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National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Accident No.: DCA-05-FR-004 

Location: San Antonio, Texas 

Date: November 10, 2004 

Time: 9:10 a.m. central standard time1

Railroad: Union Pacific Railroad 

Train: YEY55-10 

Type of Accident: Collision and derailment into the Crystal Cold Storage 

 warehouse maintenance building 

Injuries: 1 

Fatalities: 1 

Property Damage: $308,637 

Synopsis 

On November 10, 2004, about 9:10 a.m., Union Pacific Railroad (UP) train 

YEY55-10 collided with a track car mover and four refrigerated boxcars that were parked 

at Crystal Cold Storage track in San Antonio, Texas. The engineer lost radio 

communication with the conductor, who was controlling the train movement, and failed 

to stop the train in time to avoid the collision. An employee of a rental car company was 

killed as one of the parked cars was shoved over a pair of wheel stops2 and into the 

Crystal Cold Storage maintenance building. (See figure 1.) A Crystal Cold Storage 

employee was injured while he was unloading frozen food from one of the parked 

boxcars. Damages totaled $308,637. 

The Accident 

The three crewmembers3 for train YEY55-10 reported for duty at the Kirby yard 

office at 7:00 a.m. in San Antonio, Texas. At the yard office, the conductor called the 

work center and got the work report4

 for the day, and the train crewmembers held a job 

briefing to discuss how they were going to proceed. The crewmembers loaded ice and 

water into the conductor’s personal vehicle and drove to train YEY55-10 located on the 

East Side Industrial Lead, which is about 3 miles away from the yard office. 

 1

 All times in this brief are central standard time. 

2

 A wheel stop is placed on each rail across from each other near the end of the track to prevent a 

freight car from rolling off. 

3

 The crew consisted of an engineer, a conductor/foreman, and a brakeman/switchman. 

4

 The work report listed the industries and the cars that were to be switched. 

 NTSB/RAB-05/05 
Figure 1. Damage to Crystal Cold Storage maintenance building. 

The engineer inspected the locomotives, and the other crewmembers checked the 

train consist and compared it to the switch list.5

 The train crew confirmed that the brake 

system was charged, and the brakeman released the hand brakes. The conductor checked 

the list to see if the car sequence was in the right order, but it was reversed. Further, the 

brakeman told investigators that the original consist showed 48 cars, but when the crew 

checked the train, there were 50 cars. Because of these inconsistencies, the crew had to 

adjust the work plan they had agreed upon earlier. 

The crew held a second job briefing to discuss how they were going to switch the 

freight cars for their respective industries. They decided to use some of the nearby 

industry tracks for temporary storage because of the limited room available for switching 

cars. The conductor checked the area, and two nearby industries, Wright Oil Company 

and Crystal Cold Storage, had room on their tracks. The crew intended to use these two 

industry tracks to store cars even though both tracks already had cars parked on them. 

The conductor cut6 the train behind the 15th car, backed it into the Wright Oil 

Company track, and coupled it to 4 parked cars. The train crew then pulled the 19 cars 

back onto the main track, moved them to the Crystal Cold Storage track, and coupled 

them to 10 cars already parked there. The crew planned to temporarily leave all 29 cars at 

that location. 

 5

 The switch list is the part of the work report that states which freight car goes to a specified industry. 

6 Cut is a railroad term that means to uncouple cars at a specific location. 

 NT 2 SB/RAB-05/05 
The train crew stated they then needed additional room to store some of the 

remaining cars parked on the main track, so they decided to shove the 29-car train farther 

down the Crystal Cold Storage track. The crew further stated that they were going to stop 

their train just short of a track car mover and four cars that were parked at the Crystal 

Cold Storage loading docks. The conductor positioned himself between the track and the 

Crystal Cold Storage building concrete wall (on the south side of the track) and just east 

of the track car mover. The brakeman was standing where he had connected the air hose 

to join the 19 cars to the 10 cars, about 25 car lengths (1,250 feet) east of the conductor. 

The engineer was in the lead locomotive unit about 46 car lengths (2,300 feet) east of the 

conductor. The conductor, the engineer, and the brakeman could not see each other; 

therefore, radio communications were used to control the train movements. 

The engineer was going to shove his train westward down a steep descending 

grade to within 1 car length of the track car mover. The conductor instructed the engineer 

to shove the train 15 car lengths (the unoccupied distance between the track car mover 

and the end car being shoved). The engineer began to shove the train, but he did not 

repeat the instructions. The conductor informed the engineer that he had 10 car lengths 

before he needed to stop. The conductor told investigators that he thought the engineer 

repeated the instructions, but he was not sure. The conductor then informed the engineer 

that he had 6 car lengths left, after which he overheard the engineer ask the brakeman if 

he had heard the last instructions. At that point, the conductor said he ran toward the train 

and repeatedly instructed the engineer to make an emergency brake application. About 

that same time, the brakeman answered the engineer and told him that he should stop the 

train if he had not heard the conductor. 

Event recorder data indicate that the train was traveling 5 mph and the engineer 

tried to stop the train with a 13-pound brake pipe reduction, but it was too late. The train 

had already collided with the car mover and the cars parked at Crystal Cold Storage. 

Brake testing and inspection found nothing remarkable. 

When the moving train collided with the car mover and the parked freight cars, an 

employee of a rental car company was killed as one of the cars was shoved over a pair of 

wheel stops and into the Crystal Cold Storage maintenance building. A Crystal Cold 

Storage employee was injured while he was unloading frozen food from one of the 

parked boxcars. 

UP Operating Rules 

UP operating rules require that when radio communication is used to make train 

movements, crewmembers must respond to specific instructions given for each 

movement. In addition, radio communication for backing and shoving movements must 

specify the direction and distance and must be acknowledged when the distance specified 

is more than four cars. Train movement must stop within half of the distance specified 

unless additional instructions are received. 

 NT 3 SB/RAB-05/05 
Radio Testing 

Because the train crewmembers reported a loss of radio communication, 

investigators field-tested the handheld radios and the radio and antenna on the lead 

locomotive, UP 1966. These field tests determined that the handheld radios and the 

locomotive radio were functioning properly, but the radio antenna on locomotive 

UP 1966 was not fully functional because of a corroded cable connection.7

 (See figure 2.) 

All field radio and antenna tests were verified during further laboratory analysis. 

Thirty-seven transmission tests were conducted between the locomotive radio and 

the handheld radios used by the conductor and the brakeman. There were 16 radio 

communication failures. Fourteen of those failures occurred when the radio was placed 

near the conductor’s reported position at the time of the accident, alongside the concrete 

wall of the Crystal Cold Storage building. 

 Figure 2. Corroded cable connection on locomotive UP 1966. 

Postaccident Actions 

Since the accident, UP has installed a derail at the entrance to Crystal Cold 

Storage track, and only Crystal Cold Storage employees can unlock the derail. Further, 

the following instructions are now issued to all train crews working at Crystal Cold 

Storage: 

 7

 UP has replaced the corroded cable on UP 1966. 

 NT 4 SB/RAB-05/05 
When entering the [Crystal] Cold Lead, crew must contact employee at the 

facility to unlock the derail. The derail will be locked with private lock. 

After completion of work, the crew needs to again notify the facility so 

that the derail can be secured. A cell phone will be provided for the 

foreman [conductor] to use daily at Kirby. The numbers will be entered 

into the memory of the phone for convenience. 

When switching Crystal Cold Storage, handle only cars coming from or 

designated for the Crystal Cold Storage facility. Any cars remaining on the 

lead after switching must be properly secured. 

When using a handheld radio to direct movements while switching and 

spotting Crystal Cold Storage, the person giving signals must place 

themselves away from the building when practicable to avoid interference. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of 

the Union Pacific Railroad accident on November 10, 2004, at Crystal Cold Storage in 

San Antonio, Texas, was the failure of the engineer to stop the train as required by Union 

Pacific Railroad radio communication operating rules. 

Adopted: August 31, 2005 

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