near Nodaway, Iowa
March 17, 2001
NTSB Number: RAB-02-01
Adopted March 5, 2002
On March 17, 2001, about 11:40 p.m. central standard time, westbound Amtrak train No. 5-17, the California Zephyr, derailed near Nodaway, Iowa. Amtrak train No. 5-17 consisted of 2 locomotive units and 16 cars. All but the last five cars derailed. No fire or hazardous materials were involved in the accident. The train crew consisted of an engineer and 2 conductors with 13 on-board service personnel. In addition, 241 passengers were on the train. As a result of the derailment, 78 people were injured, including 1 fatal injury.
Amtrak train No. 5-17 had been operating over class 4 track belonging to the Burlington Northern and Santa Fe Railway (BNSF) Creston Subdivision at the time of the derailment. A broken rail was discovered at the point of derailment.
The train had originated at Chicago, Illinois, at 3:35 p.m. on March 17, 2001, (30 minutes late) and was destined for Oakland, California. The train crew had boarded at Chicago. The engineer on duty when the accident occurred had relieved the original engineer at Ottumwa, Iowa, milepost (MP) 280, about 9:00 p.m.
As the train progressed on its assigned route, the engineer found that the horn/whistle on the lead locomotive failed near Murray, Iowa, MP 370, around 10:21 p.m. He advised the dispatcher for the district of the problem and discussed the failure with the conductor. They decided that the conductor would ride in the second locomotive and activate the horn/whistle on the second locomotive when the train approached and passed through grade crossings. They used this procedure until, at Corning, Iowa, MP 414, the train entered a different train dispatcher's district. The new train dispatcher, upon learning of the malfunctioning horn/whistle, instructed the crew to reduce the speed of the train at the grade crossings rather than use the horn/whistle on the second unit. The conductor of train No. 5-17 came forward and rode in the lead locomotive with the engineer to assist him in observing the crossings. The engineer stated (and event recorder information confirmed) that he began reducing the train's speed at grade crossings. At MP 418.94, the train speed had been 16 mph while passing through a grade crossing. The engineer was accelerating the train during the approach to the accident site (MP 419.92). The event recorder indicated that, at MP 419.90, the train was traveling at 52 mph.
The engineer stated that near MP 419.90, he felt a "tugging" sensation in connection with the train's progress and heard a "grinding, screeching noise," so he made an emergency brake application about 11:40 p.m. When the locomotives came to a stop, the engineer and conductor looked back and realized that the train's cars had uncoupled from the locomotives, and most cars had derailed. The cars were about 1/8 mile behind the stopped locomotives. The engineer radioed the dispatcher and asked him to contact emergency responders. The conductor walked back and surveyed the damage. After reaching the cars, the conductor radioed the engineer and said, "...the wreck look[s] real bad." The conductor found the assistant conductor, and they cared for the passengers. Soon thereafter, local emergency medical service personnel began to arrive and immediately started to evacuate the injured from the train. The emergency response effort was completed by 4:00 a.m., March 18.
A broken rail was discovered at the point of derailment. The broken pieces of rail were reassembled at the scene, and it was determined that they came from a 15-foot, 6-inch section of rail that had been installed as replacement rail at this location in February 2001. The replacement had been made because, during a routine scan of the existing rail on February 13, 2001, the BNSF discovered internal defects near MP 419.92. A short section of the continuous welded rail that contained the defects was removed, and a piece of replacement rail was inserted. This rail, referred to as a "plug," was used to replace the defective rail segment. The plug rail did not receive an ultrasonic inspection before or after installation. It would have been visually inspected for obvious surface damage, defects, and excessive wear before installation.
The Safety Board could not reliably determine the source of the plug rail. Two different accounts were given concerning its origin. The local supervisor said the rail came from his inventory of rail and had been in the inventory for several years. Another engineering manager thought that the rail had come from a rail rehabilitation facility in Springfield, Missouri. In either case, the replacement rail would have been rail removed from another track location for reuse.
Portions of the broken plug rail were sent to the National Transportation Safety Board laboratory for further analysis. The analysis indicated that the rail had multiple internal defects. Specifically, the laboratory found that the rail failed due to fatigue initiating from cracks associated with the precipitation of internal hydrogen. Cracks associated with the precipitation of internal hydrogen occur in steels due to excessive hydrogen content produced during processing.
The National Transportation Safety Board determines that the probable cause of the derailment of Amtrak train No. 5-17 was the failure of the rail beneath the train, due to undetected internal defects. Contributing to the accident was the Burlington Northern and Santa Fe Railway's lack of a comprehensive method for ensuring that replacement rail is free from internal defects.
As a result of its investigation of the Nodaway, Iowa, railroad accident, the National Transportation Safety Board makes the following safety recommendations:
To the Federal Railroad Administration:
Require railroads to conduct ultrasonic or other appropriate inspections to ensure that rail used to replace defective segments of existing rail is free from internal defects. (R-02-5)
To Class I and Passenger Railroads (except the Burlington Northern and Santa Fe Railway):
Conduct ultrasonic or other appropriate inspections on all rail used to replace defective segments of existing rail to ensure that the replacement rail is free from internal defects. (R-02-6)
To the Burlington Northern Santa Fe Corporation:
Implement a permanent policy of inspecting for internal defects, using ultrasonic or other appropriate means, any rail used to replace a defective segment of existing rail. (R-02-7)