Accident at South Sacramento, California
INTERSTATE COMMERCE COMMISION
WASHINGTON
REPORT NO. 3672
THE WESTERN PACIFIC RAILROAD COMPANY
IN RE ACCIDENT
AT SOUTH
SACRAMENTO, CALIF., ON
JANUARY 4, 1956
SUMMARY
Date: January 4, 1956
Railroad: Western Pacific
Location: South Sacramento, Calif.
Kind of accident: Collision
Equipment involved: Locomotive with cars : Locomotive unit
Locomotive numbers: Diesel-electric : Diesel-electric unit 502 unit
921-C
Consist: 3 cars :
Estimated speed: 5-10 m. p. h. : Undetermined
Operation: Operating rules
Track: Yard track; tangent; 0.30 percent descending grade eastward
Weather: Raining intermittently
Time: 6:40 p. m.
Casualties: 1 killed; 4 injured
Cause: Diesel-electric locomotive unit moving out of control as a
result of improper preparation of the unit for operation
INTERSTATE COMMERCE COMMISION
REPORT NO. 3672
IN THE MATTER OF MAKING ACCIDENT INVESTIGATION REPORTS UNDER THE
ACCIDENT REPORTS ACT OF MAY 6, 1910.
THE WESTERN PACIFIC RAILROAD COMPANY
February 17, 1956
Accident at South Sacramento, Calif., on January 4, 1956, caused by
a Diesel-electric locomotive unit moving out of control as a result
of improper preparation of the unit for operation.
REPORT OF THE COMMISION
Under authority of section 17 (2) of the Interstate Commerce Act the
above-entitled proceeding was referred by the Commission to
Commissioner Clarke for consideration and disposition.
CLARKE, Commissioner:
On January 4, 1956, there was a collision between a locomotive with
cars and a Diesel-electric locomotive unit moving out of control on
the Western Pacific Railroad at South Sacramento, Calif., which
resulted in the death of one train-service employee, and the injury
of three train-service employees and one mechanical department
employee. This accident was investigated in conjunction with
representatives of the Public Utilities Commission of California.
Location of Accident and Method of Operation
This accident occurred on that part of the Western Division
extending between Stockton Yard and Oroville, Calif., 113.1 miles.
In the vicinity of the point of accident this is a single-track
line, over which trains are operated by signal indications. At South
Sacramento, 44.5 miles east of Stockton Yard, two sidings and two
auxiliary tracks, which are used for the storage of cars and other
purposes, parallel the main track on the south. Extensive shop
facilities for the maintenance and repair of locomotives and cars
are located south of these auxiliary tracks and approximately 2.1
miles west of the station at Sacramento. These facilities are
designated as Sacramento Shops. A coach and paint shop, which is
served by seven stub end tracks, is located in the shop area 600
feet south of the main track and parallel to it. A load track in the
shop yard designated as track E-30 connects the east ends of the
tracks at the coach and paint shop and several adjacent shop tracks,
and extends eastward approximately 1,500 feet to a connection with
the auxiliary storage and switching tracks. A shop track designated
as track E-34, on which locomotive fueling facilities are provided,
is located immediately north of shop structures, which extend
parallel to the coach and paint shop on the north. This track is
approximately 950 feet long and converges with the lead track at a
switch, which is trailing-point for eastbound movements, located 860
feet east of the coach and paint shop building. The accident
occurred on track E-30 at a point 322 feet east of this switch. The
lead track is tangent throughout a distance of more than 600 feet
immediately west of the point of accident. Track E-34 is tangent
west of the turnout of the lead track switch. The grade for
eastbound movements on the lead track varies between 0.30 percent
ascending and 0.50 percent descending, and it is 0.30 percent
descending at the point of accident.
This carrier’s operating rules read in part as follows:
DEFINITIONS
Yard Speed: A speed, according to conditions, prepared to stop
within one-half the range of vision and short of *** cars, misplaced
switch *** or other obstruction***
105. Unless otherwise provided, trains and engines using siding or
other inside track not protected by signals must proceed at yard
speed. ***
The general and safety rules of the mechanical department of the
carrier read in part as follows:
B. Employees must have proper understanding and working knowledge of
and must obey all rules and instructions applicable to or affecting
their duties. If in doubt as to their meaning they must consult
their supervisor for an explanation.
Description of Accident
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Diesel-electric locomotive 502, a switcher type unit, was assigned
to switching service at Sacramento. A few minutes before 6:40 p. m.
this locomotive, moving in backward motion and pulling a cut of
three cars, departed eastbound from the vicinity of the coach and
paint shop. While it was moving eastward on track E-30 at a speed
variously estimated as from 5 to 10 miles per hour the west car of
the cut was struck by Diesel-electric unit 921-C at a point 322 feet
east of the switch at which track E-34 converges with the lead
track.
Diesel-electric unit 921-C, a booster type freight locomotive unit,
was placed on track E-34 at a point approximately 450 feet west of
the fueling station and 850 feet west of the lead track switch by a
Diesel foreman of the shop force about 3 p. m. Several hours
afterward, while this unit was being operated by an engine watchman
who intended to refuel and service the unit at the fueling station,
it proceeded eastward out of control, trailed through the lead track
switch, which was lined for movement on the lead track, and while
moving on that track at an undetermined rate of speed it collided
with the west end of the cut of cars which was being moved westward
by locomotive 502.
The truck at the west end of the car which was struck was derailed
to the north. The cut stopped with the west end of the derailed car
225 feet east of the point of collision and several feet north of
the centerline of the track. No other equipment was derailed. The
west car and the car adjacent to it in the cut were somewhat
damaged, and locomotive 502 was slightly damaged. Diesel-electric
unit 921-C stopped with the front end against the corner of the
derailed car. The front end of this unit was slightly damaged.
The yard conductor of locomotive 502 was killed. The engineer, the
fireman, and one yard brakeman of locomotive 502, and the engine
watchman who was operating Diesel-electric unit 921-C were injured.
It was dark and rain was falling intermittently at the time of the
accident, which occurred about 6:40 p. m.
Diesel-electric unit 921-C is of the booster type. It weighs 247,770
pounds and is mounted on two four-wheel trucks. The length over the
couplers is 50 feet. It is provided with 24-RL type brake equipment
and hostler’s controls for independent movement. These controls are
located adjacent to a circular window on the right side of the unit
and consist of a controller handle, with eight power positions, a
reverser mounted on the control box, and an independent brake valve
of the SA-2 type. Two cutout cocks are located immediately below the
independent brake valve and are so arranged that when they are in
closed position the independent brake valve is inoperable. An air
gauge, and an emergency brake valve by means of which brake-pipe
pressure can be vented to make emergency application of the brakes,
are provided at the control station. A geared hand brake which
operates on one pair of wheels of the front truck of the unit is
located to the rear of the control station. Cab and gauge lights are
provided, and the unit is equipped with a headlight at the rear end.
At the time of the accident the front end of this unit was toward
the east.
Discussion
Before the accident occurred locomotive 502 was coupled to the east
end of a cut of three empty box cars on a track of the coach and
paint shop in the shop yard at Sacramento. The fireman was operating
the locomotive under the supervision of the engineer. Shortly before
6:40 p. m. the locomotive, moving in backward motion and pulling
these cars, departed from the vicinity of the coach and paint shop
to perform switching service at another location. Members of the
crew estimated that as the locomotive with cars proceeded eastward
on track E-30 the speed was 5 to 10 miles per hour. The enginemen
were maintaining a lookout in the direction of movement from their
respective positions in the control compartment at the rear of the
locomotive. The yard conductor and two yard brakeman were on the
west end of the locomotive. One yard brakeman slighted from the
locomotive at a point several hundred feet east of the switch of
track E-34. He said that immediately after he alighted the rear car
of the cut was struck by the following Diesel-electric locomotive
unit. As the switching locomotive lurched from the force of the
impact the yard conductor and the other yard brakeman fell from
locomotive. A second impact then occurred. When the collision
occurred the fireman immediately applied the independent brake.
Apparently after the impact of the first collision the following
unit was separated from the rear car of the cut and collided with it
a second time before it stopped.
The engine watchman was the only mechanical department employee on
duty at Sacramento Shops at the time of the accident. He said that
shortly before he went on duty, at 3:30 p. m., the Diesel foreman
instructed him to service Diesel-electric units 921-C, 921-D, 714,
and 712 and that he understood this to mean he was to move these
unit’s as necessary to supply them with fuel, water, sand, and other
supplies. Diesel-electric unit 921-C previously had been placed on
track E-34 at a point approximately 450 feet west of the fueling
station and the engine had been left running. The other units had
not arrived. The engine watchman said that before the foreman went
off duty, at 5 p. m., he repeated these instructions and asked to be
notified at his home when the servicing was completed. Before the
other units arrived the engine watchman boarded Diesel-electric unit
921-C to move it to the fueling station. This unit was to be
assembled with Diesel-electric unit 712 into a two-unit locomotive,
and the engine watchman said that he intended to service it before
the latter unit arrived. He said that there was an exhaust from the
independent brake valve when he moved the handle, and he assumed
that the valve was operative. He did not observe the air gauge. He
said that he released the hand brake and placed the controller in
No. 2 position. The unit then moved slowly eastward, and as it
approached the fueling station the engine watchman returned the
controller to idle position and placed the independent brake valve
in application position. He said that there was no reduction in
speed, and that he then applied the hand brake and jumped off the
unit. He was unable to estimate the speed of the unit. He said that
he fell when he lighted and that he then ran after the unit
intending to warn other persons in the vicinity. He was unable to
overtake the unit before the collision occurred.
The Diesel foreman who issued the instructions to the engine
watchman said that he instructed the watchman to notify him when the
other Diesel-electric units arrived and that he would then return to
the shop to supervise the coupling of the units. The engine watchman
was not qualified to operate Diesel-electric units of the type of
unit 921-C, and the foreman said that he intended to operate this
unit and any other unit which the engine watchman was not qualified
to operate.
Examination of Diesel-electric unit 921-C at the scene of the
accident disclosed that all control buttons had been pulled out. The
cutout cocks under the independent brake were in the closed
position. Under these circumstances the independent brake valve was
inoperative, and it would have been necessary to open the emergency
brake valve or otherwise deplete brake-pipe pressure to effect an
application of the brakes. A locomotive fireman who boarded the
locomotive unit several minutes after the accident occurred said
that when he entered the unit the engine watchman was endeavoring to
stop the Diesel engine. The fireman immediately applied the brake
and then pulled the safety control on the governor to stop the
Diesel engine. He did not observe the air gauge. The brakes were
tested before this locomotive unit was received from the scene of
the accident, and they functioned properly. The unit afterward was
inspected and the control and brake apparatus were tested. No
defective condition was found.
The investigation disclosed that when Diesel-electric unit 921-C was
placed on track E-34 by a Diesel foreman the independent brake was
not applied and the cutout cocks of the brake valve were in the
closed position. The shop superintendent said that it was a regular
practice to leave units of this type with the cutout cocks in this
position.
At Sacramento Shops Diesel-electric locomotive units are operated in
shop movements by Diesel foremen and engine watchmen. Mechanical
department employees have been instructed not to operate any
equipment unless they have been instructed and qualified in its
operation. The engine watchman involved had been employed by the
carrier as acetylene plant attendant and stationary engineer from
June 15, 1950, until July 18, 1955, and was assigned as engine
watchman on the latter date. He had been qualified for duty as an
engine watchman after working two days with other engine watchman
and receiving further verbal instructions from a foreman. He was not
familiar with the location or function of the cutout cocks adjacent
to the brake valve. He previously had operated only Diesel-electric
units of the switcher type, which were regularly serviced at this
point, and he had not been qualified in the operation of other types
of Diesel-electric motive power. The carrier should take steps to
insure that employees who may be required to move locomotive units
are thoroughly instructed in the operation of the controls of any
equipment which may be placed in their charge.
Cause
This accident was caused by a Diesel-electric locomotive unit moving
out of control as a result of improper preparation of the unit for
operation.
Dated at Washington, D. C., this seventeenth
day of February, 1956.
By the Commission, Commissioner Clarke.
(SEAL) HAROLD D. McCOY
Secretary.