Railroad Accident Report - Derailment of Burlington Northern and Santa Fe Railway Company Intermodal Freight Train S-CHILAC1-31

Crisfield, Kansas
September 2, 1998

NTSB Number: RAR-00-01
NTIS Number: PB2000-916301
Adopted July 11, 2000
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Executive Summary

About 6:10 a.m., central daylight time, on September 2, 1998, the 17th through 19th cars and the first two platforms of the five-platform 20th car of westbound Burlington Northern and Santa Fe Railway Company intermodal freight train S-CHILAC1-31 derailed at Crisfield, Kansas. The accident occurred when the 18th car from the locomotive, DTTX 72318, an articulated, five-platform, 125-ton double-stack car, experienced a separation between the floor shear plate and bulkhead bottom angle at the leading end of the car's B platform. The separation allowed the car to sag below the rails, catch a part of a switch, and derail.

The train was traveling 68 mph through the east siding switch at Crisfield, milepost 291.7, on the Panhandle Subdivision of the railroad's Amarillo Division, when it began to derail. The train then went into emergency braking and stopped after traveling about 1/2 mile. The derailment resulted in a pileup involving four articulated multiplatform cars carrying intermodal shipping containers. Some of the containers were breached, resulting in the release of hazardous materials and fires. About 200 people were evacuated within a 5-mile radius. No injuries resulted from either the derailment or the hazardous materials releases. Estimated damage was $1.3 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the structural failure of intermodal car DTTX 72318 due to fatigue cracking initiated when a container was misloaded onto a foreign object. The misloading of the container occurred because of the railroad industry's inadequate preloading inspection procedures for double-stack well cars. Contributing to the accident was the improper and undocumented repair of the car.

The safety issues addressed in the report include:

  • Adequacy of the Association of American Railroads' and Federal Railroad Administration's intermodal container loading and securement standards for the preloading inspection of double-stack cars; and
  • Adequacy of railroad industry training and practices with respect to emphasizing the importance of removing foreign objects from the wells of double-stack cars before loading.

The report also discusses the industry's response to the structural failures experienced by Thrall Car Manufacturing Company's 125-ton double-stack cars, the Federal Railroad Administration's oversight of preloading inspections, the improper and undocumented repairs to DTTX 72318, the modification or redesign of double-stack cars, and the adequacy of emergency preparedness in Harper County, Kansas.

As a result of its investigation of this accident, the Safety Board makes recommendations to the Federal Railroad Administration, to the Class I railroads, and to the Association of American Railroads.

Recommendations

To the Federal Railroad Administration:

Audit the Association of American Railroads and individual railroad equipment repair databases to determine whether adequate quality control procedures have been incorporated to ensure that database information is complete, accurate, and secure. Direct the Association of American Railroads and the individual railroads to correct all identified deficiencies. (R-00-9)

Require that double-stack well car floors be inspected and that all foreign objects be removed before loading. (R-00-10)

Revise 49 Code of Federal Regulations Part 215 to include comprehensive safety inspection standards and procedures for all intermodal cars. (R-00-11)

To the Class I Railroads:

Require intermodal loading facilities to inspect double-stack well car floors before loading and remove any foreign objects. (R-00-12)

To the Association of American Railroads:

Revise training and instructional materials to emphasize the necessity of conducting a thorough preloading inspection of container cars while empty, particularly double-stack cars, to ensure the removal of foreign objects before loading. The training should also discuss the consequences of not conducting such inspections. (R-00-13)

Revise intermodal container loading and securement standards, including Standard Operating Procedures for Intermodal Securement, to emphasize the necessity of conducting a thorough preloading inspection of intermodal cars while empty, particularly double-stack cars, to ensure the removal of foreign objects before loading. (R-00-14)

Revise the Intermodal Securement Safety Audit Form to include, as a safety check item, the removal of all foreign objects from double-stack cars before loading. (R-00-15)

Revise the Internal and Inter-road Securement Failure Report to include, as a reportable failure, the misloading of a container onto a foreign object. (R-00-16)

Conduct a study to determine whether other double-stack cars similar in design to the Thrall 125-ton model are also susceptible to misloading and whether remedial actions would be appropriate. (R-00-17)