The National Transportation Safety Board (NTSB) has determined that an engine shutdown switch cited previously as poorly placed caused the derailment of a Union Pacific Railroad freight train in California earlier this year.
On January 12, 1997, at 11:52 a.m., a Union Pacific Railroad Company (UP) freight train derailed after an accelerated descent beyond the 20-mph speed limit down Cima Hill near Kelso, California. The engineer accidentally activated the engine shutdown switch, which shut off the locomotive unit diesel engines and eliminated the train's dynamic braking capability. The train eventually reached a speed of 72 mph and derailed 68 of its 75 cars. There were no fatalities. The total damage was $4,376,400.
The engine shutdown switch, located on the left side of the console where the engineer's knee might have rested, was found still depressed after the accident. Neither the engineer nor the conductor was aware of what caused the shutdown. Therefore, they took no action to reactivate the system.
Each locomotive unit on the train was equipped with dynamic brakes, which use the engine power to apply braking to the locomotives only, not the cars. The Safety Board determined that although dynamic braking is considered by the railroad industry to be a nonessential system, dynamic braking is in practice critical to train control. Dynamic braking is used to avoid total dependence on the air brakes, the primary braking source. The Board learned that once dynamic braking is lost, a train operating on a steep downgrade can become uncontrollable within seconds, even if the air brake system is fully functional.
In its final report issued today, the Board determined that neither weather, signal and train-control systems, crewmember fatigue, nor track conditions were factors in the accident. Nonetheless, the NTSB found that failure of Union Pacific management to recognize the engine shutdown switch location as a safety hazard and expedite the relocation of the switch created the conditions that led to the accident.
The Board's report discusses other issues including adequate train-speed safety margins for steep grade railroad, accurate car weight reporting, the power brake rulemaking process, and the use of air brake retainers.
As a result of this accident investigation, the National Transportation Safety Board made recommendations to the Federal Railroad Administration, the Association of American Railroads, and the Union Pacific Railroad Company including,
• Alerting locomotive manufacturers and railroad operators about the dangers posed by improperly located safety controls and switches in locomotives;
• Separating the dynamic brake requirements from the Power Brake Law rulemaking;
• Requiring railroads to ensure that all locomotives with dynamic braking be equipped with a device in the cab of the controlling locomotive that indicates the real-time condition of the dynamic brakes on each trailing unit;
• Researching, investigating and analyzing the maximum authorized speeds for safe operation of trains of all weights to establish new speed-based margins of safety that can be easily used by traincrews;
• Implementing formal training on the proper procedures needed to set retainers for those traincrews that may be required to do so;
• Reexamining the system of car weighing and car-consist weight reporting and taking action to ensure that train consist weights reflect actual train weights.
The NTSB's complete report, PB98-916301, may be purchased from the National Technical Information Service, 5285 Port Royal, Springfield, VA 22161, (703) 487-4650.