CNN.com - Human error blamed for runaway train

'Proper safety procedures were not followed'

Lumber is strewn around the wreckage of the derailed freight cars. Story Tools

COMMERCE, California (CNN) -- Federal investigators Thursday released a timeline of events that led to the crash of 31 runaway train cars June 20 into a cul de sac in a community east of Los Angeles, and a company official said it was the failure to set hand brakes that led to the accident.

Twenty-eight of the cars derailed in the accident, which wound up obliterating two houses and slightly injuring 13 people.

A string of 31 cars -- most of them loaded with lumber -- had become loose 25 minutes earlier as they were being prepared for switching in a rail yard in Montclair, the National Transportation Safety Board said.

The train's two-man crew started work at the company's rail yard in Los Angeles at 5:45 a.m. and boarded the 2,281-foot train, which at that point consisted of three locomotives and 69 cars, the NTSB said.

The train departed for Union Pacific's nearby rail yard in East Los Angeles, where 38 cars were detached for switching.

Now 31 cars long, the train then departed the yard for Union Pacific's Montclair rail yard, about 40 miles east, the NTSB said.

In Montclair, a conductor for the yard switching crew told the train operators to take the train to the yard's east end, disconnect the locomotives and "hi-ball the brakes" -- railroad jargon for "Leave the brakes alone -- we'll take care of them," the statement said.

Following those instructions, the crew disconnected their locomotives from the rest of the cars, which caused the cars' air brakes to be applied automatically, the statement said.

"The conductor for the yard then began bleeding air off some of the brakes on the freight cars to release the air brakes to expedite the switching operation.

"As the brakeman from the yard approached the middle of the train, the conductor instructed him to start there (in the middle) and bleed air from the cars eastward."

There is no mention that hand brakes were set. "Proper safety procedures were not followed," said Union Pacific spokeswoman Katherine Blackwell. "Procedures require hand brakes to be set before releasing air brakes, and that was not done."

The people working on the train apparently did not immediately recognize a mistake had been made until it was too late.

"When the yard brakeman looked back, he saw that they had begun to move and he started chasing after them. The yard conductor also noticed the cars moving and began running toward them, telling his engineer to call the dispatcher and advise that the cars were loose."

That was 11:33 a.m., and for the next 25 minutes the freight cars, moving without the power of locomotives, rolled 28 miles.

Twelve minutes later, Union Pacific warned maintenance crews to stand clear as the cars continued their journey.

Meanwhile, Union Pacific personnel were trying to figure out how they could stop the train before it reached the yard in East Los Angeles, ultimately deciding their only hope was track 4, the track at the switch at the city of Commerce.

The company's East Los Angeles train yard contained stores of liquid propane gas, diesel fueling tanks and Metrolink passenger trains, Blackwell said.

At 11:54 a.m., four minutes before they were intentionally switched onto the track at Commerce, the rail cars were whizzing along at 86 mph, the statement said. The speed limit at the switch is 15 mph, it added.

"At 11:56 a.m., a [Union Pacific] employee is reported to have told the chief dispatcher that there were homes at the east end of track 4, but the corridor manager and chief dispatcher said that they did not see any other option," the report said.

"The assistant dispatcher is reported to have told the corridor manager that he had to 'decide right now' because the cars were approaching the switch."

The decision was made and the wreck occurred at 11:58 a.m.

"There was no notification from the UP to any local authorities before the derailment," said the report of the investigation, which is expected to continue for several weeks.

Blackwell said the derailment was not intentional, and that the decision was made after rail officials had been told by police that there were only 10 cars on the loose, not 31.

"The physics [for 10 cars] were a heck of a lot different than 31, if you remember anything about high school physics," she said.

Company officials had predicted that, if any of the cars left the track, they would travel westward, away from the houses, she said.

"In fact, that's what happened for the first several cars in that pile. But because so many of them, as the rear cars were coming to a stop, the cars in the middle buckled and fell [eastward] to the right."

Blackwell acknowledged that local agencies were not notified before the crash, but said company officials had less than 20 minutes to do so once they had determined what was going on.

Asked if anyone had been fired, she said, "We can't comment on that." But, she added, all company personnel involved in the event have been suspended.

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