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Description
About 4:10 a.m., Pacific standard time, on February 1, 1996, westbound Atchison, Topeka and Santa Fe Railway Company1 (ATSF) freight train H-BALT1-31 derailed near Cajon Junction, California. (See figure 1.) The point of derailment (POD) occurred at milepost (MP) 60.4 on the ATSF south main track, southern California division, Cajon subdivision. HBALT1-31 consisted of 4 locomotives and 49 rail cars traveling from Barstow, California, en route to Los Angeles with a traincrew of an engineer, a conductor, and a brakeman. A fire resulted from the derailment and the subsequent car pileup, which involved five cars containing hazardous materials, and the immediate area was evacuated. The conductor and the brakeman sustained fatal injuries; the engineer incurred serious injuries. Barstow and Los Angeles were the designated away-from-home and home terminals, respectively, for all three H-BALT1- 31 crewmembers. The traincrew, having been off duty for 12 hours 50 minutes, had reported for duty at the ATSF yard in Barstow at 5 p.m. on January 31, 1996. They were instructed not to couple the locomotive consist to the train because a yard crew was connecting car ATSF 90033, following its repair, to the train cars. Car ATSF 90033 was joined onto the train as the 16th car from the head end, and the crew then coupled the locomotive consist to the westernmost car on the track. The engineer said that after the locomotive consist was coupled to the train, a carman informed the crew that the car department needed to inspect and to test the air brakes on car ATSF 90033. The test of the ATSF 90033 air brakes was done in conjunction with the initial terminal air brake test. The engineer stated that he performed the initial terminal air brake test with the assistance of a carman, who was at the rear of the train. The engineer continued that after the train line2 was fully charged with air, about 86 pounds per square inch (psi), at the rear of the train, he reduced the train line air pressure by 20 psi and noticed that the head-end device (HED) indicated that the air pressure reading on the end-of-train device (ETD) had decreased accordingly. Located in the locomotive control compartment, the HED displays the brake pipe pressure being transmitted from the ETD on a digital read out and activates the red rear-end marker light. This multipurpose receiver will indicate whether an attempt to “arm” the twoway function on the ETD was successful. When attempting to arm the ETD, an individual at the rear of the train tells the engineer the ETD number, which the engineer enters on the HED key pad. The individual at the rear of the train then pushes the test button, and the engineer waits for the ready-to-arm message to then press the arm button. The message indicates that the ETD is armed after the link is made. The battery-powered ETD is mounted to the rear coupler on the last car of the train, and an air hose connects the ETD to the brake pipe. The one-way ETD has a pressure transducer to monitor the brake pipe pressure and a flashing red marker light to protect the end of the train. A two-way ETD provides the same functions as the one-way ETD except it additionally has the capability of venting the brake pipe for applying emergency brakes. The signal to vent the brake pipe comes from a starter switch on the HED controlled by the engineer. The advantage of applying emergency brakes from the rear of the train is that any blockage in the brake pipe would be bypassed and braking would occur at both the front and rear of the train simultaneously. The engineer had waited about 1 minute and then did a leakage test, noting the train line leakage was 2 pounds per minute meeting the requirements under 49 Code of Federal Regulations (CFR) 232.12. After the leakage test, the engineer released the train air brakes, and the air pressure at the rear of the train, as indicated by the ETD, returned to 86 pounds. The engineer then informed the carman at the rear of the train that he intended to make an emergency brake application to test that feature of the train brakes. He initiated the emergency brake application from the automatic brake valve3 on the locomotive, and according to the carman, the emergency brake application propagated through the train. The engineer released the brakes, and the air pressure on the ETD returned again to 86 pounds. One of two carmen who were near car ATSF 90033 said that he observed the brakes set and release on the car during the first part of the air test. During the air brake tests with the assistance of the carman at the rear of the train, the engineer also attempted to arm the two-way telemetry feature on the ETD. The engineer stated that he received a "com/test/fail" error message on the HED on the locomotive during the ETD arming procedure. He informed the carman of this error message, and the carman responded, "Okay." The engineer said that they had no further conversation about the ETD. Because of a mudslide in the Cajon area, the ATSF management decided to hold H-BALT1- 31 at the Barstow yard, and the traincrew was taken off duty at 7:30 p.m. The engineer said that before leaving the train, he had applied its air brakes by reducing the brake pipe pressure by approximately 20 pounds. The engineer resided in the nearby town of Newberry Springs, California, and went home; the other two crewmembers returned to the motel. The traincrew was recalled for duty at 11:45 p.m., and another set and release, initiated from the head end of the train, was performed on the air brake system. The braking system was charged for 3 minutes 6 seconds, and then a 12 psi reduction was made. About 1:17 a.m. on February 1, 1996, HBALT1-31 with its 4 locomotives and 45 loaded and 4 empty rail cars departed Barstow and proceeded to and stopped for 30 seconds at Hodge, California, (MP 13.6). The event recorder data indicated that a 7-pound reduction was made to the automatic air brakes of the train. H-BALT1-31continued west and did not stop until 2:30 a.m. at Victorville, California, (MP 36.7). The event recorder registered the use of its automatic air and dynamic brakes. The engineer said he believed that using the air brakes to stop at Victorville complied with the timetable instruction requiring him to make a "running" air brake test at that location and that the air brakes were operating properly at that time also. After 5 minutes 17 seconds at Victorville, H-BALT1-31 continued on to and arrived at Summit, California, (MP 55.9) at 3:40 a.m. (The engineer did not recall making a stop at MP 50.1 [Lugo, California].) The engineer stopped at Summit by using the train air brakes, and the train remained there while the crew waited for a permissive signal permitting them to proceed westward. The engineer said that the conductor and the brakeman were sitting in the cab with him. The engineer stated that after receiving a permissive signal, he made at least a 10-pound brake pipe reduction, as required by timetable instruction. The engineer continued that he moved the three-position cut-out valve from the freight position to the passenger position.4 At 3:50:08 a.m., the train brakes were released, the train brake pipe pressure was 86 psi 1 minute 42 seconds later. The throttle went from zero to one at 3:56 a.m. The engineer said that both the dynamic and the train brakes functioned as expected up to and including the stop at Summit. The engineer reported that H-BALT1-31 crested and began to descend the mountain and at Cajon Pass, he applied the dynamic brakes, “bunching”5 the train toward the engines. He also made a first-service brake application by reducing the brake pipe pressure between 5 and 8 pounds. The engineer noted that the speed of the train was increasing, and he applied more braking. The engineer stated that when the train reached the speed of 18 mph, he and the conductor were aware that the train was moving too fast. They were discussing what action to take when the engineer realized that the speed had reached between 20 and 21 mph, and he said that he wanted to “plug it.”6 The engineer stated that the conductor said, “No, let’s not plug it. Let’s make a full set on it, get it stopped.” The engineer continued that he then initiated a full-service brake application, immediately placing the train in emergency. At this time, the engineer noted that the HED was reading 81 psi on the rear of the train. He said that he put the train into emergency and the air pressure reading did not reduce to zero. The engineer stated that he radioed the ATSF dispatcher to warn all traffic ahead that HBALT1-31 was a runaway train. The engineer recalled that both crewmembers had stood and then proceeded down the steps in the cab to a door leading to the front of the locomotive and that the speed indicator now showed 45 mph. And he felt the wind coming through the front door. The engineer remained in the cab and continued the attempt to stop the train. The event recorder registered that the brakes were charged to 40 pounds and reapplied 8 seconds later. The engineer reversed the engines7 about 7 seconds later, felt the lead locomotive tilting to the right, and then crouched down. The locomotive left the track on the curve at MP 60.4 about 4:10 a.m. After rolling onto its right (engineer's) side into a dry creek bed, it slid to a stop on the sand and came to rest, (see figure 2) without striking anything, south and west of an ATSF trestle. (See figures 3 and 4.) The engineer, who had sustained serious injuries, crawled out of the cab through the window on the left (fireman's) side of the locomotive to reach the ground. Then, hearing someone call on the cab radio, he climbed back into the cab to answer to the call. Two local residents arrived at the locomotive and then assisted the engineer from the cab. The four locomotives and 45 of the 49 cars derailed, and H-BALT1-31 was compressed into a 400- to 500-foot long pileup of cars. (See figure 5.) Five rail cars in the pileup contained hazardous materials. (See figure 6.) In addition, two underground pipelines, which transported petroleum products, were near the derailment site. A fire ignited after the derailment, and the center of the pileup and the surrounding area were engulfed in flames. Sand in the creek bed around the derailed cars north of the trestle and for 0.5 mile south of the trestle was burned. The conductor and the brakeman, who had sustained fatal injuries, were found, respectively, partially buried in the sand 20 feet south and 30 feet west of the trestle and lying in the burned sand creek bed 30 feet south and east of the trestle.

Description
About 4:10 a.m., Pacific standard time, on February 1, 1996, westbound Atchison, Topeka and Santa Fe Railway Company1 (ATSF) freight train H-BALT1-31 derailed near Cajon Junction, California. (See figure 1.) The point of derailment (POD) occurred at milepost (MP) 60.4 on the ATSF south main track, southern California division, Cajon subdivision. HBALT1-31 consisted of 4 locomotives and 49 rail cars traveling from Barstow, California, en route to Los Angeles with a traincrew of an engineer, a conductor, and a brakeman. A fire resulted from the derailment and the subsequent car pileup, which involved five cars containing hazardous materials, and the immediate area was evacuated. The conductor and the brakeman sustained fatal injuries; the engineer incurred serious injuries. Barstow and Los Angeles were the designated away-from-home and home terminals, respectively, for all three H-BALT1- 31 crewmembers. The traincrew, having been off duty for 12 hours 50 minutes, had reported for duty at the ATSF yard in Barstow at 5 p.m. on January 31, 1996. They were instructed not to couple the locomotive consist to the train because a yard crew was connecting car ATSF 90033, following its repair, to the train cars. Car ATSF 90033 was joined onto the train as the 16th car from the head end, and the crew then coupled the locomotive consist to the westernmost car on the track. The engineer said that after the locomotive consist was coupled to the train, a carman informed the crew that the car department needed to inspect and to test the air brakes on car ATSF 90033. The test of the ATSF 90033 air brakes was done in conjunction with the initial terminal air brake test. The engineer stated that he performed the initial terminal air brake test with the assistance of a carman, who was at the rear of the train. The engineer continued that after the train line2 was fully charged with air, about 86 pounds per square inch (psi), at the rear of the train, he reduced the train line air pressure by 20 psi and noticed that the head-end device (HED) indicated that the air pressure reading on the end-of-train device (ETD) had decreased accordingly. Located in the locomotive control compartment, the HED displays the brake pipe pressure being transmitted from the ETD on a digital read out and activates the red rear-end marker light. This multipurpose receiver will indicate whether an attempt to “arm” the twoway function on the ETD was successful. When attempting to arm the ETD, an individual at the rear of the train tells the engineer the ETD number, which the engineer enters on the HED key pad. The individual at the rear of the train then pushes the test button, and the engineer waits for the ready-to-arm message to then press the arm button. The message indicates that the ETD is armed after the link is made. The battery-powered ETD is mounted to the rear coupler on the last car of the train, and an air hose connects the ETD to the brake pipe. The one-way ETD has a pressure transducer to monitor the brake pipe pressure and a flashing red marker light to protect the end of the train. A two-way ETD provides the same functions as the one-way ETD except it additionally has the capability of venting the brake pipe for applying emergency brakes. The signal to vent the brake pipe comes from a starter switch on the HED controlled by the engineer. The advantage of applying emergency brakes from the rear of the train is that any blockage in the brake pipe would be bypassed and braking would occur at both the front and rear of the train simultaneously. The engineer had waited about 1 minute and then did a leakage test, noting the train line leakage was 2 pounds per minute meeting the requirements under 49 Code of Federal Regulations (CFR) 232.12. After the leakage test, the engineer released the train air brakes, and the air pressure at the rear of the train, as indicated by the ETD, returned to 86 pounds. The engineer then informed the carman at the rear of the train that he intended to make an emergency brake application to test that feature of the train brakes. He initiated the emergency brake application from the automatic brake valve3 on the locomotive, and according to the carman, the emergency brake application propagated through the train. The engineer released the brakes, and the air pressure on the ETD returned again to 86 pounds. One of two carmen who were near car ATSF 90033 said that he observed the brakes set and release on the car during the first part of the air test. During the air brake tests with the assistance of the carman at the rear of the train, the engineer also attempted to arm the two-way telemetry feature on the ETD. The engineer stated that he received a "com/test/fail" error message on the HED on the locomotive during the ETD arming procedure. He informed the carman of this error message, and the carman responded, "Okay." The engineer said that they had no further conversation about the ETD. Because of a mudslide in the Cajon area, the ATSF management decided to hold H-BALT1- 31 at the Barstow yard, and the traincrew was taken off duty at 7:30 p.m. The engineer said that before leaving the train, he had applied its air brakes by reducing the brake pipe pressure by approximately 20 pounds. The engineer resided in the nearby town of Newberry Springs, California, and went home; the other two crewmembers returned to the motel. The traincrew was recalled for duty at 11:45 p.m., and another set and release, initiated from the head end of the train, was performed on the air brake system. The braking system was charged for 3 minutes 6 seconds, and then a 12 psi reduction was made. About 1:17 a.m. on February 1, 1996, HBALT1-31 with its 4 locomotives and 45 loaded and 4 empty rail cars departed Barstow and proceeded to and stopped for 30 seconds at Hodge, California, (MP 13.6). The event recorder data indicated that a 7-pound reduction was made to the automatic air brakes of the train. H-BALT1-31continued west and did not stop until 2:30 a.m. at Victorville, California, (MP 36.7). The event recorder registered the use of its automatic air and dynamic brakes. The engineer said he believed that using the air brakes to stop at Victorville complied with the timetable instruction requiring him to make a "running" air brake test at that location and that the air brakes were operating properly at that time also. After 5 minutes 17 seconds at Victorville, H-BALT1-31 continued on to and arrived at Summit, California, (MP 55.9) at 3:40 a.m. (The engineer did not recall making a stop at MP 50.1 [Lugo, California].) The engineer stopped at Summit by using the train air brakes, and the train remained there while the crew waited for a permissive signal permitting them to proceed westward. The engineer said that the conductor and the brakeman were sitting in the cab with him. The engineer stated that after receiving a permissive signal, he made at least a 10-pound brake pipe reduction, as required by timetable instruction. The engineer continued that he moved the three-position cut-out valve from the freight position to the passenger position.4 At 3:50:08 a.m., the train brakes were released, the train brake pipe pressure was 86 psi 1 minute 42 seconds later. The throttle went from zero to one at 3:56 a.m. The engineer said that both the dynamic and the train brakes functioned as expected up to and including the stop at Summit. The engineer reported that H-BALT1-31 crested and began to descend the mountain and at Cajon Pass, he applied the dynamic brakes, “bunching”5 the train toward the engines. He also made a first-service brake application by reducing the brake pipe pressure between 5 and 8 pounds. The engineer noted that the speed of the train was increasing, and he applied more braking. The engineer stated that when the train reached the speed of 18 mph, he and the conductor were aware that the train was moving too fast. They were discussing what action to take when the engineer realized that the speed had reached between 20 and 21 mph, and he said that he wanted to “plug it.”6 The engineer stated that the conductor said, “No, let’s not plug it. Let’s make a full set on it, get it stopped.” The engineer continued that he then initiated a full-service brake application, immediately placing the train in emergency. At this time, the engineer noted that the HED was reading 81 psi on the rear of the train. He said that he put the train into emergency and the air pressure reading did not reduce to zero. The engineer stated that he radioed the ATSF dispatcher to warn all traffic ahead that HBALT1-31 was a runaway train. The engineer recalled that both crewmembers had stood and then proceeded down the steps in the cab to a door leading to the front of the locomotive and that the speed indicator now showed 45 mph. And he felt the wind coming through the front door. The engineer remained in the cab and continued the attempt to stop the train. The event recorder registered that the brakes were charged to 40 pounds and reapplied 8 seconds later. The engineer reversed the engines7 about 7 seconds later, felt the lead locomotive tilting to the right, and then crouched down. The locomotive left the track on the curve at MP 60.4 about 4:10 a.m. After rolling onto its right (engineer's) side into a dry creek bed, it slid to a stop on the sand and came to rest, (see figure 2) without striking anything, south and west of an ATSF trestle. (See figures 3 and 4.) The engineer, who had sustained serious injuries, crawled out of the cab through the window on the left (fireman's) side of the locomotive to reach the ground. Then, hearing someone call on the cab radio, he climbed back into the cab to answer to the call. Two local residents arrived at the locomotive and then assisted the engineer from the cab. The four locomotives and 45 of the 49 cars derailed, and H-BALT1-31 was compressed into a 400- to 500-foot long pileup of cars. (See figure 5.) Five rail cars in the pileup contained hazardous materials. (See figure 6.) In addition, two underground pipelines, which transported petroleum products, were near the derailment site. A fire ignited after the derailment, and the center of the pileup and the surrounding area were engulfed in flames. Sand in the creek bed around the derailed cars north of the trestle and for 0.5 mile south of the trestle was burned. The conductor and the brakeman, who had sustained fatal injuries, were found, respectively, partially buried in the sand 20 feet south and 30 feet west of the trestle and lying in the burned sand creek bed 30 feet south and east of the trestle.