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Index:NTSB - Railroad Accident Report - Derailment on May 25, 1989.djvu

Title Railroad accident report—Derailment of Southern Pacific Transportation Company freight train on May 12, 1989 and subsequent rupture of Calnev petroleum pipeline on May 25, 1989—San Bernardino, California
Author National Transportation Safety Board
Year 1990
Publisher National Transportation Safety Board
Location Washington, D.C.
Source djvu
Progress To be proofread
Transclusion Index not transcluded or unreviewed
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 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
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
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