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 |
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