National Transportation Safety Board

“ Of SP’s road fleet of 2,100 units, 1,800 units, according to the chief mechanical officer, are equipped with dynamic brakes. SP locomotives are designed such that when the train brakes are applied in emergency, an interlock will nullify the dynamic braking. According to SP’s chief mechanical officer, the system is designed in this manner "...to prevent train handling problems in the case of a break in two [a separation of two cars] and to prevent wheel slide because of excessive braking which would be the combination of the electric [dynamic] braking and the independent brake...." ”

“ The yard clerks understood that the tonnage figure would be updated at a later time when the shipper's bill of lading was received in the billing office. SP's director of clerical operations testified that cars are often moved in service before the shipper's bill of lading information is received and entered into the billing system. He further testified that following the train derailment, "We have changed the system so that regardless of what estimate is put into the release, the computer will go to the car file and automatically update that tonnage to the capacity of the car." ”

“ Each time a locomotive unit was moved, it was necessary for one of the cranes to cross through the haul road over the pipeline. Calnev personnel agreed that the crane could cross over the pipeline in this location. Calnev’s maintenance superintendent testified, "I did not see any activity which I believed damaged the pipeline. Any time you are using large pieces of excavating type equipment near a pipeline, you certainly have the potential for danger." ”

“ Calnev’s maintenance superintendent, who supervised the trona removal activity from about 8:00 p.m., on May 15, to about 4:00 a.m., on May 16, testified that several pieces of debris, including portions of truck assemblies [from a train car] and two pieces of rail—one about 3 feet in length and one about 10 feet in length—were found during removal of the trona. He further testified that while he was supervising the removal of the trona, two excavations of the pipeline were performed where debris had been found at natural grade level. ”

“ The other 50 percent was devoted to efficiency testing of other operating rules. According to the road foreman, there was no set policy on the number of efficiency tests to be made on grade operations or through the use of radar. With respect to train rides, the road foreman testified that he would ride with each engineer at least once or twice a year or more if the engineer was experiencing problems. ”

“ Because Lake Minerals Corporation did not have rail facilities at its Owens Lake plant, the trona was shipped by truck from there to the rail facility at Rosamond, where the trona was loaded into the open-top hopper cars by a loading contractor hired by the Lake Minerals Corporation. The Lake Minerals Corporation had shipped trona by rail to the Port of Los Angeles on only one previous occasion. The superintendent of Lake Minerals Corporation testified that on that first shipment the company had averaged 88 tons per car when the contract had also called for 100 tons per car. ”

“ As stated by SP's general road foreman, who observed the simulations with Safety Board investigators, "Test one is the only test that we could run that would allow us to go down the hill in the same manner that this train went down the hill and make the air brake reductions as they were made on the strip chart." Test one was made with 12 axles of dynamic braking on the head-end locomotive units, 6 axles of dynamic braking on the helper units, and with a trailing tonnage of about 8,900 tons. ”

“ Railroad personnel are to be contacted and advised of the location of the pipeline. In the event of possible damage, the pipeline is to be shut down, and upstream and downstream valves are to be closed. The procedures also indicate that once the pipeline has been secured, the location of the pipeline through the derailment area should be accurately marked, heavy equipment should not be allowed to operate over the pipeline if it is considered hazardous to the pipeline, and Calnev personnel should be present on scene until all work is completed. ”

“ Dispatch Center The pipeline system is controlled by dispatchers from a dispatch center at the Colton Pump station. The system is equipped with a monitoring system that scans selected system parameters, such as pipe pressures and motor drive amperages, every 13 seconds, compares the data with programmed acceptance values, and through visual and audible alarms, alerts the dispatcher to changes to operating conditions in the system and abnormal or unacceptable occurrences. ”

“ In 1969 and 1970, when the Calnev pipeline was constructed along the eastern edge of the SP right-of-way, no houses had yet been erected on that portion of Duffy Street that paralleled the railroad; only a few houses had been built within the subdivision. According to recollections of long-term residents, intensive construction within the area occurred from 1970 to 1970.
The City of San Bernardino's General Plan for land use is a policy document that establishes goals, objectives, and policies for the future. ”

“ In order to hold speed steady on a descending grade, the force of gravity must be balanced by the sum of train resistance and brake retarding force. The heavier the grade, the lower the effect of train resistance; and the more brake must be used. ”

“ Train Vibration Study At the request of the Safety Board, the Test and Engineering Center of Failure Analysis Associates, an engineering and scientific consulting service, conducted tests at the accident site to measure and record vibration and strain levels to determine if the passage of trains induced vibration or strain in the buried pipeline. ”

“ Of eight residents in their homes at the time of the accident, two were killed and one received serious injuries as a result of being trapped under debris for 15 hours. Local officials evacuated homes in the surrounding area because of a concern that a 14-inch pipeline owned by the Calnev Pipe Line Company, which was transporting gasoline and was located under the wreckage, may have been damaged during the accident sequence or was susceptible to being damaged during wreckage clearing operations. Residents were allowed to return to their homes within 24 hours of the derailment. ”

“ Between 11:00 p.m. and 11:30 p.m., the conductor called the yard clerk and informed him that locomotive unit SP 7551 was "dead-in-consist" and could not be started. The engineer testified that the crew attempted to determine the reason the unit would not start but was unsuccessful. The yard clerk instructed the crew to use another unit (SP 8278) that was in the yard next to the three-unit consist. The yard clerk then informed the assistant chief dispatcher, who had come on duty in Los Angeles at 10:30 p.m., of the condition of SP 7551 and of the use of SP 8278. ”

“ By reviewing the stripchart generated from the information recorded from unit 7549, Safety Board investigators attempted to determine if the dynamic braking on that unit was functioning. If the dynamic brakes on a locomotive unit are functioning, whenever an engineer uses dynamic braking, corresponding amperage activity should occur and be recorded on the stripchart. ”

“ Southern Pacific Training Programs Engineer Training Program Trainees for the engineer training program were selected from employee applications with preferential treatment given to those applications submitted by United Transportation Union (UTU) members—brakemen, switchmen, and hostlers—because of existing labor agreements between the SP and the UTU. Those trainees selected initially entered a 4-week formal training program during which preliminary air brake, mechanical, locomotive, and operating rules are covered both in the classroom and in the field. ”

“ On June 27, 1989, a locomotive was being used to switch the order of rail cars at a Union Pacific Railroad yard at Las Vegas, Nevada. About 8:30 a.m., Pacific daylight time, 34 rail cars were being moved when the leading 9 cars and the trailing 12 cars derailed with several rail cars overturning on top of two Calnev petroleum products pipelines. The 6-inch pipeline located on one side of the rail line contained jet fuel, and the 8-inch pipeline on the opposite site of the rail line contained gasoline. ”

“ The head-end engineer of Extra 7551 East testified that he had never been trained on procedures concerning the reversing of engines, had never received instruction concerning the effects of extended brake application on the deterioration of brake shoes, had never received instruction regarding train handling while receiving helper engine assistance, and had never been placed in an emergency situation during simulator training. ”

“ According to the director of system clerical operations, "It's not always feasible to give these people classroom training when, in fact, they may be trained in a classroom for 2 weeks and then have somebody exercise their seniority against them or they bid to another position...." ”

“ Freight trains handling cars with single capacity brakes (*) , with tonnage exceeding 80 tons per operative brake, must not exceed 45 mph, except maximum speed must not exceed: (1) 25 mph; or (2) 20 mph in grade territories as designated by Superintendent by milepost locations under appropriate subdivision.
*Loaded cars with empty-load brakes are to be considered the equivalent of one and one-half (11⁄2) cars in determining tons per operative brake. ”

“ About 7:36 a.m., Pacific daylight time, on May 12, 1989, Southern Pacific Transportation Company freight train 1-MJLBP-111, which consisted of a four-unit locomotive on the head end of the train, 69 hopper cars loaded with trona, and a two-unit helper locomotive on the rear of the train, derailed at milepost 486.8, in San Bernardino, California. The entire train was destroyed as a result of the derailment. Seven homes located in the adjacent neighborhood were totally destroyed and four others were extensively damaged. ”

“ Railroad
the means by which the shipping weights were determined for the shipment of the trona laden hopper cars; the dispatching of locomotives without operable dynamic brakes on mountain gradients; the information received by the road engineer regarding the weight of the train and the number of operable dynamic brakes; the communication between the road and helper engineers regarding the operation of the train, and communication with the dispatcher; the engineer’s training program, which did not adequately address emergency situations ”

“ The Santa Fe has never experienced any damage as a result of a train derailment where the pipe was buried 3 feet or more below ground. However, it did experience damage to its pipeline during the derailment clearing operations for the Montclair accident.
On June 20, 1989, the California Senate Committee on Toxics and Public Safety Management and the California Assembly Select Committee on Hazardous Materials and Pipeline Safety held a joint public hearing on the San Bernardino accidents. ”

“ The Safety Board is aware that similar rules exist on other railroads. Rule 501B of the Burlington Northern Air Brake and Train Handling Rules states:
Train handling must be performed in a manner that will be most fuel efficient consistent with good train handling. Therefore, maximum use must be made of the trottle modulation, throttle reduction and dynamic braking methods for slowing, controlling, and stopping trains. ”

“ Helper locomotives entrained may not use dynamic brake unless road engine has operative dynamic brake.
The number of axles of dynamic brakes of the helper engine (s) will be added to axles of dynamic braking of the road engine to determine the tonnage that may be handles in accordance with applicable Air Brake Rules.
Dynamic brake on head end of freight trains must not exceed 24 axles. Each helper entrained must not exceed 36 axles. ”