Uncontrolled Movement, Collision, and

Passenger Fatality on the Angels Flight

Railway in Los Angeles, California

February 1, 2001

Railroad Accident Report

NTSB/RAR-03/03

PB2003-916303

Notation 7575

National 

Transportation

Safety Board

Washington, D.C.

Railroad Accident Report

Uncontrolled Movement, Collision, and 

Passenger Fatality on the Angels Flight Railway 

in Los Angeles, California 

February 1, 2001

NTSB/RAR-03/03

PB2003-916303 National Transportation Safety Board

Notation 7575 490 LíEnfant Plaza, S.W.

Adopted August 5, 2003 Washington, D.C. 20594
National Transportation Safety Board. 2003. Uncontrolled Movement, Collision, and Passenger

Fatality on the Angels Flight Railway in Los Angeles, California, February 1, 2001. Railroad Accident

Report NTSB/RAR-03/03. Washington, DC.

Abstract: About 12:17 p.m. on February 1, 2001, the two cars of the Angels Flight funicular railway

collided in downtown Los Angeles, California. The accident resulted in 7 injuries and 1 fatality among the

20 passengers aboard the two cars and injuries to a pedestrian. The Angels Flight Operating Company

estimated monetary damage to the cars at $370,000 with an additional $1.2 million to replace the funicular

haul system.

The safety issues discussed in this report are the adequacy of the safety oversight of the Angels Flight

reconstruction project; the adequacy of the design of the reconstructed Angels Flight system; the adequacy

and appropriateness of the braking systems designed for Angels Flight; and the adequacy of Angels Flight

Operating Companyís maintenance and operating procedures

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

the California Public Utilities Commission, the City of Los Angeles Community Redevelopment Agency,

and the American National Standards Institute.

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.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2003-916303 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Railroad Accident Report

Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Angels Flight Funicular Railway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Postaccident Onsite Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Reconstruction of Angels Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Angels Flight Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Drive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Braking Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Design Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Track Brakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

End Gates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Emergency Walkway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Haul Cable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Cable Drum Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Deropement Switch Device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Gearbox Overheating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Shafts, Splines, and Bearings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Brake System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Capacity of Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Funicular Railway Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Regulatory Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Current Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Gear Hub Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Brake System Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Angels Flight Operations and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Oversight of Angels Flight Design and Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

City of Los Angeles Community Redevelopment Agency Oversight . . . . . . . . . . . . . 38

California Public Utilities Commission Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Contents iv Railroad Accident Report

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Appendix A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
v Railroad Accident Report

Executive Summary

About 12:17 p.m. on February 1, 2001, the two cars of the Angels Flight funicular

railway (Angels Flight) collided in downtown Los Angeles, California. The accident

resulted in 7 injuries and 1 fatality among the 20 passengers aboard the two cars and

injuries to a pedestrian. The Angels Flight Operating Company estimated monetary

damage to the cars at $370,000 with an additional $1.2 million to replace the funicular

haul system.

The National Transportation Safety Board determines that the probable cause of

this accident was the Yantrak Companyís (Lift Engineeringís) improper design and

construction of the Angels Flight funicular drive and the failure of the City of Los Angeles

Community Redevelopment Agency, its contractors (Pueblo Contracting Services,

Yantrak, and Harris and Associates), and the California Public Utilities Commission to

ensure that the railway system conformed to initial safety design specifications and known

funicular safety standards. 

The major safety issues identified in this investigation are:

ï The adequacy of the safety oversight of the Angels Flight reconstruction

project; 

ï The adequacy of the design of the reconstructed Angels Flight system;

ï The adequacy and appropriateness of the braking systems designed for Angels

Flight; and

ï The adequacy of Angels Flight Operating Companyís maintenance and

operating procedures.

As a result of the investigation, the National Transportation Safety Board makes

safety recommendations to the California Public Utilities Commission, the City of Los

Angeles Community Redevelopment Agency, and the American National Standards

Institute.

1 Railroad Accident Report

Factual Information

Accident Synopsis

About 12:17 p.m. on February 1, 2001, the two cars of the Angels Flight funicular

railway1

 (Angels Flight) collided in downtown Los Angeles, California. The accident

resulted in 7 injuries and 1 fatality among the 20 passengers aboard the two cars and

injuries to a pedestrian. The Angels Flight Operating Company2

 estimated monetary

damage to the cars at $370,000 with an additional $1.2 million to replace the funicular

haul system.

Angels Flight Funicular Railway

Angels Flight is a funicular railway in downtown Los Angeles that was originally

built in 1901 to move passengers one city block between the commercial district at the

bottom of Bunker Hill and the residential area at the top of the hill. Angels Flight operated

until 1969, when it was dismantled, and the original cars and portions of the infrastructure

were stored. Beginning in 1993, the Angels Flight funicular was reconstructed 1/2 block

from its original location. It began operations in 1996 using the original two cars. (The

two Angels Flight cars were named Olivet and Sinai. The cars were given these names in

1901, and the names were retained for the renovation.)

In a basic funicular, the two cars operate in tandem and are connected to each other

by a single haul rope (a steel cable). When one car goes up the incline, the other comes

down. The two cars counterbalance each other, with the descending carís weight working

to neutralize the weight of the ascending car. Therefore, the power required for operation

is nominal, basically only that which is necessary to overcome friction and the relatively

equal countervailing forces. The reconstructed Angels Flight funicular used a different

haul system (described in the ìAngels Flight Designî section of this report), with each car

connected to its own cable and the cars interconnected through the cable drums and

driving gears.

The guideway was a single track at the top and bottom with offset passing sidings

midway on the incline. (See figure 1.) The Angels Flight funicular was 298 feet long on an

approximately 33-percent grade. Passengers boarded and disembarked from either the

lower station or the upper station that was one block uphill. (See figure 2.) Car movement

was controlled by an operator inside the upper station house. No Angels Flight personnel

1 A funicular railway, or funicular, is a cable railway on a steep incline with counterbalanced cars

simultaneously ascending and descending on parallel sets of rails. 

2 The Angels Flight Operating Company managed the revenue operations and physical maintenance of

the Angels Flight railway under a contract with the Angels Flight Railway Foundation.
Factual Information 2 Railroad Accident Report

were on board either car during movement. The single operator in the upper station house

was responsible for visually determining that the track and vehicles were clear for

movement, closing the platform gates, pressing the start button,3 monitoring the operation

of the funicular cars, observing car stops at both stations, and collecting fares from

passengers.

3 The start button initiated automatic operations. This was the mode of operation at the time of the

accident. Manual control was available and occasionally used.

Figure 1. Angels Flight viewed from upper station.

Figure 2. Angels Flight car at the passing siding with upper station in the background.
Factual Information 3 Railroad Accident Report

Accident Narrative

Just after noon on February 1, 2001, the Angels Flight operator was making

change for a customer when he saw the ascending car stop about 30 feet from the top

platform. As he focused his attention on the stopped car, he said, it slid downward a few

feet, hesitated for an instant, and then began accelerating downward. The operator said

that he had seen cars stop on the hill before but had never seen a car reverse direction. He

said that as soon as the ascending car started moving downward, he pushed the emergency

stop button. He said that the car did not slow or stop after he pushed the button and that the

car continued gaining speed until it collided with the other car near the bottom of the hill.

(See figure 3.) Persons waiting at the bottom platform who witnessed the collision said

that the struck car stopped before the collision.

The runaway car derailed during the crash; the struck car did not. The derailment

marks and the dispersal of debris after the collision indicated that both cars moved about

20 feet downward from the point of impact. 

Emergency Response

The collision occurred about 12:17 p.m. in a busy section of downtown Los

Angeles. Local emergency response agencies reported receiving multiple phone calls

almost immediately. A Los Angeles police officer heard the collision and responded to the

accident scene within 1 minute. The first fire department vehicle arrived within 4 minutes.

Firefighters and paramedics used wooden extension ladders to reach, provide emergency

Figure 3. Position of cars after collision.
Factual Information 4 Railroad Accident Report

treatment to, and evacuate the passengers. (See figure 4.) The injured passengers were

strapped to backboards that were lowered to the ground by firefighters standing along the

lengths of the ladders. (See figure 5.) 

Figure 4. Ladders placed for the emergency evacuation. Walkway on the other side of 

the tracks can be seen below track level.

Figure 5. Passenger evacuation after collision.
Factual Information 5 Railroad Accident Report

Injuries

At the time of the accident, 8 people were aboard the runaway car and 12 were

aboard the car that was struck. One passenger was ejected from the open end of the struck

car. Other passengers were injured when they struck vertical grabrails, each other, and

various objects inside the cars. One of these injured passengers, an 83-year-old man, died

later at a hospital. The Los Angeles County coronerís office reported the cause of his

death as multiple traumatic injuries. Debris from the collision fell onto the surrounding

area and injured one pedestrian.

Table 1. Injuries.a

Damage

The lower inboard quarter of the runaway car struck the upper inboard quarter of

the stationary car. Approximately 4 feet of each car was crumpled. (See figures 6 and 7.) 

Passengers Pedestrians Total

Fatal 10 1

Serious 50 5

Minor 21 3

None 12 0 12

Total 20 1 21

a 49 Code of Federal Regulations 830.2 defines fatal injury as ìany injury which results in death within 30 days of the

accidentî and serious injury as ìan injury which: (1) requires hospitalization for more than 48 hours, commencing within

7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers,

toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5)

involves second or third-degree burns, or any burn affecting more than 5 percent of the body surface.î The minor injury

category includes all other persons, not cited in the other injury categories, who were reported treated by area

hospitals within 24 hours following the incident.
Factual Information 6 Railroad Accident Report

Figure 6. View of some of the exterior damage to cars.

Figure 7. View of some of the interior damage to one of the cars.
Factual Information 7 Railroad Accident Report

The concrete crossties and rail fasteners under the derailed car were scored and

dislocated. Some internal haul system components were broken and destroyed. Monetary

damage estimates provided by the Angels Flight Operating Company were as follows:

Table 2. Damage.

Meteorological Information

At the time of the accident, the temperature was 72o F, winds were calm, and the

skies were clear.

Postaccident Onsite Examination

The systemís operating machinery was in the machinery room underneath the

operatorís station house. The Angels Flight haul system consisted of a separate cable,

drum, axle, and planetary gear for each car, with a sun gear driven by a single 100-

horsepower electric motor. (See figure 8.) The driven sun gear meshed with the planetary

gear for the Olivet car (the struck car in this accident), which in turn meshed with the

planetary gear for the Sinai car (the striking car). Axle shafts (about 3 inches in diameter)

connected the planetary gears with their respective cable drums. This gear arrangement

meant that the two planetary gears, and thus the two cable drums, were counter-rotational,

resulting in counterbalancing loads as one car descended while the other ascended. 

Emergency brakes (discussed in detail later in this report) that were designed to

stop the rotation of the drum were found to be in the released position even though the

emergency stop button had been pressed by the operator. Initial inspection also revealed

that the 7/8-inch-diameter cable for the Sinai car was intact but that two rows of the

wound cable had de-spooled from its drum. 

Reconstruction of Angels Flight

The City of Los Angeles Community Redevelopment Agency (Community

Redevelopment Agency) purchased Angels Flight in 1962 because Angels Flight was

within the Bunker Hill district urban renewal project area. At that time, Angels Flight was

Damage Estimate

Equipment $370,000

Wreckage removal 57,000

Infrastructure 73,000

Haul mechanism 1,200,000

Total $1,700,000
Factual Information 8 Railroad Accident Report

a designated historic and cultural monument. In response to community interest in and

concern about the eventual fate of Angels Flight, the Community Redevelopment Agency

pledged to restore the funicular railway as part of the Bunker Hill urban renewal project.

In 1991, the Community Redevelopment Agency hired Parsons Brinckerhoff

Quade & Douglas Engineering (Parsons) as an advisor on the reconstruction of Angels

Flight. In 1992, the Community Redevelopment Agency hired Harris and Associates

(Harris) as the construction manager for the renovation of Angels Flight. In 1993, Harris

hired Parsons to design specifications for the project. 

On June 17, 1993, the Community Redevelopment Agency approved the Angels

Flight Restoration and Reconstruction Plan. The Community Redevelopment Agency

selected Pueblo Contracting Services, Inc., (Pueblo) to be the general contractor for the

Angels Flight reconstruction. On November 17, 1994, the Community Redevelopment

Agency awarded two construction contracts to Pueblo to rebuild Angels Flight according

to the Parsons specifications, and construction began soon afterward. In 1995, Pueblo

hired Lift Engineering (Yantrak4

) to implement Parsonsís conceptual design by designing

and building the funicular drive, control, and braking systems and the haul and drum

assembly. (See figure 9.) About 15 months later, a ceremonial opening of Angels Flight

took place on February 23 through 25, 1996. 

Figure 8. Schematic of Angels Flight haul system.

4 Yantrak, a company that built automated trains such as those used at airports, was established in the

early 1990s by the owner of Lift Engineering, which until that time had built only ski lifts. During the

Angels Flight project, Lift Engineering often sent letters and faxes bearing the Yantrak company name, and

parties to the reconstruction commonly referred to Lift Engineering as Yantrak.

Gearbox

To 

Olivet 

Car

LEGEND

Cable

Deropement Device

Planetary Gears

Sun Gear

Motor

Axle Shaft

Service 

Brake

OlivetCable Drum

To 

Sinai 

Car

Point of Failure

Axle Shaft

Emergency Brakes

SinaiCable Drum

Olivet Cable Drum

Sinai
Factual Information 9 Railroad Accident Report

During the project, the Community Redevelopment Agency had responsibility for

contract negotiations, safety oversight, deletions from and modifications of the original

safety designs, and safety certification. As owner of the funicular, the Community

Redevelopment Agency made final decisions concerning the original engineering design

of Angels Flight and subsequent modifications. The project lasted from 1991 through

April 1997, when the completed funicular was leased to the nonprofit Angels Flight

Railway Foundation, which entered into a 99-year lease with the Community

Redevelopment Agency to operate and maintain Angels Flight. The Community

Redevelopment Agency maintained ownership but was not involved with the operation or

maintenance of Angels Flight. The Angels Flight nonprofit foundation contracted with the

for-profit Angels Flight Operating Company to manage the operation and maintenance of

the railway.

The Angels Flight Operating Company hired the Millar Elevator Service Company

(Millar) in 1996 to perform maintenance and inspections. The Millar elevator mechanic

assigned to Angels Flight eventually became the maintenance contractor, and he

subsequently became vice president of the Angels Flight Operating Company while

simultaneously remaining an employee of Millar.

Figure 9. Organizations involved in Angels Flight design, construction, and operation.

CITY OF LOS ANGELES

COMMUNITY REDEVELOPMENT AGENCY

Angels Flight Owner

1962 - Present

HARRIS & ASSOCIATES

Construction Manager

1992 - 1996

PARSONS BRINCKERHOFF

Transportation Consultant

1991 - 1996

PUEBLO CONTRACTING SERVICES, INC.

General Contractor

1994 - 1996

LIFT ENGINEERING (YANTRAK)

Designer and Builder

GEAR DRIVE, DRUM, ROPE,

AND SPLINE

1995 - 1996

ANGELS FLIGHT RAILWAY FOUNDATION

Nonprofit Fundraiser 

1995 - Present

MILLAR ELEVATOR COMPANY

Maintenance and Inspection

1996 - Present

ANGELS FLIGHT OPERATING COMPANY

Operator

1995 - Present

LEGEND

Design

Construction

Operation

CALIFORNIA PUBLIC UTILITIES COMMISSION

Safety Oversight

CITY OF LOS ANGELES

COMMUNITY REDEVELOPMENT AGENCY

Angels Flight Owner

1962 - Present

HARRIS & ASSOCIATES

Construction Manager

1992 - 1996

PARSONS BRINCKERHOFF

Transportation Consultant

1991 - 1996

PUEBLO CONTRACTING SERVICES, INC.

General Contractor

1994 - 1996

LIFT ENGINEERING (YANTRAK)

Designer and Builder

GEAR DRIVE, DRUM, ROPE,

AND SPLINE

1995 - 1996

ANGELS FLIGHT RAILWAY FOUNDATION

Nonprofit Fundraiser 

1995 - Present

MILLAR ELEVATOR COMPANY

Maintenance and Inspection

1996 - Present

ANGELS FLIGHT OPERATING COMPANY

Operator

1995 - Present

LEGEND

Design

Construction

Operation

CALIFORNIA PUBLIC UTILITIES COMMISSION

Safety Oversight
Factual Information 10 Railroad Accident Report

Angels Flight Design

Parsonsís specifications for the funicular system included a trackway design with

standard steel rails attached to concrete ties, all supported on an elevated framework from

10 to 20 feet above the ground. (See figure 10.) 

Drive System

When originally built in 1901, Angels Flight was a basic funicular, with two cars,

connected by a single cable, whose weights counterbalanced each other. The haul system

was powered through an arrangement of wheels and gears that the cable passed around at

the top of the hill. 

For the reconstruction of Angels Flight, Parsons did a conceptual design of the

haul system. (Subsequently, Yantrak modified the haul system design. A schematic

diagram of the Yantrak haul system is shown in figure 8.) Instead of a single cable

connecting the two cars, the new haul system consisted of an autonomous cable, drum,

axle, and planetary gear for each car, with a common driven, or sun, gear. Thus, each car

was attached to its own cable; each cable was wound around and attached to the outside of

an independent 6-foot-diameter drum; each drum was connected to its own axle; the axles

were connected inboard to separate planetary gears; and the planetary gears were meshed

together. One of the planetary gears meshed with a driven sun gear that was powered by a

100-horsepower motor. This design made Angels Flight a double winding drum system

that was operated as a double reversible funicular.5

 Maximum operating speed was about

352 feet per minute (4 miles per hour). 

Figure 10. Elevation of Angels Flight track (at left).

5 A double reversible funicular has two cars that reciprocate between stations or terminals on two paths

of travel.
Factual Information 11 Railroad Accident Report

The 1901 Angels Flight had a second ìsafety cableî that was used to prevent a

runaway if one of the cars became detached from the primary cable, if the primary cable

failed, or if anything else happened to cause uncontrolled movement. The reconstructed

version of Angels Flight did not have a safety cable.

Braking Systems

Angels Flight was equipped with two disc-brake-style braking systems: a service

brake and emergency brakes. The service brake stopped rotation of the motor shaft

powering both cable drums through the gear train. Because the service brake acted on the

motor shaft only, it would have no effect on a car that became disconnected from the

motor because of failure of a cable or gear train component. 

Each of the two cable drums was equipped with emergency brake calipers that

operated by closing against the drum flanges when the emergency brake was activated.

The calipers on both drums closed when the emergency brake was activated; thus, the

emergency brake stopped the rotation of both drums simultaneously. The emergency

brakes operated to stop the cars if a failure in the gear train caused them to be

disconnected from the drive motor; however, the emergency brakes could not stop a car

whose drive cable had broken or become detached from the drum. 

The service and emergency brake systems were both spring-applied brake systems.

Hydraulic pressure for the two systems was provided by two identical hydraulic pumps. In

the ìappliedî state for both brake systems, spring pressure held the brake calipers closed.

Hydraulic pressure was then used to counteract the spring pressure and release the brakes.

The brakes would remain in the released state as long as the hydraulic systems were

sufficiently pressurized. To activate the service brake, a solenoid valve had to open,

thereby relieving hydraulic pressure in the system. Similarly, to activate the emergency

brakes, an identical solenoid valve had to open to relieve the hydraulic pressure. With

hydraulic pressure reduced or removed, spring pressure would close the brake calipers

against the motor shaft disc or the cable drum flanges, depending on which brake system

was activated. The operatorís console had an emergency stop button and a button that

operated the service brake. 

Design Changes

Parsonsís specifications called for both cars to be fitted with emergency track

brakes, end gates on the cars to contain passengers, and an emergency walkway for the

entire length of the tramway to facilitate the evacuation of passengers in the event of an

emergency. As discussed below, none of these features were included in the final design

and construction. 
Factual Information 12 Railroad Accident Report

Track Brakes

The original design submitted by Parsons and approved by the Community

Redevelopment Agency called for both cars to be fitted with emergency track brakes.

Track brakes are attached to the underside of the car body with the brake pads configured

to apply against the top of the rail, against the sides of the rail, or around the entire

railhead. In the event a car exceeds a safe speed because of a loose or broken cable or

other catastrophic failure of either the drive or haul system, track brakes provide an

independent means of stopping the car by applying a retarding force directly between the

car and the track structure. 

Parsons interoffice communications indicate that final track brake application and

configuration was being discussed routinely throughout 1993. Records show that Parsons

continued to research recent funicular construction even after the original design was

submitted and approved. Nothing in the records from 1993 indicates that the elimination

of track brakes was being considered.

An August 22, 1995, letter from Yantrak (which was building the drive, control,

and braking systems) to Parsons summarized the technical points of a meeting held that

morning. Under the section ìTrack Brake,î the letter stated the following:

This track brake is frequently eliminated on modern high-speed (more than 10

m/sec) tramways. Track brake used in the case of overspeed is not very practical.

ÖWith such a short track, there is little room to brake, and the probability of

running out of track before the tramway stops is high. Rail brake as suggested by

the specification is not possible. (Clearances, dynamics, lack of braking surface,

lateral displacement of the undercarriage, etc.)Ö.

In response, Parsons (which had developed the design specifications) sent Yantrak

the engineering calculations for braking Angels Flight, information from two

manufacturers of modern track brakes, and comments concerning the use of a disc brake

on a 33-percent grade. On August 30, 1995, Parsons wrote Harris (the construction

manager) about its concerns regarding Yantrakís response:

[Yantrak] states ëThis track brake is frequently eliminated on modern high-speed

(more than 10 m/sec) tramways.í This statement appears to be incorrect and

irrelevant to inclined railway applications. The average speed specified for the

Angelís Flight is around 6 ft/s or (1.8 m/s). All modern inclined railway systems

[Parsons is] aware of are equipped with an emergency track brake for safety

reasons.

In the letter, Parsons went on to ask for ìa list of modern inclined railway systems

not equipped with an emergency track brake to support [Yantrakís] claim [that track

brakes are not practical].î In support of Parsonsís inclusion of track brakes in its design,

the letter stated the following: 

The statement made that ëthe probability of running out of track before the

tramway stops is highí because of ësuch a short trackí appears incorrect. A simple

calculation shows that the minimum specified track brake rate (1.75 mph/s) at the

specified speed (about 4 mph), the stopping distance is approximately 8 to 10 feet.

This calculation considers the response time of the brake system.
Factual Information 13 Railroad Accident Report

The statement that ërail brake as suggested by the specification is not possibleí is

incorrect. The suggested concept is actually in use in the USA, Switzerland,

Germany, and France, and has been proven to be efficient and reliable. [Yantrak]

should support [its] claim with specific evidence.

Between August 22, 1995, and September 6, 1995, Harris, Parsons, and Yantrak

exchanged correspondence concerning track brakes. The need for a ìfail-safeî application,

current industry applications of various forms of track brakes, track brake guard rails, a

second haul cable, and additional braking calculations were discussed. A September 7,

1995, interoffice Parsons communication stated:

Öit is my understanding that a decision has been made by [Harris] not to have a

track brake to stop the Angelís Flight vehicles should a rupture of the haul cable

occur.

It is my professional opinion that the above violation of the technical specification

is unacceptable because of the risks of potential injuries/fatalities it may cause to

the passengersÖ. My advice is that [Parsons] should stand firm on the issue or

disclaim any responsibility. Alternate solutions will require a complete re-study of

the conceptual design. (Example: 2 haul cables.)

Parsons sent a letter to Harris on September 8, 1995, objecting to the elimination

of track brakes from the Angels Flight vehicles. That letter stated, in part:

[Harris has] advised that [Yantrak] Ö has proposed to delete the track brake

required.Ö The reason stated for this deletion was incompatibility between the

conceptual arrangement of the track brakeÖand the guard railÖ. As previously

stated, we find no incompatibility between the conceptual arrangement of the

track brake and the guard rail. It is our opinion that the deletion of the track brake

is an unacceptable departure from the technical specifications. In the event of a

rupture of the haul cable the absence of the track brake poses the risk of potential

injury or fatality to passengers. Therefore, it is recommended that [Yantrakís]

proposal be rejected.

Harris, with the Community Redevelopment Agency giving final approval,

decided not to equip the Angels Flight vehicles with track brakes. An October 10, 1995,

Parsons document details a review of Yantrak technical drawings. Under the ìTrucksî

section, the review states in part: ìOnly a single cable is shown. Since it is understood that

the vehicle will not have track brakes, there should be two cables for safety conditions.î

Records indicate that on October 11, 1995, a Parsons engineer sent an interoffice

communication with annotated photographs of current funicular operations that had either

track brakes or two haul cables; these were Peak Tramway in Hong Kong, with two haul

cables and no track brakes, and Rigiblick in Switzerland, with one haul cable and track

brakes.

A meeting was held in Atlanta, Georgia, on November 11, 1995, between Parsons

and Harris. Minutes of that meeting state the following:
Factual Information 14 Railroad Accident Report

The general safety philosophy of the drive system is discussed at length.

[Parsonsís] representatives state that over-design of the drive system is not a

satisfactory answer to their concerns about the safety of the system. A failure

analysis has not been performed by [Yantrak] to identify the possible catastrophic

hazards, and should be required. However, it can be said that there is always a

possibility of rupture of the haul cable, or slip of a pinion or bull gear, and both

may cause a catastrophic hazard. Present industry practices show that a track

brake will satisfy the safety requirements, as well as the redundancy approach of

having a second haul ësafetyí cable. However, due to the project schedule, the

track brake approach seems the only possible solution to comply with the safety

requirements without impact on the project schedule. A quick review of the

undercarriage structure shows that there should be no problems to weld two track

brake mounting assemblies to the metallic beams supporting the wooden carbody.

The Harris construction manager wrote to Pueblo on November 28, 1995, to

express concern about modifying Parsonsís original Angels Flight design:

One of [Parsonsís] concerns about your design was the lack of precedent for a

system without a safety cable or track brake. [Yantrak] has always indicated that

the systems in Pittsburgh operate without either component. [Yantrak] is incorrect.

I have photographs of the two Pittsburgh systems and both have safety cables. It

would be of benefit if you could produce a documentable example of a system in

operation that is similar to the one you are currently designing.

On January 22, 1996, about 1 month before Angels Flight began passenger service,

Parsons wrote the following to Harris:

The submitted documents [see below] show evidence that the proposed design is

not in compliance with the required scope of work as related to the safety of the

system. As written, they pass on to the Owner, or his representative, the

responsibilities/liabilities of a non compliant and non failsafe design.

Supporting documentation for the letter detailed the following specific safety

weaknesses:

ï Lack of a back-up safety feature for a haul cable rupture; 

ï Inadequate definition of supervisory responsibilities; 

ï Lack of detailed operating procedures; 

ï Inappropriate operating prohibitions; 

ï Lack of an emergency evacuation plan; 

ï Lack of details, definitions, and values for maintenance procedures and

inspections of the undercarriage, haul cable, drive frame, gear case, gearbox

mounting flange, rope drum, D-9 hubs, and gearbox; 

ï Out-of-date log sheets and inspection forms; and 

ï Inadequate recommendations to address the deficiencies of the proposed

design identified in the hazards analyses. 
Factual Information 15 Railroad Accident Report

There is no indication that, in response to this letter, substantial revisions or

inspection procedure changes were made to Angels Flight before it opened for passenger

service. In a February 13, 1996, letter to Pueblo, Yantrak declared that a careful analysis of

the conceptual design showed areas that were technically incorrect or inefficient. On the

issue of track brakes, the letter stated that ìSuggested use of the caliper rail brake was an

oversight, since such a brake cannot be employed on the split rail of the train bypass.î The

letter also stated that: 

A higher level of safety was achieved by conservatively sizing the rope and rope

supporting elements and in the redundancy of rope attachment, than by

monitoring the loss of the rope tension and vehicle overspeed and applying a

secondary safety device acting in the case of rope failure.

End Gates

End gates were proposed for the Angels Flight vehicles by Parsons in its 1993

design. The proposal was based on a formal hazard analysis. The Community

Redevelopment Agency approved installation of end gates and included the requirement

in the contract that was later awarded to Pueblo.

Throughout the Angels Flight reconstruction project, the Los Angeles

Conservancy, a historic conservancy group, provided information to the Community

Redevelopment Agency concerning the historical accuracy of the restoration.6 The historic

conservancy group objected to the Angels Flight vehiclesí being equipped with end gates.

According to the group, the cars operated with open entrances and exits without incident

from 1901 until 1969. The cars were restored without end gates.

In a February 14, 1996, letter to Pueblo, Harris included in its safety concerns

about Angels Flight the following about the end gates on the cars:

Ö The formal design (not concept) required gates on the cars. These have not

been installed on four of the openings. What issues are involved with the removal

of these gates?

The cars were operated without end gates at the ceremonial opening February 23

to 25, 1996, and in passenger service thereafter.

A March 25, 1996, letter from Harris to Pueblo about contract requirements that

needed to be either completed or discussed stated: ìProvide gates to cars and automatic

stop provisions as required or provide professional opinion supporting evidence that the

system can be operated safely without the specified gates and interlocks.î

A Community Redevelopment Agency memorandum to Pueblo dated April 5,

1996, requested a change order in the existing contract regarding the end gate. The

memorandum stated the following: 

6 The primary liaison between the Conservancy and the Community Redevelopment Agency was an

individual who later became president of both the Angels Flight Railway Foundation and the Angels Flight

Operating Company.
Factual Information 16 Railroad Accident Report

The contract specifications Ö required gates to be added to the two historic

funicular cars as part of the rehabilitation of the cars. As work progressed Ö for

the reconstruction of Angels Flight, it became apparent that there was a conflict

between the two contracts. Ö Review of the plans for the reconstruction by the

system designer [Parsons] and the system operator [the operating company] along

with the regulatory agencies [Public Utilities Commission] led to the question of

whether or not the gates are really necessary.

In a May 20, 1996, letter to Pueblo, Harris wrote: 

[Community Redevelopment Agency] desires that [Pueblo] take the necessary

steps to immediately install the gates to the cars. Gates at the lower ends are of

utmost importance at this time. Please advise [Harris] of the proposed schedule

for shop drawings, construction and installation.

In a July 29, 1996, letter to the Community Redevelopment Agency concerning

this issue, the Angels Flight president (the president of both the nonprofit foundation and

the for-profit operating company) wrote: 

[Rule Company (the company that provided liability insurance for Angels Flight),

in its] ëInsurance Review of Operationsí confirms the opinions expressed when

the underwriters first studied [Angels Flight] and underwrote [the] liability

insurance with the cars operating open-ended ñ as the cars operated for 68 years. 

The letter from the Angels Flight Operating Company also stated that the Rule

Companyís letter confirmed that after conducting a review of the first 5 months of

operations, ìthe insurers are not aware of any problems, including any relating to ëthe

traditional open end of the cars.íî (Emphasis in original.)

On July 30, 1996, Harris sent a written proposal detailing ìSafety Gate Shop

Drawingsî and ìSample of Metal Meshî to Tetra Design, Inc.,7 for review and approval.

In an August 6, 1996, letter to Pueblo, Harris mentioned the end gates and reminded

Pueblo that it had not yet complied with the contract requirement that Angels Flight would

not operate if a gate were open and would stop if a gate were opened while the tramway

was operating.

During October 1996, the Community Redevelopment Agency staff exchanged a

series of memorandums concerning end gates for Angels Flight. In that correspondence,

the Community Redevelopment Agency deputy administrator first opposed the addition of

end gates because he believed the risk of a passenger falling from a car with an open end

was lower than the risk of a passenger being pinched or hurt by a gate, and ìthe additional

occasional risk from a passenger relying upon a closed end gate that fails is far greater

than the risk of having no gates.î However, the Community Redevelopment Agency

engineer assigned to the Angels Flight project protested the decision not to have end gates

on the Angels Flight cars. Some of that engineerís objections were as follows:

7 Tetra Design, Inc., was a prospective subcontractor for designing the end gates.
Factual Information 17 Railroad Accident Report

ï He and others had observed conditions on Angels Flight cars where accidents

could have occurred. 

ï The original design team of engineers and transportation experts saw the need

for gates to prevent a person from falling out of the Angels Flight cars, which

led to gates being specified that were to be interconnected to the control system

to stop the drive system if a gate was opened. 

The project engineer summarized his view as ìWhen weighing the risks of persons

getting a pinched finger vs. a possible fatality, Ö we should protect against the possible

fatality.î 

The deputy administrator then changed his mind on end gates. The Harris

construction managerís written notes indicate that the project engineer:

ï Told the Harris construction manager that he had been directed by his

supervisor to install the gates, 

ï Had prepared a letter to Harris directing that the gates be installed, and

ï Sent word to the Community Redevelopment Agency director asking whether

the decision to install the gates would be appealed to the Community

Redevelopment Agency board.

Before the end gates could be installed, the Angels Flight president wrote an

objection to the Community Redevelopment Agency deputy administrator, stating: 

Ö Is it most prudent to add new gates, as some have suggested, or is it more

prudent to leave the cars as they always have beenóopen at the ends? This is an

issue that the Angels Flight Operating Company and our insurance advisers have

studied carefully. Our conclusion is that it would be less prudent to add new gates.

Ö In every case, the hazards of adding gates equal or outweigh the hazard of

leaving the cars as they have been for the first 68 years of operation and for the

past 8 months of renewed operation. This is why my advisers and I have

concluded that what is most prudent is to not alter the cars by adding the

proposed end gates. [Emphasis in original.]

In response, the Community Redevelopment Agency administrator wrote to the

Angels Flight president announcing the issuance of a contract change order to delete

installation of the end gates. The letter noted that it was at the insistence of the Angels

Flight foundation and operating company that the agency had contemplated issuing the

change order. The administrator also stated that there were safety advantages and

disadvantages involved with installing end gates and that the decision not to install the end

gates must continue to be studied. Finally, the letter stated that the change order to delete

the end gates from the Angels Flight cars would be issued provided that five safety

conditions were incorporated in the agreements to be executed between the Community

Redevelopment Agency and the Angels Flight Railway Foundation for the conveyance

and operation of Angels Flight. As written, those conditions were as follows: 
Factual Information 18 Railroad Accident Report

First, upon the execution of the conveyance documents, the [foundation] and the

[operating company], or any subsequent operator, will be wholly responsible for

the maintenance and operation of Angels Flight, including the safety and security

of the Angels Flight patrons, as already set forth in the conveyance documents.

Second, the [foundation] and the [operating company] will be legally liable for

any event or occurrence related to the design, installation and operations of the

railway following the conveyance of Angels Flight to the [foundation] and must

defend, indemnify and hold harmless the Agency, its Board and staff and the City

of Los Angeles.

Third, appropriate signage must be installed or verbal warnings enhanced to

advise riders of the potential for harm that exists because of the open ends of the

cars. Ö

Fourth, a monitoring procedure, including electronic monitoring, such as was

discussed in the August meeting and agreed to in your October 29 letter, should be

considered by the [foundation] and must be formally incorporated into the Angels

Flight operations. Ö

Fifth, and finally, the end opening of the cars must continue to be studied by the

[foundation] and [the operating company] for the dual purposes of potential future

installation of the end gates and equally important, the introduction of other safety

and security measures which may be beneficial.

In a November 13, 1996, letter, the Community Redevelopment Agency

administrator instructed Harris to prepare a change order that deleted the requirement for

end gates on the Angels Flight vehicles. The letter stated that the gate requirement was

deleted after a comprehensive and diligent review at the request of the current operator of

Angels Flight and the nonprofit foundation. The next day, November 14, Harris issued a

request for quotation to Pueblo that stated: ìDelete the four gates, hardware, design and

interconnect to the operating system as shown at the top and bottom of the funicular

cars.Öî

Emergency Walkway

Parsonsís original design called for a walkway along the entire length of the

guideway for the evacuation of passengers from stranded vehicles. Preservationists raised

concerns about the historical accuracy of the walkway as early as 1993, pointing out that

Angels Flight did not have such a walkway between 1901 and 1969. Parsons wrote a

memorandum to Harris on December 6, 1993, on the subject of safety versus historical

accuracy issues:

Öthe Project Owner [Community Redevelopment Agency] must exercise final

approval on various Project features, characteristics, etc. i.e., it cannot delegate

certain policy matters to its consultants. Under California Government Code

Section 835, a public entity is liable for injury caused by a dangerous condition of

its property if the dangerous condition was created by a negligent or wrongful act

or omissionÖand failed to take appropriate measures to protect against the
Factual Information 19 Railroad Accident Report

dangerous condition. Ö a successful effort by others to override the Public

Utilities Commission and/or the Fire Department on the need for the emergency

staircase Ö would place the Community Redevelopment Agency in jeopardy. 

The Community Redevelopment Agencyís deputy director of engineering detailed

his position concerning the necessity of an emergency walkway next to the Angels Flight

trackway in a memorandum to the Community Redevelopment Agency director of

engineering dated March 2, 1995. In that memorandum, he stated that the Community

Redevelopment Agencyís acting administrator and senior staff concurred with the need for

an emergency walkway and raised concerns that Angels Flight might not be insurable

without it. 

In a March 24, 1995, letter to the Angels Flight Operating Company, an insurance

loss control consultant stated his opinion that the track-adjacent walkway ìcould present

an attractive nuisance and facilitate vandalism and malicious mischief.î In a March 28,

1995, letter to the Community Redevelopment Agencyís deputy director of engineering, a

supervising engineer from the Public Utilities Commission Rail Transit Safety Section

noted that the Public Utilities Commission staff agreed that the safety advantages of the

proposed emergency walkway immediately adjacent to the Angels Flight trackway were

outweighed by the attractive nuisance safety hazards created. 

On April 18, 1995, the Community Redevelopment Agencyís director of

engineering issued a memorandum to eliminate the emergency stairway. That

memorandum stated the following:

This Change Order authorizes the contractor to proceed with designs for requested

changes which would alter the method of providing emergency egress from the

funicular. The Los Angeles City Fire Department (LAFD) and the State Public

Utilities Commission have given their approval to delete the trackway emergency

stairway they had required, if certain other equipment and facilities are added to

Angels Flight.

BACKGROUND

During the planning for the reconstruction of Angels Flight, the regulating

agencies, the LAFD and the Public Utilities Commission, required that some

method of emergency egress be provided for the funicular even though

historically there was none. After many discussions, LAFD and the Public

Utilities Commission recommended that a trackway emergency stairway be

included in the plans.

Because a trackway emergency walkway was not in keeping with the historic

context of Angels Flight, the Los Angeles Conservancy expressed concerns about

its inclusion during review of the reconstruction plans. ... a member of the

Conservancy and potential operator of Angels Flight, further investigated the need

for the trackway emergency stairway and any alternatives thereto. Through

various meetings with LAFD and the Public Utilities Commission, [he] has

convinced them to agree to an alternative to the trackway emergency stairway

which would consist of:
Factual Information 20 Railroad Accident Report

ï A combination ground-level and elevated stairway separated from the

trackway

ï Auxiliary emergency power supply

ï Reversible funicular controls

ï Security system and fence

The items noted above were added during the renovation of Angels Flight by the

Community Redevelopment Agency. A walkway next to the trackway to facilitate the

emergency evacuation of passengers was never constructed.

Haul Cable

In the aftermath of the decision not to include track brakes or a safety cable on the

reconstructed system, Yantrak specified a haul cable that was thicker (7/8, or .875, inch in

diameter) and had a higher safety factor than the cable specified in the original Parsons

design. Yantrak did not redesign the drums on which the cable wrapped and unwrapped,

which were constructed to the original specifications. 

Cable Drum Design

The two Angels Flight cable drums were grooved to accept the cables as they were

wound onto the drums to help prevent deropement. The cable drums had outer flanges to

help contain the cable. Investigators measured the height of the flanges on both drums. On

the Olivet drum, the flanges measured .594 inch on the outer side and .75 inch on the

gearbox side. For Sinai, the measurements were .625 inch for the outer side and .75 inch

for the gearbox side. Postaccident examination of the drum for Sinaiís cable revealed that

during or immediately after the accident, the cable had become partially unspooled from

its drum. 

Deropement Switch Device

Both of the Angels Flight cable drums were equipped with switches intended to

activate the system brakes to stop the funicular in the case of deropement. (See figure 11.)

The switches contained pressure-sensitive edges and were mounted directly above the

surface of each haul cable when it was stored on its respective drum. Because the

deropement switches did not extend all the way across the drumís surface, the outboard

haul cable coils could derope without triggering the deropement switch, as occurred with

the Sinai drum in this accident.
Factual Information 21 Railroad Accident Report

Angels Flight had been in passenger service for several months before the

deropement switches were added. On August 12, 1996, Harris sent a letter to Pueblo

listing ìde-roping annunciation and system haltingî as requirements that had not been

completed. The deropement switches described above were subsequently added.

Operations

Gearbox Overheating

According to the Angels Flight president, high oil temperatures in the gearbox

became a concern soon after Angels Flight opened in February 1996. Angels Flight

representatives made repeated telephone calls to Yantrak in a continuing attempt to

evaluate and correct the problem. Yantrakís initial response referenced a memorandum

from Fairfield Manufacturing,8 which stated: 

Ö oil temperatures up to 225 degrees F will not cause gear or seal problems in

your Angels Flight drive. ÖThe level of oil in the box will change your operating

temperature. I would lower it to the centerline and see how much that helps. As

you continue to lower the level, the temperature will fall to a point where you are

no longer getting enough lubrication and then it will start to rise. Since your unit is

critical, I would not take this test to the point where you get the temperature rise

Figure 11. Deropement device.

8 Fairfield Manufacturing supplied most of the gears (but not the hubs, which were supplied by

Yantrak) for the Angels Flight gearbox.
Factual Information 22 Railroad Accident Report

but do feel you could safely go two inches below centerline and would see

significant improvement in oil temperature. 

During periods of overheating, incidents occurred in which the Angels Flight

system automatically shut itself down while in passenger service.9 A California State

assistant attorney general told the Safety Board that he had stopped riding Angels Flight

long before the accident because he had been stranded on the hill several times when the

system shut down while the cars were midway between stations. The assistant attorney

general said that Angels Flight operators told him that the shutdowns occurred when the

system ìgot hotî and that the only thing they could do was to wait for it to cool down. He

further said that on occasions when the system had stopped, he had observed other

passengers exit the cars and walk on the track structure to the bottom of the hill. The

Angels Flight vice president stated that he had seen a passenger evacuate a car and walk

down the track to the bottom of the hill when the cars were stopped. In a February 27,

1995, letter addressed to the insurer for Angels Flight, the Angels Flight president

referenced an insurance loss control consultantís recommendations that ìpassenger egress

from the cars or from the landings onto or near the tracks should be prevented at all times,

ëemergencyí or otherwise.î 

The Angels Flight president issued instructions that the cars would be stopped at

their terminal berths any time the oil temperature approached 225o F, but this procedure

did not completely eliminate the shutdowns. The operating company continued Angels

Flight passenger service and did not modify the operating schedule to help prevent delays

caused by excessive oil temperatures. 

According to the Angels Flight vice president, in 1996, the gearbox oil would heat

to the point that it vaporized and the vapor filled the machine room. As the oil cooled, it

would condense and leave a slick surface on the floor, walls, ceiling, and equipment.

During the on-scene investigation, the Angels Flight vice president said he had feared

during this period that an electrical spark or other source of ignition could trigger an

explosion. He stated that Yantrak was reluctant to install an oil cooler. Initially, an

expansion tank that collected the hot oil and returned it to the gearbox sump was added to

the lubrication system. The vice president said this measure helped with the overflow

situation but did not eliminate the overheating problem. He stated that the high oil

temperatures had carbonized the seals around the bearings in the gearbox in 1996, and the

seals began to leak. 

After a debate throughout 1996 that involved Yantrak, Angels Flight, the

Community Redevelopment Agency, Pueblo, and Harris, an oil cooler was added to the

system in 1997. Additionally, a synthetic oil replaced the conventional oil used previously,

and the bearings and seals on the drive side were replaced. The Angels Flight vice

president stated that the oil temperatures dropped into ìÖthe 150o [F] to 175o [F]

rangeÖî after these changes were made to the system. Eventually, all of the seals and

bearings that had been affected by excessive oil temperatures in 1996 were replaced in

1997.

9 An oil temperature sensor and monitoring system automatically shut down the funicular drive when

the oil temperature exceeded 225o F.
Factual Information 23 Railroad Accident Report

Maintenance

According to the Angels Flight Railway Operations and Maintenance Manual,

published by Yantrak and accepted by the operating company in 1996, the oil in the

gearbox was to be sampled and analyzed every 18,000 cycles or 6 months.10 There was no

guidance regarding the reasons for performing the oil analyses, the contaminants or

properties that should be measured, or how to evaluate the results of such testing. The

manual noted that the gears were to be inspected visually on an annual basis, but there was

no guidance on measuring gear wear or the appropriate tolerances between major

components within the gearbox.

Records of fluids analyses for 1997ñ1999 were reviewed. Fluids analysis tests

were performed on Angels Flight five times in 1997, three times in 1998, and three times

in 1999. The tests in 1999 showed that the level of iron in the oil was increasing. A fluids

analysis on June 2, 1999, noted that ìFE (iron) is starting to increase.î The company that

conducted the oil sampling recommended resampling after 250 hours. After the June 1999

oil analysis, bearings were replaced, and the drive system gears were visually inspected.

The gear hub splines (described in the next section of the report) were not inspected. No

further fluids analysis tests were performed after June 1999, however, contrary to the

semiannual requirement in the operations and maintenance manual. A postaccident fluids

analysis test on February 28, 2001, showed elevated iron levels in the gearbox oil

compared to previous oil analysis results.

Tests and Research

A series of tests and inspections was conducted at the accident site and at the

laboratory of Exponent Failure Analysis Associates (Exponent). The complete funicular

system and individual components were examined. The Public Utilities Commission, the

Community Redevelopment Agency, Angels Flight Railway Foundation, Pueblo,

Caterpillar,11 and Fairfield Engineering12 participated in the postaccident inspections and

testing. Testing and inspection protocols were developed by Safety Board staff and

Exponent, reviewed by the participants, modified as appropriate, and conducted and

documented by Exponent. The outcome of initial testing resulted in additional

examination in some areas.

Shafts, Splines, and Bearings

In the Angels Flight drive system, the planetary gears were connected to the cable

drums through axle shafts. Longitudinal grooves (splines) about 4 inches long had been

machined into each end of each axle shaft. These splined sections fit into and meshed with

10 Section VII, Gearbox, under Maintenance ñ Procedures and Intervals.

11 The drums for both of the cars were mounted on Caterpillar D-9 final drive hubs. 

12 The D-9 hubs were connected to a gearbox, with many of the parts supplied by Fairfield

Manufacturing.
Factual Information 24 Railroad Accident Report

splined receiving hubs for the planetary gears and the cable drums. The splines were

designed to lock these components in place.

The Angels Flight gearbox was disassembled. The gears, shafts, and splines from

both the Sinai side and the Olivet side were removed and examined and the results

documented. Parties to the investigation were present. 

Axle Shafts and Splines. The Caterpillar-manufactured axle shafts for both the

Sinai and the Olivet sides were found to be in good condition. For the Sinai car, metal

shavings were found on the surface of the axle shaft, and the splines of the end of the axle

shaft that engaged the planetary gear were slightly worn but otherwise intact. (See figure

12.) The outside diameter of the Sinai shaft, measured at the splines that mated with the

receiving hub splines, was 2.912 inches. The outside diameter for the Olivet shaft at the

corresponding splines was 2.917 inches.

Both axle shafts were subjected to Rockwell C hardness tests.13 The average

Rockwell C hardness for the Olivet shaft was 57 and for the Sinai shaft, 60. These

hardness levels are near the higher end of the range measured for steel and indicate that

the axle shafts were subjected to a hardening heat treatment to maximize their loadbearing capacity.

Figure 12. Splined end of Sinai axle shaft that engaged the planetary gear receiving hub.

13 Rockwell hardness tests range from A to V, with the test chosen depending on the hardness of the

material tested. The Rockwell C test is used for steel, hard cast iron, and titanium. The Rockwell B test is

used for softer metals, such as copper and aluminum alloys, soft steel, and malleable iron.
Factual Information 25 Railroad Accident Report

Sinai Receiving Hub and Splines. The Yantrak-supplied receiving hub for the

Sinai planetary gear was pressed out of the gear and then sectioned by electron discharge

machining. The splines that mated with those of the axle shaft were found to be stripped,

thereby preventing the interlocking of the planetary gear with the cable drum. (See figure

13.) Thus, the Sinai carís cable drum had effectively become disconnected from the drive

mechanism, and it became freewheeling. The metal shavings removed from the surface of

the Sinai shaft were consistent with the metal of the sheared female splines of the

planetary gear receiving hub with which the Sinai axle shaft splines mated. The sectioned

piece from this receiving hub was polished using standard metallurgical techniques and

then examined under an optical microscope. The microstructure was found to consist of

ferrite and pearlite typical of an unhardened steel. The sample of the receiving hub was

then subjected to hardness testing at a variety of locations through its cross section, both

near and away from the spline teeth. The hardness of the steel was between 78.0 and 80.5

on the Rockwell B scale for softer metals and was consistent throughout the piece. The

receiving hubís average Rockwell B hardness of 79 is typical of a nonheat-treated, soft

steel. Thus, the Sinai receiving hub was softer than the axle shaft. 

Ball Bearings. The ball bearings supporting the receiving hubs on both the Sinai

side and the Olivet side of the gearbox were inspected. The bearings on both the Sinai and

Olivet sides were coated with a hard black material where they were exposed to the oil

reservoir. The bearing races, or grooves for the ball bearings, showed some bluing.

Figure 13. Section of planetary gear receiving hub showing stripped splines.
Factual Information 26 Railroad Accident Report

Ground metallic residue that was removed during disassembly of the bearings was found

to contain both metal shavings originating from the sheared splines and small, spherical

pieces of metal that had spalled from the balls. The drum side (outer) ball bearing from the

Sinai side of the gearbox was sectioned for study. The outer race was found to be

relatively smooth with some pitting. The balls were badly chipped and pitted, as was the

surface of the inner race. The condition of the ball bearings was consistent with exposure

to high temperatures and inadequate lubrication. The bearings also may have been

subjected to high contact stress.

Brake System

As mentioned previously, the service and emergency braking systems have

calipers that are normally clamped shut by a number of springs, and hydraulic pressure is

needed to open the brake calipers. Investigators and party members measured the capacity

of the emergency brakes on each of the two drums by attaching the cable from the drum

through a 20,000-pound load cell to a winch attached to structural members in the

machine room. The winch was then used to increase the load on the cable gradually until

the drum moved. The maximum force indicated by the load cell was then recorded. Sinaiís

emergency brake withstood a cable load of 7,150 pounds before moving. Olivetís

emergency brake capacity was 4,700 pounds. In a second test, the Olivet emergency brake

capacity was measured to be 5,300 pounds, for an average of 5,000 pounds.

Service brake capacity was also tested. The service brake, like the emergency

brake, is normally clamped in the absence of hydraulic pressure. The test was conducted

by attaching a 10-foot torque bar to the coupling flange on the service brake and using a

hydraulic jack to apply a load to the end of the torque bar. In this test, the disk began to

slip when 2,250 foot-pounds of torque were applied to the service brake. This was within

the expected range for the service brake.

When the emergency brakes were operationally tested, the hydraulic pump

functioned as expected to build pressure in the system and cause the brakes to release.

This was the normal state during operation of Angels Flight. Further testing, however,

revealed that the brakes, once released, could not be reapplied. Investigators determined

that the solenoid valve, which was intended to open to relieve pressure (by returning oil to

the oil reservoir), had a burned-out coil and therefore did not operate. Because the valve

had failed in the closed position, pressure would build in the system to release the brakes,

but the always-closed valve would prevent the pressure reduction needed to engage the

brakes when needed. 

Solenoid valves are designed to be ìnormally openî or ìnormally closedî when

de-energized. In other words, application of electrical current to the solenoid will close a

normally open valve and open a normally closed one. The design of the electrical control

system for the Angels Flight emergency and service brake systems called for the hydraulic

pumps and solenoid valves to be energized whenever the brakes were to be released for

operation of the railway. To function properly, this design required a normally open

solenoid valve, which would close when energized, thus allowing sufficient hydraulic

pressure to build within the system to compress the springs and release the brake calipers.
Factual Information 27 Railroad Accident Report

Cutting power to the hydraulic pump and to a normally open solenoid valve would have

caused the solenoid valve to open, thus reducing hydraulic pressure and applying the

brakes. A normally open valve would also have been fail-safe, that is, it would have kept

the brakes applied (because of insufficient hydraulic pressure) in all four failure

modesfailure of the electrical system, failure of the solenoid itself, failure of the

hydraulic pump, or significant leakage within the hydraulic system. Moreover, in this

design, if a normally closed solenoid valve (which opens when energized, thereby

preventing hydraulic pressure buildup) were used, neither the service nor the emergency

brakes would have released. 

The latest available schematic diagram of the brake hydraulic system was stamped

and dated February 16, 1996, by a civil engineer employed by Yantrak. The diagram for

the service brake showed a normally closed solenoid valve. The diagram for the

emergency brake system did not indicate whether the solenoid valve was of the normally

closed or normally open type, but the parts list supplied by Yantrak specified a normally

closed valve. Although the two solenoid valve types perform opposite functions, they look

identical except for the part numbers imprinted on them. Inspection of the solenoid valves

used in the Angels Flight brake systems determined that the defective valve for the

emergency brake system was of the normally closed type, whereas the valve for the

service brake system was of the normally open type. 

Electronic Control System. As noted above, Yantrakís electric control drawings

show a system that either supplies electrical power to both the hydraulic pump and the

solenoid valve at the same time or to neither the pump nor the valve. When power is

supplied to both the pump and a normally closed solenoid valve, the pump attempts to

pressurize the brake system (to open the brake calipers) while at the same time the open

solenoid valve is draining off the pressure (to close the calipers). When no power is

provided to either the pump or the valve, the valve is closed, and it retains whatever

pressure was in the system at the time of the closing, resulting in unpredictable brake

behavior. In this design, normally open solenoid valves would have been required to apply

and release the brakes in a conventional, fail-safe manner.

Electronic-Hydraulic Control Interaction. The control electronics and hydraulics

for the emergency brake were reassembled. Pressure sensors were installed, and system

voltages were read at key locations using a computer data acquisition system. The

hydraulic hoses were attached to the emergency brake calipers to simulate, as closely as

possible, the conditions during actual use. Angels Flight personnel provided their

recollections of maintenance events to assist in the process. The following was determined

from the bench experiments and discussion:

ï Using the as-built Angels Flight control electronics and the normally closed

solenoid valve called for in Yantrakís design and parts list, the emergency

brake hydraulic system developed minimal hydraulic pressure because of the

open relief valve. Because the specifications called for the hydraulics to supply

a minimum pressure of 1,500 psi to open the brakes, it was concluded that in

the as-designed condition, neither the emergency brakes nor the service brake

should ever have released.
Factual Information 28 Railroad Accident Report

ï The fact that the Angels Flight system operated for 5 years showed that the

brakes did, in fact, function to some extent. It was theorized that Yantrak may

have discovered during initial testing that the brakes would not function and

must have replaced the normally closed solenoid valves with normally open

ones. After this replacement, both the emergency brakes and the service brake

would have functioned. Another possibility is that the system was initially

constructed using normally open valves even though the drawings and parts

list indicated normally closed valves. 

ï Angels Flight service logs show that one of the solenoid valves later burned

out and was replaced. After the solenoid valve failed, Angels Flight ordered

normally closed replacement valves. It is not clear from the logs or statements

made by Angels Flight maintenance personnel whether the solenoid valve that

burned out was an original equipment unit or a replacement unit that was

ordered in accordance with Yantrakís parts list. 

As previously noted, however, a normally closed solenoid valve would have

prevented the emergency brake from releasing. No information was available to

investigators that would explain how the funicular could have been operated with a

normally closed valve installed in the emergency brake system. However, once the

normally closed solenoid valve failed, the railway could be operated, albeit without

available emergency brakes. 

Daily Brake Testing. The Angels Flight vice president stated that he personally

performed the daily and monthly maintenance inspections, following the operations and

maintenance manual, which included inspecting brake operation. Daily inspections were

performed in the morning before passenger service began. The vice president said he

would manually reposition the cars from their overnight storage positions14 so that one car

(typically Olivet) was at the upper station and the other car was at the lower station. When

the cars had been repositioned, he would place the system in automatic operation from the

operatorís station house and wait for the cars to begin accelerating. Before the cars

attained full speed, he would engage the emergency brake button. The vice president

further testified ìAs I was doing my inspection in the machine room, daily, I would climb

up this ladder and the machine was set on a cantilever and you could actually, you know,

physically see that the pads were dropped and thatís one of the procedures.î However, the

emergency brake pads always looked like they were dropped, because of their distance

from the ladder and the small clearances separating the brake pads from the drum flanges.

As noted previously, the postaccident inspection found that the emergency brake system

had a burned-out coil and therefore did not operate. 

Capacity of Components

Exponent reviewed and analyzed calculations generated by Yantrak for the size

and durability of gears, ropes, splines, brakes, bearings, and structural components. The

calculations were stamped by a Yantrak civil engineer and dated October 9, 1995. In the

14 The cars were stored beside each other on the passing portion of the track structure.
Factual Information 29 Railroad Accident Report

course of its review, Exponent discovered several errors in those calculations that are

believed to have affected the selection of brake size and the lifetime of the gears and

splines:

ï In a hand calculation sheet marked ìDrive Frame Analysis, Angels Flight

Funicular, Community Redevelopment Agency ñ Los Angeles, CA,î under the

subheading ìEqpt Weights & Rope Forces,î rope tensions are calculated

assuming a ìcrush loadî of 20,000 pounds in the car and a slope of 19 degrees.

In a later page of calculations titled ìHaul Rope Analysis,î Yantrak uses a 0.1 g

acceleration rate to the calculated maximum rope tension noted above to arrive

at a total maximum rope tension of 9,080 pounds. In the Angels Flight

acceptance tests on February 15, 1996, the cars were brought to a stop from

full speed in 1.0 second under a variety of loading conditions, including crush

loads on both vehicles. Since the maximum speed of the cars was 352

feet/minute, or about 5.9 feet/second, this test corresponds to a measured

average acceleration of 0.18 g, almost double the acceleration assumed by

Yantrak. Thus, Yantrakís calculation underestimates the maximum rope

tension (10,680 pounds) by 1,600 pounds. Furthermore, this figure accounts

for the average acceleration only, and not for transient dynamic effects, which

occur whenever the brakes are applied. These dynamic effects can be

substantial and further increase component stresses. The underestimation of

the load affects the calculated life of all gears, shafts, and splines.

ï According to page 7 of Yantrakís typed calculation and the catalog from the

emergency brake caliper manufacturer, the disc brakes have a maximum

available braking force of 12,814 pounds. Assuming Yantrakís figure for

maximum rope tension, 9,080 pounds, and accounting for the difference in

effective moment arm for the brakes (29.5 inches from the drumís center of

rotation) and the rope (35 inches from the drumís center of rotation), Yantrak

calculates a maximum required brake force of 10,772 pounds. Using the larger

acceleration described above, the maximum required brake force is 12,671

pounds, which is at the upper limit of published maximum brake capacity for

these brake calipers. 

ï On page 6 of the typed calculations, under the headings ìInput [Axle] Shaft to

D-9 Hubî and ìGear Shaft [Hub] Splined onto D-9 [Axle] Shaft,î appear to be

calculations of the stresses in these components. However, the calculations do

not address the splines themselves, but only the two parts that are splined

together (the D-9 axle shaft and the receiving hub on the planetary gear). But

because the splinesí teeth reduce the load-bearing surface area and introduce

stress concentrations, the splines are significantly weaker than the shafts.

Furthermore, the stresses in the shafts are calculated assuming 15,000 inchpounds of torque. Assuming Yantrakís own figure of 9,080 pounds of rope

tension on a 35-inch-radius drum and accounting for the 20:1 gear reduction on

the D-9 hub results in a torque of 15,900 inch-pounds. The corrected rope

tension of 10,680 pounds results in a hub torque of 18,700 inch-pounds. These

figures exceed the torque used by Yantrak in its calculations. Transient

dynamic effects would lead to further increases in the effective torque

experienced by the gears, shafts, and splines.
Factual Information 30 Railroad Accident Report

Funicular Railway Standards

At the time Angels Flight was redesigned and renovated, California had no

standards or regulations for the design, construction, and operation of funiculars. Also at

that time, the American National Standards Institute (ANSI)15 had no explicit standard

covering funiculars, although sections of Standard B77.1, Aerial Tramways, Aerial Lifts,

Surface Lifts, and Tows Safety Requirements, contained guidance that could apply to

portions of the Angels Flight system. Since approximately 1984, Colorado has had

regulations that cover design, construction, and maintenance of funiculars in the Colorado

Passenger Tramway Safety Boardís Passenger Tramway Rules and Regulations. The

Colorado regulations include ANSI Standard B77.1, revisions to ANSI rules by the

Colorado Board, and additional technical rules. The California Public Utilities

Commission did not reference any particular set of standards that were to be followed in

the reconstruction of Angels Flight.

By February 2001, ANSI began internal circulation of a draft Standard B77.2,

Funicular Safety Requirements, specifically for funiculars. The B77 Accredited Standards

Committee has approved a draft, but it has not been adopted as final by ANSI. The first

tentative funicular standards were developed in the early 1980s. The tentative standards

were available to the parties during the Angels Flight reconstruction project. Because

Standard B77.1 did not cover funicular systems, the tentative standards were suggested for

use as a guideline for any authority having jurisdiction in connection with the design,

manufacture, construction, and operation of a funicular system.

After the accident, a review was made of the ANSI and Colorado standards that

were available to, if not specifically referenced by, the Public Utilities Commission and

that addressed issues of funicular safety. The guidance existing at the time Angels Flight

was redesigned and rebuilt (ANSI tentative standards and the Colorado regulations)

agreed that a tramway should have two completely independent brake systems that do not

operate at the same time and that each car should be equipped with a braking system

capable of stopping and holding the car in the event of a rope failure. 

The tentative ANSI standards called for each car to have doors that filled the entire

entrance opening. Additionally, they stated that each door should have a lock located so

that it could only be locked and unlocked automatically or by an authorized person. The

tentative standards also stated that funiculars should be equipped with means for

evacuation of passengers from stranded vehicles along the entire length of the guideway.

The tentative ANSI standards and the Colorado standards stated that cable drums should

be designed and built to retain the cable in the event of the failure of a drum, shaft, or

mounting. Grooves in the drum were to be designed and built to retain the haul cable in the

event of a deropement. A minimum flange extension of 1 1/2 times the cable diameter

(measured from the bottom of the cable groove) was considered adequate.16

15 ANSI is a private organization that administers and coordinates the U.S. voluntary standardization

and conformity assessment system.

16 The Angels Flight cable was .875 inch in diameter. Therefore, the minimum flange extension would

be 1.31 inches. The flanges on the Angels Flight cable drums measured between .594 and .75 inch.
Factual Information 31 Railroad Accident Report

Regulatory Oversight

In a December 10, 1991, letter to the Community Redevelopment Agency project

manager, Parsons called for the creation of a task force to address jurisdictional and safety

issues related to the renovation of Angels Flight. Representatives from the California

Public Utilities Commission, the City of Los Angeles Department of Building and Safety,

the Los Angeles Fire Department, and the Community Redevelopment Agency staffed the

task force. 

The California Public Utilities Commission accepted the responsibility to view

Angels Flight as a public utility and to monitor the safety of the design, construction, and

operation of Angels Flight. In so doing, it applied selected portions of the provisions from

its Rail Transit Safety Sectionís procedures manual for State safety oversight of rail fixed

guideway systems. In part, California Public Utilities Code 99152 reads as follows: 

Any public transit guideway planned, acquired, or constructed, on or after

January 1, 1979, is subject to regulations of the Public Utilities Commission

relating to safety appliances and procedures. Ö The commission shall develop an

oversight program employing safety planning criteria, guidelines, safety

standards, and safety procedures to be met by operators in the design,

construction, and operation of those guideways. Existing industry standards shall

be used where applicable.Ö

On September 16, 1994, the Rail Transit Safety Section of the Public Utilities

Commission Safety Division issued Safety Oversight Plan for Design and Construction of

Angels Flight Funicular Railway. That plan stated, in part: 

Successful implementation of the [Public Utilities Commission] staffís safety

oversight plan will Ö effectively serve as an endorsement of the Community

Redevelopment Agencyís decision to begin revenue service on the Angels Flight

Funicular Railway Project.

The Public Utilities Commission staff suggested that the Community

Redevelopment Agency and its consultants perform safety hazards analyses on the Angels

Flight project and then indicate the actions required to mitigate hazards to passengers and

employees through design solutions and operating procedures. The Public Utilities

Commission staff commented on the adequacy and completeness of the hazard analysis

and on the efficacy of the design solutions and operating procedures and witnessed the

testing of equipment where the effectiveness and completeness of those procedures were

demonstrated.

Between 1993 and 1996, Parsons and Harris submitted copies of the preliminary

hazard analysis report, the preliminary operations and evacuation plan, and the emergency

evacuation plan to the Public Utilities Commission. The preliminary hazards analysis

report identified hazards that needed to be addressed during the reconstruction process.

Among the identified hazards were the lack of end gates on both cars, the lack of track

brakes, and the absence of an emergency stairway. Public Utilities Commission staff

reviewed the documents and concurred with the reportís findings. 
Factual Information 32 Railroad Accident Report

The Federal Transit Administration required States to designate an oversight

agency to implement requirements of 49 Code of Federal Regulations 659, ìState Safety

Oversight of Fixed Guideway Systems.î The Governor of California designated the Public

Utilities Commission as the State oversight agency. Public Utilities Commission

representatives said that although Angels Flight met the definition of a railway for Public

Utilities Code 99152, it did not meet the full Federal Transit Administration definition of a

rail fixed guideway system. Nevertheless, Public Utilities Commission staff members said

they believed it necessary to monitor the operations of Angels Flight, and they applied

some of the provisions of the Public Utilities Commissionís Rail Transit Safety Section

Procedures Manual for State Safety Oversight of Rail Fixed Guideway Systems.

The day before the scheduled ceremonial opening of Angels Flight on

February 23, 1996, the Harris construction manager sent a letter to the Community

Redevelopment Agency that stated: 

I have reviewed the submissions by Pueblo and Yantrak relating to the safety and

capacity of Yantrakís design. Based on that review I will recommend to the

[Community Redevelopment Agency] that the system designed by Yantrak be

accepted by change order as equivalent in safety and operation to the Ö design

proposed in the contract drawings.

The Public Utilities Commission supervising engineer sent a letter to the

Community Redevelopment Agency acknowledging the Public Utilities Commissionís

acceptance of the Community Redevelopment Agencyís letter certifying that ìAngels

Flight is safe for limited use during the three-day dedication weekend.î The letter stated

that Public Utilities Commission safety oversight would ìcontinue after the dedication

weekend until all of the outstanding issuesî were completed, that is, acceptance of the

operations and maintenance manual, completion and acceptance of the hazards analysis,

and training of the Angels Flight operating personnel. On February 23, 1996, Angels

Flight began service to the public for the ceremonial opening. 

In March 1997, Public Utilities Commission staff performed an inspection of

Angels Flight that was limited to witnessing a magnetic haul cable inspection. Public

Utilities Commission staff members stated that they performed informal checks of Angels

Flight throughout the succeeding years. 

On January 9, 2002, the Public Utilities Commission filed an order to initiate

rulemaking concerning safety certification. The Public Utilities Commissionís existing

requirements (General Order17 164-B) focused on the safety of transportation systems

after they are placed in passenger service. On February 27, 2003, the Public Utilities

Commission adopted General Order 164-C, Rules and Regulations Governing State Safety

Oversight of Rail Fixed Guideway Systems, which supersedes General Order 164-B. The

new rule strengthens the safety review process before passenger service is initiated by

17 General Orders set rules for all utilities or classes of utilities, as opposed to decisions rendered in a

particular case for a particular utility.
Factual Information 33 Railroad Accident Report

establishing Public Utilities Commission review and approval requirements for safety

certification program plans, project-specific safety certification plans before construction,

and project-specific safety certification verification reports before passenger service. As

defined in the rule, a public transit guideway would include all rail transit agencies, rail

fixed guideways, and all other light rail, rapid rail, monorail, inclined plane, funicular,

trolley, or automated guideways offering transit service to the public, whether or not

Federal guidelines or definitions apply. 

Current Status

The Angels Flight railway has not been in operation since the accident on

February 1, 2001. 
34 Railroad Accident Report

Analysis

The Accident

Postaccident inspection of the Angels Flight drive mechanism revealed that the

Sinai car stopped ascending and began its uncontrolled descent when the drive axle for the

carís cable drum became disengaged from its driving planetary gear. When the Angels

Flight operator saw the car begin to descend the grade, he pushed the stop button on the

operatorís console, which should have simultaneously activated the service and

emergency brakes. But the service brakes, which operated on the drive train, had no effect

on the freewheeling cable drum that was no longer connected to the drive train

mechanism. The emergency brake would have stopped, or at least slowed, the rotation of

the cable drum had it applied, but it was found to be inoperative. The cars themselves were

not equipped with track brakes that could have operated independently to significantly

slow the car or bring it to a stop before the collision. End gates on the cars may have

prevented the passenger from being ejected from the end of the Olivet car when it was

struck by the Sinai car. Finally, rescue efforts were hampered by the absence of emergency

walkways that would have facilitated evacuation of injured passengers. 

The Safety Boardís investigation of this accident focused on the following safety

issues:

ï The adequacy of the safety oversight of the Angels Flight reconstruction

project; 

ï The adequacy of the design of the reconstructed Angels Flight system;

ï The adequacy and appropriateness of the braking systems designed for Angels

Flight; and

ï The adequacy of Angels Flight Operating Companyís maintenance and

operating procedures.

Gear Hub Failure

The splines on the Sinai planetary gear receiving hub were found to be stripped,

which prevented the gear from engaging the axle shaft. This allowed the axle shaft to

rotate within the planetary gear hub and rendered the cable drum (connected to the other

end of the axle shaft) freewheeling. Testing revealed that the steel used for the receiving

gear hub was much softer than the steel used for the axle shaft. The difference between the

hardness of the receiving gear hub and that of the axle shaft likely contributed to the

failure of the gear by accelerating the damage to the softer gear hub splines. The presence

of metal shavings on the Sinai car axle shaft indicated that damage to the planetary gear

hub splines had been occurring for some time before the accident. 
Analysis 35 Railroad Accident Report

The failure of the Sinai planetary gear receiving hub may also have been

accelerated by the daily brake tests conducted on the system. The Angels Flight Operating

Company vice president tested operation of the brakes by placing the cars in operation and

then activating the system service and emergency brakes to bring the cars to a stop. Under

normal conditions, the service brakes would have stopped rotation of the motor shaft

while the emergency brakes simultaneously stopped rotation of the two cable drums. But

postaccident investigation revealed that, for some period of time before the accident, only

the service brakes were operable. During the daily brake tests, the service brake activated

to stop the driven sun gear, but without emergency brakes, substantial dynamic forces

acted on the cable drums and various components of the drive system. 

Finally, the investigation determined that the dynamic and transient forces acting

on the various components of the drive gear system, including the axle and receiving gear

hub splines, were greater than those calculated by Yantrak. Because these calculated loads

were used to develop the specifications for the drive system components, the service life

of those components, including the gear hubs and splines, would likely have been less

than predicted even under normal conditions. Under the abnormal stress conditions posed

by the daily brake tests conducted with non-functioning emergency brakes, the rate of

damage likely increased, as did the likelihood of the kind of catastrophic failure that

occurred in this accident. The Safety Board concludes that the planetary gear hub for the

Sinai car failed because of one or a combination of the following: (1) the metal used in the

manufacture of the gear hub was considerably softer than the metal used for the axle shaft

with which it mated, causing deformation damage and eventual failure; (2) the drive train

components, including the planetary gear hubs, were not designed for the stresses to

which the components were subjected during operation; and (3) the daily brake tests,

which were conducted for some period of time without working emergency brakes, placed

additional stress on the drive train components and accelerated gear hub damage. 

Postaccident research and inspection also revealed that the Angels Flight drive

system was equipped with deropement switches and cable drum flanges that were

inappropriately sized. The .875-inch-diameter cable needed 1.31-inch flange extensions

on the drums to meet the minimum height that was considered adequate. However, all of

the flange extensions were less than 1 inch high. Further, initially the gearbox lubrication

system was problematic, allowing the lubrication oil to overheat and cause system

shutdowns. This deficiency went unresolved for more than a year until an oil cooler was

installed.

The Safety Board therefore believes that before recommencing passenger service

on the Angels Flight funicular railway, the Community Redevelopment Agency should

conduct a comprehensive review of the design and specifications for the Angels Flight

drive system, then make the design or component changes necessary to ensure that the

drive system meets accepted industry standards and engineering practices. 
Analysis 36 Railroad Accident Report

Brake System Failure

Once the cable drum for the Sinai car became disconnected from the drive gear

system, the carís haul cable was able to unwind freely as gravity pulled the car down the

incline. The emergency braking system was designed to prevent such an occurrence by

clamping against the cable drum flanges to stop the drumís rotation. Had the emergency

brakes functioned when activated by the operator, the descent of the car would have been

stopped even though the cable drum was no longer connected to the rest of the drive

system. The Safety Board therefore concludes that had the Angels Flight emergency

braking system been functional on the day of the accident, the brakes would likely have

stopped the descent of the runaway car and prevented the collision. 

The investigation determined that if the Angels Flight service and emergency

braking systems had been installed in accordance with the design drawings and parts list,

neither of the brakes would have released, and Angels Flight could not have been

operated. In this design, normally open solenoid valves would have been required to apply

and release the brakes in a conventional, fail-safe manner. At some point, either during

initial brake system installation and testing or shortly thereafter, at least the service brake

system had to have been equipped with a normally open valve. Postaccident inspection

found that the service brake was still equipped with a normally open valve, and it operated

properly. But the emergency brake system was equipped with a normally closed valve.

Because the valve had failed in the normally closed position, the emergency brake could

be released, but it could not be reapplied when needed. 

Angels Flight records indicated that a solenoid valve had burned out and been

replaced with a normally closed valve as indicated on the drawings and parts list. But as

noted, this would not have allowed the system to be operated. Although it cannot be

known for sure, it is possible that the new valve was inoperative when it was installed or

was defective and failed very quickly after its initial activation. Either scenario would

explain how the system was able to be operated and would account for the valve

configuration found during the postaccident inspection. 

Although the test procedure for the Angels Flight emergency brakes was

conducted daily, the button that activated those brakes simultaneously activated the

service brake. Therefore, this method of testing could not confirm that both braking

systems were operational. The Safety Board therefore concludes that the brake system as

designed was inoperable, as implemented was not fail-safe, and was further inadequate

because the emergency brakes could not be activated independent of the service brake and

tested separately, which would have revealed that the systemís emergency brakes were

inoperative. 

The Safety Board believes that before recommencing passenger service on the

Angels Flight funicular railway, the Community Redevelopment Agency should require

that the current Angels Flight emergency braking system (acting on the cable drums) be

redesigned to allow it to be tested independent of other braking systems. 
Analysis 37 Railroad Accident Report

Angels Flight Operations and Maintenance

The primary responsibility for day-to-day operations and maintenance of Angels

Flight belonged jointly to the Angels Flight Railway Foundation and the Angels Flight

Operating Company. Shortly after Angels Flight began passenger service, a problem was

noted with overheating of the gearbox oil. The problem was severe enough that on

numerous occasions, the system shut down automatically, leaving passengers stranded

between stations. At these times, witnesses reported seeing passengers making

unauthorized and unsafe evacuations from the cars over the unprotected elevated track

structure. As a loss control consultant had noted, such evacuations were so dangerous to

passengers that they should have been prevented even during emergencies. 

But despite the hazard posed to passengers, the operating company did not

establish operational practices that would have prevented the system shutdowns or egress

onto the tracks. For example, the number of scheduled trips per hour could have been

reduced to allow the gearbox to cool between trips while a permanent solution was

researched and implemented. Instead, the system was kept operating for more than a year

until the overheating problem was ultimately resolved by the installation of an oil cooler. 

In addition to representing an inconvenience and possible hazard to passengers

because of the system shutdowns, the overheating and vaporizing oil was also likely not

providing optimal lubrication to the Angels Flight drive system. Within the first few

months of operation of Angels Flight, the bearing seals had carbonized due to overheating

and had begun to leak. The gearbox bearings and seals had to be replaced in 1997. 

After the overheating problem had been addressed in 1997 and synthetic oil was

used, the Angels Flight Operating Company never changed the oil. It did initially adhere

to a regular fluids analysis schedule, sampling the lubricating oil about once every 4

months from 1997 to 1999. After three successive fluid analyses during 1999 showed an

increased presence of iron in the oil, the company that conducted the fluid analyses in June

1999 recommended resampling the oil after an additional 250 hours. However, although

bearings were replaced and the drive system gears were inspected after the June 1999

analysis, the operating company conducted no additional fluid analyses. As a result, the

lubricating oil went untested for 20 months while Angels Flight continued daily operation

until the accident occurred. 

The Safety Board is concerned at the lack of detailed guidance regarding the oil

analysis program or maintenance procedures for the funicular drive gearbox. A

postaccident fluids analysis test on February 28, 2001, confirmed the presence of elevated

iron levels in the gearbox oil. In addition, ground metallic residue, containing both metal

shavings from the sheared splines and small metal pieces from the ball bearings, was

removed during disassembly of the gearbox after the accident, indicating that damage was

occurring before the planetary gear hub splines failed. Therefore, if Angels Flight

Operating Company personnel had continued the oil analyses, as required in the

operations and maintenance manual, and if the cause of the elevated iron content had been
Analysis 38 Railroad Accident Report

investigated further, through a gearbox teardown, for example, they may have discovered

the damage in the Sinai carís planetary gear hub splines. 

The Safety Board concludes that by allowing Angels Flight to remain in normal

passenger service for more than a year with an unresolved problem with overheating of

the gearbox, which at times caused cars to stop unexpectedly between stations, the Angels

Flight Railway Foundation and the Angels Flight Operating Company adversely affected

drive system component integrity and compromised passenger safety. 

The Safety Board believes that before recommencing passenger service on the

Angels Flight funicular railway, the Community Redevelopment Agency should require

that the organization(s) responsible for operating and maintaining the Angels Flight

funicular develop and follow detailed operating, inspection, and maintenance procedures

to ensure the operational integrity of the system and safety of passengers. 

Oversight of Angels Flight Design and Construction

A complex web of organizations was involved in the Angels Flight redevelopment

project. Ultimately, this complexity may have contributed to the failure of various

oversight agencies to ensure that the Angels Flight system was reconstructed and operated

with adequate passenger safeguards. 

City of Los Angeles Community Redevelopment Agency Oversight

As the owner of Angels Flight, the Community Redevelopment Agency was

responsible for contract negotiations, safety oversight, design changes, and safety

certification. Additionally, beginning in 1991 with its selection of Parsons as a consultant,

the Community Redevelopment Agency was responsible for the selection of many of the

companies involved in the design and construction of Angels Flight. It hired Harris as the

construction manager and selected Pueblo as the general contractor. And even though the

Community Redevelopment Agency did not hire Yantrak directly, it was responsible for

the selection of the company in its role as overseer of the performance of its contractors

and subcontractors and for monitoring how its money was being spent.

The Community Redevelopment Agency contracted with Harris as construction

manager for the project, and Harris subsequently contracted with Parsons for the design

specifications for the reconstructed Angels Flight. Parsonsís specifications called for both

cars to be fitted with emergency track brakes and end gates to contain passengers. They

also called for an emergency walkway to be constructed for the entire length of the

tramway to facilitate the evacuation of passengers in the event of an emergency. None of

these features was included in the final system build. 

Track Brakes. The original Parsons design specifications for the reconstructed

Angels Flight included track brakes designed to deploy automatically and stop a runaway

car in case of an overspeed condition or the failure of the haul cable or other major
Analysis 39 Railroad Accident Report

components that might allow a car to freely translate. Yantrak, the design-build contractor

for Angels Flight, took issue with the track brakes in the design specifications. In a

September 8, 1995, letter, Parsons informed Harris that it considered the elimination of the

track brakes to be unacceptable in that, without either the brakes or a suitable alternate

backup safety system, a break in the haul cable could result in injury or fatality to

passengers. Based on this risk, Parsons continued to recommend that Harris reject the

Yantrak proposal to omit track brakes. Nonetheless, Harris, with the approval of the

Community Redevelopment Agency, decided not to equip the Angels Flight vehicles with

the track brakes that would likely have prevented the February 1, 2001, collision.

In a series of letters and memorandums, Yantrak argued that track brakes would be

ineffective in this application and that, in any case, the design of the cars and trackway

would not permit their installation. In its February 13, 1996, letter to Pueblo, Yantrak had

said that track brakes could not be used on the split rail of the train bypass. The Safety

Board notes, however, that the conceptual design specified track brakes only on the outer

rail, thereby avoiding the shared (split) rail used by both cars. Increasing the diameter of

the haul cable (rope) and other measures proposed by Yantrak did increase the safety

factors associated with loss of the cable or car attachment. However, deleting the track

brakes (a secondary safety device) ignored other potential failure modes that were

unrelated to the haul cables. Redundancy has always been a key factor in the design of

transportation systems. For example, even though the original Angels Flight was not

equipped with track brakes, it did have a safety cable designed to prevent a runaway car.

Further, the guidance on funiculars existing at the time Angels Flight was redesigned and

rebuilt (ANSI tentative standards and the Colorado regulations) called for each individual

car to be equipped with a braking system. A survey of funiculars worldwide also found

that each system utilized cars equipped with braking systems or backup safety cables.

The Safety Board therefore concludes that had the Angels Flight cars been

equipped with track brakes or a safety cable in accordance with known funicular safety

standards and redundant design principles, either of those safety features likely would

have stopped the runaway car and prevented the collision even without working

emergency brakes. 

End Gates. The initial design specifications for the reconstructed Angels Flight

also called for the installation of end gates to prevent passengers from falling from the

cars. The Community Redevelopment Agency approved the installation of end gates and

required them in the contract to Pueblo. Later, objections were raised by a conservancy

group, which argued that end gates not only would have been inconsistent with the

original Angels Flight design but also were unnecessary as shown by the fact that the

system had been operated without them and without incident between 1901 and 1969. 

The Community Redevelopment Agency, while reviewing the issue of whether

end gates were necessary to the safety of the system, allowed Angels Flight to begin

passenger service without them. In November 1996, some 9 months after Angels Flight

began passenger service, the Community Redevelopment Agency consented to requests

from Angels Flight officials and issued a change order directing that end gates not be
Analysis 40 Railroad Accident Report

installed. Although the Community Redevelopment Agency stated that the issue would

need continued study, there is no record of such, and the gates were never installed. 

Emergency Walkway. The original Angels Flight did not have a walkway

adjacent to the trackway that would extend the entire length of the trackway. Such a

walkway was included as part of the original reconstruction design specifications, but as

with the end gates, a conflict soon developed with the historic preservationist viewpoint.

In addition, Public Utilities Commission staff and an insurance loss control consultant

supported the view that the walkway would be an attractive nuisance more hazardous than

the absence of the walkway. However, the Safety Board notes that an attractive nuisance

can be averted in many cases with relatively simple measures, such as installing a fence

with locking gates to restrict access.

Community Redevelopment Agency officials did require that alternatives to the

walkway be included in the final design, including a combination ground-level and

elevated stairway separated from the trackway, an auxiliary emergency power supply,

reversible funicular controls, and a security system and fence. But none of these

alternatives directly addressed the purposes of the emergency walkway, and because of the

nature of the accident, these alternatives did nothing to facilitate access to and egress from

the funicular vehicles. The Safety Board concludes that the absence of an emergency

walkway hampered access by emergency responders to passengers in this accident, made

difficult the evacuation of the injured, and increased the risk to both passengers and

emergency responders. 

The agency with overall safety oversight of the reconstruction and subsequent

operation of the Angels Flight system was the Public Utilities Commission. Like the

Community Redevelopment Agency, although the Public Utilities Commission often

came down initially in support of the safety features, in most cases, the Public Utilities

Commission ultimately either permitted the removal of safety features from the final

Angels Flight design or allowed the system to be operated in passenger service while

certain safety issues remained unresolved.

Apart from cost issues, it appears that during the Angels Flight reconstruction

project decisions about safety features were based in large part on a featureís adherence to

historical accuracy. In the years since the original Angels Flight was built in 1901, there

have been great advances in engineering and transportation safety, and, therefore,

transportation systems are not designed as they were 100 years ago. Even assuming that

accurate accident records exist, the fact that accidents have not occurred with a historic

design does not ensure that the design is safe. Given current state-of-the-art technologies,

public transportation designs should not be dictated by a desire for historical accuracy at

the expense of safety features. 

The Safety Board believes that before recommencing passenger service on the

Angels Flight funicular railway, the Community Redevelopment Agency should direct

that the Angels Flight funicular be redesigned in accordance with all applicable funicular

safety standards and include provisions for (1) emergency stopping under all foreseeable

failure modes, including track brakes or some other independent backup system on the
Analysis 41 Railroad Accident Report

cars to prevent a runaway car if a failure occurs in the cable or its associated braking

systems; (2) containment of passengers in the event of a collision; and (3) emergency

egress and ingress for passengers and emergency responders. 

California Public Utilities Commission Oversight

The Public Utilities Commission had responsibility for the safety of the design,

construction, and eventual operation of Angels Flight. The Public Utilities Commission

required that the Community Redevelopment Agency and its consultants perform safety

hazards analyses on the Angels Flight project and indicate what actions were planned that

would mitigate the danger to passengers and employees through design solutions or

operating procedures. But the Public Utilities Commission did not require that track

brakes, end gates, or an evacuation walkway be installed to address the safety hazards

identified by the analyses. These inconsistent decisions suggest that the Public Utilities

Commission policies and procedures were insufficient for ensuring the safety of Angels

Flight.

The Public Utilities Commission granted limited authority for Angels Flight to

operate for a 3-day dedication ceremony beginning February 23, 1996. The authorization

letter acknowledged that there were ìoutstanding issuesî related to safety at the time. Yet,

Angels Flight opened for passenger service on February 26, 1996, without those safety

issues being resolved. The Public Utilities Commission did not have an effective process

in place to ensure that Angels Flight met all safety requirements before passenger

operations were allowed to begin. The Safety Board therefore concludes that the

Community Redevelopment Agency and the Public Utilities Commission failed to fulfill

their safety oversight responsibilities for the Angels Flight reconstruction by allowing

Angels Flight to begin passenger operations with unresolved safety issues. 

The Safety Board is encouraged by the Public Utilities Commissionís new General

Order 164-C involving safety certification. The circumstances surrounding this accident

accentuate the need to make ongoing safety assessments from the outset of a project.

Under rules existing at the time of the accident, an agency or organization could

potentially operate for 3 years before the first safety inspection. 

California has no standards or regulations for the design, construction, and

operation of funiculars. Although funicular standards of another State were available, the

Public Utilities Commission did not require that the Angels Flight Railway be

reconstructed and operated in accordance with them. Without established regulations, the

Public Utilities Commission had no clear standards to use to evaluate the safety of the

Angels Flight funicular project. The Safety Board believes the Public Utilities

Commission should adopt comprehensive funicular design, construction, and operation

regulations that include provisions for (1) emergency stopping under all foreseeable

failure modes, (2) containment of passengers in the event of a collision, and (3) emergency

egress and ingress for passengers and emergency responders. 

To ensure that deficiencies discovered during the investigation of the Angels Flight

funicular railway accident are specifically addressed, the Safety Board believes that before
Analysis 42 Railroad Accident Report

certifying Angels Flight to restart passenger service, the Public Utilities Commission

should independently verify that the drive system meets accepted industry standards and

engineering practices and that the funicular includes provisions for (1) emergency

stopping under all foreseeable failure modes, including track brakes or some other

independent backup system on the cars to prevent a runaway car if a failure occurs in the

cable or its associated braking systems; (2) containment of passengers in the event of a

collision; and (3) emergency egress and ingress for passengers and emergency responders. 

The Safety Board is encouraged that ANSI is making progress on developing

funicular safety standards. Although a draft standard has been approved by the B77

committee, it has not been adopted as final by ANSI. Such a standard would inform and

guide organizations such as the Public Utilities Commission in their safety oversight of

operations like the Angels Flight railway. Therefore, the Safety Board believes ANSI

should establish an accelerated schedule for adoption of the draft ANSI Standard B77.2

for funicular safety requirements. 
43 Railroad Accident Report

Conclusions

Findings

1. The planetary gear hub for the Sinai car failed because of one or a combination of the

following: (1) the metal used in the manufacture of the gear hub was considerably

softer than the metal used for the axle shaft with which it mated, causing deformation

damage and eventual failure; (2) the drive train components, including the planetary

gear hubs, were not designed for the stresses to which the components were subjected

during operation; and (3) the daily brake tests, which were conducted for some period

of time without working emergency brakes, placed additional stress on the drive train

components and accelerated gear hub damage.

2. Had the Angels Flight emergency braking system been functional on the day of the

accident, the brakes would likely have stopped the descent of the runaway car and

prevented the collision.

3. The brake system as designed was inoperable, as implemented was not fail-safe, and

was further inadequate because the emergency brakes could not be activated

independent of the service brake and tested separately, which would have revealed

that the systemís emergency brakes were inoperative. 

4. Had the Angels Flight cars been equipped with track brakes or a safety cable in

accordance with known funicular safety standards and redundant design principles,

either of those safety features likely would have stopped the runaway car and

prevented the collision even without working emergency brakes. 

5. The absence of an emergency walkway hampered access by emergency responders to

passengers in this accident, made difficult the evacuation of the injured, and increased

the risk to both passengers and emergency responders. 

6. The City of Los Angeles Community Redevelopment Agency and the California

Public Utilities Commission failed to fulfill their safety oversight responsibilities for

the Angels Flight reconstruction by allowing Angels Flight to begin passenger

operations with unresolved safety issues.

7. By allowing Angels Flight to remain in normal passenger service for more than a year

with an unresolved problem with overheating of the gearbox, which at times caused

cars to stop unexpectedly between stations, the Angels Flight Railway Foundation

and the Angels Flight Operating Company adversely affected drive system

component integrity and compromised passenger safety. 
Conclusions 44 Railroad Accident Report

Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the Yantrak Companyís (Lift Engineeringís) improper design and

construction of the Angels Flight funicular drive and the failure of the City of Los Angeles

Community Redevelopment Agency, its contractors (Pueblo Contracting Services,

Yantrak, and Harris and Associates), and the California Public Utilities Commission to

ensure that the railway system conformed to initial safety design specifications and known

funicular safety standards.
45 Railroad Accident Report

Recommendations

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

following safety recommendations:

To the California Public Utilities Commission:

Adopt comprehensive funicular design, construction, and operation

regulations that include provisions for (1) emergency stopping under all

foreseeable failure modes, (2) containment of passengers in the event of a

collision, and (3) emergency egress and ingress for passengers and

emergency responders. (R-03-14)

Before certifying Angels Flight to restart passenger service, independently

verify that the drive system meets accepted industry standards and

engineering practices and that the funicular includes provisions for

(1) emergency stopping under all foreseeable failure modes, including

track brakes or some other independent backup system on the cars to

prevent a runaway car if a failure occurs in the cable or its associated

braking systems; (2) containment of passengers in the event of a collision;

and (3) emergency egress and ingress for passengers and emergency

responders. (R-03-15)

To the City of Los Angeles Community Redevelopment Agency:

Before recommencing passenger service on the Angels Flight funicular railway:

Conduct a comprehensive review of the design and specifications for the

Angels Flight drive system, then make the design or component changes

necessary to ensure that the drive system meets accepted industry standards

and engineering practices. (R-03-16)

Require that the current Angels Flight emergency braking system (acting

on the cable drums) be redesigned to allow it to be tested independent of

other braking systems. (R-03-17)

Require that the organization(s) responsible for operating and maintaining

the Angels Flight funicular develop and follow detailed operating,

inspection, and maintenance procedures to ensure the operational integrity

of the system and safety of passengers. (R-03-18). 
Recommendations 46 Railroad Accident Report

Direct that the Angels Flight funicular be redesigned in accordance with all

applicable funicular safety standards and include provisions for

(1) emergency stopping under all foreseeable failure modes, including

track brakes or some other independent backup system on the cars to

prevent a runaway car if a failure occurs in the cable or its associated

braking systems; (2) containment of passengers in the event of a collision;

and (3) emergency egress and ingress for passengers and emergency

responders. (R-03-19)

To the American National Standards Institute:

Establish an accelerated schedule for adoption of the draft American

National Standards Institute Standard B77.2 for funicular safety

requirements. (R-03-20)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

Ellen G. Engleman Mark V. Rosenker

Chairman Vice Chairman

John J. Goglia

Member

Carol J. Carmody

Member

Richard F. Healing

Member

Adopted: August 5, 2003
47 Railroad Accident Report

Appendix A

Investigation 

Both headquarters and Los Angeles staff of the National Transportation Safety

Board became aware of the Angels Flight railway collision in Los Angeles, California,

within a few minutes of its occurrence at 12:17 p.m. on February 1, 2001, from local and

national coverage by the news media. Two railroad accident investigators were sent to the

scene from the Gardena, California, office. They arrived on scene about 45 minutes after

the accident occurred. No Board Member went with the team. 

Parties to the investigation included the California Public Utilities Commission,

the City of Los Angeles Community Redevelopment Agency, and the Angels Flight

Operating Company. The company that designed and built the drive, control, braking, and

haul systems, Lift Engineering/Yantrak, is no longer in business, and the principalís

whereabouts are unknown.

As part of its investigation, on June 12, 2001, the Safety Board took testimony

from the president and vice president of Angels Flight and from the administrator of the

City of Los Angeles Community Redevelopment Agency. All parties to the investigation

attended the proceeding.