Accident: DCA-85-RM-005 Location: Granby, Colorado Date and Time: April 16, 1985, 7:25 p.m., mountain standard time Train Owner: National Railroad Passenger Corporation (Amtrak) Railroad and Operator: Denver and Rio Grande Western Railroad (D Type of train, locomotive units, and cars: Passenger, 2 units, 12 cars 5 Dcrewmembers, Persons on Board: 12 Amtrak service employees, and 129 passengers Injuries 2 Amtrak service employees and 14 passengers hospitalized Damage: $2,920,000 Other Damage or Injuries: None Type of Occurrence: Derailment (earth slide) Phase of Operation: En route on main track

About 7:15 p.m., m.s.t., April 16, 1985, eastbound Amtrak Train No. 6, The California Zephyr, departed Granby, Colorado, milepost 75.8, en route to Denver, Colorado. The train was 1 hour behind schedule as it entered a series of curves in the Fraser River Canyon, approximately 3 miles east of Granby.

The fireman, a qualified engineer, who was at the controls of the lead locomotive unit, stated that as the train neared milepost 70.3, about 7:25 p.m., both he and the engineer noticed a long void under the track structure where the roadbed fill had slumped into the river bed. The fireman immediately made an emergency application of the train's air brake valve. However, the emergency brake application did not materially slow the 30-mph speed of the train before the two locomotive units and first four cars derailed. The two locomotive units fell into the void below the track structure and the two following baggage cars jackknifed and came to rest across the top of the locomotive units. The next two cars, a sleeper and a coach, jackknifed on the track structure at the west end of the void. The remaining eight cars did not derail. The locomotive units and first four cars were heavily damaged, and 420 feet of track were destroyed.

Immediately after the accident, the engineer and the fireman attempted to contact the dispatcher via radio. However, they were unsuccessful because the batteries for the locomotive were damaged during the derailment. They then crawled out of the lead locomotive unit and walked about 1/2 mile east of the accident site to a dispatcher block telephone and requested assistance.

At 7:58 p.m., the police dispatcher at the Colorado State Patrol and the Grand County Sheriff's Department, located in Hot Sulphur Springs, was notified of the Amtrak train derailment by the Denver and Rio Grande Railroad dispatcher.

The Grand County Sheriff's Department responded to the accident and requested that emergency rescue units assemble at the Granby D&RGW railroad depot which was to be used as a staging area for access to the accident site located 5 1/2 miles to the east. The Granby Volunteer Fire Department and the Grand Lake Fire Department also responded to the emergency. Local emergency medical and first-aid personnel were taken to the accident site by hi-rail vehicles since the site of the accident was inaccessible by road.

An emergency medical technician from the Grand County Emergency Rescue Services, who arrived at the derailed train at 8:35 p.m. with the first rescue units on motorized rail cars, stated that the passengers were triaged by the two lead emergency medical technicians at the crash site. Three passengers were to be brought out from the scene by the motorized rail car, but it was learned that another locomotive was on its way in to pull the train back to Granby. Consequently, the motorized rail car would have blocked the track for the locomotive so these passengers were placed back on the train. The emergency medical technician also stated that he walked through the entire train of standing cars and did not observe any emergency lights in the dining and lounge cars. In some cars, the emergency lights were burning but were of such a low intensity that they were of no value for rescue purposes.

The locomotive from the following freight train was dispatched to the crash site and the eight non-derailed passenger cars were pulled back to the Granby depot, arriving at 10:20 p.m. At the depot, some injured passengers were removed from the top level of the cars by a front end loader because of the narrow stairway between the two levels of the cars which would have aggravated passenger injuries.

Injured passengers then were transported to the Community Clinic and Emergency Center (C.C.E.C.) in Granby. Three passengers were transported to the hospital in Kremmling, Colorado. Seven of the 32 injured passengers who were taken to the C.C.E.C. were airlifted to a hospital in Denver, Colorado. Uninjured passengers were taken by school buses to the high school in Granby and were later transported to Denver by buses provided by Amtrak.

The D&RGW crew members had reported for duty at Grand Junction, Colorado, about 1 p.m. on the day of the accident. Each crewmember stated that he was fully rested and in compliance with the hours of service law when he reported for duty and that he was thoroughly familiar with the train operation and the physical characteristics of the railroad for the scheduled run of 275 miles to Denver.

Granby is at an elevation of 7,935 feet. The high temperature for the day of the accident was 82 F, some 20 above the normal high temperature. Snow was melting from the mountainside adjoining the track because warmer temperatures had prevailed several days before the accident. At the time of the accident, it was dark, and the weather was party cloudy with a temperature of 51 F.

The train derailed 5 1/2 miles east of Granby on the D&RGW Railroad, Colorado Division, main track. The accident site consists of a single main track constructed on a 25-foot-high side hill fill built from rock and dirt materials cut from the mountainside during construction of the roadbed in 1907.

The single main track extends north and south in a geographical direction (timetable direction is westward and eastward, respectively). The track alignment at the point of derailment is tangent and the grade is ascending at 0.68 percent for eastbound trains. The track is constructed with a series of curves between milepost 73.0 and milepost 67.0 which restrict train speed to a maximum of 30 mph. At the time of the derailment, the train had just begun to exit a 2-degree, 59-minute left-hand curve with the locomotives moving on tangent track before entering a 6-degree right hand curve.

The track structure is constructed of 136-pound continuous welded rails. The rails rest on 8- by 14-inch double shoulder tie plates with two inside and two outside spikes per tie plate. The treated timber crossties measure 7 inches by 9 inches by 8 feet 6 inches. Every other crosstie is box anchored. The crossties rest on about 12 inches of slag ballast. The track is well-maintained and exceeds the minimum requirements of the Federal Railroad Administration's Track Safety Standards for a class 3 track.

A D&RGW track supervisor patrols the track on a high-rail vehicle between Tabernash and Bond, milepost 66.0 and milepost 130. The track is patrolled at least in one direction every other day and, in some instances, once each day. Since some of the territory is class 5 track, the Federal Railroad Track Safety Standards require a twice weekly track inspection with at least one calendar day interval between inspections.

On the day of the accident, the track supervisor was patrolling his territory in a westerly direction. He stated that he arrived at milepost 70.3, the accident site, at approximately 1 p.m. and that he noticed some ice and debris accumulating at the inlet of the 36-inch-diameter corrugated metal pipe culvert approximately 40 feet west of the point of the accident. He said that he notified the section foreman to proceed to milepost 70.3 to clean out the inlet of the culvert and another 36-inch-diameter culvert located approximately 1,000 feet east of the point of derailment.

A westbound coal train passed over the track about 2:20 p.m. The crew of that train stated they did not notice any sign of track roughness or instability.

The section foreman stated that when he and two crewmen arrived by motor car at milepost 70.3, there was some water flowing in the drainage ditch between the two culverts. Most of the water flowed from a stream located about 1,000 feet east of the slide. The stream normally flowed directly through the culvert at that location; however, the culvert had become blocked, mostly with ice. They cleaned out the ice and debris from the inlet ends of the culverts and viewed water flowing through the pipes. The section foreman stated that they did not notice anything wrong with the track structure or subgrade when they left at approximately 3:30 p.m.

About 3,500 cubic yards of subgrade and ballast that slumped into the river bed were washed away. The landslide, which was first noticed after the accident, probably began as a slump of the berm supporting the railroad, and then rapidly became a debris flow. The slump/debris flow occurred sometime between 3:30 p.m. and just prior to the derailment at 7:25 p.m. The debris flow extended some 100 feet out into the Fraser River and nearly dammed the river. The slide, which was about 100 feet wide along the track centerline and about 220 feet long from top to base, probably was very mobile and occurred within a few minutes.

The debris flow portion of the slide included many large blocks of railroad subgrade over 2 feet thick. Inspection showed that the blocks were frozen solid and that many of the blocks had dry grasses growing, indicating that they came from the sloping face of the berm. Other blocks had top surfaces composed of ballast which came from the track structure.

The material involved in the slide consisted primarily of dark gray, silty sand with rock fragments up to boulder size. This material was used to construct the berm. Seepage was observed through the fractures in the bedrock. Excavation within the slide area exposed small springs in the head of the slide area which flowed continuously during reconstruction of the berm. The springs apparently are charged with water flowing through the vertical fractures in the mountainside bedrock.

The failure of the embankment by landsliding apparently occurred as a result of saturation of the embankment material by snowmelt water. Water probably entered the embankment through (1) surface runoff from melting snow on the mountain slope above the embankment, (2) seepage into the embankment from joints in the bedrock, and (3) water from the ditch between the track and the uphill bedrock slope.

In addition, three extraordinary circumstances which existed at the time of the accident may have contributed to the saturation of the embankment: (1) both surface and ground-water flow probably were greater than normal for the time of year because of abnormally high temperatures during the previous week, and residual ground-water levels in the embankment foundation probably were high before spring runoff began as a result of the extraordinary levels of precipitation in the area in 1983 and 1984; (2) the frozen surface of the embankment may have served as an impermeable membrane preventing drainage from the embankment; and (3) extra water probably was introduced into the embankment with plugging by ice of the culvert about 1,000 feet upstream from the landslide. The plugging resulted in a significant flow of water in the ditch between the track and the upward bedrock slope; the water exited the ditch through a free-flowing culvert under the embankment downstream from the landslide. The section crew noted no ponding of water in the ditch at 3:30 p.m. However, persons who arrived first at the scene of the accident noted a flow about 3 to 4 feet wide and 1 foot deep in the ditch. Although there apparently was no significant pending in the ditch, flow of this magnitude undoubtedly resulted in some seepage into the embankment and probably contributed to the failure.

Granby County has a 5-year-old disaster plan which is the responsibility of the Director of the Grand County Emergency Medical Services located in Granby. According to the Director, the disaster plan needs updating. The disaster plan was not put into effect on the night of the accident, and no formal command post was established. The Sheriff requested that responding rescue units assemble at the Granby depot because he knew that they would be relayed into the crash site by motorized rail cars and because that seemed like the logical place to stage rescue units. Communications between the initial rescue units that proceeded to the crash site and rescue personnel at the depot were poor because the Amtrak locomotive radio batteries providing power were damaged and portable radios were inadequate to communicate between the accident site and Granby. No one at the depot knew the number of persons injured or the severity of their injuries until the undamaged passenger cars were pulled back to the depot. However radio communications improved when a locomotive, which had been dispatched to pull the train, arrived at the scene. Portable lights also were provided at the crash site because it was dark and the coach emergency lights were too dim to provide adequate illumination.

The operation of the emergency lights in the cars after an accident is important for several reasons. First, sufficient illumination is necessary for the crew to assist injured passengers. Both crew and passengers must simply be able to see one another. Second, rescue personnel must have sufficient light to be able to locate passengers, conduct them to the triage area, and render medical assistance to those who need it. If the emergency lights are of such a low intensity that rescue personnel must depend on flashlights and lanterns for illumination, their value is negated. Third, sufficient light is needed so that passengers can evacuate the cars at night. This accident occurred in a completely dark canyon in rural Colorado. Also, with the lights on, passengers are less likely to become panicky. After the train comes to a stop, confidence is restored once passengers can see each other, the crew, rescue personnel, and exits.

The Safety Board initially recommended improvements to emergency lighting systems in passenger cars in its investigation of the Amtrak derailment at Emerson, Iowa, on June 15, 1982. 1/ As a result of that investigation, the Board recommended that the National Railroad Passenger Corporation (Amtrak):

Evaluate and modify, as necessary, emergency lighting systems in passenger-carrying cars to better protect the functioning of emergency lights in emergency situations. (Class II, Priority Action) (R-83-25)

In a June 23, 1982, fire in a sleeping car of an Amtrak passenger train at Gibson, California, 2/ 2 passengers died, 2 passengers were seriously injured, and 57 passengers and 2 train crewmembers were treated for smoke inhalation. As a result of its investigation, the Safety Board recommended that Amtrak:

Install in each sleeping compartment and all passenger car hallways effective, low mounted emergency lights which provide a lighted escape path in the event of heavy smoke when an emergency evacuation is required. (Class II, Priority Action) (R-83-66)

In response to the Safety Board's recommendations, Amtrak stated:

In a continuing effort to improve emergency lighting features, Amtrak will use invertor ballast direct current fluorescent lights in the new low level prototype cars. Construction of two sleeping cars and one dining car with this type of lighting is expected to begin in July 1985. If this type of emergency lighting proves to be more beneficial, we will include this lighting system in the new prototype coaches when they are built.

Emergency lights remain dependent upon energy from the storage batteries. We believe that the existing type and placement configuration of storage batteries are adequate.

The Safety Board ultimately placed Safety Recommendation R-85-66 in a "Closed--Unacceptable Action" status since Amtrak does not intend to retrofit the existing fleet of passenger cars. The Board, however, continues to hold Safety Recommendation R-83-25 in an "Open--Unacceptable Action" status since we believe that modifications to the existing fleet are needed.

While improvements in emergency lighting may and should be built into the new prototype coaches, the low speed derailment near Granby, in which there was virtually no damage to the coaches (all but one passenger car remained on the tracks and yet a number of the emergency lights in the cars did not function), again demonstrates the need for improved emergency lighting in the existing fleet of passenger cars. Consequently, the Safety Board reiterates Safety Recommendation R-83-25 as it pertains to the existing fleet of Amtrak passenger cars.

____________________ 1/ Railroad Accident Report--"Derailment of Amtrak Train No. 5 (The San Francisco Zephyr) on the Burlington Northern Railroad, Emerson, Iowa, June 15, 1982" (NTSB/RAR-83/02).

2/ Railroad Accident Report--"Fire Onboard Amtrak Passenger Train No. 11, Coast Starlight, Gibson, California, June 23, 1982" (NTSB/RAR-83/03)

The investigation of this accident revealed that the nearest microwave base station for receiving and transmitting radio communications was about 29 miles from the accident site. Under such circumstances, reliable communications from a locomotive radio source require at least 72 volts of power. Hand-carried radios and CB radio packs do not have a sufficient power source to transmit effectively in restricted topographic areas, such as the Fraser River Canyon. The conductor's hand-carried set was able to receive radio transmission from the dispatcher but could not transmit to him. Had the locomotive been equipped with an emergency battery source capable of providing at least 5 minutes of 72-volt production, communication to the dispatcher could have been maintained.

The lead locomotive unit involved in the accident was equipped with the latest type of radio equipment which can operate on any one of the 97 Association of American Railroad (AAR) standard communication channels. This single, two-way radio is designed to operate in any area that Amtrak serves. Amtrak positions the removable radio pack in front of the fireman's seat in the front bulkhead. Examination and postaccident testing of the radio equipment indicated that the transmitter/receiver functioned properly. A wet cell battery section located under the floor frame on the left side of the locomotive supplies power to the radio. A postaccident examination of the batteries indicated power was grounded out to the radio because water had entered the battery locker.

The location of the batteries in the locker under the frame of the locomotive units, which is peculiar to Amtrak's F40PH type units, makes them highly vulnerable when a locomotive derails and the carbody separates from the trucks. The locomotive and carbody separated in this accident as well as the Amtrak derailment near Connellsville, Pennsylvania, on May 29, 1984, 3/ and the Amtrak derailment near Essex Junction, Vermont, on July 7, 1984. 4/ In the Connellsville derailment, 2.1 inches of rain had fallen in the area resulting in rapid runoff that backed up behind a blocked box culvert. About 60 feet of the Chessie System's former Baltimore and Ohio Railroad's embankment was washed into the Youghiogheny River before Amtrak's Capital Limited reached the location at 6:40 a.m. where the two locomotive units and the following two baggage cars derailed in the washed-out area. In the Essex Junction accident, two locomotive units and the forward seven cars of the train derailed and were destroyed or heavily damaged as the train went into the washed-out area.

At Essex Junction, as at Granby, it was necessary for an engineman to walk a considerable distance to reach a telephone and report the accident. In the Connellsville accident, the conductor had to walk 2 1/2 miles to use the telephone in a private residence. In all three accidents, the locations were relatively remote. There were 5 fatalities and 26 persons seriously injured in the Essex Junction derailment, and 23 persons were injured, 4 seriously, in the Connellsville accident. With almost total reliance on radios for communications on the railroads, it is intolerable that help for the injured occupants of passenger trains is delayed because it is necessary for train crewmembers to walk to the nearest telephone.

____________________ 3/ Railroad Accident/Incident Report--"Derailment of Amtrak Train No. 440 (The Capitol Limited) on the Baltimore and Ohio Railroad, Connellsville, Pennsylvania, May 29, 1984" (NTSB/RAR-85/01/SUM).

4/ Railroad Accident Report--"Derailment of Amtrak Train No. 60 (The Montrealer) on the Central Vermont Railway, Essex Junction, Vermont, July 7, 1984" (NTSB/RAR-85/14).

As a result of its investigation of the Amtrak derailment at Essex Junction, the Safety Board recommended that the National Railroad Passenger Corporation:

Eliminate the vulnerability of the battery boxes supplying power for radio usage and lighting on its locomotives in a derailment by relocating them in the carbody, above the underframe of the locomotive units. (Class II, Priority Action) (R-85-125)

The Safety Board believes that reliable emergency power for radio usage or an ability for the radio to broadcast an emergency message in the event of a serious accident is essential on Amtrak locomotives.

See attached brief of accident for probable cause.

/s/ JIM BURNETT Chairman

/s/ PATRICIA A. GOLDMAN Vice Chairman

/s/ JOHN K. LAUBER Member

March 31, 1986

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D.C. 20594. Reported by: Denver and Rio Grande Western Railroad Brief of Railroad No.: DCA-85-R-M005 Location: Granby, Colorado Time: 1925 MST Date: April 16, 1985 Weather: Clear Visibility: Darj/1,000 feet

Train: Railroad: Class Direction Operating Phase: Track No.: 1 Amtrak Passenger East Enroute Main 2 ________ ____________ ________ ____ ______ ____

Accident Description:

Amtrak Passenger Train No. 6, the California Zephyr, traveling on the Denver & Rio Grande Western Railroad Company, Colorado Division main track, derailed at Mile Post 79.3, 5 1/2 miles east of Granby, Colorado. The derailment resulted when two locomotives and the first 4 coaches of a 12-coach train derailed at a 20 foot deep and 100 foot long roadway embankment slide. The two locomotive units and four coaches were heavily damaged when the first two coaches (baggage cars) landed on top of the locomotive units. In addition, 420 feet of the main track structure was destroyed and approximately 3,500 cubic yards of sub-grade and ballast were washed away by the Fraser River.

Probable Cause: 1. Track embankment slide because of excessive soil saturation from rapid snow melt, underground water and diverted water from a plugged under track culvert.

Probable Cause of Casualty: Property Losses

1. _________________________ Railroad: $2,920,000 2. _________________________ Non-Railroad: ___________