On the night of June 22, 1997 at 10:52 pm, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided head-on in Devine, Texas on the railroad bridge over Highway 132 derailing cars into the highway below. The devastating collision left a pile of wreckage with approximately 20 railcars stacked up below the bridge, four fatalities, and two injured.
The accident happened 26 years ago, but is remembered by most everyone in Devine and the surrounding towns as the explosion was seen from many, many miles away, and homes were evacuated in case toxic chemicals were aboard, which fortunately were not.
The trains were operating on a single main track with passing sidings in dark (nonsignalized) territory in which train movement was governed by conditional track warrant control authority through a dispatcher.
The conductor from 5981 North, the engineer from 9186 South, and two unidentified individuals who may have been riding on the northbound train were killed in the derailment and subsequent fire. The engineer from 5981 North received minor injuries, and the conductor from 9186 South was seriously burned.
Estimated damages exceeded $6 million.
Investigation Details
What Happened
At 10:52 p.m. on June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided head-on in Devine, Texas.
The following is a Railroad Accident Report was issued on May10,1998 following the investigation of the June 22, 1997 head on collision and derailment of the two Union Pacific Freight Trains in Devine. Source: National Transportation Safety Board
RAILROAD ACCIDENT REPORT Adopted: May 19, 1998 Notation 6889A
NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, DC 20594 RAILROAD ACCIDENT REPORT COLLISION AND DERAILMENT OF UNION PACIFIC RAILROAD FREIGHT TRAINS 5981 NORTH AND 9186 SOUTH IN DEVINE, TEXAS ON JUNE 22, 1997
Abstract: On June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided head-on in Devine, Texas. The conductor from 5981 North, the engineer from 9186 South, and two unidentified individuals who may have been riding on 5981 North were killed. The engineer from 5981 North received minor injuries, and the conductor from 9186 South was seriously burned. The major safety issues discussed in this report are the train dispatcher’s performance and workload, the adequacy of management oversight of the dispatcher apprentice program and dispatching operations, the sufficiency of the Federal Railroad Administration (FRA) oversight of dispatching operations, the effectiveness of conditional track warrant control authority, the adequacy of disaster preparedness, the crashworthiness of locomotives and event recorders, and the merits of positive train separation control systems. As a result of its investigation, the National Transportation Safety Board issued safety recommendations to the UP, the FRA, and the Texas Railroad Commission. In addition, the Safety Board reiterated a safety recommendation to the FRA.
Executive Summary: At 10:52 p.m. on June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South collided head-on in Devine, Texas. The trains were operating on a single main track with passing sidings in dark (nonsignalized) territory in which train movement was governed by conditional track warrant control authority through a dispatcher. The conductor from 5981 North, the engineer from 9186 South, and two unidentified individuals who may have been riding on 5981 North were killed in the derailment and subsequent fire. The engineer from 5981 North received minor injuries, and the conductor from 9186 South was seriously burned. Estimated damages exceeded $6 million. The National Transportation Safety Board determines that the probable cause of this accident was the failure of the third-shift dispatcher to communicate the correct track warrant information to the traincrew and to verify the accuracy of the read-back information because the UP management had not established and implemented workload policies and operational procedures to ensure a safe dispatching system and the Federal Railroad Administration (FRA) had failed to provide standards and oversight in all aspects of train dispatching operations. Contributing to the accident was the lack of an installed positive train separation control system that would have prevented the trains from colliding by automatically intervening in their operation because of inappropriate actions being taken. The major safety issues discussed in this report are the train dispatcher’s performance and workload, the adequacy of the UP management oversight of the dispatcher apprentice program and dispatching operations, the sufficiency of the FRA oversight of dispatching operations, the effectiveness of conditional track warrant control authority, the adequacy of disaster preparedness, the crashworthiness of locomotives and event recorders, and the merits of positive train separation control systems. As a result of its investigation, the Safety Board makes recommendations to the UP, the FRA, and the Texas Railroad Commission. In addition, the Safety Board reiterates a safety recommendation to the FRA.
Investigation:
Accident Narrative: About 10:52 p.m. on June 22, 1997, Union Pacific Railroad (UP) freight trains 5981 North and 9186 South1 collided head-on in dark (nonsignalized) territory at milepost (MP) 290.4 in Devine, Texas.2 The collision occurred on a single main track at the north end of a concrete ballast deck bridge. (See figure 1.) Five locomotive units and 20 freight cars derailed, and a fire ensued. The engineer from 9186 South, the conductor from 5981 North, and two unidentified individuals received fatal injuries. The conductor from 9186 South sustained serious injuries, and the engineer from 5981 North received minor injuries.
Earlier that day at 2:30 p.m., train 5981 North had departed Laredo. (See figure 2.) Train 5981 North was given authorization by track warrant3 from the second-shift train dispatcher4 to proceed to Callaghan (MP 385.3), the first station after Laredo. (See figure 3 for blank standard UP track warrant form.) At Callaghan, the 5981 North met a southbound train and was authorized by the dispatcher to proceed to Gardendale (MP 339.5), where it was stopped and met another southbound train. While 5981 North was stopped, the U.S. Border Patrol apprehended two suspected illegal immigrants who were riding the train. Leaving Gardendale about 6:45 p.m., train 5981 North proceeded to the side track at Derby (MP 321.5), where eight ballast cars were added to the train. The engineer said that after these cars were added and the proper air test was performed, the train proceeded to and entered the siding at Melon (MP 318.0).
footnotes:
1 The UP designated them as freight trains MLDLI and ZYCMX, respectively.
2 All train movements and locations are within Texas except where specified otherwise. 3 A track warrant is given via radio by or through proper railroad personnel to govern train movements. The Federal Railroad Administration interprets track warrants as train orders by radio. Until 1985, train orders were written instructions to govern the movements of a train issued by the train dispatcher through the telephone to online train order operators, who in turn typed these instructions for delivery to the traincrews of passing trains. These instructions involved the transmitting, typing, and repeating of their contents. In 1985, the train order method for train movements was discontinued and replaced by the track warrant system on most railroads. 4 Dispatchers for the Austin subdivision work either a first (6:30 a.m. to 2:30 p.m.), second (2:30 to 10:30 p.m.), or third (10:30 p.m. to 6:30 a.m.) shift at the UP Harriman Dispatch Center in Omaha, Nebraska.
5 Generated from the train dispatcher’s work station computer, as displayed on the screen when the instructions were radio-issued to the crew.
6 Opened in 1989, the dispatch center houses the entire UP main track operations system and the dispatchers who oversee train operations.
7 Supports the track warrant system that is unique to the UP.
9 Maintained to accommodate passenger and freight trains at maximum allowable speeds of 80 and 60 mph, respectively.
10 Track bulletins are addressed to trains that operate through the dispatcher’s assigned territories and contain temporary speed restrictions, locations of personnel and equipment working, and possible safety hazards.
11 Although authority for the train movement has been issued, a specific condition must be met before the authority is acted on.
14 The postmortem production of alcohol can occur during the decomposition process with no prior alcohol consumption.
16Pulse Electronics, Incorporated, Rockville, Maryland.
17The railroad recording time was not synchronized with the time of the police report.
At that time, the engineer of train 5981 North requested automobile transportation and was driven to a nearby store to purchase food. The conductor remained with train 5981 North. As the engineer was returning to the train, he overheard an exchange on a railroad radio installed in the car; in this exchange, the dispatcher authorized the second of the two trains being met at Melon to proceed farther south beyond Melon. The engineer stated that after he boarded the locomotive, the conductor received the track warrant authorization from the second-shift train dispatcher at 9:18 p.m. instructing the train to depart Melon and proceed to Gessner (MP 278.5), where 5981 North would be required to take (enter) the siding.
At 10:30 p.m., the third-shift train dispatcher issued a track warrant instructing 5981 North to proceed from Gessner to San Antonio after meeting 9186 South at Gessner. Train 5981 North was instructed to enter the siding at Gessner so that 9186 South could pass on the main track. At Devine, the 5981 North crew noted a bright glow on the horizon, and both the engineer and the conductor rose from their respective seats trying to identify this glow. At that moment, the headlight of an oncoming locomotive came into view. The engineer of 5981 North said he placed the train into emergency braking, exited the rear door of the control compartment, and jumped from the locomotive. The conductor exited the forward door of the control compartment and either jumped or was thrown from the locomotive.
Earlier at 9:56 p.m. on June 22, 1997, train 9186 South had been authorized by track warrant 8261 from the second-shift train dispatcher to proceed to Gessner, departing San Antonio about 10:10 p.m. The train was authorized by track warrant 8289 (see figure 4) from the third-shift dispatcher at 10:28 p.m. to proceed from Gessner to Melon. Train 9186 South passed the Gessner siding and entered the city of Devine. At some point, the crew saw the oncoming northbound train, and both the engineer and the conductor jumped from the lead locomotive as the trains collided.
The printed copy5 of track warrant 8289 (see figure 4) contained four elements: (box 2) Proceed from Gessner to Melon on main track, (box 7) Not in effect until after arrival of 5981 North at Gessner, (box 8) Hold the main track at last named point [Melon], and (box 15) Flag protection not required against following trains on the same track. According to the voice recordings between the 9186 South crew and the third-shift train dispatcher, the instructions contained three elements: (box 2) Proceed from Gessner to Melon on main track, (box 8) Hold the main track at last named point, and (box 15) Flag protection not required against following trains on the same track. In the voice recordings, 9186 South was authorized to proceed from Gessner to Melon (box 2); absent from the voice recordings was “not in effect until after arrival of 5981 North at Gessner” (box 7).
The third-shift (relieving) dispatcher reported that during the shift changeover between 10:15 and 10:20 p.m., he discussed with the second-shift (departing) dispatcher how many trains were operating and their status. The majority of the UP trains on the Austin subdivision at that time were on the San Antonio to Laredo territory, and a National Railroad Passenger Corporation (Amtrak) train was operating from Temple to Taylor. The third-shift dispatcher stated that several radio calls were coming in and “it was busy,” which was “probably an average night for that position.” His first radio conversation was at 10:20:37 p.m. with the Amtrak traincrew. During this conversation, the third-shift dispatcher cleared and voided the track bulletin item that had been previously issued to the Amtrak train. The conversation ended at 10:21:50 p.m. The next radio communication was initiated at 10:24:10 p.m. by the traincrew of UP IYCLD, which was operating on the Austin subdivision. The traincrew “gave up” its track warrant to the dispatcher, who then created a new track warrant directing the train to proceed from Gardendale on the main track of the Austin subdivision. This conversation ended at 10:26:03 p.m.
At 10:26:05 p.m., the dispatcher called train 9186 South, and the conductor responded immediately. The dispatcher said, “Yeah, let me get you an ‘after-arrival’ there at Gessner while I have a minute, over.” The conductor responded, “All right, ready.” When communicating track warrant instructions to a traincrew, dispatchers are required to read the information, as it is presented on the screen, and to verify the accuracy of the information, comparing the oral read-back from the traincrew with the information shown on the screen. The third-shift dispatcher then transmitted the track warrant information to 9186 South, omitting the instruction “not in effect until after arrival of 5981 North at Gessner” (the box 7 instruction on the track warrant). The third-shift dispatcher later said that he could not recall whether he had included the box 7 instruction (to remain at Gessner) on the track warrant when formally transmitting authorization to 9186 South by voice. The recorded radio transcripts of the transmission of this track warrant between the dispatcher and the 9186 South traincrew did not include this instruction. The conductor repeated the information to the dispatcher, and the dispatcher okayed the read-back information despite the omission of the box 7 instruction that was on the computer screen display. Their conversation ended at 10:28:10 p.m. Four seconds later, the dispatcher called train 5981 North and accurately relayed the track warrant (8290) information for that train to its conductor. Their conversation ended at 10:30:04 p.m. (See appendix A for transcript of track warrants 8289 and 8290.)
See the Operations Information section for more information about UP dispatching techniques.
Railroad Damage
Two locomotive units and 14 cars were derailed from train 9186 South; both locomotive units and 2 cars were destroyed. Three locomotive units and six cars were derailed from train 5981 North; one locomotive unit and five cars were destroyed.
The estimated costs were:
Locomotives $ 4,150,000
Cars 501,300
Track 40,000
Structures 900,000
Lading 320,000
Clearing 103,767
Total $ 6,015,067
Personnel Information
Third Shift Dispatcher — The 39-year-old train dispatcher began working for UP as a section man in 1975, and he transferred in 1979 to the signal department, where he worked as the systems signal man in Salt Lake City, Utah. He became a signal maintainer in Caliente, Nevada, in April 1990; an electronics technician at the Harriman Dispatch Center (HDC)6 in February 1994; and then an apprentice train dispatcher in May 1996.
According to the third-shift dispatcher, his training began at the HDC with a 3-week class in the railroad operating rules, including the dispatching and air brake rules. He stated that because he had replaced a trainee who had dropped out, his training had been shorter than that of other dispatchers and he had missed the basic railroading review, which was primarily designed for apprentice train dispatchers lacking a background in railroading. He then had 1 month of training in dispatcher duties using a simulator to become familiar with the computeraided dispatching (CAD) system.7 In July, he started 1-month on-the-job training (OJT), during which he observed an experienced dispatcher operate the line and later operated the line while being observed by the OJT dispatcher trainer. Afterwards, as part of the qualifying period, the manager of train dispatchers observed him as a trainee performing dispatch duties during a shift. He became a qualified dispatcher on August 17, 1996, and since then had worked on the Austin subdivision. Before June 22, 1997, he had not been cited for any dispatching rules violations.
After the Devine accident, the third-shift dispatcher stated that he believed that he had been adequately trained to operate as a dispatcher. He added that the simulator and OJT were not equal to handling the dispatching demands and said, “How can training be equal to . . . a dozen radios going off and 10 people yelling at you at the same time. . . . I guess the main thing that would be missing from all of that would be really interaction with somebody out in the field . . . especially when you’re new. . . . Having to deal with that sort of thing is hard.”
The third-shift dispatcher reported that he was in good health, and, according to his medical records, he had normal vision, with no color-vision problems, and normal hearing. His last UP physical was in 1989. He reported that he was not taking any prescription or over-thecounter medications at the time of the accident. He stated that he did not smoke tobacco or drink alcohol.
The third-shift dispatcher had not worked on Friday, June 20, 1997. On Saturday, June 21, he woke about 9 a.m., remained at home performing chores, left for work about 9:40 p.m., and arrived there at 10:15 p.m. He started his shift about 10:20 p.m. and worked until 6:20 a.m. on Sunday, June 22. After returning home, he retired at 7 a.m. and slept until about 12:30 p.m. He remained at home during the day, left for work about 9:40 p.m., arrived about 10:15 p.m., and started his shift.
5981 North Traincrew — The UP records indicated that the crew of train 5981 North met the requirements as prescribed in the Hours-ofService Act.
The 27-year-old engineer was hired in July 1989 by the UP as a trainman at San Antonio. In June 1993, he transferred to engine service and worked as a fireman while participating in the training program to become a locomotive engineer. In December 1993, he was promoted to locomotive engineer. He had passed his most recent physical examination in March 1995. His vision and hearing were normal. He reported being well-rested before the accident. The engineer had worked the previous 3 days before the accident. He was a certified locomotive engineer under the regulations found in 49 Code of Federal Regulations (CFR) Part 240, was current on the UP operating rules, and had passed his last rules examination in January 1995.
The 48-year-old conductor was hired in May 1973 by the UP as a trainman at San Antonio. In May 1975, he was promoted to conductor. He passed his last physical examination in May 1996. According to the guidelines established by UP, the conductor was qualified to perform the duties of a conductor on the Austin subdivision. He was current on the UP operating rules and had passed his last rules examination in April 1995. The conductor had worked the previous 2 days before the accident.
9186 South Traincrew — The UP records indicated that the crew of train 9186 South met the requirements as prescribed in the Hours-of Service Act.
The 39-year-old engineer was hired in August 1976 by the UP as a laborer at San Marcos. In May 1985, he transferred to a clerical position; moving to Omaha in July 1989, he worked in a crew dispatching position. He transferred to San Antonio in May 1993 as a trainman and in October 1994 was promoted to conductor. In March 1995, he transferred to the position of student engineer to learn the craft of locomotive engineer; on May 12, 1995, he was promoted to locomotive engineer. He passed his last physical examination on September 12, 1996. According to the UP guidelines, the engineer was qualified to perform the duties of a locomotive engineer on the Austin subdivision. He was a certified locomotive engineer under the regulations found in 49 CFR Part 240, was current on the UP operating rules, and had passed his last rules examination on June 10, 1997. The engineer had worked the previous 2 days before the accident.
The 37-year-old conductor was hired in June 1996 by the UP as a brakeman at San Antonio. Within 3 weeks, he received formal training, with examinations, that would later qualify him as a conductor. In February 1997, he was qualified as and promoted to conductor; during the previous 6 months, he had worked primarily in yard service. In April 1997, he was assigned to work as a freight conductor. For the 60 days before the collision at Devine, he worked as a freight conductor, alternating his duty cycles with yard service positions. He passed his last physical examination in December 1996. According to the UP guidelines, the conductor was qualified to perform the duties of a conductor on the Austin subdivision. He was current on the UP operating rules and had passed his last rules examination on June 27, 1996. The conductor had worked the previous 2 days before the accident.
Train Information
Train 5981 North — The train consisted of locomotive units UP5981 (a 3,800-horsepower EMD8 SD60), UP4211 (a 3,000-horsepower EMD SD-40-2), and UP5084 (a 3,500- horsepower EMD SD50M) and 83 loaded and 11 empty freight cars. On June 22, 1997, at 7,200 feet long and drafting 8,200 tons, train 5981 North originated at Laredo, where it was inspected at 12:20 p.m. An initial terminal air brake test was successfully completed at 2:20 p.m., and the train departed at 3 p.m. Eight loaded ballast cars were added at Derby. Train 9186 South — The train consisted of locomotive units UP9186 (a 4,000-horsepower General Electric C40-8) and UP6143 (a 3,800- horsepower EMD SD60-M) and 62 loaded freight cars. At 4,071 feet long and drafting 3,284 tons, train 9186 South originated at the UP Yard Center near Chicago, Illinois, on June 21, 1997. Two carmen inspected the train and then assisted in performing a successful initial terminal air brake test, and the train departed at 6:03 a.m. On June 22 at 2:40 a.m., the train was given an intermediate (1,000-mile) air brake test at Texarkana. The air brake test was successfully completed, and 9186 South departed at 4:09 a.m.
Train 9186 South arrived at 8:48 p.m. at San Antonio, where it was to receive another air brake test. The outbound traincrew reported that the radio was defective on the lead locomotive unit, and the radio was subsequently replaced. The air brake test was successfully completed by the traincrew, and 9186 South departed at 10:10 p.m.
Postcollision Train Information
The three-unit locomotive consist of train 5981 North remained on the bridge, but the twounit locomotive consist of train 9186 South toppled from the bridge onto the road below. A 8 Electro-Motive Division of General Motors. number of trailing freight cars in each train piled up on and around the locomotive wreckage on the bridge and in the street below. Diesel fuel spilled, and a fire ensued, extensively damaging most of the equipment in the immediate proximity of the overpass. (See figure 5.)
Train 5981 North — The lead locomotive unit UP5981 exhibited massive catastrophic structural damage; the short-hood structure, cab assembly, and electrical cabinet were effectively sheared off horizontally at the top of the frame assembly deck plate surface. The diesel engine was found to have been displaced aft about 8 feet, and the main generator had separated from the engine. The frame had bowed downward, displaying a bend estimated at 1 foot. The remaining car body (sheet metal) was heavily deformed, and the entire unit had been consumed by the fire.
The trailing locomotive unit UP4211 also exhibited massive damage; the cab assembly and electrical cabinet were found to be sheared off level with the top deck of the short-hood structure, which remained relatively structurally undamaged. The car body (sheet metal) and internal machinery on the aft-end of the unit were compressed in a forward direction, having been contacted by the third locomotive in the consist, which overrode this unit. Approximately one-third of the front of the unit exhibited fire damage.
The trailing locomotive unit UP5084 overrode the aft-end of the succeeding unit and came to rest with its lead-end resting on top of the frame of the locomotive in the number two position. The leading truck assembly had detached from its mounting and was wedged between the two locomotive structures. The trailing truck remained attached. The fuel tank was detached from its normal mounting position and came to rest on the ballast beneath the unit. The locomotive, which exhibited fire damage on its exterior surfaces, was the least damaged of the units involved.
Train 9186 South — The lead locomotive unit UP9186 traveled down the northwest embankment slope and landed upright on the road, approximately parallel to the bridge, with the aft-end of the unit resting on the northwest embankment slope. The unit lost its front truck assembly, exhibited inward deformation to its front pilot plate and short-hood structure, and was consumed by the fire. The cab structure remained intact and was not crushed by the impact.
The trailing locomotive unit UP6143 fell toward the pavement on the east side of the bridge, landed cab-end down, and oriented slightly on its right side on top of derailed freight car wreckage, with the aft-end raised up and the left side resting on wreckage that remained on the bridge. The front truck assembly had separated, and the fuel tank showed massive deformation damage. The front pilot plate and short-hood structure were substantially deformed inward; the cab remained structurally intact. The remainder of the unit exhibited extensive car body panel (sheet metal) deformation, and the entire unit was consumed by the fire.
Track and Signal Information
The track in the area of the collision was constructed with 112-pound rail, which was manufactured and laid in 1943, and later restructured into continuous-welded-rail. The rail rested in double shoulder tie-plates secured to 9-foot timber cross ties with 5/8- by 6-inch cut track spikes. The ties were supported in 2- inch crushed rock ballast and maintained with 12-inch shoulders to restrain lateral movement. Longitudinal movement was restricted with channel lock rail anchors base-applied to every cross tie in a box pattern.
The southbound alignment for the undulating track was tangent at the point of impact (POI). Train 9186 South negotiated a 1° 23′ left-hand curve at MP 289.5, ascended a 0.51-percent grade before cresting the hill at MP 290, and was descending the 0.82-percent grade leading to the POI. At MP 290.4, 5981 North negotiated the 3° 11′ right-hand curve at MP 293 before entering the long tangent approach to the POI.
The track is maintained to meet or exceed the Federal Railroad Administration (FRA) standards for a class 4 track.9 The UP track personnel inspect the track 7 days a week. The weekly inspection records between May 1 and June 3, 1997, indicate no FRA track defects were found. An inspection of the track was conducted on the day of the accident, and no FRA defects were discovered.
The 140-foot concrete ballast deck bridge at the POI consisted of two 30-foot approach spans and an 80-foot main span extending over the highway. The bridge had extensive damage as a result of the collision and was replaced with a similar structure on the approach spans. The main span was changed from built-up beam sections over the highway to welded beams over the highway. The concrete deck was replaced with a steel deck to hold the ballast and ties.
The accident territory did not employ a block signal system (wayside signals) to govern train movements and was called dark (nonsignalized) territory; the movement of trains was controlled by a track warrant system.
Operations Information
According to the UP, 12 or 13 trains in both directions pass through the Devine area daily. The movement of trains over the territory is governed by the UP operating rules, timetable instructions, and general orders. The operating rules were provided by the Third Edition of the General Code of Operating Rules, dated April 10, 1994. Any rule modifications or revisions to the operating rules were part of the UP Timetable No. 2, effective October 29, 1995, that included the “System Special Instructions,” which provided general revisions, and the “Service Unit San Antonio, Austin Subdivision,” which contained information specific to operating trains through the territory where this accident occurred. The permanent track speeds for the trains were designated in the timetable, and temporary speed restrictions were issued through the train dispatcher by track bulletin.10
The train movements were controlled by the train dispatcher, who issued instructions in the form of track warrants. Track warrants evolved from train orders and are not addressed in the CFR. Each train received its original movement instructions at the initial station of the train. Subsequently, the train dispatcher issued additional track warrants by radio to the traincrews at intermediate locations. The receiving crewmember was required to write down the track warrants, as received over the radio, on a standard UP form and to read them back to the train dispatcher. This method of operation allowed the train dispatcher to establish or change the meeting locations of trains and add movements on the territory.
To establish a meeting point between opposing trains, the train dispatcher issued a track warrant (see figure 3) to one train that included, at a minimum, a box 2 that stated the “proceed from” and “to” limits being granted and a box 10 that instructed “clear main track at last named point” as prescribed in box 2. The train traveling in the opposite direction was issued a track warrant that included, at a minimum, a box 2 that stated the “proceed from” and “to” limits being granted and a box 8 that instructed “hold main track at last named point” (the “to” limit granted in box 2). The train instructed to clear the main track at the station where the meet was to take place was not authorized to proceed on the main track beyond the initial switch of the siding without additional track warrant authority. The train instructed to hold the main track was not authorized to proceed beyond the switch at the end of the last named point for the “to” station until additional track warrant authority was issued. This system protected the two opposing trains, and the physical passing of the trains was accomplished.
When one train arrived at a station earlier than the other train, the dispatcher had two options for giving the first train further instructions. The dispatcher could either wait until the meet had taken place and then authorize both trains to proceed beyond this station in the opposite directions or authorize the train that had arrived at the station early to proceed to the next station but not leave that station until “after the arrival” (after-arrival) of the opposing train. The dispatcher gave movement instructions to trains, but the trains could not act on these instructions until a prescribed event occurred, such as the arrival of another train. This method (conditional track warrant control authority)11 allowed the train dispatchers to prepare the train movements in advance and pace their workloads.
All track warrants that were issued by the train dispatcher were created on a computer screen using the CAD system. The dispatcher requested a track warrant by entering the train’s ID (mainframe computer symbol) and the subdivision on the computer screen menu. The CAD system then generated a track warrant screen displaying a box 1 (to void a previously issued track warrant), a box 2 (to establish directional authority limits), and a box 4 (to establish “work between” or nondirectional limits). Should the train dispatcher choose to establish directional authority, the dispatcher would place an “x” in box 2 and type the “proceed from” and “to” locations (specifying the limits the train was being granted). (See figure 3 for the blank UP track warrant form.) Trains were authorized from station to station, moving through the territory in short segments, which gave the dispatcher flexibility in establishing a meeting location between opposing trains.
A conflict resolution logic had been developed for the CAD system to prevent two trains from receiving nonconditional authorization onto the same segment of track at the same time. For example, if a train dispatcher authorized a southbound train from station A to station B, the computer accepted this as a valid track warrant. If the train dispatcher subsequently issued a track warrant authorizing a northbound train from station B to station A, the CAD system detected the conflict, and the screen immediately displayed the required conditional authority instruction (box 7) that the northbound train not leave station B until after-arrival of the southbound train. At the same time, a third screen displayed a conflict between the two trains. After interviews with several dispatchers, the Safety Board found that dispatchers were aware that this protection was available in the system.
During an interview with the third-shift train dispatcher, he recalled mentioning to the 9186 South traincrew that he intended to issue an afterarrival authority. During the formal transmission of track warrant 8289, the dispatcher failed to orally communicate the box 7 requirement (not in effect until after the arrival of 5981 North at Gessner) even though the CAD system had generated the box 7 after-arrival instruction on the screen. When the train dispatcher was later asked how he had determined that the track warrant would be an after-arrival, he stated that he had logically come to that conclusion because of the train movements in the territory and, specifically, the conflict with the northbound train.
Meteorological Information
At 10:51 p.m., the weather station at Hondo, which is 19 nautical miles northwest of Devine, reported clear skies with 10-mile visibility, 78°- F temperature, 71°-F dew point, and 11-knot winds.
Medical, Pathological, and Toxicological Information
Third-Shift Dispatcher — Following the accident, the third-shift dispatcher was removed from service. Consistent with FRA regulations, he took a breath test and provided blood and urine specimens for postaccident alcohol and drug testing. About 2 a.m. on June 23, a breath test was administered to the dispatcher, who was then taken to a local hospital, where at 3:45 a.m., he provided blood and urine specimens, which were sent to and analyzed by Northwest Toxicology, Incorporated. The results of the urine analysis and the blood and breath test analyses were negative for drugs and for alcohol.
5981 North Traincrew — The engineer was transported to an area hospital for treatment of superficial abrasions and released the same day. His postaccident toxicological testing was negative for drugs and alcohol.
The body of the conductor of 5981 North was found adjacent to the track beneath wreckage debris. The autopsy report indicated that he had received severe chest and abdominal injuries, that he had sustained severe burn trauma, and that his right arm had been severed. The postaccident toxicological testing indicated the presence of ethyl alcohol in his blood (0.011 w/v%) and urine (0.024 w/v%). Northwest Toxicology, Incorporated, concluded, Based upon the information provided by the FRA regarding the putrefaction of the body and the low concentration of ethyl alcohol found, it cannot be determined whether the ethyl alcohol present in the blood and urine is due to antemortem consumption or postmortem production. 14
The severely burned and mangled bodies of two unidentified people, believed to have been the individuals who may have been riding on one of the 5981 North locomotive units, were found beneath wreckage debris on the pavement under the bridge near the POI.
9186 South Traincrew — The body of the 9186 South engineer was found adjacent to the track about 126 feet north of the north bridge abutment. The autopsy report indicated that he had sustained severe chest injuries and blunt force trauma to the head. His postaccident toxicological testing was negative for drugs and alcohol.
Within minutes after the collision, a firefighter found the conductor of 9186 South standing on the road on the east side of the overpass near the burning wreckage. He had sustained first and second degree burns to the face, torso, and leg, and was helicoptered to the U.S. Army Hospital in San Antonio for treatment. His postaccident toxicological testing was negative for alcohol but indicated the presence of morphine in both the urine (107,929 ng/ml) and blood (45 ng/ml). Morphine was administered to the conductor at the medical facility to which he was admitted.
Emergency Response
Shortly before 11 p.m. on June 22, 1997, a Devine Police Department (DPD) officer, on routine motor patrol near the UP track south of the railroad bridge at MP 290.4, reported that he observed a passing northbound train, heard a loud explosion sound, and noted that the passing train was rapidly decelerating. Seeing flames and black smoke at the railroad overpass in his rear view mirror, he radioed the DPD dispatch desk, which received the transmission at 10:52 p.m. and notified the Devine Volunteer Fire Department (DVFD) and the DPD with an “allhands” respond request. Numerous 911 phone calls were also received from concerned residents reporting a loud explosion sound.
While driving to the accident scene, the officer who had witnessed the event encountered the engineer of 5981 North, who had been injured after jumping from the northbound train; the engineer indicated that the other train possibly contained hazardous materials. Other police officers and an emergency medical service (EMS) ambulance and staff soon arrived at that location, which later functioned as the medical staging area for the accident. The EMS ambulance staff determined that the engineer of 5981 North did not have life-threatening injuries, and he was later transported by ambulance to a local hospital. The chief of the DVFD activated the Incident Command System and assumed control as the incident commander. A temporary command post was established on the west side of the overpass.
Because the 5981 North engineer had indicated that hazardous materials may have been on board a train, the community disaster plan was implemented, and the Devine Emergency Management Coordinator was dispatched. The Chemical Transportation Emergency Center15 was contacted about 11:06 p.m. by the DPD, which also contacted the railroad to request hazardous materials consist information. The UP responded by phone and fax that no hazardous materials products were on board either train. Because of the concern about a toxic materials release, the DVFD chief had directed an evacuation of all residences within a 1/4-mile radius of the fire. The DPD had closed roads around the fire scene to all traffic but emergency vehicles. Between 75 and 100 residents were sheltered at the local high school and were permitted to return to their residences when the UP confirmed that no 15The center, operated by the Chemical Manufacturers Association, was established to provide initial and immediate information about handling hazardous materials and other chemicals. hazardous materials products were involved in the fire.
The firefighting suppression effort continued to focus on the blaze, which reportedly flared several hundred feet high and was seen up to 30 miles away. About 1 a.m. on June 23, the fire had been substantially suppressed, and the DVFD chief directed that all water lines be shut down. About 1:37 a.m., the fire was declared under control.
Survival Aspects
Locomotive Cab Survivability — On the northbound train, the operating cab had separated from the lead unit (UP5981) and was found crushed beneath the wreckage debris. The cab had been fully consumed by fire, and no survival space remained. On the southbound train, the operating cab of the lead unit (UP9186) had not been significantly crushed during the collision, but the cab and the entire unit were fully consumed by the fire.
Fire and Rescue Services — The 29- member DVFD provides exclusive firefighting support to Devine, a rural community of about 4,000 people. Supplementary firefighting support is available through mutual aid requests to neighboring communities. The DVFD is commanded by the chief (he works professionally for and in the city of San Antonio as a trained, full-time firefighter) and is supported by three assistant chiefs. At the time of the accident, the DVFD fire suppression equipment consisted of two conventional pump trucks (750 gpm and 1000 gpm) and three small support trucks. The DVFD’s support apparatus included ladders, nozzles and hoses, lights, selfcontained breathing equipment, and a small stock of fire suppression foam.
Municipal Disaster Plan — The City of Devine has a comprehensive, documented plan (issued in 1990 and revised in August 1996), based on the State model, which is coordinated by the Emergency Management Coordinator and an assistant staffer of the Devine Emergency Management Agency. Under the plan, Devine conducts an annual simulated live-disaster exercise and a semiannual table-top drill. All the Devine municipal agencies (fire, police, emergency management, and public works) participated in the most recent simulation exercise, which occurred about 6 months before the train accident. The exercise involved a hazardous materials truck fire in a congested residential neighborhood and the hazardous materials cleanup. The most recent table-top drill occurred about 1 year before the train accident.
Locomotive Event Recorders
— On August 11, 1997, the Safety Board laboratory received the Pulse Data Pack event recorder, the Pulse Data Pack DP-400 event recorder cartridge, and the speed indicator from locomotive UP4211 of train 5981 North; the QTron event recorder, the UP event recorder download diskette, and the speed indicator from locomotive UP5084 of train 5981 North; and the burned remains of the event recorder from locomotive UP9186 of train 9186 South.
The Pulse Data Pack event recorder from locomotive UP4211 was designed to record the time, distance traveled (miles), speed (mph), traction motor current (load amps), automatic brake setting, throttle position, independent brake pressure (psi), and reverser position. These digitally encoded parameters were sampled every 5 3/4 seconds. The data were then written to the magnetic tape in two consecutive and identical records of 2 7/8 seconds in length during the 5 3/4-second period between the samples. The data from the cartridge of the Pulse Data Pack event recorder from locomotive UP4211 were found to be anomalous when read out using equipment in the Safety Board laboratory. The recorder and its magnetic tape were taken to the manufacturer16 for analysis. The manufacturer indicated that the event recorder appeared to be operating properly and the magnetic tape could be read, but no input signals concerning traction motor current or brake reduction levels could be found.
Locomotive UP5084 was equipped with a Q-Tron Datacord 5000 solid-state recording system that was designed to record the time, date, unit number, distance traveled (miles), speed (mph), traction motor current (load amps), brake pipe pressure (psi), throttle position, and brake cylinder pressure (psi). The parameter values were recorded whenever a parameter changed. The magnitude of the change necessary to trigger a parameter recording is preprogrammed into the recording system. The manufacturer of the Q-Tron recorder indicated that the maximum recording resolution of the recorder was 1/10 second, with the exception of speed, which was recorded at 1-second intervals.
The collision log report from the locomotive UP5084 Q-Tron recorder read-out at the Safety Board laboratory follows: Recorder Train Time Speed Action 10:49:44 p.m. 43.6 mph Throttle position changed from 8 to 4. Traction motor current decreased steadily from 416 to 205 amps during the following 6 seconds.
10:49:50 p.m. 42.5 mph Throttle position changed from 4 to 0 and remained at 0 thereafter. Traction motor current decreased from 205 to 99 amps about 1 second later and gradually decreased to 0 amps during the following 4 seconds.
10:49:52 p.m. 42.2 mph Brake cylinder pressure changed from 0 to 6 psi and increased to 76 psi during the following 10 seconds.
10:49:53 p.m. 41.7 mph Brake pipe pressure changed from 89 to 59 psi and decreased to 0 psi within 1 second.
10:50:23 p.m. 18.7 mph Brake cylinder pressure changed from 77 to 7 psi and decreased to 0 psi during the following 3 seconds.
10:50:25p.m. 0 mph
(17)
The type of event recorder equipment from locomotive UP4211 of train 5981 North and from locomotives UP9186 and UP6143 of train 9186 South was customarily carried in the nose section of the controlling end of the locomotive. The event recorder equipment from locomotive units UP5981 and UP5084 of train 5981 North was most likely located in the locomotive alcove either immediately on the right, attached to the sidewall, or on the left, attached to the bulkhead wall. No standards have been developed for the location of event recorder equipment.
The event recorder from locomotive UP5981 of train 5981 North was destroyed by crushing force, and the event recorders on locomotives UP9186 and UP6143 of train 9186 South were destroyed by the fire. The Safety Board is working with the FRA, class 1 railroads, railroad employee union representatives, and locomotive event recorder and locomotive manufacturers to develop and implement an FRA rule detailing specific survivability standards that locomotive event recorders must adhere to. The Safety Board has encouraged the FRA to address the survivability of event recorders in all known or anticipated accident scenarios, considering the experience with other modal standards of event recorder crashworthiness. At the time of this report, the FRA had no anticipated date of issuance for the standards.
The railroad recording time was not synchronized with the time of the police report.
