WASHINGTON — The National Transportation Safety Board on Tuesday blamed Southern Pacific Transportation Co. for a "series of management errors" that resulted in four deaths when a runaway freight train derailed in a West San Bernardino neighborhood.
The safety board also found that a pipeline explosion 13 days after the May, 1989, train wreck occurred because officials of Calnev Pipe Line Co. failed to uncover pipeline damage caused by earthmoving equipment used to clear away the train wreck. The two accidents killed six people, injured dozens of others and destroyed or damaged 29 homes in the working-class neighborhood.
"This isn't a human performance accident, it's a management accident," Jim Burnett, an NTSB board member, charged during a brief board debate over the culpability and precise cause of the back-to-back disasters.
Before the board reached unanimous agreement on the probable cause of the train accident, Chairman Jim Kolstadt and Vice Chairman Susan M. Coughlin attempted to persuade their two other colleagues, John K. Lauber and Burnett, to place a dose of responsibility for the accident on the train's engineers and conductor.
"You can't leave the crew out," Kolstadt said, his voice rising. "There were so many deficiencies in the operation (of the train) by this crew."
Added Coughlin: "I'm uncomfortable leaving the crew out of the picture."
Both Kolstadt and Coughlin based their arguments on evidence cited by William Pugh, the chief investigator and head of the NTSB's railroad division, who told the board that the train's crew could have stopped the train before proceeding down the 23-mile grade leading to the crash site.
However, Pugh said, head engineer Frank Holland, who suffered multiple injuries in the crash, was following company procedures and had not been trained in special emergency braking methods. In addition, the train's crew was unaware that only three of its six locomotives had functioning brakes.
And, compounding the string of mishaps leading to disaster, a Southern Pacific billing clerk failed to indicate the accurate tonnage of the cargo on the shipper's bill of lading. Instead of noting the correct weight of 9,000 tons, the clerk estimated that the train's 69 hopper cars full of trona--a sand-like, sodium bicarbonate material--weighed 6,150 tons.
The train's conductor, Everett Crown, and brakeman Alan R. Reiss were killed in the accident.
From the beginning, the safety board has focused its investigation on the weight of the train, which exceeded speeds of 105 m.p.h. before it rushed around a curve, left the tracks and slammed into a row of houses at the foot of the treacherous Cajon Pass.
Southern Pacific's operating rules "provided inadequate guidance" to Holland regarding the allowable speed and braking requirements, said Pugh.
"Other engineers probably had done the same thing . . . following SP's operating guidelines," he said. The difference this time was that the train carried more weight than the crew had been told or for which it could compensate in time to make a difference, he said.
"They were totally misinformed about something that was fundamental to the operation of the train," Lauber said. His argument persuaded the other board members to place the bulk of the responsibility for the wreck on the railroad managers and operating procedures.
As for the pipeline accident, the board agreed without debate that "Calnev's pipeline was mechanically dented and gouged at several locations by earthmoving equipment," resulting in a rupture that initially emitted gas fumes into the air and later ignited to produce a firestorm over the community.
They declined to say how the accident occurred or whose piece of equipment was directly responsible, noting that they could not be precise.
"Calnev's and Southern Pacific's surveillance of excavating equipment operations was insufficient to prevent damage to Calnev's pipeline," the board concluded.
Andrew Anderson, a vice president at Southern Pacific in San Francisco, said that while he had not yet read the NTSB's report, the company long ago accepted responsibility for the derailment and thus did not disagree with the safety board's primary conclusion.
"This was one of the worst train wrecks in our company's history . . . and we will pay close attention to the (NTSB's) recommendations," Anderson said. "We have already spent a good bit of time since (the derailment) trying to make sure it doesn't happen again."
Specifically, Anderson said, many of the recommendations included in the safety board's report had been implemented by the company or will be in the near future. These include modifications in engineers' emergency training, changes in the listing of cargo weights to improve accuracy, and regulations to improve communications among crew members.
A spokeswoman for GATX Terminals Corp., Chicago-based parent of Calnev Pipe Line Co., said there would be no immediate comment on the NTSB findings.
In addition to their specific comments on the twin accidents, the safety board faulted San Bernardino's land use planning for failing to address the hazards posed by allowing railroads and high-pressure gas pipelines in close proximity to residential communities.