Index:NTSB - Railroad Accident Report - Derailment on May 25, 1989.djvu

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NTSB - Railroad Accident Report - Derailment on May 25, 1989.djvu

Pages 111 and 112 missing

CONTENTS

EXECUTIVE SUMMARY
vi
 
INVESTIGATION
Events Preceding the Train Derailment
1
 Loading of Hopper Cars
1
 Preparing the Shipper’s Bill of Lading
3
 Activities of Extra 7551 East
5
 Activities of Helper Unit
8
 Movement of Extra 7551 East from Oban to Hiland
8
The Train Derailment
8
Emergency Response to Train Derailment
9
Wreckage Clearance/Pipeline Surveillance Operations Following the Train Derailment
17
 May 12, 1989
17
 May 13, 1989
20
 May 14, 1989
25
 May 15 and 16, 1989
25
 May 17, 18, and 19, 1989
30
Events Preceding the Pipeline Rupture
31
Pipeline Rupture
31
 Pipeline Operations on May 25, 1989
31
 Witnesses’ Observations
33
Emergency Response to Pipeline Rupture
33
Pipeline Surveillance Operations
35
Injuries
37
Damages
37
 Train Derailment
37
 Pipeline Rupture
39
 Damage to the Pipeline
39
Track and Signal Information
42
 Track
42
 Signals
43
Train Information
43
 Locomotive Units
43
 Hopper Cars
44
Mechanical Information
45
 Use of Dynamic Brakes
45
 Maintenance Reports and Reporting of Defective Locomotive Units
46
 Recovering Dynamic Brakes
47
 FRA’s Position Regarding Functioning Dynamic Brakes
48
Southern Pacific’s Method of Operation
48
 Air Brake Rules and Timetable Instructions
48
 Communication Between Head end and Helper Engineers
53
 Tonnage Information for Cars
53
The Calnev Pipeline
54
 Description
54
 Check Valves
55
 Block Valves
56
 Dispatch Center
56
 Emergency Response Manual
57
Personnel Information
58
 Operating Crew of Extra 7551 East
58
 Other Southern Pacific Personnel
60
 Calnev Pipeline Dispatcher
61
Southern Pacific Training Programs
61
 Engineer Training Program
61
 Dispatcher Training Program
63
 Clerk Training Program
64
Calnev Pipeline Dispatcher Training Program
64
Southern Pacific Management Oversight of Train Operations
65
Industry Pipeline Standards and Federal Regulations
66
Oversight of Calnev Pipeline Operations
67
Meteorological Information
69
Medical and Pathological Information
69
 Train Derailment
69
 Pipeline Rupture
70
Toxicological Information
70
Southern Pacific’s Physical Examination Policy
71
Tests and Research
71
 Event Recorders
71
 Train Dynamics Analyzer Runs
72
 Instrumented Brake Shoe Tests
73
 Train Vibration Study
73
 Soil Inspection Report
73
 Metallurgical Testing
75
 Simulation of Excavating Equipment Operations
79
Other Information
80
 Train Movements Following the Train Derailment and Preceding the Pipeline Rupture
80
 Agreement Between the Southern Pacific and the City of San Bernardina Following the Train Derailment
80
 Development of Land Adjacent to the Southern Pacific Railroad and the Calnev Pipeline
81
 Disaster Preparedness
82
 Train Derailments over Pipelines
82
 
ANALYSIS
General
85
The Train Derailment
85
 Axles of Dynamic Brakes
86
 Trailing Tonnage
87
 Operation of Extra 7551 East Down the 2.2 Percent Grade
90
 Derailment Speed
92
Communication
92
Testing Dynamic Brakes
94
Event Recorders
95
 
Computer-Generated Tonnage Profile Information
97
Dynamic Brake/Emergency Interlock
98
Reporting Defective Conditions on Locomotives
98
Training Program for Engineers
99
Southern Pacific Training Program for Yard Clerks
99
Southern Pacific Management Oversight of Train Operations
100
The Pipeline Rupture
101
 Removal of the Train Wreckage
103
 Removal-of Trona From Over the Pipeline
103
 Excavation and Inspection of the Pipeline
104
 Removal of Trona From the Oer ailment Area
105
Adequacy of Calnev's Inspection cf the Pipeline Following the Train Derailment
105
The Timing of the Pipeline Rupture
108
Calnev Pipeline Monitoring System
108
Shutdown of Failed Pipeline
109
 Check Valves
109
 Remotely Operated Valves
110
 Federal Reguations
112
Enhancing Public Safety Near Railroads and Pipelines
115
Survival Aspects
117
Emergency Response
117
Medical and Toxicological Factors
119
Southern Pacific's Physical Examination Policy
119
 
CONCLUSIDNS
Findings
120
Probable Cause
123
 
RECOMMENDATIONS
124
 
APPENDIXES
Appendix A—Investigation and Hearing
129
Appendix B—Personnel information
130
Appendix C—Bill of Lading Information
131
Appendix D—Tonnage Profile of Extra 7551 East
137
Appendix E—OPS Hazardous Facility Order and Subsequent Amended Orders
144
Appendix F—Assessment of Damages to Residences and Property
153
Appendix G—FRA Letter Regarding Functioning Dynamic Brakes
155
Appendix H—Southern Pacific Timetable Instructions (Maximum Tons per Operative Brake)
156
Appendix I—Selected Provisions of ASA Code B31.4
157
Appendix J—Pertinent Provisions of 49 CFR Part 195
159
Appendix K—Pertinent Provisions of 49 CFR Part 192
165
Appendix L—Alert Bulletin Issued by RSPA on November 13, 1989
166
Appendix M—Strip charts From Event Recorders of Extra 7551 East
171
Appendix N—Report of Converse Consultants
174
Appendix O—Agreement Between the Southern Pacific and the City of San Bernardino
183