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Safety Recommendation Details

Safety Recommendation R-98-016
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: REVIEW THE FUNCTIONS & RESPONSIBILITIES OF THE UNION PACIFIC RAILRAOD GENERAL DIRECTOR OF SAFETY & MAKE ANY ORGANIZATIONAL CHANGES NECESSARY TO ENSURE THAT THIS OFFICIAL" (1) REPORTS DIRECTLY TO THE UNION PACIFIC RAILROAD PRESIDENT & CHIEF OPERATING OFFICER; (2) IS INVOLVED IN ALL UNION PACIFIC RAILROAD OPERATIONAL ISSUES THAT COULD AFFECT TRAIN, RAILROAD, & PERSONNEL SAFETY & (3) HAS THE AUTHORITY TO TAKE EFFECTIVE SAFETY ACTIONS THROUGHOUT THE UNION PACIFIC RAILROAD.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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 Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Union Pacific
Date: 6/5/2001
Response: The Safety Board notes that subsequent to the issuance of this recommendation, UP combined the Operating Practices Department and the Safety Department and that the combined organization now reports to the Senior Vice President Safety. The Senior Vice President Safety reports directly to you, the Executive Vice President Operations. The Safety Board believes that the lead safety officer in the railroad's management structure should report directly to the primary managerial authority to avoid possible conflicts of interest between business operations and safety. In the final report of the accident in Kelso, California, the Board concluded that the UP General Director of Safety should report directly to the UP President and Chief Operating Officer. Although this specific reporting hierarchy is not in place, you indicate that the Senior Vice President of Safety has daily contact with you, has routine contact with the President, and provides a formal report to the Chairman and the Audit Committee of the Board of Directors at UP. Based on this information and your assurance that the Senior Vice President, Safety, is closely involved in the day-to-day operating issues impacting safety, and that this official has the authority to introduce changes to constructively affect safety, Safety Recommendation R-98-16 is classified "Closed--Acceptable Alternate Action."

From: Union Pacific
To: NTSB
Date: 12/12/2000
Response: Letter Mail Controlled 12/20/2000 12:24:06 PM MC# 2001797 At the time of the recommendation, safety on Union Pacific Railroad was organized under two separate departments, Operating Practices and Safety. Operating Practices dealt with derailment prevention and operating rules and practices. Safety managed employee injury prevention and grade crossing incident prevention. Subsequent to the recommendation, these two organizations combined to take advantage of overlapping issues and strengths. The combined organization now reports to Mr. Tom Jacobi, Senior Vice President Safety. Mr. Jacobi reports directly to me. Mr. Jacobi has daily contact with me, and routine contact with President Ike Evans. Mr. Jacobi provides a formal report to Chairman Dick Davidson, and the Audit Committee of the Board of Directors at Union Pacific. This organization and reporting structure ensures that Mr. Jacobi is closely involved in the day-to-day operating issues impacting safety and has the authority to introduce changes to constructively affect safety.

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 NOTES THE UP HAS REVIEWED THE GENERAL DIRECTOR OF SAFETY'S POSITION AND HAS DETERMINED THAT NO CHANGES ARE NECESSARY AT THIS TIME. THE SAFETY BOARD BELIEVES THAT THERE IS ENOUGH SUPPORTING INFORMATION TO ASK THE UP TO RECONSIDER ITS POSITION. PENDING ADDITIONAL INFORMATION REGARDING THE CURRENT SAFETY MANAGEMENT HIERARCHY AND ORGANIZATIONAL CHANGES THAT MAY OCCUR, THE BOARD HAS CLASSIFIED R-98-16 "OPEN--UNACCEPTABLE RESPONSE."

From: Union Pacific
To: NTSB
Date: 4/15/1998
Response: Letter Mail Controlled 4/20/98 4:17:54 PM MC# 980493 UNION PACIFIC'S PRESIDENT AND CHIEF OPERATING OFFICER IS, IN FACT, THE SENIOR SAFETY OFFICER FOR THE RAILROAD. IN THIS CAPACITY HE CERTAINLY HAS THE AUTHORITY TO DIRECT WHATEVER SAFETY ACTIONS HE DEEMS NECESSARY THROUGHOUT THE SYSTEM. UNION PACIFIC BELIEVES THAT THE GENERAL DIRECTOR OF SAFETY AND THE ADMINISTRATION OF THE SAFETY DEPT., INCLUDING THE REPORTING RELATIONSHIP, ARE APPROPRIATE AND WILL REMAIN AT THE DISCRETION OF THE UNION PACIFIC.