all water-monitoring devices to become plugged with scale,

the Safety Board believes that the chance

that all the devices will be plugged at the

same time is remote and that, therefore, two

devices provide a degree of redundancy and

accuracy that the currently required single

water glass and gage cocks do not.

Water-Glass Lighting and Conspicuity--Title

49 CFR Part 230.42, “Water Glass Lamps,”

requires that all water glasses be supplied

with a suitable lamp that is located where it

enables the engineer to easily see the water

in the glass. In the accident locomotive, the

light for the water glass did not work. The

firemen indicated that they carried no other

light source, such as a flashlight, with which

to check the water glass. The second fireman

said that at night the crew used the cab lights

powered by the gasoline generator on the

tender and that they had an electric lantern

that sat on the floor by the seat of either the

engineer or the fireman. The Safety Board

concludes that the water glass was not

illuminated as required.
42

Although it was not possible to determine

the preaccident conspicuity of the water

glass, both firemen testified that they had no

trouble seeing the water glass. The cab of

the locomotive was an all-weather enclosed

one of the type commonly found on steam

locomotives used in northern climates. The

cab had side doors and other features that

limited the entrance of light and air. Given

the lengthening shadows and the light of

early evening, it is possible the amount of

light in the cab and on the water glass was

restricted.

While the Safety Board does not dispute

the claims of the firemen that they had no

problem reading the water glass, the Board

believes that a working light on the water

glass, as required by the regulations, would

have made reading the water glass easier and

might have yielded more accurate information about the action of the water level in

the water glass and, thus, the amount of

water in the boiler. A working light might

also have allowed the engineer, who indicated that the water-level movement was

normally 4 to 5 inches, to see that the level

was moving only an inch or less before the

accident. He might have realized that something was wrong and been able to take

preventive action.

Water Treatment--Since scale, particularly

as it affected the water-monitoring devices,

became a factor in the investigation, Safety

Board investigators explored how Gettysburg Passenger Services treated its water in

order to control the mineral content.

According to experienced steam-locomotive

operators and historical railroad documentation, water treatment is critical to the

maintenance and safe operation of steam

locomotives. Testimony from steam-locomotive experts and investigators, from the

owner of Gettysburg Railroad, and from

representatives of Gettysburg Passenger

Services showed that water treatment for

locomotive 1278 was, at best, undocumented and inconsistent.

The attempts at water treatment appeared

to be irregular, rather than part of a planned

and researched policy. According to his

testimony, the engineer sent boiler- and/or

supply-water samples to Water Chem for

testing. However, Water Chem has no

record of doing any testing for Gettysburg

Passenger Services. The engineer told Safety

Board investigators that he did his own

water testing with a kit and that he kept a

journal of his testing. There was no

documented evidence that this was done on

a regular, program-type basis or that

anything was done with any test result

information. Investigators were unable to

determine the effectiveness of such irregular

water treatment, since no test results were

found or provided. The Safety Board

concludes that Gettysburg Passenger Services did not have a comprehensive watertreatment program. The Safety Board

believes that the FRA should require steamlocomotive operators to have a documented

water-treatment program as a basis for boiler

maintenance and operation.

Boiler Washing--The first fireman’s testimony about boiler washing described the

manner in which Gettysburg Passenger

Services personnel washed the boiler.

Contrary to the regulatory requirement that

all washout plugs be removed, the fireman

removed only 4 of the boiler’s 29 washout

plugs. With only four plugs removed, it is

doubtful that even the most conscientious

effort to wash out the boiler would have

been very effective in removing a significant

amount of sediment.
43

There was also a discrepancy between the

method the fireman said he used to wash out

a boiler and the methods described in maintenance literature or described by the Strasburg Railroad CMO. The fireman did not

use any special nozzles or equipment, which

the ARA had adopted as recommended

practice in 1915. His casual description of

the procedure displayed his lack of knowledge and training in this critical procedure.

The Safety Board concludes that the boiler

washing procedure described by the fireman

was inadequate to ensure that the boiler was

properly and thoroughly cleaned as required

by FRA regulations.

Although the CFR requires boiler washings, it does not describe the procedure.

When all railroads depended on steam, the

railroad industry had detailed methods and

special equipment for boiler washing; however, much of this expertise has disappeared.

Despite TRAIN’s recent efforts to promote

the proper boiler washing methods, it is obvious from this accident that some steam-locomotive operators do not have the initiative

or the resources to find and employ proven

and accepted boiler washing methods.

Therefore, the Safety Board believes that the

FRA should describe the proper boiler washing methods and techniques in its regulations in order to set some basic safety

standard for steam-locomotive operators.

Feed Pump and Gage--According to testimony from the two firemen, they did not use

the water injector during the accident trip—

they used only the feed pump. When the

train left Aspers with the helper, the first

fireman stated, the feed pump was shut off

to prevent the locomotive drivers from

slipping on the wet rail, which was wet

because of the leaking check valve between

the feed pump and the boiler. Consequently,

for the time the feed pump was shut off, no

water entered the boiler. As soon as the train

began moving, the first fireman said, the

feed pump was turned back on. However,

the second fireman testified that when he

relieved the first fireman at Gardners, the

feed pump was still turned off and that he

(the second fireman) turned it on. The Safety

Board believes the feed pump was off on the

ascent to Gardners.

On the fireman’s side of the locomotive

cab, three gages had been removed from a

mounting plate, leaving only a stoker-engine

steam-pressure gage and a boiler-pressure

gage. Gages displaying stoker-jet pressure,

steam-heat pressure, and feed-pump pressure

had been removed. Firemen use the feedpump pressure gage to ensure that heated

feed water is overcoming boiler pressure and

flowing into the boiler. Consequently, the

investigation steam-locomotive experts were

concerned to find locomotive 1278 lacked

the gage.

When the accident firemen were asked

how they could tell whether the feed pump

was working, they both said they relied upon

the sound and movement of the feed-pump

rod. Yet without a feed-pump gage to show

that the pressure was high enough to force

water into the boiler, the feed-pump rod

could have been moving only because

pressure was being relieved by the leaking of

the check valve. The Safety Board concludes

that because the feed-pump gage was

missing, the traincrew had no reliable way to

determine whether the feed-pump pressure

was overcoming the boiler pressure and

delivering water into the boiler.

Malfunctioning Check Valve--Investigators

al-so examined another defect in the watersupply system. A check valve between the

feed pump and the boiler had been leaking

all day, although the valve had recently been
44

returned from repair. While it is not known

how much water was leaking from the valve,

it was enough water to necessitate clearing

half an open-decked observation car when

the locomotive was pulling in reverse. If

nothing else, the leak reduced the efficacy of

water delivery to the boiler. It should also be

noted that had the accident locomotive been

equipped with a feed-pump gage, the gage

would not have provided an accurate pressure indication, since it would have been

connected between the feed pump and the

leaking check valve, which was relieving

pressure.

The leaking of the check valve indirectly

contributed to the lack of water in the boiler.

Because the valve leaked, the feed pump

was shut down, cutting off the water supply

to the boiler and contributing to the cause of

the crownsheet failure.

Injector--The other means of water delivery to the boiler was the injector, which

was not used, according to the locomotive

crew. Postaccident examination of the injector showed that it had the wrong type of

steam valve disk. Such a disk would make it

difficult to prime the injector, and if a lifting

injector cannot be primed, it will not operate

correctly. It would be possible for the

injector to function, but only with some

difficulty. Although the injector does not

appear to have been involved in the crownsheet failure, it is typical of another device

on locomotive 1278 that either did not

function or functioned marginally. The

Safety Board concludes that because the

wrong type of disk had been installed in the

injector, it would have been difficult to use

the injector to add water to the boiler.

Water-Glass and Gage-Cock Testing--During

the testimony, both accident firemen, the

helper engineer (who also worked as a

steam-locomotive engineer), the helper fireman, another Gettysburg Passenger Services

employee (who was qualified as both a

steam-locomotive fireman and an engineer),

and the owner of Gettysburg Railroad each

described and demonstrated how he would

blow down and verify the water glass. Only

the owner of Gettysburg Railroad, the

engineer’s father, demonstrated the correct

method of blowing down. All the Gettysburg

Passenger Services employees had been

taught by the engineer. No one said that he

also tested the gage cocks when he blew

down the water glass, as required by

regulation. The Safety Board therefore

concludes that the firemen did not know,

because they had not been properly taught,

how to blow down the water glass or test the

gage cocks. The lack of knowledge about

such basic procedures reflects the lack of an

effective training program at Gettysburg

Passenger Services.

Delineation of Responsibilities--According

to the testimony of the two firemen, responsibility was not clearly divided among

the members of the crew, particularly between the two firemen. Each fireman felt he

had a firm grasp of the tasks that needed to

be done and how to do them; however,

neither was totally aware of who was

responsible for what tasks. The situation is

much the same as the one in which two

baseball outfielders run toward a fly ball.

Each may know how to catch the ball, but

unless there is a clear understanding of

responsibility, each may expect the other to

catch the ball, and the ball may fall to the

ground. Or each may attempt to catch the

ball, resulting in a collision and the ball’s

being dropped. In either case, delineation of

responsibility is critical. In this case, instead

of a ball, the critical item “dropped” was the

feed pump. The Safety Board concludes that

there was no clear division of responsibility
45

among the members of the crew in this

accident, particularly between the two firemen.

Unlike modern electric and diesel-electric

locomotives, which may be operated with

some degree of safety by the engineer alone,

operating a steam locomotive requires the

close coordination of both fireman and

engineer. Such coordination is impossible

unless everyone involved has a clear understanding of his responsibilities. While 49

CFR 230.40 states that before each trip, the

water glass must be blown out and each gage

cock must be tested, the regulation does not

assign anyone this specific responsibility.

The Safety Board believes that the FRA

should delineate such basic levels of

responsibility and duties, since close

coordination between and among the

engineer and fireman (firemen) is critical to

the safe operation of the steam locomotive.

The Safety Board also believes that until the

FRA specifies who is responsible for what,

Gettysburg Passenger Services should

specify.

Hours of Service--Although fatigue does

not appear to have been a factor in this accident, the Safety Board is concerned that the

cumulative and consecutive hours worked

by employees, particularly part-time employees, of tourist railroads such as Gettysburg Passenger Services, may make such

employees susceptible to accidents caused at

least in part by fatigue or sleep deprivation.

Such an accident exposes the public to danger. The members of the enginecrew of locomotive 1278 had worked a full day, taken

a 2-or 3-hour break, and then returned at

5:00 p.m. expecting to work until midnight.

Whether part-time or full-time, such a dayto-day pattern can easily cause sleep deprivation and tiredness. This is particularly

disturbing in the case of the engineer who,

as co-owner of Gettysburg Passenger Services, had duties and responsibilities beyond

running and maintaining the entire operation.

While the Safety Board acknowledges

that it is up to the FRA to enforce the Hours

of Service Act,40 the work-rest routine of

Gettysburg Passenger Services train personnel exceeds the intent of the legislation and

might threaten the safety of the public. The

Safety Board concludes that Gettysburg Passenger Services management was not aware

of the Hours of Service Act. The Safety

Board believes that the FRA, in cooperation

with TRAIN, should promote awareness of

and compliance with the Hours of Service

Act.

Training--Based on the description provided of the formal training given to Gettysburg Passenger Services employees, the

training was a 1-day recurrent or refresher

training module, rather than a comprehensive training program. The closest thing that

Gettysburg Passenger Services had to a comprehensive training program was a generic

fill-in-the-blank document from the

American Shortline Association used to satisfy FRA engineer certification requirements

of 49 CFR 230.101.

Gettysburg Passenger Services employees

said they received their training through

OJT. But the company’s OJT program was

not organized enough to be comprehensive

or complete. The greatest failing of the OJT

 

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46

was that it was built upon either misunderstood instructions or misinformation that

had come second- or third-hand from a certified or professional commercial-railroad

source. Thus, misunderstood, incomplete, or

incorrect information was continually passed

on until it became the norm. Therefore, the

Safety Board concludes that Gettysburg Passenger Services had no effective formal

training or certification program and that its

OJT was dependent on second- and thirdhand expertise.

Progressive Crown-Stay Failure--Although

not a warning or preventative device, the design of the accident locomotive boiler

appeared to mitigate the effects of the

crownsheet failure. As previously discussed,

the locomotive had alternating rows of

straight-thread and button-head crown stays

to help ensure that any crownsheet failure

due to low water would occur relatively

gradually and in stages, rather than instantaneously and catastrophically.

The design was suggested in the 1922

Master Boiler Association manual report. It

appears to have been unique to the Canadian

Locomotive Company, Ltd. and may well

have prevented a more sudden catastrophic

failure of the crownsheet, which could have

sent the boiler rocketing off the frame,

killing or injuring the crew and passengers.

The Safety Board believes such a design

may be worthy of further study for

incorporation in steam locomotives when

they are repaired or rebuilt. The Safety

Board also believes that the FRA, in

cooperation with the NBBPVI and the

tourist-railroad industry steam-locomotive

operators should explore the feasibility of

requiring progressive crown-stay failure

features in steam locomotives.

Steam-Locomotive Maintenance Expertise--

The Safety Board is concerned that the

incorrect injector disk, the leaking check

valve, the missing feed-pump gage, the

inoperative dynamo, and the nonfunctioning water-glass light together reflect

a disturbing pattern of poor maintenance

and/or improper repair. Such maintenance,

in the opinions of the investigation steamlocomotive experts, clearly indicated a lack

of knowledge and expertise on the part of

the locomotive owners and crew. As

previously noted, steam-locomotive

expertise is gone from most modern

commercial railroads, and generally only a

small number of experts and a limited

supply of knowledge and skill remain.

Today, many operating steam locomotives

are in the hands of a generation who have

had to develop steam-locomotive maintenance and operation second- or third-hand,

much like the personnel of Gettysburg

Passenger Services. One way to establish a

minimum level of steam-locomotive expertise and thereby better ensure the safety

of operators and the public would be to

establish an education and certification

program that establishes and enforces basic

standards for steam-locomotive operation

and maintenance.

The NBBPVI and the tourist-railroad industry steam-locomotive operators have

agreed to establish a program for the safe

maintenance and operation of boilers. The

Safety Board supports such efforts and believes that the FRA, in cooperation with the

NBBPVI and the tourist-railroad industry

steam-locomotive operators, should develop

certification criteria and require steam-locomotive operators and maintenance personnel to be periodically certified to operate

and/or maintain a steam locomotive.
47

The Safety Board believes that the FRA,

in cooperation with the NBBPVI, should

update 49 CFR Part 230 to take advantage of

accepted practical modern boiler-inspection

techniques and technologies, to minimize

interpretation based on empirical experience,

and to maximize the use of objective

measurable standards.
48

1. The explosion in the locomotive resulted

from crownsheet failure caused by

having too little water in the boiler.

2. Because the water-glass spindles were

restricted, the water glass could not

represent the water level in the boiler

accurately.

3. Although the engineer had signed the

Federal Railroad Administration’s forms

No. 1, certifying that the work had been

done, the water-glass spindles and gage

cocks were not cleaned on a monthly

basis.

4. The water glass was not illuminated as

required.

5. Gettysburg Passenger Services, Inc., did

not have a comprehensive watertreatment program.

6. The boiler washing procedure described

by the fireman was inadequate to ensure

that the boiler was properly and

thoroughly cleaned as required by

Federal Railroad Administration

regulations.

7. Because the feed-pump gage was

missing, the traincrew had no reliable

way to determine whether feed-pump

pressure was overcoming boiler pressure

and delivering water to the boiler.

8. Because the wrong type of disk had been

installed in the injector, it would have

been difficult to use the injector to add

water to the boiler.

9. The firemen did not know, because they

had not been properly taught, how to

blow down the water glass or test the

gage cocks.

10. There was no clear division of

responsibility among the members of the

crew in this accident, particularly

between the two firemen.

11. Gettysburg Passenger Services, Inc.,

management was not aware of the Hours

of Service Act.

12. Gettysburg Passenger Services, Inc., had

no effective formal training or

certification program, and its on-the-job

training was based on second- and thirdhand expertise.

CONCLUSIONS
49

The National Transportation Safety

Board determines that the probable cause of

the firebox explosion on steam locomotive

1278 was the failure of Gettysburg Passenger Services, Inc., management to ensure

that the boiler and its appurtenances were

properly maintained and that the crew was

properly trained.

PROBABLE CAUSE
50

As a result of this special investigation,

the National Transportation Safety Board

makes the following recommendations:

--to the Federal Railroad Administration:

Require that each operating steam

locomotive have either a water column

or a water glass in addition to the

water glass and three gage cocks that

are already required. (R-96-53)

Require steam-locomotive operators to

have a documented water-treatment

program. (R-96-54)

Describe basic responsibilities and

procedures for functions required by

regulation, such as blowing down the

water glass and washing the boiler. (R96-55)

In cooperation with the Tourist

Railway Association, Inc., promote

awareness of and compliance with the

Hours of Service Act. (R-96-56)

In cooperation with the National

Board of Boiler and Pressure Vessel

Inspectors and the Tourist Railway

Association, Inc., explore the feasibility of requiring a progressive crownstay feature in steam locomotives. (R96-57)

In cooperation with the National

Board of Boiler and Pressure Vessel

Inspectors and the Tourist Railway

Association, Inc., develop certification

criteria and require that steam-locomotive operators and maintenance

personnel be periodically certified to

operate and/or maintain a steam locomotive. (R-96-58)

In cooperation with the National

Board of Boiler and Pressure Vessel

Inspectors and the Tourist Railway

Association, Inc., update 49 Code of

Federal Regulations Part 230 to take

advantage of accepted practical modern boiler-inspection techniques and

technologies, to minimize interpretation based on empirical experience,

and to maximize the use of objective

measurable standards. (R-96-59)

--to the National Board of Boiler and

Pressure Vessel Inspectors:

Cooperate with the Federal Railroad

Administration and the Tourist Railway Association, Inc., in exploring the

feasibility of Federal regulations requiring progressive crown-stay failure

features in steam locomotives. (R-96-

60)

Participate with the Federal Railroad

Administration and the Tourist Railway Association, Inc., in developing

criteria to be used in the periodic certification of steam-locomotive operators

and maintenance personnel. (R-96-61)

Participate with the Federal Railroad

Administration and the Tourist Railway Association, Inc., in updating 49

Code of Federal Regulations Part 230

to take advantage of accepted practical

modern boiler-inspection techniques

and technologies, to minimize

interpretation based on empirical

experience, and to maximize the use

RECOMMENDATIONS
51

of objective measurable standards. (R96-62)

--to the Tourist Railway Association,

Inc.:

In cooperation with the Federal Railroad Administration, promote awareness of and compliance with the Hours

of Service Act. (R-96-63)

Encourage its members who operate

steam locomotives to cooperate with

the Federal Railroad Administration

and the National Board of Boiler and

Pressure Vessel Inspectors in exploring the feasibility of Federal regulations requiring progressive crown-stay

failure features in steam locomotives.

(R-96-64)

Encourage its members who operate

steam locomotives to participate with

the Federal Railroad Administration

and the National Board of Boiler and

Pressure Vessel Inspectors in developing criteria to be used in periodically certifying steam-locomotive operators and maintenance personnel.

(R-96-65)

Encourage its members who operate

steam locomotives to participate with

the Federal Railroad Administration

and the National Board of Boiler and

Pressure Vessel Inspectors in updating

49 Code of Federal Regulations Part

230 to take advantage of accepted

practical modern boiler-inspection

techniques and technologies, to minimize interpretation based on empirical

experience, and to maximize the use

of objective measurable standards. (R96-66)

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

November 15, 1996

APPENDIX A

53

Investigation and Sworn Testimony Proceeding

The accident occurred about 7:30 p.m. edt on Friday, June 16, 1995, and was reported to the

Coast Guard’s National Response Center (NRC) in Washington, D.C., the following morning at

7:17 a.m. The NRC incident report number was 295913. The incident report was electronically

sent to the National Transportation Safety Board (NTSB) at 7:39 a.m. on Saturday, June 17,

1995.

The NTSB investigator arrived at the Gettysburg Railroad about 10 a.m. on Tuesday, June 20,

1995, and initiated the accident investigation. The Gettysburg Railroad, Gettysburg Passenger

Services, Inc., the Federal Railroad Administration, the Hartford Steam Boiler Inspection and

Insurance Co., and members of the Tourist Railway Association, Inc., participated and assisted in

the investigation.

As part of the investigation, a 2-day sworn testimony proceeding was held at the Holiday Inn

in Gettysburg, Pennsylvania, on September 27 and 28, 1995. Parties to the proceeding included

the Gettysburg Railroad, Gettysburg Passenger Services, Inc., the Federal Railroad Administration, the Hartford Steam Boiler Inspection and Insurance Co., the National Board of Boiler and

Pressure Vessel Inspectors, Inc., and members of the Tourist Railway Association, Inc. Twelve

witnesses testified.

APPENDIX A

53

Abbreviations Used in this Publication

ARA: American Railroad Administration

CFR: Code of Federal Regulations

CMO: chief mechanical officer

ESC: Engineering Standards Committee for Steam Locomotives

FRA: Federal Railroad Administration

ICC: Interstate Commerce Commission

MP&E: motive power and equipment

NBBPVI: National Board of Boiler and Pressure Vessel Inspectors

OJT: on-the-job training

psi: pounds per square inch

TRAIN: Tourist Railway Association, Inc.

APPENDIX B