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Safety Recommendation Details

Safety Recommendation R-96-078
Details
Synopsis: ABOUT 4:10 A.M. ON 2/1/96, ATCHISON, TOPEKA AND SANTA FE RAILWAY COMPANY (ATSF) FREIGHT TRAIN H-BALT1-31, EN ROUTE FROM BARSTOW, CALIFORNIA, TO LOS ANGELES, WAS TRAVELING WESTBOUND ON THE ATSF SOUTH MAIN TRACK WHEN IT DERAILED AT MILEPOST 60.4 NEAR CAJON JUNCTION, CALIFORNIA. AFTER THE DERAILMENT AND THE SUBSEQUENT RAIL CAR PILEUP, WHICH INVOLVED FIVE CARS CONTAINING HAZARDOUS MATERIALS, A FIRE IGNITED THAT ENGULFED THE TRAIN AND THE SURROUNDING AREA. THE CONDUCTOR AND THE BRAKEMAN SUSTAINED FATAL INJURIES; THE ENGINEER SUFFERED SERIOUS INJURIES.
Recommendation: THE NTSB RECOMMENDS THAT THE ASSOCIATION OF AMERICAN RAILROADS: DEVELOP WRITTEN GUIDELINES FOR ASSESSING THE INDIVIDUAL AND COMBINED EFFECTS OF MECHANICAL OR FIRE AND HEAT DAMAGE OR BOTH TO TANK CARS INVOLVED IN A DERAILMENT AND FOR THE HANDLING AND MOVEMENT OF SUCH TANK CARS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: Cajon, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MR002
Accident Reports: Derailment of Freight Train H-BALTI-31 Atchison, Topeka and Santa Fe Railway Company
Report #: RAR-96-05
Accident Date: 2/1/1996
Issue Date: 3/5/1997
Date Closed: 8/8/2005
Addressee(s) and Addressee Status: Association of American Railroads (Closed - Acceptable Alternate Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: Association of American Railroads
Date: 8/8/2005
Response: The Safety Board notes the AAR's belief that too many variables exist regarding the combined effects of mechanical and fire or heat damage for the Association to develop specific written guidance. The Board has acknowledged that many variables must be considered when investigating railroad accidents involving damage or fire to a tank car; however, the Board has also stated that at the very least, some cautionary information could be added to the two tank car specialist courses taught at TTCI, indicating that the combined effects of mechanical and heat or fire damage have the potential to seriously compromise the integrity of tank cars and that extra caution is necessary. In this regard the Safety Board notes that, on January 17, 2005, the Emergency Response Training (ERT) staff at TTCI issued this warning notice to its ERT students about the combined effects of mechanical and fire damage to railroad tank cars: "The combined effects of mechanical and fire damage can compromise the structural integrity of tank cars." The Safety Board also notes that, on February 14, 2005, the ERT staff issued an insert to be placed in the student manual in the "Damage" section, page 5, paragraph 3, for the Tank Car Specialist and Advanced Tank Car Specialist Course Manuals, which are included in the new workbooks as of April 2005. Thank you for providing us a copy of that insert. The ERT instructor noted that a lecture provides students with additional information about the combined effects of mechanical and fire damage of tank cars. These additions constitute an acceptable alternate approach to this recommendation. Accordingly, Safety Recommendation R-96-78 is classified "Closed--Acceptable Alternate Action."

From: Association of American Railroads
To: NTSB
Date: 2/17/2005
Response: AAR's Transportation Technology Center Incorporated has modified the curriculum of its Emergency Response Training Center - Tank Car Specialist and Advanced Tank Car Specialist courses to include the following language: "The combined effects of mechanical and fire damage can compromise the structural integrity of tank cars." This acknowledges that mechanical and fire damage together can seriously compromise the integrity of tank cars and should satisfy this recommendation. In consultation with the NTSB Investigator in charge of this investigation, it is understood that the incorporation of our curriculum will exceed the intent of the recommendation.

From: NTSB
To: Association of American Railroads
Date: 11/24/2004
Response: At the February 19, 2004, meeting, the AAR expressed concern that because each train accident is unique, a "one-size-fits-all" approach, in terms of written guidelines, is not realistic, and flexibility is needed to handle the specific circumstances of each accident. Subsequently, Safety Board staff spoke with TTCI staff who were also concerned about developing written guidance because of the variables involved with respect to both mechanical damage and damage caused by heat or fire (i.e., how long has there been impingement by flame, is it a torch or pool flame, how many BTUs are being generated, how big an area is being affected, what type of product is burning, is the mechanical damage visible, and can the mechanical damage be quantified). TTCI staff also indicated that flame impingement can be quantified and qualified in a testing environment, but not in an actual derailment, and staff was unaware of any methodology that combines both mechanical and fire or heat damage. The Board acknowledges that there are many variables to consider in railroad accidents involving damage or fire to a tank car, but we believe that if specific written guidance cannot be developed, at least some cautionary information that mechanical and fire damage together can seriously compromise the integrity of tank cars should be emphasized in the two tank car specialist courses. Pending the AAR's consideration of this suggestion, Safety Recommendation R-96-78 is classified "Open--Acceptable Response."

From: NTSB
To: Association of American Railroads
Date: 2/19/2004
Response: On 2/19/2004, Board staff met with representatives from the AAR to discuss this recommendation. In this meeting, the AAR indicated that it believes that all train wrecks are unique and the "one-size fits all" approach is not realistic. Instead, the AAR has some general guidelines. The AAR believes that because train wrecks are too cumbersome and complicated, flexibility is needed to handle individual accidents. The AAR thinks the information contained in the advanced tank car course manual contains written guidelines to alternately meet the requirements of this recommendation.

From: NTSB
To: Association of American Railroads
Date: 12/6/2000
Response: The Safety Board notes that the AAR requests that these recommendations remain in an “open” posture as the association’s committees consider action. As these recommendations were issued between 2 and 9 years ago, the Safety Board would appreciate receiving a substantive response to all of them within 60 days as to contemplated actions and a schedule to complete such actions. Pending receipt of the requested information within 60 days, the above-listed Safety Recommendations are classified "Open--Acceptable Response." In your reply, please refer to the Safety Recommendations by number.

From: Association of American Railroads
To: NTSB
Date: 8/21/2000
Response: Letter Mail Controlled 08/22/2000 3:27:22 PM MC# 2001124 The rail industry, through its appropriate committees, is carefully considering the above-referenced recommendation. When that review is completed, I will notify you of the resolution.

From: NTSB
To: Association of American Railroads
Date: 8/6/1998
Response: THE BOARD NOTES THAT THE AAR HAS PROVIDED INTRUCTION ON THE TANK CAR DAMAGE ASSESSMENT GUIDELINES AS PART OF THE TANK CAR SAFETY COURSES OFFERED AT THE AAR'S TRANSPORTATION TECHNOLOGY CENTER IN PUEBLO, COLORADO. THE BOARD IS ALSO PLEASED THAT THE AAR IS CURRENTLY WORKING WITH FRA TO VALIDATE THESE GUIDELINES & THAT THE AAR IS OFFEREING ADDITIONAL INSTRUCTION ON THESE GUIDELINES THROUGH ITS ANNUAL HAZARDOUS MATERIALS SEMINAR & THE ADVANCED TANK CAR SPECIALIST COURSE. THE BOARD HAS SEVERAL QUESTIONS & WOULD APPRECIATE MORE INFO ABOUT THIS MODEL. SPECIFICALLY, WILL THE MODEL BE USED AS A DESIGN TOOL, OR CAN IT BE USED AT THE SCENE OF AN ACCIDENT TO PROVIDE EMERGENCY RESPONDERS & RAILROAD OFFICIALS WITH SOME INDICATIONS OF TANK CAR INTEGRITY? DOES THE MODEL PERFORM ANY CALCULATIONS ON THE STRENGTH OF THE TANK MATERIAL THAT IS SUBJECTED TO A FIRE? DOES THE EVALUATION OF STRUCTURALLY INTACT TANK CARS INCLUDE TANK CARS THAT SUSTAINED MECHANICAL DAMAGE IN A DERAILMENT OR OTHER TYPE OF ACCIDENT? WRITTEN DOCUMENTATION ABOUT THE APPLICATION & USE OF THE MODEL MAY BE SUFFICEINT TO ADDRESS THESE QUESTIONS. THE BOARD AGREES WITH MR. OGLESBY'S ASSERTION THAT ASSESSING THE COMBINED MECHANICAL & THERMAL DAMAGE TO TANK CARS IS DIFFICULT & MADE MORE COMPLEX WITH THE WIDE VARIETY OF TANK CAR TYPES & PRODUCTS TRANSPORTED IN THEM. HOWEVER, THE BOARD DOES NOT AGREE THAT THE DEVELOPMENT OF GUIDELINES AS SPECIFIED IN R-96-78 "IS FRAUGHT WITH RISK WITHOUT A COMMENSURATE INCREASE IN SAFETY." ALTHOUGH THE BOARD AGREES THAT EXPERTS FROM THE RAILROAD, SHIPPER, & TANK CAR COMMUNITIES MUST JOINTLY MAKE JUDGEMENTS ABOUT THE STRUCTURAL INTEGRITY OF TANK CARS THAT HAVE SUSTAINED MECHANICAL & THERMAL DAMAGE, THE BOARD ALSO BELIEVES THAT SUCH JUDGEMENTS, TO BE EFFECTIVE, MUST BE FOUNDED ON SOUND GUIDANCE BASED ON AN ENGINEERING ANALYSIS OF THE COMBINED EFFECTS OF MECHANICAL THERMAL DAMAGE. BECAUSE OF THE POSITIVE WORK TO VALIDATE THE EXISTING DAMAGE ASSESSMENT GUIDELINES & THE DEVELOPMENT OF THE AFETC MODEL, R-96-78 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: Association of American Railroads
To: NTSB
Date: 3/10/1998
Response: (Letter Mail Controlled 3/17/98 5:58:03 PM MC# 980350) AAR'S TRANSPORTATION TECHNOLOGY CENTER, INC. (TTCI) NEAR PUEBLO, COLORADO, CURRENTLY TEACHES TANK CAR DAMAGE ASSESSMENT GUIDELINES AS PART OF ITS TANK CAR SPECIALIST COURSE. AN IMPORTANT PART OF THIS COURSE IS ASSESSING THE SEVERITY OF MECHANICAL DAMAGE (I.E., DENTS, SCORES, GOUGES, ETC.) AAR IS CURRENTLY WORKING WITH THE FRA TO VALIDATE THE GUIDELINES USED IN THIS COURSE. TTCI IS OFFERING AN ADVANCED TANK CAR SPECIALIST IN 1998. ASSESSING THE SEVERITY OF MECHANICAL DAMAGE TO TANK CARS IS DIFFICULT. DOING SO IN CONJUNCTION WITH FIRE &/OR HEAT IS EVEN MORE COMPLEX. ATTEMPTING TO DEVELOP SEPCIFIC ACTION GUIDELINES THAT TAKE INTO ACCOUNT ALL RELEVANT FACTORS (SOME OF WHICH MAY NOT BE KNOWN) IS FRAUGHT WITH RISK WITHOUT A COMMENSURATE INCREASE IN SAFETY. THE ADVANCED TANK CAR COURSE WILL INCLUDE WRITTEN INSTRUCTION ON WHAT FACTORS THE RESPONDER NEEDS TO CONSIDER (E.G. TANK CAR ORIENTATIN, MATERIAL CONTAINED, ETC.) IN THE RARE CIRCUMSTANCES WHERE CARS HAVE BOTH FIRE & MECHANICAL DAMAGE, AAR BELIEVES JUDGEMENTS ABOUT THE HANDLING OF THESE CARS ARE BEST MADE BY HIGHLY TRAINED EXPERTS FROM THE RAILROAD, SHIPPER & TANK CAR COMMUNITIES WORKING TOGETHER.

From: Association of American Railroads
To: NTSB
Date: 2/3/1998
Response: Letter Mail Controlled 2/10/98 2:58:04 PM MC# 980156

From: Association of American Railroads
To: NTSB
Date: 1/28/1998
Response: Letter Mail Controlled 2/2/98 4:00:43 PM MC# 980120