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Safety Recommendation Details

Safety Recommendation R-86-042
Details
Synopsis: ABOUT 1:33 P.M., C.D.T., ON JUNE 9, 1985, ST. LOUIS SOUTH WESTERN RAILWAY COMPANY (COTTON BELT) FREIGHT TRAIN EXTRA 4835 NORTH DERAILED WHILE PASSING OVER A BALLAST-DECK PILE TRESTLE LOCATED ABOUT 3.3 MILES SOUTHWEST OF PINE BLUFF, ARKANSAS. EIGHTEEN OF THE 42 DERAILED CARS WERE LOADED TANK CARS, AND 14 OF THESE CARS CONTAINED REGULATED HAZARDOUS OR TOXIC CHEMICAL COMMODITIES; 4 OTHERS CONTAINTED NON-REGULATED FLAMMABLE PETROLEUM AND LIQUID PLASTICS PRODUCTS. FIRE BROKE OUT IN THE WRECKAGE, AND SMOKE AND TOXIC GASES WERE RELEASED INTO THE ATMOSPHERE. TWO TANK CARS WHICH WERE SUBJECTED TO INTENSE THERMAL EXPOSURE EXPLODED BUT DID NOT ROCKET. MORE THAN 2,800 PERSONS WERE EVACUATED FROM WITHIN A 1-MILE RADIUS OF THE DERAILMENT SITE. PROPERTY DAMAGE WAS REPORTED TO BE MORE THAN $4 MILLION.
Recommendation: TO THE ST. LOUIS SOUTHWESTERN RAILWAY COMPANY: Provide intensive full-time supervisory oversight to its mainline train operations with particular emphasis placed on the enforcement of speed restrictions and operating rules. (Superseded by R-90-17)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action/Superseded
Mode: Railroad
Location: Pine Bluff, AR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA85RM007
Accident Reports: Derailment of St. Louis Southwestern Railway Company (Cotton Belt) Freight Train Extra 4835 North and Release of Hazardous Materials
Report #: RAR-86-04
Accident Date: 6/9/1985
Issue Date: 11/18/1986
Date Closed: 7/20/1990
Addressee(s) and Addressee Status: St. Louis Southwestern Railway Company (Closed - Unacceptable Action/Superseded)
Keyword(s):

Safety Recommendation History
From: NTSB
To: St. Louis Southwestern Railway Company
Date: 7/20/1990
Response: From the greensheet issuing R-90-12 through R-90-21: The Safety Board has previously addressed the issue of supervisory oversight of train operations with the SP. On November 18, 1986, as a result of its investigation of the derailment on June 9, 1985, of a St. Louis Southwestern Railway Company freight train near Pine Bluff, Arkansas, the Safety Board issued the following Safety Recommendation to the SP: R-86-42 Provide intensive full-time supervisory oversight of its mainline train operations with particular emphasis placed on the enforcement of speed restrictions and operating rules. In its response of September 8, 1987, the SP advised the Safety Board, in part, of the following: A comprehensive program to control speed as well as overall rules compliance has been initiated. This program ... includes efficiency testing by all of our officers, both individually and as teams, to insure rules compliance both day and night. Our officers are required to make a preponderant number of their tests during hours of darkness. Team testing is done by assigning our officers in groups of four with one officer designated as captain .... They test all areas of the division, on a random basis to ensure no patterns are established that would nullify the surprise element.... Our road foremen of engines are required to ride 12-15 trains each month, concentrating on those engineers with lesser skills in train handling techniques, air brakes and rules knowledge. This program is designed to upgrade all of our enginemen to a high level of performance... A large percentage of our locomotives are now equipped with event recorders. The tapes are captured at strategic locations and all of them are read and evaluated by our road foremen of engines for speed violation and train handling techniques.... The safety recommendation was being held in an "Open-"Acceptable Action" status pending completion of the Board's investigation of an accident at Yuma, Arizona, in which supervisory oversight was again raised as an issue. The SP informed the Board that as a result of the Yuma accident, the company was placing an officer on duty 24 hours a day at the Yuma yard office. The results of the investigation of the San Bernardino accident again suggest that the SP needs to examine supervisory oversight of train operations. In view of the new safety recommendation being issued in this report, Safety Recommendation R-86-42 has been classified as CLOSED—UNACCEPTABLE ACTION/ SUPERSEDED.

From: St. Louis Southwestern Railway Company
To: NTSB
Date: 1/18/1989
Response:

From: NTSB
To: St. Louis Southwestern Railway Company
Date: 4/25/1988
Response:

From: St. Louis Southwestern Railway Company
To: NTSB
Date: 2/1/1988
Response: I AM PLEASED TO NOTE THAT THE BOARD HAS PLACED RECOMMENDATION R-86-41 IN A "CLOSED--ACCEPTABLE ACTION" STATUS. HOWEVER, I AM SOMEWHAT CONCERNED TO NOTE THAT THE STATUS OF RECOMMENDATION R-86-42 HAS BEEN CHANGED FROM "OPEN--ACCEPTABLE ACTION" STATUS TO "OPEN--UNACCEPTABLE ACTION" STATUS FOLLOWING THE UNFORTUNATE ACCIDENT AT YUMA, ARIZONA, ON JUNE 15, 1987. THE ACCIDENTS AT PINE BLUFF, ARKANSAS, AND YUMA, ARIZONA, REFERRED TO IN YOUR LETTER OF DECEMBER 1, 1987, HAVE NOTHING IN COMMON. THE PINE BLUFF ACCIDENT WAS TRACK RELATED WHILE THE ACCIDENT AT YUMA, ARIZONA, WAS CAUSED BY ALCOHOL ABUSE AND NON-COMPLIANCE, ON THE PART OF CREW MEMBERS, WITH WELL-ESTABLISHED OPERATING RULES AND OPERATING PRACTICES. I BELIEVE THE ACTION TAKEN BY SOUTHERN PACIFIC ADEQUATELY ADDRESSES THE BOARD'S RECOMMENDATION R-86-42 AND THAT THIS RECOMMENDATION SHOULD NOT BE TIED TO THE YUMA ACCIDENT OF JUNE 15, 1987, DUE TO THE DISSIMILAR NATURE OF THE TWO ACCIDENTS. AS INFORMATION, FOLLOWING THE YUMA, ARIZONA ACCIDENT, SOUTHERN PACIFIC HAS TAKEN SEVERAL STEPS TO ALLEVIATE THE PROBLEMS EXPERIENCED AT YUMA: 1. A TERMINAL SUPERINTENDENT AND THREE (3) ASSISTANT TRAINMASTER POSITIONS HAVE BEEN ESTABLISHED, BRINGING THE TOTAL OFFICER COMPLIMENT TO SIX (6) OPERATING OFFICERS AT YUMA. EACH OF THESE OFFICERS HAVE ATTENDED A TWO-DAY DRUG AND ALCOHOL IDENTIFICATION CLASS CONDUCTED AT DR. FOREST TENNANT'S CLINIC IN WEST COVINA, CALIFORNIA. IN ADDITION, THE THREE ASSISTANT TRAINMASTERS ATTENDED A SAFETY AND RULES CLASS AT OUR CERRITOS ENGINE SERVICE TRAINING CENTER AND HYRAILED THE TERRITORY BETWEEN WEST COLTON, CALIFORNIA, AND TUCSON, ARIZONA, TO FAMILIARIZE THEMSELVES WITH TERRITORY FOR WHICH THEY HAVE SOME RESPONSIBILITY. 2. A BRIEFING ROOM HAS BEEN CONSTRUCTED AT YUMA YARD OFFICE WHERE TRAIN AND ENGINE CREWS GO ON DUTY. ALL TRAIN AND ENGINE CREWS GOING ON DUTY AT YUMA REPORT TO THIS ROOM TEN (10) MINUTES AFTER ASSUMING DUTY WHERE THEY ARE MET BY AN OPERATING OFFICER. A DISCUSSION IS HAD WITH THE CREW REGARDING THEIR FORTHCOMING TRIP AND A THREE (3) QUESTION RULES REVIEW QUESTIONNAIRE IS ADMINISTERED AND IMMEDIATELY CORRECTED. ANY WRONG ANSWER IS DISCUSSED AND AN UNDERSTANDING IS REACHED AS TO THE PROPER ANSWER AND APPLICATION OF THE RULE. ALSO, A PART OF THIS PROGRAM INCLUDES OBSERVATION OF EACH CREWMEMBER TO ASCERTAIN THEIR FITNESS FOR DUTY. IN VIEW OF THE GOOD FAITH ACTION TAKEN BY THE SOUTHERN PACIFIC TRANSPORTATION COMPANY, I BELIEVE THAT SAFETY BOARD RECOMMENDATION R-86-42 SHOULD BE RECONSIDERED AND PLACED IN CLOSED STATUS.

From: NTSB
To: St. Louis Southwestern Railway Company
Date: 12/1/1987
Response:

From: St. Louis Southwestern Railway Company
To: NTSB
Date: 9/8/1987
Response: A COMPREHENSIVE PROGRAM TO CONTROL SPEED AS WELL AS OVERALL RULES COMPLIANCE HAS BEEN INITIATED. THE PROGRAM, WHICH IS A PART OF OUR OVERALL SAFETY PROGRAM, INCLUDES EFFICIENCY TESTING BY ALL OF OUR OFFICERS, BOTH INDIVIDUALLY AND AS TEAMS, TO INSURE RULES COMPLIANCE BOTH DAY AND NIGHT. OUR OFFICERS ARE REQUIRED TO MAKE A PREPONDERANT NUMBER OF THEIR TESTS DURING HOURS OF DARKNESS. TEAM TESTING IS DONE BY ASSIGNING OUR OFFICERS IN GROUPS OF FOUR WITH ONE OFFICER DESIGNATED AS CAPTAIN. THERE ARE FOUR SUCH TEAMS ON THE DIVISION. THEY ARE REQUIRED TO TEST AS A TEAM A MINIMUM OF ONCE EACH WEEK, GENERALLY AT NIGHT. THEY TEST ALL AREAS OF THE DIVISION, ON A RANDOM BASIS TO ENSURE NO PATTERNS ARE ESTABLISHED THAT WOULD NULLIFY THE SURPRISE ELEMENT. THIS MEANS THAT 4 DAYS/NIGHTS EACH WEEK THE VARIOUS SUBDIVISIONS ARE BEING MONITORED BY OFFICERS TO ENSURE RULES COMPLIANCE. THESE TEAMS ALSO STOP THE TRAINS, AND INTERROGATE CREWMEM BERS ON THEIR KNOWLEDGE OF THE RULES AS WELL AS COMPLIANCE. THIS TYPE OF TESTING OF CREWS BRINGS ALL THE OFFICERS INTO THE RULES ENFORCEMENT BUSINESS ON ALL PARTS OF THE DIVISION AND SUPPLEMENTS ANY SUPERVISOR VOID THAT MIGHT SEEM TO EXIST BY ONLY ONE OFFICER BEING ASSIGNED TO A GIVEN TERRITORY. FOR EXAMPLE, THE CAMDEN TRAINMASTER IS ASSIGNED IS RESPON SIBILITY FROM FORDYCE TO TEXARKANA WITH NO ASSISTANT. HOW EVER, THE TRAINMASTER AT SHREVEPORT, THE TERMINAL SUPERIN TENDENT AT PINE BLUFF AND HIS STAFF OF FOUR OTHER OFFICERS, AND A ROAD FOREMAN OF ENGINES, HAVE TESTING RESPONSIBILITY ON THE SAME TERRITORY. THIS ARRANGEMENT IS IN EFFECT ON ALL CREW DISTRICTS TO ASSURE ALL OUR PEOPLE ARE COVERED. THERE ARE TWO AUDITS OF THE DIVISION ANNUALLY, ONE BY THE GENERAL MANAGER AND ONE BY THE SUPERINTENDENT. THESE AUDITS CENTER ON SAFETY, RULES KNOWLEDGE AND COMPLIANCE. THE SUPERINTEN DENT'S AUDIT GENERALLY TAKES 2 WEEKS TO COMPLETE AS IT IS VERY THOROUGH WITH THE GOAL TO TEST AND GRADE THE MAXIMUM NUMBER OF PEOPLE ON THEIR RULES KNOWLEDGE AND COMPLIANCE. THE GENERAL MANAGER'S AUDIT GENERALLY TAKES 1 WEEK AND ITS PURPOSE IS TO "SAMPLE" THE DIVISION ON ALL SUBDIVISIONS FOR OVERALL COMPLIANCE WITH OUR OPERATING RULES. OUR ROAD FORE MEN OF ENGINES ARE REQUIRED TO RIDE 12-15 TRAINS EACH MONTH, CONCENTRATING ON THOSE ENGINEERS WITH LESSER SKILLS IN TRAIN HANDLING TECHNIQUES, AIR BRAKES AND RULES KNOWLEDGE. THIS PROGRAM IS DESIGNED TO UPGRADE ALL OF OUR ENGINEMEN TO A HIGH LEVEL OF PERFORMANCE. WHEN THEY ARE NOT RIDING TRAINS, THEY ARE GENERALLY WORKING WITH OUR TEAM TESTING PROGRAM. IN ADDITION TO OUR OFFICERS USE OF RADAR TO MEASURE SPEED, WE HAVE TWO ADDITIONAL PROGRAMS IN PLACE. A LARGE PERCENT AGE OF OUR LOCOMOTIVES ARE NOW EQUIPPED WITH EVENT RECORDERS. THE TAPES ARE CAPTURED AT STRATEGIC LOCATIONS AND ALL OF THEM ARE READ AND EVALUATED BY OUR ROAD FOREMEN OF ENGINES FOR SPEED VIOLATION AND TRAIN HANDLING TECHNI QUES. THE OTHER PROGRAM THAT HAS PROVIDED TO BE A DETERRENT TO SPEED VIOLATIONS IS OUR HOT BOX DETECTORS. ALL OF OUR DETECTORS ARE NOW EQUIPPED WITH MICROPROCESSORS THAT COMPUTE THE TRAIN SPEED AS THE LAST CAR IN THE TRAIN PASSES OVER THE TRANSDUCERS AT THE DETECTOR. A TAPE IS PRODUCED OF EACH TRAIN INDICATING DIRECTION, TIME, DATE AND SPEED, IN ADDI TION TO ANY ALARMS. THESE TAPES ARE CAPTURED AND EVALUATED BY THE TRAINMASTER OF THE DISTRICT. ANY VIOLATIONS NOTED ARE PROCESSED FOR DISCIPLINE. THE ACTION PROGRAMS IN PLACE ON SOUTHERN PACIFIC, I BELIEVE, WILL ENHANCE OUR EFFORTS TO ASSURE THE STRICT COMPLIANCE WITH OPERATING RULES AND ESTAB LISHED STANDARDS.

From: NTSB
To: St. Louis Southwestern Railway Company
Date: 7/13/1987
Response:

From: St. Louis Southwestern Railway Company
To: NTSB
Date: 5/13/1987
Response: IN AN EFFORT TO CONTROL ABUSE OF SPEED, WE HAVE INSTITUTED A PROGRAM WHEREBY DISCIPLINE IS BEING ASSESSED IN ALL CASES OF EXCESSIVE SPEED VIOLATIONS. ALL CREW MEMBERS ARE BEING HELD RESPONSIBLE FOR COMPLIANCE. LET ME ASSURE YOU THAT IT IS THE UTMOST DESIRE OF SOUTHERN PACIFIC TO CONTINUE TO STRESS THE REQUIREMENT THAT STRICT COMPLIANCE WITH OPERATING RULES AND STANDARDS BE CONSTANTLY ENFORCED.

From: NTSB
To: St. Louis Southwestern Railway Company
Date: 4/24/1987
Response: