- the engineer’s training program, which did not adequately address emergency situations;
- changes in operating procedures made by Southern Pacific after the accident;
Pipeline
- Southern Pacific’s wreckage clearing operations in the area Calnev’s pipeline alignment;
- Calnev’s oversight surveillance of the train wreckage clearing operations and trona removal in the derailment area;
- Calnev’s assessment of pipeline integrity prior to resuming full pressure operation of the pipeline after the derailment;
- the effectiveness of the pipeline check valves used to minimize product release;
- the adequacy of Federal regulations to address the inspection and maintenance of valves for liquid pipelines.
The National Transportation Safety Board determined that the probable cause of the train derailment on May 12, 1989, was the failure to determine and communicate the accurate trailing weight of the train, failure to communicate the status of the train’s dynamic brakes, and the Southern Pacific operating rule that provided inadequate direction to the head-end engineer on the allowable speed and brake pipe reduction down the 2.2-percent grade.
The National Transportation Safety Board determined that the probable cause of the pipeline rupture on May 25, 1989, was the inadequate testing and inspection of the pipeline following the derailment that failed to detect damage to the pipe by earth-moving equipment. Contributing to the cause of the pipeline rupture was the severity of the train derailment that resulted in extensive wreckage and commodity removal operations. Contributing to the severity of the damage resulting from substantial product release was Calnev’s failure to inspect and test check valves to determine that they functioned properly, particularly after the train derailment.
As a result of its investigation, the Safety Board issued safety recommendations to the Southern Pacific Transportation Company, the Calnev Pipe Line Company, the Federal Railroad Administration, the Association of American Railroads, the City of San Bernardino, the Research and Special Programs Administration, the National Association of Counties, and the National League of Cities. The safety board also reiterated safety recommendations to the Research and Special Programs Administration and the Federal Railroad Administration.
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