Railroad Accident Report - Derailment of Amtrak Train 4, Southwest Chief, on the Burlington Northern Santa Fe Railway

Near Kingman, Arizona
August 9, 1997

NTSB Number: RAR-98-03
NTIS Number: PB98-910403
Adopted August 31, 1998
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Executive Summary

About 5:56 a.m., on August 9, 1997, National Railroad Passenger Corporation (Amtrak) train 4, the Southwest Chief, derailed on the Burlington Northern Santa Fe Railway tracks about 5 miles northeast of Kingman, Arizona. Amtrak train 4 was en route from Los Angeles, California, to Chicago, Illinois, and had just left the Kingman station. The train was traveling about 89 mph on the eastbound track when both the engineer and assistant engineer saw a "hump" in the track as they approached bridge 504.1S. They applied the train's emergency brakes. The train derailed as it crossed the bridge. Subsequent investigation revealed that the ground under the bridge's supporting structure had been washed away by a flash flood.

Of the 294 passengers and 18 Amtrak employees on the train, 173 passengers and 10 Amtrak employees were injured. No fatalities resulted from the accident. The damages were estimated to total approximately $7.2 million.

The National Transportation Safety Board determines that the probable cause of this accident was displacement of the track due to the erosion and scouring of the inadequately protected shallow foundations supporting bridge 504.1S during a severe flash flood because the Burlington Northern Santa Fe management had not provided adequate protection, either by inspection or altering train speeds to fit conditions. Contributing to the accident was the failure of the Burlington Northern Santa Fe management to adequately address the erosion problems at bridge 504.1S.

The major safety issues identified in this report are:

  • Safety of structures subject to damage in severe storms,
  • Passenger safety and emergency response procedures, and
  • Protection of employees on or adjacent to the track in the performance of their duties.

As a result of this accident investigation, the Safety Board makes recommendations to the Burlington Northern Santa Fe Corporation, the Federal Railroad Administration, the Federal Highway Administration, the Arizona Department of Transportation, the National Railroad Passenger Corporation (Amtrak), the Mohave County Sheriff's Department, the International Association of Chiefs of Police, the National Sheriffs' Association, the Association of American Railroads, and the American Short Line and Regional Railroad Association. Also, the Safety Board reiterates one safety recommendation to the Federal Railroad Administration.

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Burlington Northern Santa Fe Corporation:

Identify and perform a risk assessment of all system bridges that have shallow foundations of similar construction to the bridge that failed in the Kingman, Arizona, accident, and replace those bridges determined to be susceptible to undermining and loss of the supporting foundation structure. In conjunction with the risk assessment, perform a hydrology study on shallow foundation structures with questionable drainage areas to determine their current drainage areas. (R-98-48)

Evaluate, and improve as necessary, your basic bridge inspection training program for track inspectors to ensure that appropriate procedures are used in emergency situations. (R-98-49)

Require your management to periodically review bridge inspection training for track inspectors to ensure that it meets program objectives. (R-98-50)

Conduct a thorough analysis to determine the appropriate personnel, inspection, and operating policies to be used during flash flooding conditions, and establish procedures designed to ensure the safe passage of all trains. The analysis should address the minimum training requirements for personnel responding to emergency inspections and evaluate current inspection procedures and response actions to determine their adequacy during abnormal or emergency situations. (R-98-51)

Change your policy regarding freight train operating speeds so that it is consistent with the required operating speeds of other trains during flash flooding weather warnings, as noted in the August 1997 Burlington Northern Santa Fe Maintenance Alert. (R-98-52)

Immediately discontinue the use of informational line-ups. (R-98-53)

To the Federal Railroad Administration:

Require that all railroads identify and perform a one-time risk assessment of the bridges on their systems that have shallow foundations of similar construction to the bridge 504.1 that failed in the Kingman, Arizona, accident, and require replacement of those bridges determined to be susceptible to undermining and loss of the supporting foundation structure. (R-98-54)

Incorporate the intent of Safety Advisory 97-1 into minimum safety standards for special inspection procedures for bridges that would be at risk during severe weather. (R-98-55)

Include in the passenger car safety standards a requirement for positive seat securement systems to provide against the disengagement and undesired rotation of seats in all new passenger cars purchased after January 1, 2000, and require the incorporation of such a system into existing passenger cars when they are scheduled for overhaul. (R-98-56) Require that event recorder system specifications be kept as part of the locomotive's records. (R-98-57)

To the Federal Highway Administration:

Examine the "System Analysis Seligman Subdivision Bridge No.'s 503.1- 505.9" report and the Arizona Department of Transportation's historical bridge inspection data to determine the hydrologic relationship between the box culvert and bridge 504.1. If the examination determines that the structures have a detrimental hydrologic effect on each other, alert the States and the Federal Railroad Administration that similarly related structures may be vulnerable to similar problems. (H-98-41)

To the Arizona Department of Transportation:

Examine the "System Analysis Seligman Subdivision Bridge No.'s 503.1-505.9" report in light of your own historical bridge inspection information and take any action you deem appropriate. (H-98-42)

To the National Railroad Passenger Corporation (Amtrak):

Expedite the development and implementation of a passenger and crew accountability system on reserved trains. (R-98-58)

Implement effective controls to monitor and ensure that all train crews and on-board service personnel receive the necessary initial and recurrent emergency training to provide for passenger safety. (R-98-59)

Install, in all new passenger equipment purchased after January 1, 2000, and in existing passenger cars during their major overhaul/rebuild operations, fixtures that use a "self-contained back-up energy reserve feature" to make the fixtures less vulnerable to the disruption of electrical power during derailments. (R-98-60)

Install a positive seat securement system to prevent disengagement and undesired rotation in all new passenger cars purchased after January 1, 2000, and incorporate such a system into existing passenger cars when they are scheduled for overhaul. (R-98-61)

To the Mohave County Sheriff's Department (R-98-62):
To the International Association of Chiefs of Police (R-98-63):
To the National Sheriffs' Association (R-98-64):

Review the circumstances of the derailment accident that occurred at Kingman, Arizona, on August 9, 1997, with your dispatchers and emphasize the importance of relaying verified factual information when communicating with other agencies.

To the Association of American Railroads (R-98-65):
To the American Short Line and Regional Railroad Association (R-98-66):

Make your membership aware of the facts and circumstances of the derailment accident that occurred at Kingman, Arizona, on August 9, 1997.

Also as a result of its investigation of this accident, the National Transportation Safety Board reiterates the following safety recommendation:

To the Federal Railroad Administration:

R-97-17
Require all passenger cars to contain reliable emergency lighting fixtures that are each fitted with a self-contained independent power source and incorporate the requirements into minimum passenger safety standards.