| 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 | |
v
