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Safety Recommendation Details

Safety Recommendation R-98-015
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: IMPLEMENT FORMAL TRAINING ON THE PROPER PROCEDURES FOR SETTING & USING RETAINERS FOR THOSE TRAINCREWS THAT MAY BE REQUIRED TO DO SO.
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: 4/5/1999
Addressee(s) and Addressee Status: Union Pacific (Closed - Acceptable Action)
Keyword(s): Training and Education

Safety Recommendation History
From: NTSB
To: Union Pacific
Date: 4/5/1999
Response: THE SAFETY BOARD NOTES THAT THE UP HAS IMPLEMENTED FORMAL TRAINING ON THE PROPER PROCEDURES FOR SETTING AND USING RETAINERS. ON THIS BASIS, THE BOARD HAS CLASSIFIED R-98-15 "CLOSED--ACCEPTABLE ACTION."

From: Union Pacific
To: NTSB
Date: 4/15/1998
Response: Letter Mail Controlled 4/20/98 4:17:54 PM MC# 980493 TO SUPPLEMENT THE FORMAL TRAINING PROCEDURES ALREADY IN PLACE FOR THE USE OF RETAINERS, THE FOLLOWING ADDITIONAL TRAINING WILL BE, OR HAS BEEN, IMPLEMENTED: (1) HEAVY GRADE SIMULATOR TRAINING FOR ENGINEERS HAS BEEN IN PLACE SINCE MAY 1997. TRAINING TO TAKE PLACE AT LOCATIONS WHERE RETAINERS MAY BE USED, (2) A NEW JOB AID IN THE FORM OF A PAMPHLET IS BEING DEVELOPED AND WILL BE ISSUED TO ALL TE&Y EMPLOYEES BY JUNE 1998, (3) A UNION PACIFIC RETAINER VIDEO WILL BE UPDATED AND REISSUED IN JUNE 1998, AND (4) BOTH THE PAMPHLET AND VIDEO WILL BE INCORPORATED INTO THE MANDATORY TRAINING OF ALL NEW SWITCHMEN/TRAINMEN.