Train Crash Blamed on U.S. Panel, Industry


The National Transportation Safety Board on Wednesday blamed the Federal Railroad Administration, the Burlington Northern Santa Fe and the railroad industry as a whole for February’s disastrous freight train wreck in the Cajon Pass near San Bernardino.

The board said the runaway train derailment apparently occurred because the FRA, the industry and the Santa Fe division of the newly formed Burlington Northern Santa Fe railroad failed to ensure that the train was equipped with a backup electronic brake system that probably could have stopped the train after its main braking system failed.

“The problem is that we asked the FRA to do something immediately, and they didn’t do it,” Robert Lauby, chief of the NTSB’s railroad division, told the board.


“It wasn’t until after the accident that the industry acted voluntarily,” Lauby said. “And if anyone should have known better, it was the Santa Fe.”

The NTSB says the Feb. 1 crash probably was caused by some sort of blockage in the main brake air line.

Investigators cannot say definitively how this blockage occurred. But there is a strong indication that as the freight cars bunched together after the train crested the summit of the pass, one of the hoses between the cars was pinched shut.

When that happens, the engineer has only partial use of the air brakes. The brakes can only be applied on those cars between the locomotive and the blockage unless the train is equipped with a radio-powered, remote-control device that can set the brakes from the rear of the train.

The train that crashed was equipped with the emergency system--called a two-way, end-of-train device, or EOT--but it was not armed.

Investigators say that after the 49-car freight crested the summit, it began to gather speed, plummeting downgrade out of control despite the engineer’s desperate efforts to stop it.


The brakeman and conductor jumped off the train and both were killed. The engineer, who elected to stay at the throttle, was seriously injured as the heavily laden freight plunged from the rails on a sharp curve.

The derailed train burst into flames on impact and the fire burned fiercely for a day and a half, closing Interstate 15 for more than 30 hours and forcing highway and rail traffic to detour as much as 100 miles around the canyon. The interstate reopened, then closed again for the better part of a day when a chemical reaction in a smoldering tank car threatened to explode.

As it began its investigation, the NTSB took note of another accident 13 months earlier, when another Santa Fe freight train broke loose on the Cajon Pass downgrade and slammed into a Union Pacific freight train parked below on the same track, causing damage estimated at $4 million.

In the aftermath of the first crash, the NTSB repeated a recommendation it had first made in 1989--that the FRA mandate the immediate installation of EOTs.

But the FRA failed to act.

Despite the lack of an FRA mandate, the Santa Fe promised to move with dispatch, and the train that started down the Cajon Pass on Feb. 1 was equipped with an EOT. The problem was that the EOT had not been activated for use as an emergency braking system.

Asked by board members why not, NTSB staff members said Thursday that although the top management of Burlington Northern Santa Fe seemed committed to the use of EOTs before the February crash, middle management was not.


The staff members said that because there was no FRA mandate for working EOTs, middle management and freight train crews apparently assumed that the mere presence of an EOT--even if it wasn’t working--satisfied top management’s concerns.

Board member Robert Francis went a step further Wednesday, questioning the depth of the railroad’s executives’ commitment to the EOTs before the February crash.

“Attitudes toward safety usually come from the top,” Francis said.

While some other railroads had gone ahead with voluntary programs to install EOTs, others had not, often saying the price per unit--variously estimated at between $3,000 and $5,000--was too high to be cost effective.

Francis and others have suggested that this may be evidence of an industrywide culture that has a built-in resistance to changes that might improve safety.

Five days after the Feb.1 crash, the FRA issued an emergency order requiring working EOTs on all Burlington Northern Santa Fe trains in the Cajon Pass.

Two weeks later, the agency requested--and got--a commitment from the nation’s 10 largest railroads to install working EOTs on “all trains operating in mountain grade territory by the end of this month.” The Assn. of American Railroads announced Wednesday that this commitment has been fulfilled.


The railroads also have agreed to the installation of the devices on “virtually all” freight trains operating anywhere in the nation by June 30.

Among its recommendations Wednesday, the NTSB proposed studies to develop better designs for air hoses and freight car sills that might lessen the chance of air-line pinching when cars bunch together.