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Safety Recommendation Details

Safety Recommendation R-98-013
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 & 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 & 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 & 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 & 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 UNION PACIFIC RAILROAD: DEVELOP PROCEDURES TO ENSURE THAT, BEFORE A TRAIN EQUIPPED WITH DYNAMIC BRAKES IS DISPATCHED, ALL THE DYNAMIC BRAKE SYSTEMS ON THE LOCOMOTIVES ARE FUNCTIONING PROPERLY.
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: 6/5/2001
Addressee(s) and Addressee Status: Union Pacific (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Union Pacific
Date: 6/5/2001
Response: With respect to R-98-13, the UP points out that locomotive maintenance instructions require that the dynamic brake circuit be tested and operational prior to dispatching any locomotive. With respect to R-98-14, UP has outlined in detail its reasons for using the accelerometer to provide dynamic train control. The Safety Board is aware that the final rule for “Brake System Safety Standards for Freight and Other Non-Passenger Trains and Equipment,” revising Title 49 of the Code of Federal Regulations, Parts 229, 231, and 232 was published in the January 17, 2001, issue of the Federal Register (Volume 66, Number 11). These new standards address the objectives of the Board’s Safety Recommendations R-98-13 and 14, by requiring that the engineer be informed of the condition of the locomotives in the consist and by requiring that the locomotives have the capability of displaying to the engineer the deceleration rate of the train or the total train brake dynamic brake retarding force. Based on UP’s procedures and the issuance of the Brake System Safety Standards, Safety Recommendations R?98-13 and -14 are classified “Closed--Acceptable Action.”

From: Union Pacific
To: NTSB
Date: 12/12/2000
Response: Letter Mail Controlled 12/20/2000 12:24:06 PM MC# 2001797 UPRR Locomotive Maintenance Instruction 9414ILMI 0012 Locomotive Departure Test requires the dynamic brake circuit to be tested and operational prior to dispatching any locomotive.

From: NTSB
To: Union Pacific
Date: 8/16/2000
Response: THE SAFETY BOARD WOULD APPRECIATE LEARNING OF ANY ACTIONS THE UPRR HAS TAKEN OR INTENDS TO TAKE SINCE THE BOARD'S LAST CORRESPONDENCE TO ADDRESS R-98-10, -13, -14, AND -16.

From: NTSB
To: Union Pacific
Date: 4/5/1999
Response: THE SAFETY BOARD IS PLEASED TO LEARN THAT THE UP PLACED THE RECOMMENDED PROCEDURES INTO EFFECT IN JANUARY 1998. WE ALSO NOTE THAT THE NEW PROCEDURES ARE NOW EMPHASIZED IN THE UP'S CARDINAL SAFETY RULES. WE NOTE THAT YOUR LETTER DOES NOT STATE WHETHER THE NEW PROCEDURES WILL ENSURE WORKING DYNAMIC BRAKES WHEN TRAINS ARE DISPATCHED. PENDING A CLARIFICATION OF THE MANDATORY NATURE OF THESE NEW PROCEDURES, THE SAFETY BOARD HAS CLASSIFIED R-98-13 "OPEN--ACCEPTABLE RESPONSE."

From: Union Pacific
To: NTSB
Date: 4/15/1998
Response: Letter Mail Controlled 4/20/98 4:17:54 PM MC# 980493 THE RECOMMENDED PROCEDURES WERE PLACED IN EFFECT IN JANUARY 1998 AND HAVE BEEN EMPHASIZED IN OUR CARDINAL SAFETY RULES.