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Safety Recommendation Details

Safety Recommendation R-95-043
Details
Synopsis: ABOUT 5:21 A.M., PACIFIC STANDARD TIME, ON 12/14/94, A WESTBOUND ATCHISON, TOPEKA & SANTA FE RAILWAY COMPANY (SANTE FE) INTERMODAL TRAIN, PBHLA1-10, COLLIDED WITH THE REAR END OF A STANDING WESTBOUND UNION PACIFIC RAILROAD COMPANY (UP) UNIT COAL TRAIN, CUWLA-10, AT MILEPOST 61.55, NEAR CAJON, CALIFORNIA, ON THE CAJON SUBDIVISION OF THE SANTA FE'S SAN BERNARDINO DIVISION. THE TWO CREWMEMBERS FROM THE SANTE FE TRAIN WERE INJURED WHEN THEY JUMPED FROM THE MOVING TRAIN BEFORE THE COLLISION. TWO HELPER CREWMEMBERS ON THE REAR OF UP TRAIN DETRAINED BEFORE THE COLLISION BECAUSE THEY HAD HEARD RADIO CONVERSATIONS AMONG THE SANTE FE CREWMEMBERS, THE TRAIN DISPATCHER, & UP CREWMEMBERS. AS A RESULT OF THE COLLISIONS, A FIRE BROKE OUT THAT BURNED THE TWO UP HELPER LOCOMOTIVE UNITS. FOUR SANTA FE LOCOMOTIVE UNITS & THREE ARTICULATED FIVE-PACK DOUBLE-STACK CONTAINER CARS WERE ALSO DESTROYED. TOTAL ESTIMAED DAMAGES WERE $4,012,900.
Recommendation: THE NTSB RECOMMENDS THAT THE ASSOCIATION OF AMERICAN RAILROADS: IN COOPERATION WITH THE AIR BRAKE MANUFACTURERS, ASSESS THE CURRENT METHODS OF BRAKING IN MOUNTAIN-GRADE TERRITORY & IDENTIFY SAFE BRAKING METHODS FOR TRAINS DESCENDING EXTENDED GRADES, & INFORM YOUR MEMBERSHIP THAT FEED VALVE BRAKING & ANY OTHER BRAKING METHOD FOUND HAZARDOUS SHOULD NOT BE CONDONED AS AN ALTERNATIVE METHOD OF CONTROLLING A TRAIN THAT IS DESCENDING AN EXTENDED GRADE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Railroad
Location: Cajon, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: LEX95MR005
Accident Reports: Rear-End Collision of Atchison, Topeka and Santa Fe Railway Freight Train PBHLA1-10 and Union Pacific Railroad Freight Train CUWLA-10
Report #: RAR-95-03
Accident Date: 12/14/1994
Issue Date: 12/15/1995
Date Closed: 5/14/1998
Addressee(s) and Addressee Status: Association of American Railroads (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Association of American Railroads
Date: 5/14/1998
Response: THE BOARD IS DISAPPOINTED THAT THE AAR WILL NOT TAKE A LEADERSHIP ROLE FOR THE RAILROAD INDUSTRY ON PROPER GUIDANCE FOR TRAIN HANDLING IN MOUNTAINOUS TERRITORY. THE BOARD BELIEVES THAT THE AAR IS THE ONLY GROUP THAT HAS ACCESS TO THE TECHNICAL EXPERTS NEEDED TO RESOLVE THIS ISSUE & PROVIDE THE PROPER GUIDANCE. BECAUSE THE AAR WILL NOT TAKE ACTION CONSISTENT WITH THIS RECOMMENDATION, THE BOARD HAS CLASSIFIED R-95-043 "CLOSED--UNACCEPTABLE ACTION."

From: Association of American Railroads
To: NTSB
Date: 12/9/1997
Response: M. B. OGLESBY, J., PRESIDENT & CHIEF EXECUTIVE OFFICER, ON 12/9/97, RESPONDED THAT THE AAR HAS SURVEYED ITS MEMBER RAILROADS & THAT FEED-VALVE BRAKING IS PROHIBITED IN THEIR RESPECTIVE CODES OF OPERATING RULES. MR. OGLESBY ALSO ASSURED THE BOARD THAT NO BRAKING METHODS SHOWN TO BE HAZARDOUS ARE CONDONED BY AAR OR ITS MEMBER RAILROADS.

From: NTSB
To: Association of American Railroads
Date: 3/7/1997
Response: IN ITS INVESTIGATION OF THE 12/14/94, CAJON ACCIDENT, THE BOARD FOUND IT VERY DISTURBING THAT EVEN THOUGH WESTINGHOUSE AIR BRAKE COMPANY & NEW YORK AIR BRAKE RECOMMENDED AGAINST BRAKING TRAINS BY USING THE REGULATING VALVE, SUCH BRAKING WAS A REGULAR PRACTICE ON THE SANTE FE RAILROAD & OTHER RAILROADS. THE USE OF THE REGULATING VALVE IN BRAKING IS OFTEN SUSPECTED TO BE A FACTOR IN OTHER RUNAWAY TRAIN ACCIDENTS THAT THE BOARD HAS INVESTIGATED. THE BOARD UNDERSTANDS THAT THE FINAL DETERMINATION OF THE PROCEDURES FOR HANDLING TRAINS IN MOUNTAIN-GRADE TERRITORY IS ULTIMATELY THE RESPONSIBILITY OF EACH RAILROAD. HOWEVER, THE AAR HAS A ROLE AS AN INDUSTRY LEADER BECAUSE IT SPONSORS THE AIR BRAKE COMMITTEE, APPROVES NEW BRAKE-EQUIPMENT DESIGNS, CERTIFIES MANUFACTURERS & REPAIR FACILITIES, & CONDUCTS AIR BRAKE TESTING & RESEARCH. THE BOARD BELIEVES THAT THE AAR IS THE ONLY ENTITY THAT HAS ACCESS TO THE INDUSTRY-WIDE TECHNICAL EXPERTS NEEDED TO RESOLVE THIS ISSUE & TO PROVIDE THE PROPER GUIDANCE ON TRAIN HANDLING IN MOUNTAINOUS TERRITORY. THE CURRENT SITUATION, IN WHICH THE BRAKE MANUFACTURERS SAY A METHOD OF TRAIN HANDLING IS UNSAFE & THE RAILROADS CONTINUE TO USE IT, DOES NOT REFLECT WELL ON THE INDUSTRY, ESPECIALLY IF THE METHOD IS CAUSAL IN AN ACCIDENT. THE BOARD REQUESTS THAT THE AAR REASSESS ITS ROLE IN THIS AREA & ADVISE THE BOARD WHETHER IT PLANS TO TAKE ANY ACTION IN RESPONSE TO THIS RECOMMENDATION. PENDING ANOTHER RESPONSE, THE BOARD HAS CLASSIFIED R-95-43 "OPEN--UNACCEPTABLE RESPONSE."

From: Association of American Railroads
To: NTSB
Date: 6/12/1996
Response: MR. EDWIN L. HARPER, PRESIDENT & CHIEF EXECUTIVE OFFICER (SINCE DEPARTED) RESPONDED ON 6/12/96, THAT AAR & BRAKE MANUFACTURERS AGREE THAT A TRAIN SHOULD NOT BE BRAKED BY MOVING THE REGULATING VALVE (FEED-VALVE BRAKING). THE SOLE PURPOSE OF THE REGULATING VALVE IS TO SET TRAIN BRAKE PIPE PRESSURE. IT WAS NEVER INTENDED TO BE USED TO APPLY OR RELEASE BRAKES. BOTH WESTINGHOUSE AIR BRAKE COMPANY & NEW YORK AIR BRAKE ADVISE & PUBLISH SPECIFIC WARNINGS AGAINST SUCH FEED-VALVE BRAKING PRACTICE. THE DETERMINATION OF METHODS/OR PROCEDURES FOR HANDLING TRAINS IN MOUNTAIN GRADE TERRITORY IS, & SHOULD BE, THE RESPONSIBILITY OF INDIVIDUAL RAILROADS. ALL OUR MEMBERS HAVE IDENTIFIED THEIR MOUNTAIN GRADE TERRITORIES & HAVE RULES IN PLACE TO HANDLE THESE TOPOGRAPHIES & PROFILES. EACH RAILROAD IS BEST ABLE TO EVALUATE PROPER METHODS TO CONTROL TRAINS & THEIR INDIVIDUAL CONSISTS ON EXTENDED DESCENDING GRADES & TO ESTABLISH THE TRAINING/COMMUNICATION PROCESSES TO ENSURE THEIR EMPLOYEES UNDERSTAND & IMPLEMENT WHAT IS REQUIRED IS TRAIN HANDLING.