Railroad Accident Brief
Derailment of Amtrak Passenger Train No. 27
Home Valley, Washington
April 3, 2005

NTSB/RAB-06/03
PDF Document [1.7 MB]

Accident No.:	DCA-05-FR-010
Location:	Home Valley, Washington
Date:	April 3, 2005
Time:	9:35 a.m., Pacific daylight time 1
Railroad:	BNSF Railway Company
Property Damage:	$854,000
Injuries:	30
Fatalities:	None
Type of Accident:	Amtrak passenger train derailment

The Accident

On April 3, 2005, about 9:35 a.m., westbound Amtrak (National Railroad Passenger Corporation) passenger train No. 27, consisting of a single locomotive unit and four passenger cars, derailed at milepost (MP) 58.56 2 on the BNSF Railway Company’s (BNSF’s) Northwest Division. The train was traveling 60 mph on single main line track when it derailed as it was traveling through a cut section of the Columbia River Gorge on the north side of the Columbia River near Home Valley, Washington. The train remained upright; however, the cars came to rest leaning up to approximately 35° against the outside curved embankment. (See figure 1.) There were 106 passengers and 9 Amtrak employees on board. Thirty people (22 passengers and 8 employees) sustained minor injuries; 14 of those people were taken to local hospitals. Two of the injured passengers were kept overnight for further observation; the rest were released. Track and equipment damages, in addition to clearing costs associated with the accident, totaled about $854,000.

The derailment occurred during daylight hours. The weather was cloudy with mist and intermittent rain. The temperature was about 45° F with 8 mph southeast winds.

On the day of the accident, westbound Amtrak passenger train No. 27 was scheduled to travel from Pasco, Washington, to Portland, Oregon, a distance of about 232 miles. The engineer performed a running air brake test at 6:35 a.m. before departing Pasco. The engineer noted nothing remarkable during the test.

Figure 1. Derailment site.

There were three crewmembers on Amtrak passenger train No. 27—an engineer, a conductor, and an assistant conductor—and all three stated that the trip was uneventful as the train approached the accident area. The engineer was operating the train on a clear signal indication at a recorded speed of 60 mph. A hot box/dragging equipment detector 3 was also located near the wayside signal, and no train defects were recorded or transmitted by radio to the train crewmembers. As the train approached the accident site, the engineer was seated at the controls on the right (north) side of the locomotive. The conductor and assistant conductor were riding in the coach cars. The conductor was attending to paperwork, and the assistant conductor was monitoring the train radio transmissions.

The Amtrak train traversed about 1 1/4 miles of straight (tangent) track before it entered a 3° left-hand curve and derailed. (See figure 2.) The engineer stated that he first became aware of the derailment when an emergency brake application occurred that he had not initiated. The conductors and passengers stated that they became aware of the derailment when they were thrown around and jostled in the coach cars, followed by clouds of dirt and debris entering the cars.

Figure 2. Sketch of accident site.

Rough Track Reports

During the 12 days prior to the accident, four separate “rough riding” reports were made regarding the area where the train later derailed. As further discussed below, the first report was not followed by an inspection, but followup inspections were conducted in response to the subsequent three reports. Only one of the three followup inspections was conducted by the BNSF track inspector regularly assigned to the track area 4 where the accident occurred. The other two inspections were conducted by a substitute BNSF track inspector normally assigned to an adjacent track territory. 5

The first report of rough track was submitted on March 23, 2005, by a Federal Railroad Administration (FRA) inspector who was riding in the locomotive of Amtrak passenger train No. 27 as it traveled from Pasco to Vancouver, Washington, when he noted two locations in the curve at MP 58.4 causing lateral movement. He e-mailed an FRA inspection report to the BNSF roadmaster 6 in charge of track maintenance for that area. The roadmaster did not inform the track inspectors about the FRA report, nor did he order a followup inspection before the accident. 7

On March 28, an Amtrak train crew reported to the BNSF train dispatcher that their train rode rough through the area of MP 58.7. Because the track inspector regularly assigned to this area was not available, a substitute BNSF track inspector was dispatched to evaluate the rough track and take appropriate remedial action as required. 8 The inspector walked the track from about MP 58.9 to MP 58.7, found no improper track conditions, and no further action was taken.

Two days later, on March 30, another Amtrak train crew reported to the BNSF train dispatcher that their train rode rough through the area of MP 58.7. The BNSF track inspector regularly assigned to that track territory was subsequently dispatched to evaluate the rough track. The inspector walked the track between MP 58.6 and MP 58.8. He also walked the track between curves No. 58A and No. 58B, which was about 1/4 mile from the area where the accident train later derailed. He identified some low spots in an area near a bridge approach at MP 58.8, about 1,270 feet east of the derailment. He raised and concurrently tamped the crossties.

On April 1, 2 days before the accident, a BNSF train crew reported to the BNSF train dispatcher that their train rode rough through the area of MP 58.7. The same substitute track inspector who had inspected the track on March 28 was again dispatched to evaluate the rough track. The track inspector identified some concrete crosstie abrasion 9 in an area at MP 58.6, about 211 feet east of the derailment. He reported the condition to the BNSF roadmaster. However, no remedial action was taken.

Description of Track

The track where the accident occurred was designated as FRA Class 4, with maximum allowable operating speeds of 60 mph for freight trains and 80 mph for passenger trains. However, because of geographical characteristics and track curvatures, the maximum allowable operating speeds through the derailment area were 55 mph for freight trains and 60 mph for passenger trains.

Approaching the derailment site from the east, there is about 1 1/4 miles of straight track that leads to a series of curves. The first curve, where the derailment occurred, curve No. 58B, is a left-hand 3° curve that is about 1,500 feet long with 4 1/2 inches of superelevation. It is followed by about 500 feet of straight track and then curve No. 58A, a right-hand 3° curve, which is about 1,800 feet long. The track grade through this area is essentially level. This segment of track follows the north bank of the Columbia River.

The track structure was built with 136-pound sections of continuous welded rail (CWR) 10 on concrete crossties. The CWR was affixed to the crossties with “Safelok” clips and insulators. A special concrete tie pad separated the CWR from the concrete crosstie rail seat. (See figure 3.) The concrete tie pad consists of a three-piece pad system. The polyethylene gasket pad is about 1.5 millimeters (mm) thick, and it is placed on the seat of the concrete crosstie underneath a layer of 1.4-mm thick steel and a 6.0-mm heavy-duty plastic pad beneath the base of the rail.

The track structure was supported on cut granite 2-inch stone ballast with an approximate depth of 28 inches under the concrete crossties. The concrete crossties were installed in 1990. Crossties were spaced about 24 inches apart on center, or about 19 crossties per 39-foot rail length. The outside curve rail was replaced in 1996.

Figure 3. Three-piece tie pad system.

Preaccident Track Inspections

Title 49 Code of Federal Regulations (CFR) 213.233 requires that Class 4 track be inspected twice weekly with at least 1 calendar day between inspections. According to BNSF policy, inspectors are also responsible for repairing identified defects that they can handle alone. The BNSF track inspector responsible for the area where the accident occurred inspected the track three times per week: Monday, Wednesday, and Friday. During inspections, he also applied rail lubricant 11 to the outside curve rails on Monday and Friday and to the inside curve rails on Wednesday. For about a month prior to the accident, the track inspector had been working by himself because his helper had been reassigned.

The track was inspected by the BNSF track geometry car 12 on May 25, 2004, and again on September 23, 2004. During both inspections, the area of curve No. 58B was flagged yellow 13 as a maintenance area for gage. 14 According to the track inspector, the roadmaster did not give him a copy of the September geometry car values until December 2004. Both the regular inspector and the substitute inspector from the adjacent territory indicated that they had received little, if any, training on concrete crosstie inspection. Both inspectors spoke of being “self-taught,” and neither inspector indicated that he had received any training about how to read reports generated by the track geometry car.

Prior to the accident, the BNSF had minimal concrete crosstie inspection criteria. In addition, there are no Federal standards specific to concrete crossties in the “Track Safety Standards” for Classes of Track 1 through 5 15 that are similar to those standards for Classes of Track 6 and higher (used for higher speed operations). 16

The regular track inspector for the area where the derailment occurred stated that his territory included both concrete and wood crossties. The concrete crossties were predominately in the curved track segments. Safety Board investigators asked the track inspector what he did when he observed concrete crosstie abrasion. He said that crosstie abrasion was not considered a track defect in the FRA sense, but if it was a “worse spot,” 17 he would unclip the rail and make an epoxy repair. He indicated that concrete tie abrasion was not a priority item during his track inspections. He also stated that he was not aware of a concrete crosstie abrasion problem in the area of the derailment.

Because of the high amount of train traffic (approximately 57 trains a day over the 58 miles of the inspector’s assigned territory), the track inspector said that he had about 1/2 hour or less to get from station to station while inspecting track from a hi-rail vehicle. 18 Stations were about 10 to 15 miles apart. He stated that his track inspection speed varied from 20 to 25 mph. The track inspector stated that on occasion he conducted a walking inspection of the curves but that it had become too difficult after he lost his helper. The BNSF procedures did not require that curves be visually inspected via a walking inspection. Further, the BNSF electronic inspection form did not provide a data field for the track inspector to indicate how he inspected curves. Therefore, there was no record of which curves had been inspected while walking versus from the hi-rail vehicle.

The extent of concrete crosstie rail seat abrasion affects the rail’s resistance to rollover. Resistance cannot be ascertained by visual inspections alone. Currently, the best way to reliably measure rollover resistance is through the use of a gage restraint measurement system (GRMS) vehicle 19 in conjunction with the use of a light load fixture. 20 The BNSF did not use its GRMS vehicle over the Fallbridge Subdivision, so rail rollover resistance was not determined.

Rail/Crosstie Interaction and Abrasion

Concrete crossties are primarily used in freight rail systems where wood has failed and in areas where high traffic density and high tonnage trains are typical. Although concrete crossties are much stronger than wood, a potential problem with concrete crossties is the rail seat abrasion that occurs under the tie pads that are placed between the rail and the crossties. In the rail pad contact areas, the cement surface of the tie is abraded by repeated flexing of the rail under load, aided by the presence of moisture and gritting agents. The partially exposed stones aggregate and deteriorate the rail seat area under the pad, thereby reducing the toeloads exerted by the spring clip fasteners. As abrasion of the rail seat increases in depth, the rail head can rotate outward and allow the gage to widen under train traffic. Once the pad area starts to deteriorate, the concrete abrasion process accelerates rapidly, and rail cant 21 is compromised. In the curve where the accident occurred, the outer rail base corner (field side) tended to rotate outward and dig into the crossties. Maintaining rail cant lessens rail rollover tendencies. A rail cant (slope) of 1:40 is used by the BNSF on its concrete crossties and is cast into the rail seat. 22