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Safety Recommendation Details

Safety Recommendation R-98-004
Details
Synopsis: ON 1/12/97, ABOUT 11:52 A.M. PACIFIC STANDARD TIME, THE UNION PACIFIC RAILROAD (UP) UNIT FREIGHT TRAIN 6205 WEST DERAILED 68 CARS ON THE UP LOS ANGELES SUBDIVISION, MILEPOST (MP) 238.7, NEAR KELSO, CALIFORNIA. THE TRAIN CONSISTED OF 3 LOCOMOTIVE UNITS AND 75 LOADED COVERED HOPPER CARS. WHILE DESCENDING CIMA HILL, THE ENGINEER INADVERTENTLY ACTIVATED THE MULTIPLE-UNIT (MU) ENGINE SHUTDOWN SWITCH, WHICH SHUT DOWN ALL THE LOCOMOTIVE UNIT DIESEL ENGINES AND ELIMINATED THE TRAIN'S DYNAMIC BRAKING CAPABILITY. THE TRAIN RAPIDLY ACCELERATED BEYOND THE 20-MPH AUTHORIZED SPEED LIMIT DESPITE THE ENGINEER'S EFFORTS TO INCREASE THE TRAIN'S AIR BRAKING, WHICH THE ENGINEER PLACE IN EMERGENCY 1 MINUTE AND 2 SECONDS AFTER DYNAMIC BRAKING LOSS. THE TRAIN'S CONSIST WEIGHT WAS LISTED AT AN AVERAGE OF 13 TONS PER CAR LESS THAN THE TRAIN ACTUALLY WEIGHED. THE TRAIN EVENTUALLY REACHED A SPEED OF 72 MPH AND DERAILED 68 OF ITS 75 CARS WHILE EXITING A SIDING NEAR KELSO, CLAIFORNIA. NO FATALITIES, INJURIES FIRES, OR HAZARDOUS MATERIALS RELEASES RESULTED FROM THE ACCIDENT. THE TOTAL DAMAGE COST WAS $4,376,400.
Recommendation: THE NTSB RECOMMENDS THAT THE FRA: CARRY OUT RESEARCH, INVESTIGATION, AND ANALYSIS TO DETERMINE MAXIMUM AUTHORIZED TRAIN SPEED FOR SAFE OPERATION OF TRAINS OF ALL WEIGHTS, USING SPEED-BASED MARGINS OF SAFETY THAT CAN BE EASILY MEASURED BY TRAIN CREWS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Kelso, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: LAX97FR004
Accident Reports: Derailment of Union Pacific Railroad Unit Freight Train 6205 West
Report #: RAR-98-01
Accident Date: 1/12/1997
Issue Date: 2/25/1998
Date Closed: 12/22/2004
Addressee(s) and Addressee Status: FRA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 12/22/2004
Response: The Safety Board notes that on January 17, 2001, the FRA issued a final rule on Brake System Safety Standards for Freight and Other Non-Passenger Trains and Equipment; End-of-Train Devices (Power Brake Rule). Title 49 CFR Part 232, §109, Dynamic Brake Requirements, in essence, requires railroads (1) to determine maximum authorized speed under all operating conditions, (2) to be able to bring trains to a stop from those speeds using only friction brakes, and (3) to include a miles-per-hour overspeed stop rule. This final rule constitutes an acceptable method of addressing the recommendation; accordingly, Safety Recommendation R-98-4 is classified "Closed--Acceptable Action."

From: NTSB
To: FRA
Date: 7/21/2004
Response: On 7/21/2004 Board staff met with FRA staff to discuss this recommendation. The discussion was led by Ron Newman. On January 17, 2001, FRA published the final rule for Brake System Safety Standards; Part 232 (Power Brake Rule). The final rule included Section 232.109 for dynamic brake requirements and Section 232.111 for train handling. The Volpe Center is developing a new Train Energy Dynamic Simulator (TEDS). The FRA believes that the brake regulation meets the intent of Safety Recommendation R-98-4 and requests the recommendation be classified "Closed-Acceptable Action."

From: NTSB
To: FRA
Date: 1/11/2000
Response: THE SAFETY BOARD IS PLEASED THAT THE FRA AGREES WITH THIS RECOMMENDATION AND INTENDS TO CONTRACT FOR THE RECOMMENDED RESEARCH WHEN FUNDING IS AVAILABLE. THE SAFETY BOARD ENCOURAGES THE FRA TO SEEK FUNDING FOR THIS RESEARCH. ASSUMING THAT THE FRA WILL FIND FUNDS IN A REASONABLE AMOUNT OF TIME, R-98-4 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FRA
To: NTSB
Date: 3/17/1999
Response: Letter Mail Controlled 3/31/99 4:10:10 PM MC# 990337 FRA IS IN GENERAL AGREEMENT WITH THE BOARD'S RECOMMENDATION, AND DESIRES TO OUTSOURCE THIS RESEARCH AS SOON AS FUNDING IS AVAILABLE. STEPS HAVE BEEN TAKEN TO SECURE FUNDING TO ALLOW THIS RESEARCH TO BE CONDUCTED BY THE VOLPE CENTER. THE VOLPE CENTER HAS CONDUCTED SIMILAR RESEARCH OF THIS TYPE USING ITS TOES MODEL, AND WILL BEGIN RESEARCHING THE AVAILABLE LITERATURE ON THIS SUBJECT AS SOON AS FUNDS BECOME AVAILABLE, HOPEFULLY BEFORE THE END OF FISCAL YEAR 1999. IT IS OUR INTENTION TO WORK IN CONCERT WITH THE RAILROAD INDUSTRY ON THIS IMPORTANT MATTER. THEREFORE, BASED UPON FRA'S INTENDED ACTION, WE RESPECTFULLY REQUEST THE BOARD TO CONSIDER THIS RECOMMENDATION AS "OPEN--ACCEPTABLE ACTION."

From: NTSB
To: FRA
Date: 2/3/1999
Response: Notation 7112: FRA Docket No. PB-9; Notice No. 13 Written comments about notice of proposed rulemaking (NPRM) for 49 Code of Federal Regulations (CFR) Parts 229, 231, and 232, "Brake System Safety Standards for Freight and Other Non-Passenger Trains and Equipment" The National Transportation Safety Board has reviewed the NPRM "Brake System Safety Standards for Freight and Other Non-Passenger Trains and Equipment." The NPRM was published in the Federal Register on September 9, 1998, and represents a positive response from the Federal Railroad Administration (FRA) to a number of Safety Board air brake-related recommendations about cold weather air brake testing, retainer valve training and use, securing standing freight cars, and controlling train speed in mountain-grade territory. The Safety Board offers the following comments. As a result of the investigation of an accident that occurred at San Bernardino, California, in May 1989,I the Safety Board recommended that the FRA: Revise regulations to require that if a locomotive unit is equipped with dynamic brakes, the dynamic brakes function. (R-90-24) On November 30, 1990, the FRA responded that it chose not to make a "definitive response" to the recommendation because the agency was developing the NPRM. On February 21, 1991, the Safety Board classified Safety Recommendation R-90-24 "Open-Awaiting Response." Seven years later, because the FRA had not made any progress on Safety Recommendation R-90-24, the Safety Board concluded that the FRA should separate the recommendation from the power brake NPRM and act on the recommendation independently. Therefore, the Safety Board classified Safety Recommendation R-90-24 "Closed-Superseded" and replaced it with Safety Recommendation R-98-5, which the Safety Board issued as a result of its investigation of the 1997 derailment of a freight train near Kelso, California.2 The Safety Board issued the following recommendations in February 1998 to the FRA: Separate the dynamic brake requirements from the Power Brake Law rulemaking and immediately conclude rulemaking to require that railroads verify that the dynamic braking systems on all locomotives equipped with dynamic brakes are functioning properly before trains are dispatched. (R-98-5) Require railroads to ensure that all locomotives with dynamic braking be equipped with a device in the cab of the controlling locomotive unit to indicate to the operating engineer the real-time condition of the dynamic brakes on each trailing unit. (R-98-6) Now that the power brake NPRM has been issued, however, it appears that any separate action the FRA takes on Safety Recommendation R-98-5 may take longer than the power brake rulemaking itself. Proposed Section 232.109 of the NPRM is responsive to Safety Recommendation R-98-5. It is the Safety Board's understanding that the NPRM requires that: • The engineer be informed in writing of the status of the dynamic brakes on all locomotive units in the consist, • Inoperative dynamic brakes be conspicuously tagged and repaired within 30 days, • Railroads operating trains using dynamic brakes have operating rules that ensure trains can be stopped safely should the dynamic brakes fail, and • Engineers be trained and certified on how to stop a train if or when dynamic brakes fail. However, the NPRM does not fulfill the intent of Safety Recommendation R-98-6. The railroads assert that no such dynamic brake indicator device exists, although the PULSE company has shown that such a device is feasible and economical and could easily be manufactured by a number of event recorder manufacturers. Therefore, the Safety Board encourages the FRA to amend the NPRM so that it meets Safety Recommendation R-98-6. Also as a result of the Kelso accident, the Safety Board issued the following recommendation to the FRA: Require railroads to implement formal training on correct retainer setting and using procedures for train crewmembers who may set or use air brake retainer valves. (R-98-7) The NPRM does not specifically address training in the use of retainers,3 particularly by operating crewmembers. It does address training in the inspection, testing, and maintenance of all brake equipment, functions traditionally performed by mechanical personnel. The NPRM seems to imply that anyone who is involved with air brake equipment should be trained. The section on "Training requirements" (49 CFR Part 232.203) proposes a comprehensive training program for each employee or contractor employee who performs brake system inspections, tests, or maintenance. Since train crews may inspect and test the air brake systems of trains, the NPRM suggests that the FRA interprets the proposed regulation as including those, such as train crewmembers, who may also use air brake equipment "as part of their duties on the equipment to which they are assigned." If the FRA interprets retainer use as included under the proposed required training program, the Safety Board fully supports the regulation. If not, the Safety Board would like to see the regulation expanded to include, under an air brake equipment training program, specific instruction on the use of retainers by train crewmembers who use and operate such equipment. Again as a result of the Kelso accident, the Safety Board issued the following recommendations to the FRA: Require railroads to review steep-grade train handling practices and, if necessary, make changes that will preserve a margin of stopping ability should a dynamic brake system fail. (R-98-3) Carry out research, investigation, and analysis to determine maximum authorized train speed for safe operation of trains of all weights, using speed-based margins of safety that can be easily measured by train crews. (R-98-4) The section of the NPRM on "General Requirements for All Train Brake Systems" states: A train's primary brake system shall be capable of stopping the train with a service application from its maximum authorized speed within the signal spacing existing on the track over which the train is operating. Safety Recommendation R-98-3 could be met if the train's air brake system was always capable of stopping the train regardless of the dynamic brake status. However, the proposed regulation is insufficient to fulfill the intent of Safety Recommendation R-98-4. Theoretically, Safety Recommendation R-98-4 could be met if the maximum authorized train speed could be precisely read from an exact speedometer and if the engineer immediately made a sufficient level of service application at the right moment to stop the train at exactly the maximum authorized speed. By the FRA's own regulations, at 49 CFR Part 229.117, however, speedometers only have to be accurate within 3 mph of the train's speed if the speed is between 10 and 30 mph and within 5 mph of the train's speed if the speed is more than 30 mph. Railroad management recognizes that controlling the speed of a freight train is not an exact science, so engineers are generally allowed to vary speed between 3 to S mph over the maximum authorized speed. Also, because of the large number of variables that go into determining a safe maximum authorized speed with an inherent safety margin, railroads are reluctant to establish a guideline that may sacrifice efficiency. Several railroads, however, have already adopted a "S-mph rule" in mountain grade territory, which seems to have been effective in reducing the number of runaway trains. Under the rule, when a train's speed exceeds the maximum authorized speed by more than S mph, the train must immediately be stopped with a full service air brake application or, if necessary, an emergency application. The rule provides an easily recognizable and measurable speed-based safety margin that can be quickly employed should the train speed become excessive. Therefore, the Safety Board urges the FRA to support Safety Recommendation R-98-4 by requiring railroads to determine maximum safe train speeds for trains of all weights and to set authorized speeds that incorporate speed-based margins of safety that are clear and easily understood and that can be quickly employed by train crews. Air brake testing is one of the most important ways of ensuring the safe operation of trains, particularly in cold weather and in mountain-grade territory. The Safety Board believes that a system should be tested under the conditions under which it will be operated. Otherwise, the test will not reveal the current status and future reliability of the system as accurately as possible. The setting of the regulating valve (feed valve) dictates the brake pipe, or train line, pressure at which a train will be operated. Neither current regulations nor the NPRM requires that air brakes be tested at the regulating valve setting at which the train will be operated. The Safety Board believes trains should be tested at the pressure at which they are operated. Such testing precludes crewmembers and supervisors from attempting (particularly in cold weather) to conduct brake tests and qualify trains with excessive leakage. In such an attempt, a crewmember or supervisor minimizes the leakage by testing the air brakes while the trainline pressure is lower than it will be when the train is being operated. The FRA should take advantage of the opportunity that the NPRM provides to close the loophole in the regulations and require railroads to test air brakes under the conditions under which they will be operated. The Safety Board is also concerned that the NPRM does not adequately address the issues involved in determining the capability of the brake system. The NPRM section on "Computation of percent operative power brakes" states: The percentage of operative power brakes in a train shall be based on the number of control valves in the train. The percentage shall be determined by dividing the number of control valves that are cut in by the total number of control valves. In the NPRM discussion of this section, the FRA says: Today, many types of freight equipment can have the brakes cut out on per truck basis and the FRA expects this tend [sic] to increase as the technology is applied to new equipment. Consequently, the FRA merely proposes a method of calculating the percentage of operative brakes based on the design of equipment used today, and thus, a means to more accurately reflect the true braking ability of the train as a whole. With modern freight equipment, a control valve can be cut in and operating while the brakes of one of the two trucks controlled by that valve are cut out and not operating. Thus, under the worst case conditions, half the brakes in the train could be nonfunctioning and yet the brakes would be considered 100-percent operational since all of the control valves would still be cut in and operational. Therefore, the Safety Board does not think that the regulation as written is adequate. Requirements should be added that preclude the railroads cutting out the brakes on one truck of a car and still considering the brakes to be 100-percent effective. The Safety Board appreciates the opportunity to comment on this proposed rule.