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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