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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 | 9 | |
| Emergency Response to Train Derailment | 15 | |
| 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 | |
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