Railroad accident report—Derailment of Southern Pacific Transportation Company freight train on May 12, 1989 and subsequent rupture of Calnev petroleum pipeline on May 25, 1989—San Bernardino, California

 including: the new destination of the car, a lading code for the car, any special handling associated with the car, and a tonnage figure. This information was entered into the computer system's car file which contains, in addition to the above information, the physical characteristics of each car on the SP system. The yard clerks understood that the tonnage figure would be updated at a later time when the shipper's bill of lading was received in the billing office. SP's director of clerical operations testified that cars are often moved in service before the shipper's bill of lading information is received and entered into the billing system. He further testified that following the train derailment, "We have changed the system so that regardless of what estimate is put into the release, the computer will go to the car file and automatically update that tonnage to the capacity of the car." According to the director of clerical operations, the maximum tonnage figure will remain in the car file of the computer until the shipper's bill of lading is received and only when the bill of lading indicates a shipper-certified weight will the maximum tonnage figure be adjusted to reflect the shipper-certified weight. If an estimated weight is indicated on the shipper's bill of lading, the maximum tonnage figure will remain in the car file of the computer system until the car has been weighed. The nearest scale to the Mojave Yard was at West Colton.

The director of clerical operations testified that the clerks in the various outlying areas are responsible for checking the accuracy and completeness of shipper-tendered bills of lading. According to his testimony, the first-line supervisor for these clerks is located in Los Angeles. He further stated that during the last few years, shippers have been sending their bill of lading information directly to the central office in Los Angeles rather than dealing with clerks at the various outlying areas.

Description
The Calnev pipeline was constructed by Mid-Mountain Contractors, Inc., during 1969 and 1970. The approximately 248-mile-long pipeline, which transports petroleum products including gasolines, jet fuels, and No. 2 diesel fuel, originates at the Colton Pump Station at Colton, California, and terminates at Las Vegas, Nevada. From the Colton Pump Station (elevation 1,040 feet), the pipeline route is generally northward and crosses Cajon Pass at an elevation of 4,480 feet at MP 28 (figure 5). From Colton to about MP 236, the pipeline is 14 inches in diameter, and from MP 236 to the Las Vegas terminal, the pipeline is 8 inches in diameter. The first 107-mile section of the 14-inch-diameter pipeline was constructed of the same grade of pipe that was involved at the rupture site. The pipe at the rupture site was manufactured of steel by Kaiser Steel Corporation to American Petroleum Institute standard 5LX 52, using an electric resistance welding process. The pipe had a 0.312-inch wall thickness and weighed 45.61 pounds per foot. As a minimum, the pipe was required to have a specified yield strength of 52,000 psi and a specified tensile strength of 66,000 psi. Records of tests performed on the steel used to manufacture the pipe indicates that the steel exceeded these minimum requirements with some tests showing minimum specified yield strengths of 66,000 psi and minimum specified tensile strengths of 74,430 psi or greater. The pipe was coated with TGF3, a coal tar base coating. According to Calnev's cathodic protection records, the pipe had a minimum negative (cathodic) voltage of 0.85 volts (generally it had a considerably more negative voltage) as measured between the pipe and the soil. A cathodic protection rectifier was located at the Colton Pump Station, and Calnev's records indicate that there had never been a corrosion leak found on this 14-inch pipeline system. Calnev's manager of operations testified that if the coating damage existed prior to the derailment, Calnev would not have been able to see any change in the cathodic protection in this case because, "There is a casing that runs under Highland Avenue. At this particular location the casing and the pipe are operating at the same potential. That large casing would probably mask any damage to the coating that might be evident in that location. I don't think you would have seen a change to the cathodic level there."

The first 107 miles of the pipeline were hydrostatically tested between June 20, 1970 and July 3, 1970; the section through the rupture site (MP 0.0 through MP 25.2) was tested on June 29 and 30, 1970. The pressure test on this section was begun at 8:15 a.m. on June 29, 1970, at 2,085 psig and completed at 12:30 p.m. on June 30, 1970, at 2,083 psig. The minimum pressure during the test was 2,075 psig, and the minimum 4-hour internal sustained pressure was 2,077 psig.

Check Valves
At the time the pipeline was constructed, Calnev installed check valves in its pipeline to prevent backflow of product from one section of the pipeline to another. These valves also serve to minimize the amount of product that can be released from the pipeline should the pipeline rupture. Generally, Calnev installed top-hinged check valves, and at some locations there are connections installed to bypass the check valves. However, on the 14-inch portion of the pipeline, Calnev installed seven Wheatley "All-Clear Check Valves." These check valves are side-hinged check valves which purportedly provided advantages over the top-hinged check valves by producing less pressure drop and offering less resistance to the passage of spheres and scrapers. Side-hinged check valves were installed at MP 0.0, 6.9, 14.9, 19.2, and 25.7. Calnev's manager of operations testified that he was not aware that Calnev had ever inspected any of the check valves installed in the pipeline between the Colton pump station and Cajon Pass to determine if the valves operated properly. He further testified that it was his understanding that check valves are not routinely inspected in the industry and that he was unaware of any Federal regulation or industry standard that required such inspection. He stated that following the rupture Calnev made plans to inspect the check valves in this area. In a letter to the Safety Board dated May 21, 1990, Calnev stated, "Calnev has installed four new check valves; [sic]  three to replace existing check valves and one additional check valve at MP 10.0. Our intention is to replace one more check valve and install a supplemental block valve near another in the next 60 to 90 days."

The OPS representative who testified at the Safety Board's public hearing stated that the proper operation of check valves can be important to the safe operation of pipelines; he also advised that the OPS historically has considered that the regulations do not apply to the maintenance of check valves. The OPS has not issued an interpretation to this effect and it has not provided to its enforcement personnel any guidance indicating that check valves do not have to comply with the maintenance requirements; however, the OPS representative stated that this position reflected what OPS has been doing from an enforcement policy.

The Calnev manager of operations further testified that, based on the amount of product eventually required to refill the line, at the time of the rupture, the check valve at MP 6.9 did not close, the valve at MP 14.9 "must have come closed at some point," and that check valve  [sic]  at MP 19.2 "probably has at minimum leaking seats."

Block Valves
Remotely operated block valves were installed on the Calnev pipeline at MP 35.4 and MP 46.7. A manually operated block valve was installed at MP 25.7. According to the testimony of the incident commander (the deputy fire chief) and Calnev's manager of operations, the deputy fire chief requested after the train derailment that a block valve be installed just north of where the derailment occurred. According to Calnev's manager of operations, "With a block valve you have the ability for positive shut-off. You can turn a crank and tighten it and possibly have a more certain measure that your pipeline is shut off at that point. I think the chief felt that given the difficulty we had in getting that check valve to seat during our drain-down, that that might be a good idea given the population in the area&hellip;We were basically in agreement with the chief that that would be a good idea." He further stated, "There is a fair amount of lead time in ordering such an item and a fair amount of time to set up an installation such as that one." Subsequent to the pipeline rupture, a remotely operated block valve was installed at MP 6.9.

Dispatch Center
The pipeline system is controlled by dispatchers from a dispatch center at the Colton Pump station. The system is equipped with a monitoring system that scans selected system parameters, such as pipe pressures and motor drive amperages, every 13 seconds, compares the data with programmed acceptance values, and through visual and audible alarms, alerts the dispatcher to changes to operating conditions in the system and abnormal or unacceptable occurrences. The audible alarm indicates that a change has occurred; however, this does not necessarily indicate that there is an emergency or that any action is required on the part of the dispatcher other than to acknowledge the alarm by pressing a key on his terminal keyboard. The visual alarms are presented in the form of numerical values flashing on a colored background. The background color varies depending on the measured value for the particular operating parameter. Background colors range from shades of white and blue, representative of the range of low pressure conditions, to yellow and red, representative of the range of high pressure conditions. Normal ranges are presented on a green background.

A computer printout of the monitoring system indicated that on the day of the accident, the dispatcher on duty received both a low suction and a low discharge pressure alarm on his computer terminal screen. The dispatcher did not detect the low discharge pressure alarm, and by one stroke on his terminal keyboard, he silenced the audible alarm, caused the flashing word "alarm" to disappear from his screen, and caused the flashing numerical information regarding the low suction pressure and the low discharge pressure to return to a steady presentation; the background color does not change until the operating condition changes. According to Calnev, subsequent to the rupture, Calnev modified its automated control system to include a high flow set point whereby if excessive flow is observed out of the Colton pump station (indicative of a potential leak or rupture), the system will automatically shut down the Colton pump, and indicate the alarm condition.

Emergency Response Manual
On the day of the pipeline rupture, Calnev did not have any procedures in its abnormal operation response plans (a section of the company's emergency response manual) that would advise the dispatchers of the actions to take upon receiving both a low discharge pressure and a low suction pressure alarm. Calnev's manager of operations stated, "We felt that it was adequately covered in the explanation section for low suction pressure" which advises that the line pressure be checked in the event of a low suction pressure alarm. He stated further that following the pipeline rupture, Calnev revised its manual to include an explanation of what to do in the event a low discharge pressure alarm is received.

Calnev's emergency response manual was last revised in January 1989. This manual contains a list, by milepost, of telephone numbers for fire and police departments, and procedures for notifying Calnev personnel and other agencies in the event of a spill or leak. The manual also contains maps of the pipeline and directions to each mainline block valve, and procedures for responding to a natural disaster and external incidents.

The procedures for a suspected leak require the pipeline to be shut down, pressures to be stabilized, remotely operated valves to be closed, and pressures in specific sections of the pipeline system to be monitored. If a leak is confirmed, the procedures outline specific actions to be taken to locate the leak and to respond to the leak.

The procedures for a natural disaster and external incident refer to the potential adverse effects of train derailments. The procedures indicate that substantial portions of the pipeline system are built on the railroad right-of-way and that train derailments pose a serious threat to the pipeline primarily by equipment being used to clear the wreckage and replace the roadbed. The areas where the pipeline system is located near railroad tracks are listed by milepost; the area of the train derailment of May 12, 1989, is included in this section. In the event of a train derailment, the procedures indicate that Calnev personnel are to be immediately dispatched to the scene and assess the situation to determine if the pipeline could have been damaged. Railroad personnel are to be contacted and advised of the location of the pipeline. In the event of possible damage, the pipeline is to be shut down, and upstream and downstream valves are to be closed. The procedures also indicate that once the pipeline has been secured, the location of the pipeline through the derailment area should be accurately marked, heavy equipment should not be allowed to operate over the pipeline if it is considered hazardous to the pipeline, and Calnev personnel should be present on scene until all work is completed.

Operating Crew of Extra 7551 East
The head-end engineer had been off duty for about 20 hours before reporting for duty at Bakersfield at 9:00 p.m. on May 11. The engineer reported the following information: He spent his off-duty time sleeping, eating, watching television, and relaxing. He had been eating regular meals during the day preceding the accident, had been receiving his usual amount of rest of about 10 hours, and was fully rested when he reported for duty on the evening of May 11. There had been no recent changes in his lifestyle, he had not consumed any alcohol during the days preceding the accident, and he was not a user of illicit substances.

The engineer held an active State of California driver's permit. An inquiry to the State of California Department of Motor Vehicles (SCDMV) revealed that the engineer had no history of having received any summons or convictions. The National Driver Register (NDR) contained no information on revocations or suspensions regarding the engineer's driving privileges.

The head-end engineer had been employed by the SP for almost 15 years at the time of the accident. He had held the positions of fuel oil attendant, laborer, and fireman before being promoted to the position of engineer on November 28, 1986. (For additional information, see Engineer Training Program.)

The head-end engineer had been qualified on the physical characteristics of the territory by making one check ride from Techachapi to Bakersfield (see figure 1) with a supervisor in September 1988. He stated that he was familiar with the descending grade in the accident area and had operated trains over this trackage several times. He stated further that he had previously operated trains with a trailing tonnage of 6,151 tons and with a trailing tonnage of about 8,900 tons. His testimony also indicated that he had never operated a train that he believed the tonnage of which was substantially more than the tonnage shown on his train documents. He did indicate, however, that this was the first unit (single commodity) freight train he had operated through the Cajon Pass; all of his prior experience through the Pass was operating mixed commodity freight trains. He added that he believed this was the first time he had transported trona. The head-end engineer stated that he had worked previously with the other head-end crewmembers  [sic] , but had no knowledge of, nor had previously worked with, the helper engineer.

The conductor of Extra 7551 East had been off duty the 4 days preceding the accident. The conductor's wife reported the following information about the conductor: On Thursday, May 11, the conductor awoke around 8:30 a.m. and remained at home during the day. He received his call for duty, as expected, and reported to the Bakersfield yard at 9:00 p.m. that evening. He had been eating regular meals and had been receiving his usual amount of rest during the days preceding the incident. Her husband was "rested as usual" when he reported for duty the evening of May 11. She had noticed no changes in her husband's lifestyle. The conductor did not smoke cigarettes or drink alcohol.

The conductor held an active State of California driver's permit. According to the SCDMV, the conductor had no history of having received a summons or conviction. The NDR contained no information on revocations or suspensions regarding the conductor's driving privileges.

The conductor had been employed by the SP for 17 years at the time of the accident. He had held the position of brakeman until April 15, 1975, when he was promoted to the position of conductor.

The head-end brakeman of Extra 7551 East had been off duty during the 48 hours preceding the accident. The brakeman's wife reported the following information about the brakeman: He spent the time during the days conducting personal business and engaged in activities with his family. On Thursday, May 11, he awoke about 9:30 a.m. having received about 10 1/2 hours of sleep, and spent the day at home. He reported for duty at Bakersfield at 9:00 p.m. that evening. He had been eating regular meals, had been receiving his normal amount of rest, and "was not fatigued" when he departed home on the evening of May 11. He did not smoke cigarettes, drink alcohol, or use illicit substances, and she had not noticed any recent changes in her husband's lifestyle.

The head-end brakeman had been employed with the SP for more than 17 years at the time of the accident. He was promoted to the position of brakeman on November 27, 1971.

The helper engineer had been off duty since 11:00 p.m., May 9, having completed at that time an approximate 10-hour tour of duty. He stated that on May 10, he attended a union meeting in the morning and for the remainder of the day engaged in personal activities. According to his testimony, on Thursday, May 11, he awoke around 10:00 a.m., having received about 8 hours of sleep. He spent the day performing personal business and retired that evening about 11:30 p.m., at which time he received a call from the crew dispatcher for a 1:30 a.m. duty call. He reported to the West Colton yard and then rode in a company van for the 1/2-hour trip to the Dike siding where he was to relieve the on-duty helper engineer.

The helper engineer reported that there had been no recent changes in his lifestyle, that he does not use illicit substances, and that he had not consumed any alcohol during the days preceding the accident.

The helper engineer stated that he had eaten regular meals during the days preceding the accident and that he normally receives 6 to 8 hours of sleep daily. In his initial statements to Safety Board investigators, he stated that when he received the call for duty on the evening of May 11, he had not received his proper rest and "was tired." He elaborated by stating that he was not tired when he first reported for duty but that he was not "in tip top condition the whole trip." When questioned if he had fallen asleep during the trip, the helper engineer replied, "I don't think so." The engineer further stated that he had expected to receive a call for duty because he had called the crew dispatcher's office several times that day, but believed that he would receive the call for duty later in the night or early the following morning. During the Safety Board's public hearing, he testified that he was not tired when he reported for duty and had no difficulty remaining alert during the trip.

The helper engineer had been employed by the SP for more than 11 years at the time of the accident. He had held the positions of hostler and fireman before being promoted to the position of engineer on November 5, 1979.

The helper engineer stated that he normally operated trains between West Colton and Yuma. He was not qualified on the physical characteristics of the railroad for the territory in which the accident occurred and could not, therefore, operate as a road engineer in this area. He estimated that during the past year he had served as a helper engineer about four times on trains operating over the accident territory. Company records indicated that during the month preceding the accident, the helper engineer had not worked with any of the other crewmembers  [sic]  assigned to the accident train.

The helper brakeman received an emergency call for duty from the crew dispatcher on the evening of May 11, to report for duty at 1:30 a.m., May 12. He stated that he had expected to be called for duty about 10:00 a.m. later that morning. Prior to the emergency call, the brakeman had been off duty since 9:00 p.m. on May 10. The helper brakeman reported the following information about his activities: He had "a normal day" on May 11, had been eating regularly (which for him was one meal in the evening) during the day preceding the accident, had been receiving his usual amount of rest, about 8 hours daily, and he was not fatigued when he reported for duty on the day of the accident. He had consumed one beer at home on the evening of May 11. His lifestyle had been altered as a result of his wife's death 3 months earlier. He did not indicate that he was not adjusting properly to this loss.

The helper brakeman had been employed by the SP for more than 38 years at the time of the accident, holding the position of brakeman since the time he was hired. He estimated that he had been a crewmember  [sic]  on trains operating over the accident area on about 10 occasions in the past and that he had worked on many occasions with the helper engineer.

On-scene investigators attempted to locate the grips (personal bags) belonging to all five crewmembers  [sic] . It was learned that the helper crew had taken their bags when they departed the accident site. The grip belonging to the conductor was removed by the wreckage by railroad officials, and investigators were unable to locate any documentation concerning the contents of this grip. The grips belonging to the head-end engineer and head-end brakeman were located in the wreckage and recovered. A review of the contents of these grips revealed nothing noteworthy.

Other Southern Pacific Personnel
The train dispatcher on duty at the time of the accident normally worked a 5-day week. Prior to the day of the accident, the dispatcher had not worked since May 6, due to illness. She stated that she was feeling fine when she reported for duty on the morning of May 12. The dispatcher had been employed by the SP for almost 10 years and had held positions as yard clerk and interlocking operator before being promoted to the position of dispatcher on November 19, 1988.

The assistant chief dispatcher, who arranged the locomotive units for the movement of Extra 7551 East, worked a regular shift of 10:30 p.m. to 6:30 a.m., 5 days a week. He had been off duty for 16 hours before reporting for duty on the evening of May 11. The assistant chief dispatcher was employed by the SP in July of 1970. He held various positions including freight clerk, yard clerk, and train order operator until being promoted to the position of train dispatcher in 1973. He was promoted to chief train dispatcher in August 1976, resigned voluntarily from that position in September 1977, and returned to the position of train dispatcher in Los Angeles until April 1983. At that time, he exercised his seniority options and returned to Bakersfield as a crew dispatcher and worked in that capacity until 1985, when he returned to the train dispatcher position. His last examination on the operating rules was conducted in 1985.

Calnev Pipeline Dispatcher
The dispatcher on duty at the time of the pipeline rupture had been employed with the Calnev Pipe Line Company since October 3, 1988. He was hired as a pipeline operator, which includes serving as a relief dispatcher. He was performing the duties of relief dispatcher at the time of the accident.

According to the dispatcher, the day of the pipeline rupture was the third day of his work week; he had finished his last shift at 3:00 p.m. the preceding day. On the day of the rupture, he reported for work at 6:45 a.m. He reported the following information: He had been receiving his usual amount of rest and was properly rested when he reported for duty. He was not taking any medication on the day of the pipeline rupture, had not consumed alcohol the day before the rupture, and he does not "involve himself" with illicit drugs.

The dispatcher had been employed previously with the Paramount Petroleum Corporation for 10 years, during which time he served as a pumper-pipeline operator, a laboratory technician, and a crude oil unit operator.

(Additional personnel information is in Appendix B.)

Engineer Training Program
Trainees for the engineer training program were selected from employee applications with preferential treatment given to those applications submitted by United Transportation Union (UTU) members&mdash;brakemen, switchmen, and hostlers&mdash;because of existing labor agreements between the SP and the UTU. Those trainees selected initially entered a 4-week formal training program during which preliminary air brake, mechanical, locomotive, and operating rules are covered both in the classroom and in the field. The class size for the program normally consisted of 10 trainees. If the trainees successfully completed examinations midway and at the end of the 4-week period, then they progressed to the next stage, which consisted of making 60 road trips with a qualified engineer. A trainee was not assigned to a specific engineer during this time (labor agreements did not provide for instructor engineers), and, thus, may have ridden with many different engineers in the process of completing 60 road trips. Following the completion of 60 road trips, the trainees were evaluated by the road foreman of engines on the respective district over which they had been working. If he determined that the trainees had reached a minimum level of proficiency, then they were scheduled for the final 3-week phase of training at the company's training facility in Cerritos, California: 1 week consisted of 40 hours of classroom instruction; the last 2 weeks consisted of 1/2 day of classroom instruction and 1/2 day of simulator training. If the trainees successfully passed all three written examinations (one each on air brakes, mechanical systems, and operating rules) and demonstrated train handling skills as observed in the train simulator, they were then promoted to the position of engineer and received a seniority date. An engineer was not qualified for a given territory until the road foreman of engines for the territory had ridden with the engineer for a period of time and had determined that the engineer was knowledgeable of the territory and could adequately handle trains over the territory. (According to the assistant manager of training and development, the number of times a road foreman of engines would ride with an engineer varied based on the level of skills of the engineer.)

The SP also had in place a 1-week and a 2-week continuing education program during which time engineers returned to the Cerritos facility for refresher training. The 1-week program consisted primarily of reviewing train handling skills (1/2 day in the classroom and 1/2 day in the simulator) and was geared for engineers who worked in heavy-grade territory or mountainous terrain. During the 2-week program, train handling skills were reviewed, and the mechanical systems on the locomotive and the operating rules book were also reviewed. The engineers were not confronted with a pass/fail situation upon completing the continuing education programs. The superintendent of an engineer's respective division received a report on the engineer's performance both on the simulator and on the written examinations. The superintendent could then use the information to determine if the road foreman of engines should spend additional time with a particular engineer.

The head-end engineer of Extra 7551 East entered the engineer's training program on October 20, 1986. After successfully completing the 2-week classroom or "presimulator" training course, he attended the 3-week training course held at the training center in Cerritos. After successfully completing 1 week of classroom instruction and 2 weeks of simulator training at the center, he was promoted to the position of engineer on November 28, 1986. The engineer returned to the training center in January 1988 for the 1-week continuing education program to receive additional instruction on heavy-grade operations. The engineer successfully completed both the classroom portion and the simulator training portion of the program.

The head-end engineer of Extra 7551 East testified that he had never been trained on procedures concerning the reversing of engines, had never received instruction concerning the effects of extended brake application on the deterioration of brake shoes, had never received instruction regarding train handling while receiving helper engine assistance, and had never been placed in an emergency situation during simulator training. He further stated that he was not taught during training how to recover dynamic brakes after an emergency application of the train brakes had been made.

The helper engineer entered the engineer's training program on August 13, 1979. He successfully completed the final phase, 1 week of classroom instruction and 2 weeks of simulator training, before being promoted to the position of engineer on November 5, 1979. He returned to the training center in Cerritos in July 1988 and successfully completed a 2-week continuing education program. The helper engineer testified that during his training, the company rule that addressed reversing the engines was discussed in situations involving "light engines or just a couple of cars, low speeds." He further testified that during this simulator training, they operated trains with helper units. He stated, "...you are trained to take and just go by what the road engineer requests. Normally, it is standard procedure just to go in full dynamics, unless he requests otherwise, and stay in full dynamics."

According to SP's assistant manager for training of engineers, reversing the engines was not taught during any aspect of the training program "because with the train in emergency, we do not allow the engineer to attempt to reset the PC switch before the train comes to a halt." His testimony also indicated that emergency situations incorporated into the simulator training were predicated on the premise that once the brakes are applied in emergency, the train will stop. With respect to helper engine service, the assistant manager for training stated, "The extent of our instruction to people as far as being helper engineers is push as hard as you can up the hill and hold back as hard as you can going down the hill and if the road engineer asks you to do something, do it."

Dispatcher Training Program
The SP was training its dispatchers at its training center in Cerritos. According to the training officer for dispatchers, the existing program had been in place for about 1 1/2 years. Candidates for the dispatcher position entered an 8-week training course that incorporated the use of the same computerized dispatching equipment that the individual would use once assigned to an office. After passing the final examination on the classroom portion of training, candidates were sent to a dispatching office where they began their on-the-job training. There was no set period of time that trainees were required to perform on-the-job training. The chief train dispatcher determined when an individual was qualified for a particular dispatcher's position.

The dispatcher, who had operational responsibility over the Mojave Subdivision and was on duty at the time of the derailment, successfully completed the 8-week dispatcher training program on August 19, 1988. She then received on-the-job instruction from an experienced dispatcher for 3 months before being qualified to operate independently as a dispatcher. The assistant chief dispatcher, who assigned the locomotive units for the movement of Extra 7551 East, had not been through the Cerritos dispatcher training program; his training for the position of dispatcher was all on-the-job training.

Clerk Training Program
The yard clerks who estimated the weight of the cars at the time the cars were released and the yard clerk who estimated the weight of the trona on the shipper's bill of lading had received no formal instructions regarding their duties, according to their testimony. All training had been on-the-job training with other clerks. According to the director of system clerical operations, "It's not always feasible to give these people classroom training when, in fact, they may be trained in a classroom for 2 weeks and then have somebody exercise their seniority against them or they bid to another position...." He estimated that about 20 percent of the clerks were receiving classroom instruction and that SP hoped to raise that percentage to between 30 and 50 percent. According to his testimony, it was standard procedure that any time a clerk estimated a weight on the waybill, some notation on the waybill was needed to indicate that the weight was estimated. He further testified that more and more shippers were dealing directly with the billing office in Los Angeles rather than dealing with yard clerks in the various outlying areas.

Calnev Pipeline Dispatcher Training Program
The primary function of a Calnev pipeline dispatcher was to operate and monitor the pipeline through use of a computer-based operating system. This computer system monitored the condition of the pipeline and incorporated several safety mechanisms that would automatically shut down the system in the event of an emergency.

According to Calnev's manager of operations, there were no written criteria the company followed in selecting an individual for the position of dispatcher. The employee turnover rate was low, and individuals filling the positions of dispatcher normally came from within the company and were knowledgeable of Calnev's operations and procedures.

A trainee received an overview of the Calnev pipeline system and was then paired with the on-duty day shift dispatcher, who was responsible for the trainee's on-the-job training. The duration of on-the-job training varied with the individual. According to the manager of operations, an individual experienced in Calnev's operations might only require 2 months of on-the-job training before being allowed to dispatch while other individuals who were not as knowledgeable might require up to 6 months of on-the-job training.

The on-duty dispatcher provided updates on the trainee's performance to the terminal supervisor and the manager of operations. After a 6-month period, a trainee received a written performance appraisal. After a trainee had completed on-the-job training and had shown a competent working knowledge of the system, the dispatcher was monitored while operating the system alone. Performance was monitored continually by an event recording system, which recorded every keystroke entered on the computer by the dispatcher and all alarms received during the employee's shift. The event recorder printout was reviewed by company officers after an occurrence involving unusual circumstances.

To supplement on-the-job training, the trainee was exposed to several on-going training programs. These programs included monthly meetings concerning safety and operations, review and completion of the operator training manual, and special training seminars. The operator training manual was a self-paced, self-instructional two-volume document that covered a wide variety of pipeline operational procedures. Trainees reviewed these manuals while on duty, a chapter at a time. When the individuals believed they had adequately reviewed the chapter, they were examined on the material. A company officer administered the exam and reviewed all incorrect responses with the trainees. Trainees were to complete all chapters and associated tests during their first year of employment.

The dispatcher on duty at the time of the rupture received his 6-month performance appraisal on March 30, 1989, with the rating of "meets most performance requirements." His instructor had described the dispatcher's ability to learn material as "slow" at that time but attributed this to the dispatcher's refinery rather than pipeline background. The instructor added that as time passed, the dispatcher "quite easily" learned the proper operating and dispatching procedures.

Southern Pacific Management Oversight of Train Operations
The SP's road foreman of engines was responsible for the direct supervision of engineers operating over his particular territory. The road foreman of engines, whose territory was involved in the train derailment, testified that he was responsible for 35 to 55 engineers, depending on the number of helper units in service and the amount of train traffic. According to his testimony, in addition to the required rules examinations, rules compliance was measured through efficiency testing, train rides, review of event recorders, and general observation.

The road foreman of engines for the territory involved in the train derailment testified that efficiency tests were conducted 7 to 8 days a month and that 50 percent of that time would be devoted to checking speed violations through use of radar. The other 50 percent was devoted to efficiency testing of other operating rules. According to the road foreman, there was no set policy on the number of efficiency tests to be made on grade operations or through the use of radar. With respect to train rides, the road foreman testified that he would ride with each engineer at least once or twice a year or more if the engineer was experiencing problems. Again, there was no written policy regarding the number of check rides that had to be made. According to the road foreman, he reviewed 15 to 20 speed tapes a month, some of which were reviewed with the engineer if the road foreman had some concern about the engineer's performance.

The SP instituted a demerit system for rules violations as one method of disciplinary action. According to the road foreman, an employee could accumulate up to 90 demerits before suspension or disciplinary action was initiated. He stated further, however, that if an employee had accumulated 60 demerits, an assessment of the employee's performance was made. For each month that no violations were incurred, two and one-half demerits were removed from the employee's record.

SP's records indicated that in the 12 months prior to the train derailment, the head-end engineer had successfully passed 68 of 70 efficiency tests conducted. His records indicated two instances of disciplinary action. On March 31, 1986, he was cited for exceeding maximum authorized speed (29 mph in a 25-mph zone) while serving as fireman during helper engine service. He waived a formal investigation and received 30 demerits. The second instance involved his failure to properly connect locomotives on February 13, 1988. Again, he waived a formal investigation and received 30 demerits.

SP's records indicated that in the 12 months prior to the train derailment, the helper engineer had successfully passed all 63 efficiency tests conducted. His records indicated no instances of disciplinary action.

None of the crewmembers involved in the train derailment on May 12, 1989, were cited for disciplinary action. According to the general manager for the Western Region, one reason for not taking any disciplinary action was because of the false information provided to the traincrew. He testified, "...it would not have seemed appropriate due to all the outside factors to cite this crew....It would have been very difficult to establish the complicity of the crew as far as the runaway train."

Industry Pipeline Standards and Federal Regulations
When the construction of the Calnev pipeline began in 1969, there were no Federal regulations in effect that addressed the operation, inspection, and maintenance of liquid pipelines. Industry-recommended standards, American Standards Association (ASA) Code B31.4 - "Liquid Petroleum Transportation Piping System" (as revised in 1966), addressed design, construction, inspection, testing, operation, and maintenance considerations, which liquid petroleum operators were encouraged to follow. Selected provisions of the code are contained in Appendix I.

Federal authority to regulate liquid pipeline carriers for safety purposes has existed since March 4, 1921, and was vested originally in the Interstate Commerce Commission (ICC). In 1967, this authority was transferred to the FRA of the U.S. Department of Transportation (DOT), and shortly thereafter, the first Federal safety regulations for liquid pipelines were issued requiring only the reporting of accidents (49 CFR 180.28).

In August 1968, the Natural Gas Pipeline Safety Act of 1968 was enacted, and the Office of Pipeline Safety (OPS) within the DOT was established to develop safety standards for natural gas pipelines and to provide technical advice to the FRA on matters relating to liquid pipelines. On September 29, 1969, the FRA issued regulations for liquid pipelines, 49 CFR Part 195. (The regulations did not apply to pipelines already constructed or under construction.) Many of the provisions of the regulations were based on the existing industry standards, including the 1966 edition of the ASA Code B31.4. Pertinent provisions of Part 195 are contained in Appendix J. Only a few substantive changes have been made to these particular provisions since the regulations were issued in 1969.

ASA Code B31.8, "Gas Transmission and Distribution Piping Systems," is the industry standard for the natural gas industry. Code B31.8, unlike Code B31.4, had established design standards based on the surrounding population. In determining the population density, the number of buildings intended for human occupancy within a 1/4-mile exposure distance on each side of a gas pipeline route was to be considered. Initially, these standards applied only to the original installation of pipelines, and modifications were not required when the population adjacent to the pipeline increased. However, the 1968 edition of Code B31.8 recommended that gas pipeline operators continually survey their pipelines, and that for pipelines operating in excess of 40 percent of the specified yield strength of the pipe, operators confirm the adequacy of the design or reduce pressure in the pipeline when prescribed population densities were exceeded. Additionally, Code B31.8 (as revised in 1968) based the frequency of several tests required for acceptance of newly installed pipeline, and of several inspections required of pipelines in operation, on the population densities adjacent to a pipeline.

The first Federal regulations for natural gas pipelines, 49 CFR Part 192, were published on August 19, 1970, and were primarily based on the 1968 edition of Code B31.8. Pertinent provisions of Part 192, specifically the population-based spacing requirements for valves on natural gas transmission lines, are contained in Appendix K.

Oversight of Calnev's Pipeline Operations
The Calnev pipeline involved in the train derailment and the subsequent pipeline rupture is an interstate liquid pipeline. Federal regulations addressing interstate pipelines, as contained in 49 CFR Part 195, are currently administered by OPS within the Research and Special Programs Administration (RSPA), a part of the DOT. The Office of the California State Fire Marshal (CSFM) has authority for the regulation, inspection, and enforcement of intrastate pipelines. On January 1, 1987, the CSFM signed an agreement with OPS that stipulates that the CSFM will act as an agent for OPS for inspecting and monitoring interstate pipelines within the State of California to determine compliance with certain provisions of 49 CFR Part 195. Because construction of the Calnev pipeline began in 1969, the provisions of 49 CFR 195 were not in effect; thus, the design, materials, installation (including the location of valves), and initial testing requirements do not apply to this pipeline. However, the provisions for reporting accident and safety-related conditions and for the operation and maintenance of the pipeline do apply.

As an agent for OPS, when CSFM detects a violation of 49 CFR 195, it advises OPS of the findings. Based on its review of the information provided by CSFM, OPS determines if enforcement action is warranted, the type of action warranted, and whether or not to pursue further action. According to a representative from the CSFM, in this arrangement, CSFM serves to detect noncompliance but has no regulatory authority in resolving any noncompliance detected. Testimony from the division chief for pipeline safety operations at CSFM indicated, however, that CSFM could request an operator to take corrective action without first consulting OPS if an immediate risk to public safety existed.

The San Bernardino deputy fire chief (incident commander) testified that although he had been contacted by a representative from the CSFM on the day of the derailment, he was not made aware of the presence or activities of the CSFM during the days following the train derailment. Testimony from the division chief of pipeline safety operations indicated that representatives from the CSFM were on site through May 16, were in contact with Calnev personnel throughout this time concerning cleanup operations and inspection of the pipeline, and relayed information concerning activities at the derailment site to the OPS' regional office in Colorado. According to his testimony, OPS did not instruct CSFM to take any actions at the site, CSFM representatives on site were satisfied with Calnev's inspections, and based on Calnev's assessment of the integrity of the pipeline, CSFM did not request Calnev to take any further action. He stated also that CSFM was not aware of any request by the deputy fire chief to fully expose and inspect the pipeline in the derailment area. The division chief further testified that representatives from CSFM routinely worked with pipeline personnel rather than fire department personnel, but that CSFM had initiated a program subsequent to the pipeline rupture to contact the fire departments within the State of California to inform them of CSFM's role in and responsibilities for liquid pipelines.

Following the pipeline rupture, representatives from the CSFM and from OPS were dispatched to the scene of the accident. The deputy fire chief stated that he was made aware of their presence and was routinely updated on their activities during the days following the rupture. (The actions taken by the OPS following the pipeline rupture have been previously discussed.)

On August 9, 1989, as a result of its preliminary investigation of the pipeline rupture, the Safety Board issued the following two Safety Recommendations to the Research and Special Programs Administration:


 * P-89-5
 * Require pipeline operators that have "All-Clear Check Valves" manufactured by the Wheatley Company installed in their pipeline systems to test these valves for proper closure and require the replacement of any that fail to close properly.
 * P-89-6
 * Establish inspection, maintenance, and test requirements to demonstrate and maintain the proper functioning of check valves installed in pipeline sytems.

On November 13, 1989, RSPA responded to the Safety Board's recommendations stating:


 * An Alert Bulletin has been issued that alerts all hazardous liquid pipeline operators to test in critical locations all check valves for proper closure and recommends the replacement of any check valve that fails to close properly. Also, the advisory recommends that valves located in noncritical areas be inspected for operation at the first opportunity the valves can be bypassed or otherwise taken out of operational service. (The full text of the alert bulletin is contained in appendix L.)
 * We have initiated a study to determine the feasibility of establishing inspection, maintenance, and test requirements to demonstrate and maintain the proper functioning of check valves installed in pipeline systems. We plan to complete this study within 9 months. If the study supports a need for such a regulation, we will initiate rulemaking.

Based on RSPA's response to the Board's recommendations, Safety Recommendations P-89-5 and -6 have been classified as "Open&mdash;Acceptable Alternate Action" and "Open&mdash;Acceptable Action," respectively.

Meteorological Information
At 7:30 a.m. on May 12, 1989, at the Norton Air Force Base, located about 4 miles from the accident site, the sky was clear with a temperature of 57 degrees F. Visibility was reported as 15 miles. Similar weather conditions existed at the time of the accident site.

Train Derailment
Two children, ages 7 and 9, suffered fatal injuries when the train derailed and hopper cars struck their house at 2348 Duffy Street (see figure 11). Postmortem examinations indicated that both children died of suffocation and compressional asphyxia.

The head-end engineer of Extra 7551 East sustained a 4-inch laceration of the left upper arm, multiple rib fractures on the left side with pneumothorax, and multiple abrasions and contusions. He was admitted to the intensive care unit at St. Bernardine Hospital where he was treated and later released.

The two crewmembers located in the last helper engine reported receiving minor injuries. Immediate medical attention was not sought, and there are no records to indicate injuries or treatment.

A resident at 2326 Duffy Street (see figure 11) sustained multiple injuries, including a right compound fracture of the femur, a large laceration of the right knee, and a compressed spinal fracture when several hopper cars struck his house. This resident was trapped for about 15 hours before being rescued and transported to a local hospital.

The conductor of Extra 7551 East, who was located in the lead engine unit, 8278, and the brakeman who was located in the third engine unit, 7549, suffered fatal injuries as a result of the derailment. Postmortem examinations indicated that both crewmembers died of multiple traumatic injuries.

Pipeline Rupture
Two residents, one of whom was in her house at 2327 Duffy Street and the other in her backyard at 2315 Duffy Street (see figure 11), sustained fatal injuries as a result of the fire.

Three residents received serious injuries, second and third degree burns, while escaping from their burning homes. Sixteen other residents reported minor burns and shortness of breath from smoke inhalation. One firefighter reported burning his foot while fighting the fire.

One person, who was not a local resident, received multiple rib fractures in an automobile accident while attempting to make a U-turn to avoid the fire resulting from the pipeline rupture. Three other persons, who also were not local residents, reported minor injuries, including lacerations and contusions, while attempting to drive away from the fire.

Toxicological Information
In accordance with current FRA requirements, toxicological samples were obtained from all five crewmembers of Extra 7551 East. These samples (blood and urine specimens from the surviving crewmembers, and blood, urine, and tissue specimens from the deceased crewmembers) were forwarded to and examined by the Center for Human Toxicology (CHT) in Salt Lake City, Utah. Additionally, in accordance with SP operating procedures, a second urine specimen was collected from each of the surviving crewmembers and forwarded to an alternate contract laboratory facility, Roche Biomedical Laboratories, Incorporated (RBL), for examination. The specimens examined by CHT and RBL were negative for alcohol and other drugs.

The train dispatcher on duty at the time of the train derailment was not requested to submit to toxicological testing. Calnev's pipeline dispatcher on duty at the time of the pipeline rupture was not requested to submit to toxicological testing. Calnev did not have a policy regarding postaccident toxicological testing of employees. Calnev employees, however, were required to submit to drug testing before being hired. Testimony by Calnev's manager of operations indicated that Calnev was aware that the company would be required by Federal regulation to implement a drug testing program in the near future.

Southern Pacific's Physical Examination Policy
SP's physical examination policy requires all employees to submit to a physical examination when they are hired. With the exception of engineers, there is no requirement that employees submit to further examinations after that date. Engineers must undergo a physical examination at the time they are promoted to the position of engineer. They are not required to submit to another examination until they reach the age of 40, at which time they must then undergo a physical examination every 5 years until the age of 60. At 60, an engineer must then receive an annual physical examination. At age 65, engineers are required to undergo semiannual examinations.

Event Recorders
The multi-event recorders recovered from head-end locomotive units 7549, 7551, 8278 were sent to the Safty(sic.) Board's laboratory in Washington D.C., for readout and evaluation.

The type of recorders installed on the SP locomotive units involved in the accident were designed to record speeds up to 90 miles per hour (mph). The three stripcharts generated from the event recorders indicated that the train speed exceeded 90 mph. Because the physical limit of these stripcharts was exceeded, the maximum speed of the train could not be determined based on the original recorded values. To determine the maximum speed attained, additional stripcharts were generated using a method that reduces the recorded speed values to half their original values (appendix M). Actual values at any point on the stripchart are then obtained by doubling the indicated speed. The results indicate that the train probably reached a speed of 110 mph before derailing.

By reviewing the stripchart generated from the information recorded from unit 7549, Safety Board investigators attempted to determine if the dynamic braking on that unit was functioning. If the dynamic brakes on a locomotive unit are functioning, whenever an engineer uses dynamic braking, corresponding amperage activity should occur and be recorded on the stripchart. A review of the stripchart indicated that unit 7549 went into dynamic braking on 15 occasions during the previous 30 hours of operation; however, the expected corresponding amperage activity was recorded on only 2 occasions. Both instances of recorded amperage activity occurred before Extra 7551 East reached Hiland. The SP chief mechanical officer testified, "...I do not have the degree of confidence in the reconstructed tape that [the general road foreman] does because of the difficulty we've experienced with the tape cartridges. It's not uncommon to have them not record on a channel." The general road foreman testified that based on his review of the stripchart for unit 7549, "During the time that the train descended the hill from Highland, the dynamic brake did not work."

The event recorder printout indicated that service braking (air/mechanical brakes) occurred for more than 25 minutes as the train descended the hill from Hiland. According to information obtained from a brake shoe manufacturer, "Composition brake shoe binders start to decompose at temperatures between 700 degrees F and 800 degrees F, provided this elevated temperature is sustained. If composition brake shoe temperatures are sustained for an extended period of time (20 minutes or greater) above 700 degrees F and decomposition takes place, the shoe will continue to produce high frictional values with small losses as the result of heat fade."

Train Dynamics Analyzer Runs
On August 15, 1989, six simulations of the movement of train Extra 7551 East down the 2.2 percent grade from Hiland were conducted on a Freightmaster Train Dynamics Analyzer in Fort Worth, Texas. Operating parameters, including air brake reductions and speeds, were based on the information contained on the stripchart made from the event recorder data pack removed from SP 7551 following the derailment. As stated by SP's general road foreman, who observed the simulations with Safety Board investigators, "Test one is the only test that we could run that would allow us to go down the hill in the same manner that this train went down the hill and make the air brake reductions as they were made on the strip chart." Test one was made with 12 axles of dynamic braking on the head-end locomotive units, 6 axles of dynamic braking on the helper units, and with a trailing tonnage of about 8,900 tons. The brake shoe efficiency was purposely degraded during the run with the level of degradation and the location of degradation estimated as follows:

The general road foreman of engines recounted the results of the simulation, "We maintained the 30 miles an hour with the reductions that was(sic) made on the strip chart and then as the speed started increasing on the strip chart, we started brake deterioration in the simulations and things deteriorated from that point on...the train obtained approximately 105 miles per hour."

Test four was conducted with 12 axles of dynamic braking on the head-end of the train, 12 axles of dynamic braking on the rear end, and a trailing tonnage of about 6,150 tons. These parameters represent the number of axles of dynamic braking and the tonnage that the head-end engineer believed existed for Extra 7551 East. The simulation revealed that the train was controlled and the speed maintained under 30 mph coming down the hill.

The other four tests were stopped when the train could not be controlled coming down the hill by using the parameters from the event recorders.

Instrumented Brake Shoe Tests
On June 12, 13, and 14, 1989, SP conducted brake shoe tests on SP cars equipped with empty/load devices and on DRGW cars not equipped with the devices. The tests were conducted to determine braking forces on cars similar to the cars that were in the accident. By replacing the actual brake shoe with an instrumented brake shoe, accurate measurements of the forces applied to the wheel could be made. According to the SP's chief mechanical officer, the tests confirmed that the SP cars had "...a braking ratio of 1...."

Train Vibration Study
At the request of the Safety Board, the Test and Engineering Center of Failure Analysis Associates, an engineering and scientific consulting service, conducted tests at the accident site to measure and record vibration and strain levels to determine if the passage of trains induced vibration or strain in the buried pipeline. As stated in the introduction to the report prepared by Failure Analysis Associates, "...an instrumentation system was assembled to provide a measure of the vertical and lateral acceleration at two locations and axial and hoop strains at two locations on the pipe. Data were acquired for a 24-hour period during which time nine trains passed through the area. In addition, consist and engine log data were acquired from the SP for several of these trains. After analyzing the data collected, Failure Analysis Associates concluded, "...it does not appear that the passage of trains, at the speeds observed, imparts a measurable strain or vibration in the pipeline."

Soil Inspection Report
On May 25, the day of a pipeline rupture, Calnev contracted with Converse Consultants, a geo-technical and environmental consulting organization, to perform work in the area of the pipeline rupture. As stated in its August 30, 1989, report of findings (appendix N), Converse Consultants' investigation "...was performed to evaluate the subsurface conditions in the vicinity of the pipeline rupture in order to locate areas where the soils may have been disturbed by excavating equipment. It is our understanding that excavating equipment may have been utilized in the vicinity of the pipe rupture during Calnev post derailment pipe inspection and/or during clean-up of the derailment debris." A total of 14 tests were conducted; tests 1 through 4 (figure 16) were performed within the area of the rupture, and tests 5 through 14 were conducted in an area ("control area") where Converse Consultants believed there had been no excavation or disturbance of the soil. According to Converse Consultants' report, tests of samples taken at locations 1 through 4 indicated "...disturbed or poorly compacted earth materials...and contained significant quantities of the mineral trona." Tests of samples taken at locations 5 through 14 indicated that the earth materials had not been recently disturbed. The tests indicated no presence of the material trona at these locations. A representative from Converse Consultants testified, "...my interpretation and conclusion is that the materials, backfill materials, which prior to the derailment would have been just clean, natural soils without the presence of trona, had become contaminated with trona by means of excavation and replacement, probably as backfill or certainly as materials that had been exposed to trona and mixed, by whatever means."

Metallurgical Testing
Two 14-inch outside diameter (OD) pipe sections, one measuring 44 inches long and containing a rupture and one about 41 inches long, were taken to the Safety Board's materials laboratory in Washington, D.C., for examination. The two sections of pipe had been adjacent to each other before they were cut apart. As received in the Board's laboratory, the pipe contained directional arrows and a marking along the top of the section to indicate the orientation of the pipe in the ground before removal. Arrows "N" and "S" denoted the north and south directions, respectively (figure 17). A longitudinal marking across the sections at the transverse cut signified the top of the pipe and the matching rotational positions of the two sections relative to each other. Yellow grid line markings had been made on the OD surface around the rupture area. Subsequent notes supplied by Failure Analysis Associates (the metallurgical consultants contracted by the SP to examine the pipe) indicated that the markings denoted positions where thickness measurements had been made on the pipe. Arrow "x" in figure 18 indicates a location where the wall thickness measured the thinnest at about 0.249 inch, which was confirmed by micrometer measurements in the Safety Board's laboratory. Wall thicknesses of 0.254 inch were also found in the origin area of the fracture. The wall thickness away from the fracture measured about 0.312 inches.

The northern section of pipe contained a gaping rupture on the east side of the pipe (bracket "o" in figure 18). As shown in figure 19, the fracture faces were gaped apart and the pipe was deformed outward.

Examination of the OD surface of the pipe sections disclosed what appeared to be mechanical damage in the form of depressions or scrapes which, for the most part, were linear. The most severe damage was on the northern section of pipe and in line with the origin of the rupture. Unmarked arrows in figure 18 outline the damage, which was readily visible. This damage produced a visible depression in the pipe OD surface with a matching bulge on the inside diameter (ID) surface. The maximum depth of the depression was estimated to be about 0.18 inch from the original OD shape. The width of the damage was about 2 inches at its maximum point.

Arrows in figure 20 outline mechanical damage to the OD surface on the southern section of pipe. This section contained two pronounced areas of elongated damage, the centers of which were 2 to 3 inches apart. Neither of these areas showed appreciable denting into the OD surface.

Visual examination of the fracture surface of the rupture disclosed no evidence of progressive cracking. All fracture features were typical of an overstress separation. A pie-shaped section containing the origin area of the rupture was excised from the pipe and further sectioned to a specimen size suitable for examination with the aid of a scanning electron microscope (SEM). SEM examination disclosed dimple rupture features throughout the fracture area that were typical of a ductile overstress separation. There was no evidence of crack arrest markings or oxidation areas that would indicate a progressive separation.

Many parallel microfissures were noted on the outside diameter in the origin area near the fracture plane. Most of these microfissures were extremely small and shallow and, for the most part, detectable only by higher magnification. However, some microfissures were readily visible with the unaided eye. SEM examination of the fractures within these larger microfissures disclosed features also representative of an overstress separation.

To better characterize the mechanical damage to the OD surface, several metallographic sections were prepared that were oriented both transversely and in line (along the length) with the linear depression. Arrows "B" and "C" in figure 18 indicate the general area where these sections were prepared. The sections were etched and examined along the OD surface for evidence of grain distortion. Except for sporadic highly isolated areas, there was no evidence of grain distortion that would signify a direction of deformation. A few very small areas were noted along the OD surface that were indicative of particles impacting the OD surface radially inward with a slight sliding movement. There was no evidence of grain distortion that would indicate a massive movement of the material in the depression.

A section of pipe located south of the rupture and which contained two areas of surface damage&mdash;one near the top centerline and one on the west side&mdash;was sent to the Southwest Research Institute for metallurgical examination. The principal objectives of the examination were to inspect for the presence of cracks and to identify the direction of surface deformation in the two damaged areas on the sample. A summary of the results follows:


 * 1) No evidence of any surface cracking was observed on the outside surface of either sample.
 * 2) No significant wall thinning had occurred in either of the scraped areas. The minimum wall thickness measured at the point of most severe damage 0.313 inch, while the undamaged wall thickness was 0.317 inch.
 * 3) The pipe had been locally dented inward approximately 0.1 inch at the damaged area near the top centerline (southernmost damage area).
 * 4) SEM and EDS analyses of the surfaces did not detect any tool-to-pipe metal transfer.
 * 5) Metallographic sectioning positively identified the direction of surface deformation in both areas of damage.
 * a. Damage near top centerline
 * The direction of surface deformation was established to be in a mainly southerly direction.
 * b. Damage near 270 degree position (west side)
 * The direction of damage was established to be in a downward and southerly direction. This direction is consistent with the nature of the coating damage.

Simulation of Excavating Equipment Operations
On January 6, 1990, in accordance with a test plan agreed to by all parties, Calnev conducted a series of field tests to determine the amount of damage that three pieces of excavating equipment could inflict on a 14-inch pipeline. These three pieces of equipment that worked in the vicinity of the pipeline between May 12 and 19, 1989, following the removal of the train cars and locomotives, were a Case 580C rubber tire backhoe, a John Deere 690 track excavator, and a Caterpillar 988B front-end loader.

Two 80-foot lengths of pipeline that had to be removed from the accident site were filled with water and pressurized to 800 psig and buried without anchors to about minimal burial conditions (one was buried to a 4-foot depth and the other to a 1 1/2-foot depth) that might have been encountered in the area of the train derailment during cleanup operations. The backhoe and the excavator were owned and operated by the Arizona Pipeline Company, and the front-end loader was owned and operated by Jimco Construction Equipment Company, working on behalf of SP. In addition to Safety Board personnel, representatives from Calnev, the Southern Pacific Transportation Company, the California State Fire Marshal's office, IT Corporation, and the Office of Pipeline Safety were present for these field tests.

The teeth on the 2-foot-wide bucket of the Case 580C backhoe penetrated the pipeline coating but could not substantially dent the pipe wall in any of the tests. Running the teeth of the bucket along the top of the pipeline resulted in shallow "chatter" type scratches in the pipe wall. The bucket of the backhoe, with teeth down, was pulled across the top of the pipeline at various angles; pulling the bucket across at an angle of 45 degrees resulted in the greatest penetration to the pipeline coating and the pipe wall with all five teeth of the bucket. Dropping the bucket from a 6-foot height and a 2-foot height and hitting the pipeline with the back of the bucket did not result in any dents to the pipe wall. Because the hydraulics of the equipment slowed the bucket speed when dropped from the 6-foot height, the damage to the coating was less than the damage that occurred when the bucket was dropped from the 2-foot height. The teeth of the bucket did not penetrate or dent the pipe wall when dropped onto the pipeline.

Running the teeth on the bucket of the John Deere 690B excavator along the top of the pipeline resulted in chatter type marks in the pipe wall similar to those made by the Case 580C backhoe. Scraping the side of the pipeline with the side of the bucket resulted in damage to the pipeline coating but no dents in the pipe. Two hits on the pipeline with the back of a loaded bucket created a dent about 1/16-inch deep in the top of the pipe.

During the first test on the second piece of buried pipeline using the Caterpillar 988B front-end loader, the operator dug into the soil covering the pipeline and then dragged the back of the bucket over the top of the pipeline. The operator stated that he did not feel the equipment hit the pipeline, and there was no noise at ground level of the equipment striking the pipeline. After the pipeline was uncovered by hand at this location, observers saw that two marks physically disturbed the metal, about 2 feet apart, on the top of the pipeline. Also, coating damage was observed. A second attempt to drag the back of the bucket over the top of the pipeline resulted in distinctive marks, 18 inches apart, to the coating and the pipe wall. During this second attempt, the operator felt the equipment hit the pipeline, and the noise of the equipment striking the pipeline was clearly heard at ground level. When the side of the bucket was forcefully scraped along the side of the pipeline in a forward motion, damage to the pipe coating was extensive. Where the coating damage ended, a tooth of the bucket struck the lower quadrant of the pipeline creating a deep dent. This action also caused the unanchored pipeline to move 4 inches in a longitudinal direction. When the side of the bucket was scraped along the side of the pipeline a second time over a 5-foot length of the pipeline, a 4-inch-wide area of coating was removed along the entire length. When the back of the bucket of the front-end loader was dragged over the top of the pipeline a third time, two marks, 5 inches apart, were observed along the top quadrant of the pipeline. There was no visible denting of the pipe at these locations.

Train Movements Following the Train Derailment and Preceding the Pipeline Rupture
Between the time the SP opened its rail line for traffic at 4:00 p.m. on May 16, 1989, and the time of the pipeline rupture on May 25, 1989, 34 trains and 1 light engine were operated eastbound, and 39 trains and 1 light engine were operated westbound.

Agreement Between the Southern Pacific and City of San Bernardino Following the Train Derailment
An agreement between the Southern Pacific and the City of San Bernardino relative to the train derailment of May 12, 1989, was presented at the Safety Board's public hearing in August 1989 (appendix O). In addition to outlining the obligations of the railroad with respect to the property destroyed or damaged as a result of the train derailment, the agreement provided that Southern Pacific, rather than the City, would be responsible for any reimbursement claims by Calnev. The agreement further stated:


 * It is further hereby acknowledged and agreed by the parties that a Cal-Neva gas line runs adjacent to the location of the derailment; that the health, safety and welfare of the persons in the vicinity of the derailment requires that such line be fully exposed to allow visual and other examination to the satisfaction of the City Fire Department. As between City and Railroad, Railroad shall bear all costs incurred thereby and for replacement of the line. Railroad's obligation to Cal-Neva shall be determined by the contract between Cal-Neva and Railroad, if any.


 * This agreement may be amended only in writing by and between the parties hereto.

The agreement was signed on May 17, 1989, by the general manager of SP's Western Region and the City Attorney for San Bernardino.

The deputy fire chief (incident commander), who stated that he had expressed the desire to Calnev's manager of operations during the immediate days following the train derailment that the pipeline be fully exposed and inspected, testified that he was not made aware of the provision of the agreement until June 21, 1989. According to his testimony, it was his understanding that he did not have the authority to require Calnev to expose and inspect the pipeline and that only the State Fire Marshal's Office through the Office of Pipeline Safety had that authority. The deputy fire chief stated that he did not make his desire known to the State Fire Marshal's Office. The deputy fire chief terminated his command of the emergency response to the train derailment on May 15, 1989.

The general manager of SP's Western Region testified that when he signed the agreement, it was his belief that the inspection outlined in the agreement had been performed. Calnev's manager of operations testified that he was not aware of any agreement between the City and SP regarding the exposure and inspection of the pipeline and that there had been no contract between Calnev and SP. He testified also that, based on his understanding of the right-of-way agreement between SP and Calnev, SP could have requested Calnev to expose and inspect the pipeline. Testimony from the SP's general manager indicates that a request to fully expose and inspect the pipeline was never made to Calnev.

Development of Land Adjacent to the SP Railroad and the Calnev Pipeline
The area affected by the May 12 derailment and the May 25 pipeline rupture was planned in 1955 for residential use, and the subdivision plat was recorded with San Bernardino County on November 10, 1955. On October 1, 1957, the subdivision was annexed by the City of San Bernardino and incorporated within the city limits. In 1967, the SP constructed the portion of its railroad where the train derailment occurred, and at that time, no houses were located on Duffy Street.

By October 1967, houses had been constructed within the eastern portion of the subdivision, but no houses were on either side of that portion of Duffy Street that paralleled the proposed railroad. In 1969 and 1970, when the Calnev pipeline was constructed along the eastern edge of the SP right-of-way, no houses had yet been erected on that portion of Duffy Street that paralleled the railroad; only a few houses had been built within the subdivision. According to recollections of long-term residents, intensive construction within the area occurred from 1970 to 1970.

The City of San Bernardino's General Plan for land use is a policy document that establishes goals, objectives, and policies for the future. The specific standards for a development are to be guided by this Plan and included in the zoning ordinances or development codes. The subject of land use control because of its proximity to railroad mainline tracks or to high pressure liquid or other pipelines is not specifically addressed.

Before these accidents, the City had developed a proposed revision to its Plan, subsequently conducted public hearings on the proposal, and approved a revised plan. A statement within the proposal advised that, in part, this plan is a foundation policy document that defines the framework for decisions by the City on the use of its land for the protection of residents from natural and human-caused hazards. Neither the proposal nor the newly adopted plan specifically addressed the use of land near mainline railroads or high pressure pipelines.

Disaster Preparedness
San Bernardino County, about 20,000 square miles in size, is located in the southeastern portion of California. Within the county are 20 incorporated cities with the heaviest concentration of population in the west-central portion. The county's population is more than 1 million.

The County of San Bernardino, the district fire agencies, and the municipal fire departments are signatories to the State of California's Master Mutual Aid Plan to combat emergency situations that may develop and that are beyond the control of any one agency. In addition, many of the agencies have developed local mutual aid and automatic aid agreements. To maximize the resources within the County and to assist in the coordination of such resources, a Mutual Aid System was developed that divides the County into 10 zones. The SP train derailment occurred in what is designated in the Mutual Aid Plan as Zone 2.

Zone 2, or the "East Valley" area is served by eight agencies in the east end of the San Bernardino Valley (figure 21). Resources of the agencies in Zone 2 include: 83 fire response vehicles, 28 specialty units and squads, and 6 pieces of specialized equipment. Within Zone 2 are 526 full-time firefighters and 25 reserve firefighters.

The San Bernardino County Communications Center located in Rialto servers as the Zone 2 Emergency Communications Center. The Communications Center is responsible for emergency dispatch functions for the San Bernardino County Fire Agency-Central Valley District and the Rialto and Loma Linda Fire Departments. Separate dispatch centers are maintained by the fire departments of the City of San Bernardino and Norton Air Force Base, and by the County Fire Warden.

Train Derailments over Pipelines
The California State Fire Marshal's Office has maintained records on pipeline failures since it began regulating hazardous liquid pipelines in 1984. On March 9, 1989, a butane car derailed at the Tosco Refinery in Martinez, California, and struck and ruptured an above-ground pipeline. No injuries, fire, or explosion resulted from the accident. In another recorded incident at Montclair, California, on December 19, 1988, an axle from a "rail car truck" had made a small hole in the 20-inch-diameter pipeline of the Southern Pacific Pipe Line Company; the pipeline ran parallel to the railroad tracks.

On June 27, 1989, a locomotive was being used to switch the order of rail cars at a Union Pacific Railroad yard at Las Vegas, Nevada. About 8:30 a.m., Pacific daylight time, 34 rail cars were being moved when the leading 9 cars and the trailing 12 cars derailed with several rail cars overturning on top of two Calnev petroleum products pipelines. The 6-inch pipeline located on one side of the rail line contained jet fuel, and the 8-inch pipeline on the opposite site of the rail line contained gasoline. Both pipelines were under about 600 psig pressure and both were buried 4 to 5 feet below the ground surface.

Pipeline inspection personnel from both the Nevada Public Service Commission and the Office of Pipeline Safety responded to the Las Vegas accident to monitor the removal of rail cars, to require inspection of both pipelines to determine if the pipelines had been damaged, and to determine if they were safe to return to service. The Office of Pipeline Safety required Calnev to fully uncover and visually inspect the pipelines for possible damage and then required Calnev to hydrostatically test the pipelines through the area of the derailment. The Office of Pipeline Safety advised the Safety Board that it had established as a policy that pipelines potentially damaged by a derailment would be both visually examined and subjected to a hydrostatic test before they could be returned to service, if OPS believes there is potential for harm to life or property.

The Safety Board requested that the Santa Fe Pacific Pipelines Company (formerly the Southern Pacific Pipelines Company) provide records of any derailments over pipelines and their results. Santa Fe advised that 55 percent of its 3,300-mile pipeline system was installed along railroad rights-of-way and that between 1966 and 1989, 121 train derailments had occurred over its pipeline. The Santa Fe has never experienced any damage as a result of a train derailment where the pipe was buried 3 feet or more below ground. However, it did experience damage to its pipeline during the derailment clearing operations for the Montclair accident.

On June 20, 1989, the California Senate Committee on Toxics and Public Safety Management and the California Assembly Select Committee on Hazardous Materials and Pipeline Safety held a joint public hearing on the San Bernardino accidents. As a result of that hearing, Assembly Bill No. 385 was passed and signed into law. The bill calls for the California State Fire Marshal to conduct and prepare a risk assessment study addressing hazardous liquid pipelines within 500 feet of a railroad track. The study is to be completed by January 1, 1991.