PB96-917008 NTSB/SIR-96/05

NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, DC 20594

SPECIAL INVESTIGATION REPORT

STEAM LOCOMOTIVE FIREBOX EXPLOSION ON THE GETTYSBURG RAILROAD NEAR GARDNERS, PENNSYLVANIA JUNE 16, 1995

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6768 Abstract: On June 16, 1995, the firebox crownsheet of Gettysburg Passenger Services, Inc., steam locomotive 1278 failed while the locomotive was pulling a six-car excursion train about 15 mph near Gardners, Pennsylvania. The failure resulted in an instantaneous release (explosion) of steam through the firebox door and into the locomotive cab, seriously burning the engineer and the two firemen.

This accident illustrates the hazards that are always present in the operation of steam locomotives. The Safety Board is concerned that these hazards may be becoming more significant because Federal regulatory controls are outdated and because expertise in operating and maintaining steam locomotives is diminishing steadily.

As a result of its investigation, the National Transportation Safety Board issued safety recommendations to the Federal Railroad Administration, the National Board of Boiler and Pressure Vessel Inspectors, and the Tourist Railway Association, Inc.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board Public Inquiries Section, RE-51 490 L'Enfant Plaza, SW Washington, DC 20594 (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703) 487-4600 STEAM LOCOMOTIVE FIREBOX EXPLOSION ON THE GETTYSBURG RAILROAD NEAR GARDNERS, PENNSYLVANIA JUNE 16, 1995

SPECIAL INVESTIGATION REPORT

Adopted: November 15, 1996 Notation 6768

NATIONAL TRANSPORTATION SAFETY BOARD

  

CONTENTS

EXECUTIVE SUMMARY...... v INTRODUCTION...... 1 INVESTIGATION Accident ...... 3 Train Damage...... 6 Gettysburg Passenger Services...... 9 Personnel Information ...... 10 Engineer ...... 10 First Fireman ...... 10 Second Fireman...... 11 Helper Engineer ...... 11 Training...... 11 Delineation of Duties ...... 12 Train and Equipment Information...... 12 Locomotive 1278 ...... 12 Boiler Information...... 13 Cab Equipment and Arrangement...... 14 Locomotive Maintenance Records...... 18 Postaccident Inspections, Tests, and Research...... 19 Crownsheet Failure ...... 19 Water Glass...... 19 Water-Glass Blowdown ...... 24 Gage Cocks ...... 26 Boiler-Water Behavior...... 26 Boiler-Water Supply System...... 29 Water Treatment ...... 30 Boiler Washing ...... 31 Low-Water Devices ...... 32 Oversight and Regulation of Steam Locomotives...... 33 Regulation and Oversight...... 35 Industry Efforts ...... 37

iii ANALYSIS General ...... 39 Investigation ...... 40 Water-Monitoring Devices...... 40 Water-Glass Lighting and Conspicuity...... 41 Water Treatment ...... 42 Boiler Washing ...... 42 Feed Pump and Gage ...... 43 Malfunctioning Check Valve ...... 43 Injector ...... 44 Water-Glass and Gage-Cock Testing...... 44 Delineation of Responsibilities ...... 44 Hours of Service...... 45 Training...... 45 Progressive Crown-Stay Failure...... 46 Steam-Locomotive Maintenance Expertise ...... 46 CONCLUSIONS ...... 48 PROBABLE CAUSE ...... 49 RECOMMENDATIONS...... 50 APPENDIXES Appendix A—Investigation and Sworn Testimony Proceeding ...... 53 Appendix B—Abbreviations Used in this Publication ...... 55

iv EXECUTIVE SUMMARY

About 7:20 p.m. on June 16, 1995, the that the deficiencies were the result of a lack firebox crownsheet of Gettysburg Passenger of the specialized knowledge, skills, and Services, Inc., steam locomotive 1278 failed training necessary to properly maintain a while the locomotive was pulling a six-car steam locomotive. It was further determined excursion train about 15 mph near Gardners, that those operating the locomotive did not Pennsylvania. The failure resulted in an understand the full scope of their duties and instantaneous release (explosion) of steam did not coordinate their efforts to ensure the through the firebox door and into the highest degree of safety. locomotive cab, seriously burning the engineer and the two firemen. The firemen The National Transportation Safety were taken by ambulance to area hospitals. Board determines that the probable cause of The engineer, who had third-degree burns the firebox explosion on steam locomotive over 65 percent of his body, was airlifted to 1278 was the failure of Gettysburg a burn center near Philadelphia. None of the Passenger Services, Inc., management to 310 passengers or other crewmembers were ensure that the boiler and its appurtenances injured. Locomotive damage was limited to were properly maintained and that the crew the firebox grates and crownsheet, with was properly trained. some ancillary smoke and debris damage to the locomotive cab. Because the Safety Board believes the circumstances surrounding this accident are Investigators found that the crownsheet not unique but reflect an ongoing attrition of failed from overheating because the train- specialized knowledge and skills within the crew had allowed the water in the tourist steam-excursion industry, the Board locomotive boiler to drop to a level that was did a special investigation of the accident. insufficient to cover the crownsheet. When As a result of its investigation, the Safety the investigators examined the locomotive Board makes seven recommendations to the components closely, they found that the Federal Railroad Administration, three boiler and its associated equipment had not recommendations to the National Board of been maintained well enough to ensure safe Boiler and Pressure Vessel Inspectors, and operation and that some repairs had been four recommendations to the Tourist done incorrectly. Investigators determined Railway Association, Inc.

v

INTRODUCTION

At about 7:20 p.m. on June 16, 1995, the Approximately 150 steam locomotives crownsheet of Gettysburg Passenger Serv- are still operated in the United States by ices, Inc., steam locomotive 1278 failed more than 82 organizations. Virtually all of while the train was pulling a six-car excur- them are used by tourist railroads, museums, sion train about 15 mph near Gardners, historical groups, and steam-excursion Pennsylvania. The failure caused fire and groups. Although there are no exact figures steam to be explosively released through the about how many people ride steam-locomo- firebox door into the locomotive cab, seri- tive trains each year, the Tourist Railway ously burning the engineer and two firemen. Association, Inc., (TRAIN) estimates that The engineer suffered third-degree burns approximately 4.8 million people, or the over 65 percent of his body. None of the 310 equivalent of 12 percent of Amtrak’s annual passengers or the other crewmembers were intercity ridership for 1995, visit tourist injured. railways, museums, and excursion opera- tions annually. A significant number of these The cause of this accident was deter- people ride trains pulled by steam lo- mined to be the failure of the train operating comotives. According to Gettysburg Pas- crew to maintain a water level in the loco- senger Services officials, about 50,000 peo- motive boiler that was sufficient to cover the ple rode Gettysburg Passenger Services crownsheet. Because of the inadequate water steam trains in 1994—and this is only one of level, the crownsheet overheated and weak- more than 80 organizations belonging to ened. When it weakened, it could no longer TRAIN that use steam-excursion trains. withstand the pressure of the steam above it. The pressure forced a section of the crown- This accident illustrates the hazards that sheet to pull away from its staybolts and are always present in the operation of steam collapse inward; the staybolt holes in the locomotives. The Safety Board is concerned collapsed section then exposed superheated that these hazards may be becoming more water and steam in the boiler to the atmos- significant because Federal regulatory con- pheric pressure of the firebox. With the sud- trols are outdated and because expertise in den reduction of pressure in the boiler, the operating and maintaining steam locomo- superheated water flashed instantaneously tives is diminishing steadily. The Safety and explosively into steam. The investiga- Board believes that the reasons for the ex- tion of this accident revealed that those re- plosion on locomotive 1278, especially sponsible for maintaining, repairing, and those reasons having to do with deficiencies operating locomotive 1278 lacked the spe- in steam-locomotive maintenance and op- cialized training and experience that have erations, may not be unique. long been judged to be prerequisites for the safe operation of steam-locomotive equip- ment.

1 Because of its concern about the safety of tions to address inadequacies it found in passengers and crews on steam trains, the regulations, standards, and certification re- Safety Board conducted a special investiga- quirements regarding steam-locomotive in- tion of the Gettysburg Passenger Services, spection, maintenance, and operation. Inc., accident and developed recommenda-

2 INVESTIGATION

Accident Near Aspers, Pennsylvania (MP 15, “the Wolf Pit”), the dinner train stopped and On the day of the accident, steam loco- waited to receive the helper train, which motive 1278 with a train of six passenger consisted of a diesel-electric locomotive cars made two 16-mile round trips from pulling four freight cars. It took several Gettysburg to Biglerville, Pennsylvania. minutes to couple the helper to the rear of About 6:00 p.m., as a “dinner train,” it the dinner train, after which the combined started its third and last trip of the day. It left consist proceeded. (See figure 1.) Gettysburg with 310 passengers for a round trip to Mount Holly Springs, Pennsylvania, According to testimony, a check valve (a where the passengers were to have a catered one-way valve) between the feed-water 2-hour dinner in local restaurants before they 2 heater pump (feed pump) and the boiler had returned to Gettysburg. been leaking all day, even though the valve After the train left Gettysburg, the co- had recently been repaired. On a previous owner and operator of Gettysburg Passenger trip that day, when locomotive 1278 was Services, Inc., (Gettysburg Passenger Serv- running backward next to a double-tiered, ices) closed the Gettysburg station and fol- open-air observation passenger car, the spray lowed the excursion train. The purpose of from the leaking check valve necessitated her “chase” by automobile (she would meet clearing the first half of the car. Consequently, according to the first the train at road crossings) was to provide a 3 contingency service to the train and, if nec- fireman, when the train left Wolf Pit the essary, limited emergency transportation. feed pump was shut off. He said, She carried a cellular telephone and a two- We shut [the feed pump] off whenever way radio that she used to monitor and talk we started up Wolf Pit because [the to the crew. Her husband, the locomotive check valve] was putting water on the engineer, also carried a radio and cellular 4 track and [the locomotive drivers ] phone. The conductors and passenger-serv- slipped. But as soon as we were ice personnel on the train had two-way ra- moving, [the feed pump] was turned dios. back on. When the dinner train left Gettysburg, it passed a Gettysburg Railroad freight train.1 It was routine procedure for the Gettysburg 2The feed-water heater is a heat exchanger located in Railroad freight-train locomotive to act as a the front of the steam locomotive, usually in the helper. smokebox. Cylinder exhaust steam is used to pre-heat water from the tender before the water is pumped into the boiler. This boosts energy efficiency and lowers fuel usage.

3The fireman tends and stokes the fire in the boiler’s firebox. 1All the equipment used by Gettysburg Passenger Services, Inc., (Gettysburg Passenger Services) is 4The drivers are the wheels that propel the loco- leased from Gettysburg Railroad. motive.

3 Figure 1. Key locations.

5 was working. Both firemen felt such cues The second fireman testified that when he relieved the first fireman at Gardners,6 were sufficient to ensure that water was flowing into the boiler. Safety Board the feed pump was still turned off. The investigators agreed that the feed pump can second fireman said he then turned the feed continue to move with little or no water pump on “all the way.” When the firemen flow. were later asked how they could tell whether the feed pump was working, they both indi- Both firemen stated that they checked the cated that the sound and visual movement of 7 water glass frequently during the trip. The the feed-pump rod told them the feed pump

7The water glass, also called the “sight glass” and 5It was the policy of Gettysburg Passenger Services to “water gage,” is a device that enables an engineman have two firemen on the dinner train trip because the or fireman to observe the height of the water in a trip was an extended one. locomotive boiler. It consists of two brass fittings 6The firemen did not agree in their testimony about screwed into the back head, one above the other, and where the transfer of responsibility took place. There connected by a stout glass tube or a metal frame in was no clear transfer of duty. To some extent, each which a glass is inserted which communicates, was acting in the capacity of fireman between Pond through the fittings, with the water and steam in the Road and Gardners. boiler. The water level showing in the glass is the same as that water level inside the boiler.

4 first fireman stated that he “always” watched and up around the bend before we the water glass. The second fireman said he started up the next grade. [The second checked it “once every 5 minutes or so.” He fireman] took the fireman’s seat, and I also said the engineer leaned back in his seat decided against…putting coal in. So, I to check the glass about three times during went to the door and waved to all the the trip. Neither fireman noted anything un- people at the crossing. And about 5 usual about the level of water in the glass. seconds later is when we had the acci- They said that the level appeared to be dent. normal and that it appeared to fluctuate Well, [when] the crownsheet about a half to a full inch, a fluctuation they failed…it just sounded like a muffled considered normal, considering the grade of .22 [rifle] pop. I instinctively turned the track and the vibrations. towards the noise….I remember getting hit with—it just got dark At Pond Road, MP 18, the second because of all the soot and the smoke fireman relieved the first. About a mile later, in the cab. And I remember feeling at Gardners, while the train was moving about 15 mph, the firebox explosion intense heat and thinking…I’ve got to occurred. According to the first fireman: get out of here. I jumped out and…yelled at [the engineer’s wife] to We got to the top of the grade and lev- call 911. And then I thought about [the eled off and…we had a normal water engineer], and I started back up just reading, had plenty of steam.8 I got up past [the other fireman]. I knew he about 30 seconds before the crown- [the second fireman] was all right sheet9 failed. I got up to put coal in the then, because I saw him. He was corners, because it’s an automatic limping, but I knew he was all right. stoker,10 and it fans [the coal] so it Then I went up to find [the engineer] won’t hit the corners, and I decided to and found him on the other side of the wait until we got across the crossing train lying there. And he asked for [his wife]. So I ran back and got [her]. And she handed me the phone, and I finished the 911 call.

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7 8 Figure 4. Bag in crownsheet. Costs vary extensively from facility to not solely, responsible for the care and op- facility. eration of the excursion equipment—in- cluding the steam locomotives. His respon- sibilities included maintaining and testing Gettysburg Passenger Services steam locomotive 1278 in accordance with Gettysburg Passenger Services is an the Federal Railroad Administration’s outgrowth of the steam-powered excursion (FRA’s) regulations. (The FRA’s regula- services begun on the Gettysburg Railroad tions are recorded in 49 Code of Federal in June 1978. The Gettysburg Railroad is a Regulations [CFR] Part 230). He was also shortline freight railroad that connects CSX the primary engineer of locomotive 1278, at Gettysburg with Conrail at Carlisle and he was operating the locomotive at the Junction, a distance of 23.7 statute miles. In time of the accident. 1986, the owner of Gettysburg Railroad formed Gettysburg Passenger Services to In 1994, Gettysburg Passenger Services run the excursion service of Gettysburg carried about 50,000 passengers. It leased Railroad, and he transferred ownership of track and equipment, including steam loco- Gettysburg Passenger Services to his son motives and passenger cars, from Gettys- and daughter-in-law. burg Railroad. Gettysburg Passenger Serv- ices and Gettysburg Railroad shared loco- The son and his wife were responsible for motive-maintenance facilities and some hiring and supervising the company’s em- traincrew personnel.Gettysburg Railroad ployees, and the son was also primarily, if diesel-electric locomotives frequently dou-

9 bled as helpers or backup relief for the ex- boiler and cleaning the spindles,13 has been cursion service. The two companies ac- done on a locomotive. The person who signs counted separately for labor, services, equip- the form is certifying the work has been ment, and supplies. done. The owner must keep the forms on file for FRA review. The engineer signed all the forms having to do with the accident lo- Personnel Information comotive. Engineer--At the time of the accident, the engineer was 48 years old. He had obtained According to his wife, the engineer had most of his knowledge of railroad and had a routine day up until the time of the steam-locomotive operation while growing accident. He had started work at 6:45 a.m., up. He said he had been surreptitiously done the necessary pre-trip work, made allowed to be the fireman on Pennsylvania excursion trips at 11:00 a.m. and 1:00 p.m., Railroad locomotives near his home starting and finished about 3:00 p.m., more than 8 when he was about 15 years old. His father hours after he had started. After a 2-hour began developing a steam tourist railroad in break, he reported back for the dinner train, Blairsville, Pennsylvania, in 1959, which about 5:00 p.m. became fully operational in 1964. The father testified that his son had first officially First Fireman--The first fireman, age 18, started running a steam locomotive when he who fired the locomotive from the time the was 18 years old, receiving instruction from dinner train left Gettysburg until the crossing professional railroaders. The engineer told at Gardners, had been employed by Safety Board investigators that he had had Gettysburg Passenger Services since 1992. no formal railroad or steam-locomotive At the time of the accident, he was a student training.12 working full time for the excursion service while on summer break. Between 1978, when Gettysburg Railroad He had had no prior railroad experience, had started its steam-powered excursion and his training as a steam-locomotive service, and the time of the accident, the fireman had been on the job (OJT). He had engineer had been the primary operator of been trained by the engineer, by one other the steam locomotives. He was also the full-time employee, and, to some extent, by primary servicer, maintainer, and repairer of the fireman with whom he was working at the locomotives and cars; however, he the time of the accident. He described his contracted out work that required specialized training as consisting of observation, skills and/or tools or was beyond routine demonstration, and then performance. maintenance or the capability of one or two people. He did many of the jobs himself He said he was well rested on the day of with little or no assistance. The FRA the accident. From 7:30 a.m. to 3:30 p.m., or requires that a form No. 1 be signed after for about 8 hours, he had worked on routine maintenance, such as washing the

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10 building an earthen ramp with a backhoe. “about 15 or 20 minutes behind” until Wolf After 3:30, he took a break until about 5:00 Pit. p.m., when he reported for the dinner train. Training--According to the engineer’s Second Fireman--The second fireman, 32, wife, the company had started a formal was a full-time supervisor at a local industry. training program “2 years ago.” The training He had worked for Gettysburg Passenger consisted of classroom and hands-on train- Services for 5 years as a part-time fireman. ing and included showing a safety film from Like the first fireman, he had had no Tourist Railway Association, Inc., (TRAIN), previous railroad experience and was given followed by a question-and-answer period. OJT, principally by the engineer. As a The engineer taught the course, which lasted fireman, he had made about 50 trips each 4 or 5 hours, once a year, before the start of season during his first 3 years and about the tourist season. Although the company “two dozen” in the 2 years preceding the did not keep attendance records, all the em- accident. ployees attended the course. Employees in- terviewed by Safety Board investigators On the day of the accident, he arrived at stated that they had a training session some the engine house at about 5:00 p.m., after time in April 1995. working a full day at his regular job. Gettysburg Passenger Services did not Helper Engineer--The helper engineer, 21, have a formal program for training or started railroading in 1989 as a part-time certifying an engineer as qualified, nor was summer employee with Gettysburg Passen- it required to have one. The company was ger Services, firing locomotive 1278. He had able to meet the FRA’s definition of had no previous railroad experience and certifying an engineer (49 CFR 2430.101) by took OJT from the engineer. After graduat- filling out a generic, American Short Line ing from high school, he became the only Association, fill-in-the-blank document and full-time train crewmember with Gettysburg sending it to the FRA. Passenger Services other than the engineer. When the helper engineer was 18, the engi- Beyond the recent pre-season training neer taught him how to operate diesel-elec- described above, each Gettysburg Passenger tric locomotives, as well as steam locomo- Services employee described his or her tives. During the off season, when the tourist training as being OJT typified by watching train did not make excursions, he helped the others do the work, demonstrating the ability engineer maintain the locomotives and cars. to do the work, and then performing the work in the context of day-to-day operations. He testified that his normal hours were The company did not use training records, 7:30 a.m. to 4:00 p.m. On the day of the task lists, tests, or other training organization accident, he said, he came to work at the or documentation papers. Training was regular time, “worked freight” from 7:30 random, based on the day’s operations. The a.m. to 12:30 p.m., and worked in the train employees were not taught regulatory yard from 12:30 p.m. to 3:30 p.m., for a total requirements, standardized industry of about 8 hours. He then went home for a practices, or the theory of steam-boiler break, reporting back for helper duty at 5:30 operation. Such training is not required. p.m. He said he followed the excursion train

11 Delineation of Duties.--The following ex- A: Yes. change with the first fireman took place Q: So you were acting as kind of the during his testimony: fireman— Q: Who was operating the feed pump A: Yes. most of the time during the trip? Q:—in charge? A: That would have been me. A: (Shrugs shoulders) Q: Would you say you were the one Q: So, when the two of you were running the feed pump all the time on working together, you had a clear that trip? understanding of who would do what, A: Not all the time. We had two who would be responsible for what? firemen. Two firemen. A: Pretty much. But I basically left it Q: But was your role the lead fireman up to him. I was there to give him a that day? break and such. A: I would not—we don’t have a lead fireman. We have [others] here to Train and Equipment Information back everyone up. Locomotive 1278--Canadian Locomotive Q: What I meant by that was, was Company, Ltd., in Kingston, Ontario, there an agreement between you and Canada, built locomotive 1278 for the [the second fireman] that you would Canadian Pacific Railway in April 1948. 14 do most of the duties and he would The locomotive had a 4-6-2 “Pacific” 15 back you up, or vice versa? wheel arrangement and was designed for passenger service. Its cylinders were 20 by A: No. 28 inches; boiler pressure was 250 psi; and Q: So you had a kind of division in driver diameter was 70 inches. It weighed responsibilities, but it wasn’t clear 234,000 pounds, with 151,000 pounds on who exactly was in charge of the drivers, and had 34,000 pounds of tractive fireman’s duties? effort. Its cab had side doors and was an A: Well, no. There’s—we both are enclosed all-weather, or winter-type, cab. competent firemen. We both know (See figure 5.) what we are doing. The second fireman, referring to operation of the feed pump, testified as follows:

Q: When you and [the first fireman] 369J[VGIU"U[UVGO"QH"UVGCO/NQEQOQVKXG"ENCUUKHKECVKQP0 were sharing the duties, had you +P" VJKU" U[UVGO." PWOGTCNU" CTG" WUGF" VQ" TGRTGUGPV" VJG actually turned the feed pump on PWODGT"QH"YJGGNU"KP"GCEJ"ITQWR"QH"YJGGNU0"6JG"HKTUV PWODGT"FGPQVGU"VJG"PWODGT"QH"YJGGNU"KP"VJG"NGCFKPI yourself in the few minutes—I mean, VTWEM=" VJG" UGEQPF." VJG" PWODGT" QH" FTKXGTU=" CPF" VJG on that leg of the trip just before the VJKTF."VJG"PWODGT"QH"YJGGNU"KP"VJG"VTCKNKPI"VTWEM0 incident, you had relieved [the first 37%QOOQP"YJGGN"CTTCPIGOGPVU"QHVGP"VQQM"QP"PCOGU. fireman], more or less? YJKEJ"YGTG"WUWCNN["CUUQEKCVGF"YKVJ"VJG"RNCEG"YJGTG VJG"CTTCPIGOGPV"QH"VJG"YJGGNU"QTKIKPCVGF0

12 Figure 5. Locomotive 1278. The locomotive had had a variety of courses, or diameters. 16 The boiler was owners and operators. In May 1965, the constructed of three connected rings or Canadian Pacific Railway sold the lo- courses of different diameters. The lowest comotive to a man in New Hampshire. In tensile strength of the steel was 72,100 psi 1969, he donated it to Steamtown, a railroad for the first course, 80,030 for the second museum then located at Bellows Falls, course, and 70,840 for the third course. The Vermont, and it was renumbered 127. From crownsheet was 3/8 inch thick when new. June 1970 to August 1971, it was leased to The water space at the firebox back was 3 the Cadillac & Lake City Railroad in Lake 1/2 inches. The firebox grate was 45.6 feet City, Michigan,as locomotive 127. In square. The lowest level of water in the September 1971, it was returned to Bellows boiler that the water glass could indicate was Falls and renumbered 1278. In 1984, it was a level 3 1/8 inches above the highest point moved, along with Steamtown, to Scranton, of the crownsheet. The height of the lowest Pennsylvania. In June 1987, Gettysburg Railroad bought the locomotive and leased it 16 to Gettysburg Passenger Services. Form No. 4 is a steam-locomotive boiler specifi- cation document required by the FRA in 49 CFR 230.54. Gettysburg Railroad had only one form No. Boiler lnformation-According to form No. 4, the one that had been filed by the Cadillac & 4, locomotive 1278 had a radial-stay, Lake City Railroad, a lessee of the locomotive. The FRA does not require a form No. 4 to reflect the straight-bottom, wagon-top boiler with three actual condition of the boiler in its present configu- ration or to be completed or submitted by a qualified person. 13 gage cock17 above the crownsheet was 3 1/4 of the boiler.21 (See figure 8.) A number of inches.18 devices, including gages and the water glass, were mounted on the backhead. The back- In accordance with Canadian Pacific head was also the location of the back of the policy, the crown stays, which supported the firebox and the firebox door. Below the 19 crownsheet from the boiler roof sheet, firebox door was the automatic stoker-auger were alternating rows of straight-thread and entrance used to deliver coal to the firebox. button-head crown stays. (See figures 6 and The backhead had a number of washout 7.) The first five rows from the rear tube- plugs.22 The engineer’s seat was to the right sheet knuckle (next to the tubes and flues) side of the boiler and slightly to the rear of were straight-thread crown stays followed by the backhead. Similarly, the fireman’s seat rows of button-head crown stays. The boiler was along the left side of the boiler. had been made that way so that if the crownsheet failed because it was not covered On the engineer’s side of the cab were the by water, it would be pushed off the straight- air-brake controls and gages, throttle lever, thread crown stays first. Consequently, al- reverser (valve cut-off control), boiler-pres- though the crownsheet would buckle, it sure gage, injector operating lever,23 the would be retained for a time by the button- three gage-cock operating handles, and a head crown stays. Thus, if the crownsheet number of other accessory controls, handles, failed because of too little water, the failure and levers. On the fireman’s side of the lo- would occur progressively and in stages, comotive cab were a number of gages and rather than instantaneously and catastrophi- controls for managing the boiler and steam cally.20 Other than being designed to make a production. Three gages—stoker jet-pressure failure a progressive, rather than an instanta- gage, steam-heat pressure gage, and feed- neous, event, the boiler did not have any pump pressure gage—had been removed low-water protection devices. from a mounting plate on the fireman’s side,24 leaving only a stoker-engine steam- Cab Equipment and Arrangement--The cab pressure gage and a boiler-pressure gage. of locomotive 1278 surrounded the backhead (See figure 9.)

21The backhead is the rearmost boiler sheet, which is located in the cab. 22Boiler designers incorporate a minimal but 17Gage cocks are used as a backup system for the necessary number of washout plugs in a boiler to water glass. ensure that it can be thoroughly washed and cleaned 18 of the sediment that contributes to scale. The gages are positioned so that the lowest reading 23 on the gage will indicate more than 3 inches of water The injector is a device for forcing water into a over the crownsheet, which is the minimum as steam boiler. A jet of steam imparts its velocity to the required by 49 CFR 230.37. water and thus forces it into the boiler against the 19 boiler pressure. The injector on locomotive 1278 was The outer boiler shell above the crownsheet. of the lifting type, which is generally used when the 20Note that (1) such a failure will still, as in this locomotive is standing still. accident, be very sudden and “explosive” and (2) no 24The missing gages were identified from a construction method will prevent a catastrophic photograph of locomotive 1278 taken several years failure, although it may attenuate the damage. before this accident.

14 Radial

ater

Section

I

Button Head Crown Stay

Water

Figure 6. Radical stay boilers and stays. 15 Roof Sheet of Boiler

Knuckle /

—“-—- —-— / -——. ~- — --- —-— - —.

I I

I Firebox 1

Figure 7. Alternating pattern of stays. Figure 8. Backhead. The engineer told Safety Board like the injector, could be adjusted to allow a investigators that he removed the original variable amount of water into the boiler, or feed-pump gage after it failed and that when none when the feed pump was turned off. the replacement also failed, he had decided not to replace it. The turret also provided steam to a number of other auxiliary devices, including A fireman uses the feed-pump pressure the dynamo. The dynamo was a steam- gage to ensure that heated feed water is turbine-powered generator for the overcoming boiler pressure and is flowing locomotive headlight, cab lights, and water- into the boiler. The gage provides a direct glass light. At the time of the accident, the indication that water is entering the boiler dynamo was connected to the turret, but the without the fireman looking at the water dynamo governor and the governor cap were glass. At the time of the accident, a missing, rendering the dynamo inoperative. distinctive pentagon-shaped brass control A portable gasoline-powered generator that knob with “feed-water pump” cast into it sat on the tender provided the power for the controlled the feed pump. Steam was headlight. In violation of the FRA’s re- delivered from the boiler through the left quirements (49 CFR 230.42), the water glass turret, or distributing valve, to the feed did not have a working light. There were no pump via the control knob. The feed pump, working cab lights.

17 of service for 6 months, from November 1, occurs. The force of the resulting ex- 1994, to May 1, 1995. plosion is in proportion to the size and the suddenness of the rupture, and the temperature and amount of water in Postaccident Inspections, Tests, and the boiler. At the instant the steam is Research released from the boiler, the water in Crownsheet Failure--The following, taken the boiler flashes into steam until a from the October 1943 Railway Mechanical heat balance is effected. This steam, Engineer, a respected industrial publication generated so instantaneously, occupies of the time, describes what happens when a space vastly greater than that occu- the crownsheet is not sufficiently covered by pied by the water in the boiler—per- water: haps 1500 or 2000 times as great. The terrific rush of the steam to occupy The flames and hot gases in a loco- this greater space often tears the boiler motive firebox at a temperature of off the locomotive frame and results in from 1500 °F to 2500 °F heat the fire- rocket-like behavior of the boiler. box sheets27 which, while covered by The FRA requires that “every boiler be water, remain at about the temperature equipped with at least one water glass and of the water. This temperature is de- three gage cocks” (49 CFR 230.37). In other pendent on the steam pressure in the words, each steam locomotive is required to boiler, and is in the neighborhood of have two independent systems to monitor 400 °F. If, however, sufficient water is the level of water in the boiler. The rationale not at all times present to keep the for having redundant systems is that if one firebox sheets at the proper tempera- fails, there will be another to prevent low ture, the sheets become overheated. water and a resulting explosion. The two Firebox steel when heated becomes systems for monitoring boiler water are the slightly stronger until about 500 °F is water glass and the gage cocks. The FRA reached, after which the strength falls also requires that every steam locomotive off very rapidly until at 1600 °F the have two independent and redundant steel has lost about 85 percent of its systems for supplying the boiler with water: strength at normal temperatures. At the injector system and the feed-pump some stage during this overheating, system. the strength of some part of the boiler, 28 usually the crownsheet, becomes less Water Glass--The water glass is the pri- than that required to withstand the mary means for the engineer and fireman to load of steam pressure, and rupture monitor the water level in the boiler. (See figure 10.) Mounted on the backhead of the boiler, the water glass is a vertical glass tube that shows the level of water in the boiler. 496JG"HKTGDQZ"UJGGVU"CTG"VJG"OGVCN"KPVGTKQT"YCNNU"QH VJG"HKTGDQZ."YJKEJ"CTG"JGCVGF"FKTGEVN["HTQO"EQODWU/ VKQP"QH"VJG"EQCN."YQQF."QT"QKN0 4:6JG"HTQPV"UGEVKQP"QH"VJG"ETQYPUJGGV."YJKEJ"KU CVVCEJGF"VQ"VJG"TGCT"VWDG/UJGGV"MPWEMNG."WUWCNN["KP/ EWTU"VJG"KPKVKCN"QXGTJGCVKPI"DGECWUG"KV"KU"VJG"JKIJGUV RQKPV"KP"VJG"ETQYPUJGGV"CPF"VJGTGHQTG"KU"VJG"HKTUV"VQ DG"WPEQXGTGF"YJGP"VJG"YCVGT"NGXGN"FTQRU0 19 Toward front of B and Steam locomotive Top Water Glass ! C-:- AI... \/-t. ,- —1

Steam Area I I 200 Psl I & I I

——====.. — ————j_+ —————————. ‘—_— —— Bottom ~—=—~=~~ (

I

————————.—— — -—”.———~. —_._— ———_—_ — ————=- —.———————_— ———’==————-- ——.’=-’==-==

! Drain Valve

*

Figure 10. Typical water glass.

20 The FRA requires that “the lowest such limited fluctuation “clearly indicates a reading that the water glass shows shall not problem with the glass” and that normal be less than 3 inches above the highest part fluctuation is as much as 4 inches ± 2 of the crownsheet” (49 CFR 230.37). Conse- inches. The expert further said he believed quently, as long as the water glass shows a that a water-level movement of only 1/2 inch water level, the crownsheet is covered by at “is a serious indication of an obstructed least 3 inches of water at all times if the glass.” locomotive is on level terrain, and somewhat less if the locomotive is going downhill. The locomotive cab was covered in ash, According to form No. 4 for locomotive dust, and small cinders from the explosion. 1278, the lowest level of water in the boiler Therefore, it was not possible to determine that the water glass could indicate was at the conspicuity of the water glass before the least 3 1/8 inches above the highest part of accident. The light for the water glass was the crownsheet. inoperative; the wiring appeared to have been grounded for some time. According to The water level in the water glass will FRA regulations (49 CFR 230.42, “Water fluctuate somewhat in response to track Glass Lamps”), all water glasses must have a conditions, vibrations, and such conditions lamp that is located in such a way that the as a surge of water in the boiler caused by engineer can easily see the water in the starting or stopping the train. An experi- glass. The firemen indicated that they carried enced enginecrew can still accurately esti- no light source, such as a flashlight, with mate the level of water in the boiler by not- which to check the water glass. The second ing the midpoint between the maximum and fireman said that at night the crew used the minimum changes in the indicated water cab lights powered by the gasoline generator level in the water glass. Some steam loco- on the tender and that they had an electric motives are equipped with dampeners that lantern that sat on the floor by either the smooth out the water-level movement in the engineer’s or the fireman’s seat. water glass in an attempt to provide a more accurate, if not instantaneous, indication of The water glass had a protective glass the boiler’s true water level. The accident covering, or shield, as the FRA required (49 locomotive did not have a dampener. CFR 230.41), to stop pieces of flying glass if the water glass broke; however, the covering The accident firemen testified that the was also covered with debris from the fluctuation in the water glass was about 1/2 firebox explosion, making it difficult to read inch up or down. Neither fireman took the water glass with any accuracy. The exception to this amount of movement, and shield was subsequently removed for further both indicated that such movement was tests. The water-glass system was dis- normal. One industry expert29 stated that assembled and inspected. (See figure 11.)

29Several steam-locomotive experts were involved in the investigation. Two, the chief mechanical officers of the Strasburg Railroad and The Valley Railroad Company, were brought into the investigation by Gettysburg Passenger Services. Two others, the cu- the field of steam-locomotive boilers and mechanics. rator of transportation for the Smithsonian Institution All four are referred to as experts for the purposes of and a representative of Combustion Engineering of this report. Teaneck, New Jersey, are recognized authorities in 21

Figure 12. End view of plugged spindle. According to the regulations, the boiler regardless of the condition of the water used. must be washed once a month and the (See figure 13.) spindles must be reamed. When asked if the amount of scale found in the spindles could The water glass itself was a glass tube have accumulated between monthly about 12 inches long and 1/2 inch in di- cleanings, one steam-locomotive expert said, ameter. Running the length of the glass was “No, no possible way.” Another said, “I a 1/4-inch-wide faded red background line have never seen a locomotive that had as that was barely visible. The diameter of the much scale inside the water-glass spindle as bore (about 1/8 inch) appeared smaller than the 1278. I worked on a lot of locomotives the 3/8-inch bore with which the inspectors all over the country and never saw anything were more familiar. They considered like this.”The chief mechanical officer whether a smaller bore would be more (CMO) of the Strasburg Railroad speculated susceptible to some form of capillary action that in such a restricted condition, the or to being plugged by lose scale (either of spindles would be much more susceptible to which could yield a false reading). However, being blocked by floating material or scale after they examined and tested the glass, flake. The investigators were unanimous in they decided the diameter of the bore was their conviction that the amount of scale acceptable. (See figure 14.) found in the spindles could not possibly have accumulated within the relatively short Safety Board investigators used a flexible time between monthly boiler washings, clear plastic hose to measure the response of

23 Figure 13. Plugged spindle after removal. the water in the water glass to changes in the trip.” However the regulations do not level of water in the boiler and to determine prescribe the blow-down procedure. how visible the water level in the water glass was to the cab’s occupants. The water-glass The National Board Inspection Code of system was reassembled in order to conduct the National Board of Boiler and Pressure this test. The water level was changed by Vessel Inspectors (NBBPVI) is recognized moving the hose attached to the boiler tap, nationally by the CFR as an American thus simulating water-level changes in the National Standard and internationally as boiler. The changes appeared immediately in ANSI/NB-23. According to that code, the the water glass, and the water-glass system proper method of blowing down a water appeared to function as designed under these glass is as follows (from Chapter II part I- non-pressure, non-operating conditions. 204.3, “Water Level Gage [Steam Boilers]”): Wafer-Glass Blowdown-One of the basic tasks an engineer and fireman must be able The inspector should ensure that the to perform is to “blow down,” or verify that water level indicated is correct by the water glass and the spindles are not having the gage tested as follows: blocked or restricted. According to the FRA a. Close the lower gage glass valve, (49 CFR 230.40), “All water glasses must be then open the drain cock and blow the blown out and gage cocks tested before each glass clear.

24 Figure 14. Water-glass tube. b. Close the drain cock and open the for doing so is not given or specified in any lower gage glass valve. Water should applicable Federal rules. Nor are any other return to the gage glass immediately. rules of the National Board Inspection Code applicable by law or regulation to steam c. Close the upper gage glass valve, locomotives not governed by the National then open the drain cock and allow the Board Inspection Code. The Gettysburg water to flow until it runs clear. Passenger Services employees did not have d. Close the drain cock and open the any reference materials that explained the upper gage glass valve. Water should proper method of blowing down a water return to the gage glass immediately. glass, If the water return is sluggish, the When Safety Board investigators asked operation should be repeated. A the first fireman to demonstrate the proper sluggish response could indicate an method of blowing down the water glass, he obstruction in the pipe connections to failed to demonstrate the correct method. the boiler. Any leakage at these fittings should be corrected to avoid Similarly, the second fireman failed to show damage to the fittings or a false and explain the proper method. He said he waterline indication. had had no formal training on blowing down the water glass, but that he had been shown Although 49 CFR 230.40 requires that how to do it. When the helper engineer was water glasses be blown down, the procedure asked to describe the blow-down procedure, 25 he said, “Open the bottom valves on the and did not know whether the engineer ever sight glass, and it blows steam through the did. glass to clean it.” He also said this was not to check the validity of the glass but “just Boiler-Water Behavior--Since the water the drain.” No crewmember was officially glass and gage cocks are redundant, they responsible for knowing the approved should indicate the same water level. method of blowing down the water glass. However, depending on the arrangement and The owner of Gettysburg Railroad (the en- maintenance of the boiler-water-monitoring gineer’s father) and a Gettysburg Passenger equip-ment, this may not be the case. Services employee who was qualified as both a steam-locomotive fireman and an en- In the early part of the century, a number gineer were each asked to explain and of locomotive boilers exploded in locomo- demonstrate how they would go about tives that had only gage-cock monitoring blowing down and verifying the water glass. systems. Consequently, the Bureau of Lo- Only the owner demonstrated the correct comotive Inspection of the Interstate Com- method. Neither the accident engineer nor merce Commission (ICC) launched an in- the firemen knew how to properly validate vestigation in 1919. The Bureau conducted a the water glass. number of tests and documented the move- ment of boiler water around the firebox, as 30 Gage Cocks--Mounted near the engineer’s discussed below. seat are three gage cocks that tap into the backhead of the boiler at various levels. The Upon entering the boiler, water from the cocks are a backup system for the water tender is relatively cool and dense. The glass and help ensure that water is water moves from the front and lower parts maintained over the crownsheet. To check of the boiler, which are “colder,” to the the water level, the engineer opens one of “hot” rear and top of the boiler, which are the gage cocks. Theoretically, if water drains warmer because they are around the firebox, from the valve, the engineer is assured that where the heat is generated and where the the level of water over the crownsheet is at greatest exchange of heat takes place. When least as high as the gage cock is. This may the water is heated, it rises as its density not always be the case if there is a false decreases. As the water finally migrates head, which will be explained later. As with around the sides and back of the firebox, the water glass, the lowest gage cock is water heating and movement are greatly mounted at least 3 inches above the highest accelerated, and steam bubbles begin to point of the crownsheet. The height of the form and rise to the surface. This rapid lowest gage cock on locomotive 1278 was 3 movement upward creates momentum and 1/4 inches above the crownsheet. an upwelling of water above and along the outside of the crownsheet. The upwelling of Removing the three gage cocks revealed water is most rapid at the firebox rear, that the lowest cock was totally obstructed especially between the door sheet and the by deposits and that the middle cock was backhead, creating a standing head of water half obstructed. Only the highest cock was clear of restrictions. The accident firemen stated that they did not test the gage cocks 524CKNYC["/GEJCPKECN"'PIKPGGT."8QN0";6."0Q0"32."R0 8520

26 (a false head) above the crownsheet rear or drill sized to fit the interior diameter of where the gage cocks are installed. the pipe or component. The reaming restored the parts to their original condition. Depending upon the placement and length of the pipes leading from the gage FRA regulations imply that unless the cocks into the boiler, the false head may gage-cock pipes are periodically cleaned, the cause the gage cocks to indicate that the pipes may become so plugged by scale that water level over the crownsheet is higher water is unable to pass through them and the than it actually is. Thus, while the gage gage cocks, as a result, might inaccurately cocks may indicate plenty of water, in reality indicate a low level of water in the boiler. At there may be little or no water over the first, it might seem that indicating that the crownsheet. Consequently, gage cocks are water level is lower than it actually is would problematic when used by themselves and not be a problem. If the enginecrew thought questionable as long-term redundant devices that there was less water in the boiler than for a water glass. Because of this there actually was, they might increase the documented phenomenon, the United States water flow to a boiler that already had Railroad Administration’s Committee on enough water. Raising the level of water in Standards adopted the water column as a the boiler unnecessarily is not necessarily recommended practice in February 1920. dangerous, but it is not efficient and could increase the chance of incompressible water The water column is a small cylindrical entering a cylinder (called “working wa- device that is connected to the boiler in ter”31) and causing a cylinder head to be much the same fashion as a water glass; blown off. however, the water column is really a platform on which to mount a water glass When water-glass spindles become and three gage cocks. (See figures 15 and progressively encrusted with scale, un- 16.) The water column has a limited predictable and unreliable indications may dampening effect and prevents the high level result. As moving water at the boiler of water (false head) in the back of the boiler backhead moves past one or both spindle from being falsely indicated by the gage orifices of the water glass, a slight pressure cocks as the true water level. This drop is created. Normally, this has little or arrangement ensures that the water glass and no effect on the height of the column of the gage cocks indicate the same and a true water in the water glass; however, should water level. one or both spindle orifices become partially closed off by the gradual buildup of scale, Steam-locomotive maintenance literature the height of the column of water in the states that maintenance has a significant ef- water glass may be affected, depending on fect on water-monitoring devices, particu- the location and extent of the buildup. larly the water glass. If the spindles that lead from the boiler to the water-monitoring de- vices are not clean, the water-level indica- tion may be false. When steam locomotives were in common use, the standard practice was to clean the interior of the spindles, 535KPEG"YCVGT"KU"CP"KPEQORTGUUKDNG"NKSWKF."CP["YCVGT water glass/water column body, gage cocks, VJCV" OKIJV" GPVGT" VJG" E[NKPFGTU" OKIJV" FCOCIG" VJG and associated piping of scale with a reamer E[NKPFGTU"QT"DGPF"C"FTKXG"TQF0 27 / Steam Area 200 Psi /. ;;./

Toward Front of Boiler and Steam locomotive Water Glass . (reflect type)

Bottom Water uper Heated Glass valve — later

Figure 15. Drawing of water column.

28 water glass had to be completely open. Partially opened valves re- sulted in the water glass showing a water level that was higher than the actual water level in the boiler. The crownsheets became overheated, and explosions occurred. Those locomotives, like the accident locomotive, had one water glass and one set of gage cocks.

Boiler- Water Supply System-The investigators also examined the devices used to supply water to the boiler. Two types of water-supply s ystems are used on steam locomotives: the injector system and the feed-water system. Most steam locomotives have both sys- tems, but older steam locomotives may have two injector systems in- stead. Locomotive 1278 had both systems. The injector and feed- water systems can be used separately or together and can act as backups for each other; how- ever, the injector system functions more efficiently when the loco- motive is standing, while the feed- water system functions more effi- ciently when the locomotive is

valves at the top or bottom of the water glass The boiler-water supply system consists are not completely open, the result again of (in order of flow) treated or untreated may be a falsely high water-level indication. water from the tender, strainers in the tender and delivery hose, the feed-water heater (if According to a leading mechanical engi- the locomotive has one), the feed pump or neer and recognized boiler expert with ABB the injector(s) with their respective check Combustion Engineering, several crown- valves to prevent pressure backup, and two sheet failures occurred in England during stop valves to shut off leaking check valves. World War II because the water-glass spin- dle valves were only partially open. The The injector pumps unheated water English crews of U.S. Army 2-8-O locomo- directly from the tender into the boiler, tives were unaware that the top valve of the heating it in the process. The feed pump

29 supplies water to the boiler indirectly enter the annular nozzle, which creates through the feed-water heater. The feed- a vacuum which raises the water. The water heater is a heat exchanger that absorbs disk that we found inside the 1278’s heat from used cylinder exhaust steam that is injector did not have that protrusion. otherwise lost up the exhaust stack. The Therefore, when the steam valve was feed-water heater is more efficient when the opened, it would be very difficult to locomotive is moving because there is more prime the injector. If a lifting injector exhaust heat and steam. cannot prime, it cannot operate. Now, it’s possible that the injector might The engineer controls the injector with a function, but only with some knob on his side of the cab. The fireman difficulty. controls the feed-water system with a pump- According to their testimony, none of the control valve that is on his side of the cab. train crewmembers were aware of the need After the accident, the injector was found for a specific disk type in the injector. closed, and the feed-pump control valve was found open 1 1/2 turns. The amount of water Water Treatment--Water used in boilers is these devices supply to the boiler depends frequently treated with chemicals and on boiler demand, so their valve control or processes to minimize the buildup of scale knob positions do not indicate whether a inside the boiler and inside all the other sufficient amount of water is being provided. devices that come in contact with the steam It is therefore critical for the fireman to and boiler water. Treating the water also closely monitor the water glass and/or gage reduces corrosion and maximizes heat cocks. transfer. Water-monitoring and -supply After the accident, the CMO of the systems are dependent on the free flow of Valley Railroad at Essex, Connecticut, water and do not work correctly if the examined the injector of locomotive 1278 boilers and their attached devices are not free of scale. Thus the cleanliness of the and reported: boilers and devices has safety implications. Upon entering the cab of the Depending on the source of the water, it locomotive…I found that the turret can be softened shortly before it is put into valve for the injector was shut off. Later on the next day, the steam valve the tender, or it can be treated while it is in reservoirs and holding tanks. Safety Board of the injector itself was disassembled to see if any problem could be found. investigators explored the nature of water Upon disassembly, it was found that treatment used by Gettysburg Passenger the steam valve disk inside the injector Services. was not the correct steam valve disk During testimony, the investigator from for that model injector. The Edna Type Gettysburg Passenger Services was asked if L lifting injector has to prime to get the company had water-treatment facilities. water up into the body of the injector. He replied: To do that, the steam valve disk has a protrusion on the end of it which Well, I saw some evidence of water allows when opened just a little bit of treatment. There were some empty steam to come by that protrusion and containers around. But we saw no

30 evidence of a regular program in The engineer told Safety Board investigators place. And by a regular program, I in a postaccident interview that he mean a written procedure for doing an performed his own water testing with a kit, analysis of the boiler water every day, much like that used for swimming pools. He recording, testing the water every day stated that he kept a journal of the water for the presence of oxygen, pH, how testing that he performed. No test results much hardness is in the water, the were found or provided. conductivity of the water, how much stuff is in there. Typically, what Boiler Washing--The interior of a boiler is people do is they test for these things washed to minimize scale buildup in order every day, they record it on a chart and to ensure that the boiler and its devices then make a determination of the operate safely and efficiently. According to chemicals based on what’s in the FRA regulations (49 CFR Part 230.45, boiler that day to correct whatever “Time of Washing”): deficiency there is in the water. And we found no evidence of that All boilers shall be thoroughly washed whatsoever. as often as the water conditions require, but not less frequently than The owner of Gettysburg Railroad said: once each month. All boilers shall be considered as having been in I noticed that [the accident engineer] continuous service between washouts had put a water softener in several unless the dates of the days that the years ago to soften the water due to boiler was out of service are properly [the fact] that Gettysburg has very, certified on washout reports and the very hard water to work with. I will go report of inspection. a little further. When we first come to Gettysburg, we were foolish enough to Locomotive 1278 had 29 washout plugs, leave water sit in that engine about 2 and the FRA regulations (49 CFR 230) months. It cost us to have the boiler require that all washout plugs be removed acid cleaned. So, he put the water when a boiler is washed. The regulations softener in. also require that special attention be given to removing scale on arch and water bar tubes According to testimony, the accident and that a record be kept of all washing (49 engineer sent boiler and/or supply water CFR 230.46 and .230. 48, respectively). samples to the Water Chemical Services Since a boiler wash and inspection are both (Water Chem) of Aberdeen, Maryland32 for required monthly, they are usually recorded testing. However, Water Chem has no and filed together on a form No. 1. record of dealing with Gettysburg Passenger Services except for filling an order for 100 The FRA regulations do not specify what pounds of sodium tri-phosphate, a constitutes a proper washing. The railroad suspension agent that was delivered May 19, industry has long had detailed methods and 1995, less than a month before the accident. special equipment for boiler washing. In 1915, the American Railroad Administration (ARA) adopted a recommended practice for boiler washing that included a number of 546JKU"EQORCP["YCU"OKUKFGPVKHKGF"CU"K9CVGT"%JGOK/ recommended designs for boiler wash ECN"%QORCP[L"FWTKPI"VGUVKOQP[0 31 nozzles. The Advisory Mechanical Com- locomotive has 17. It was just the way mittee, Equipment Engineering Department, the locomotive was built according to of the C&O Railway, the Erie Railroad, the the railroad specifications. So you just Nickel Plate, and the Pere Marquette Rail- wash it as thoroughly as you can and way issued Standard Maintenance Equip- wash the stuff basically from the top ment Instructions #105 on August 3, 1936, down, from the front [to] back, collect for boiler washing and blow down. In everything in the mud ring, then use November 1995, the members of TRAIN, in your four corner plugs to wash that an effort to promote safe steam-locomotive stuff out of there. And you make a operation, sponsored seminars on the proper special attempt to rattle your arch method of boiler washing. tubes, which is a mechanical cleaning process. During his testimony, the first fireman The CMO was asked whether he thought described how he washed the boiler of the boiler in locomotive 1278 had been locomotive 1278 by himself: recently washed out. He replied: You take the four plugs out. In the It could have been; I don’t know. I boiler under—by the firebox, there’s a have never seen a locomotive that plug in the right-hand side and on the blew up before, so I don’t know what left-hand side up front, and there’s two effect that had on things. It had a lot of in the back, both sides. You take those scale in it. It had a lot more scale than out. There’s three plugs along the top I would like to see in a boiler if that in the cab right above the firebox boiler was in service at Strasburg. doors. You take them out and then you wash the boiler out. You run—we Low-Water Devices--During the investi- have, I believe it’s a 2-inch hose that gation, the Safety Board explored the we run through it. We wash it to the availability of devices that can prevent or point where we get no sediment out warn of low water or mitigate the effects of anymore and the water is clear. such a condition. Research revealed that the The CMO of the Strasburg Railroad in railroad industry has over the years Pennsylvania summarized how a steam- developed several such devices. locomotive boiler should be washed out: Low–Water Alarms-–Railroad industry Take out all the washout plugs, and manufacturers and suppliers developed a va- essentially that’s any plug in the boiler riety of devices that warned that the level of that allows access into the boiler. And water in the boiler was too low. The devices when you do that, then basically we warned engine crewmembers before the use a hose to try and get the highest boiler exploded or the crownsheet burned. pressure we can. And we go to each Low-water alarms were made by the Nathan washout hole, and we attempt to wash Manufacturing Company of New York, the all surfaces, the interior surfaces of the Ohio Injector Company of Illinois, and the boiler. And that’s more or less diffi- Barco Manufacturing Company, Inc. Some cult depending upon the design of the of the alarms used floats while others de- locomotives. Our little locomotive has tected abnormal expansion and/or tempera- 34 washout plugs on it. Our biggest ture. Once activated, the alarm signaled the

32 cab crew, using a warning whistle that con- and placement of the plugs, the activation tinued to blow until the level of water in the may continue, effectively preventing perma- boiler rose or a crewmember reduced the nent damage or an explosion, but at the same heat of the crownsheet by releasing the fire time disabling the locomotive. Once fusible in the firebox into the ashpan. plugs have been activated, the locomotive must be taken to a maintenance facility for There was and is no Federal requirement repair. This disadvantage makes fusible that steam locomotives have low-water plugs, like low-water alarms, controversial. alarms. Opinions about the effectiveness of As with low-water alarms, the use of fusible low-water alarms do and did vary widely plugs varied widely, depending on the rail- among steam-locomotive experts of today road. and railroad officials from the days of steam. Depending on the sensitivity of the alarm, Federal regulations do not require the use locomotive crews were known to treat the of fusible plugs but do require that if the alarm as a nuisance and muffle the whistle. plugs are used, they must be maintained. Mechanical employees found the alarms to According to the FRA’s regulations (49 be an additional burden and expense to CFR 230.14, “Fusible Plugs”): maintain. Some railroads favored low-water alarms; others did not. Some steam If boilers are equipped with fusible locomotives still operating are equipped plugs they shall be removed and with low-water alarms.33 Locomotive 1278 cleaned of scale at least once every had no low-water alarm. month. Their removal must be noted on the report of inspection. Fusible Plugs--The crewmembers cannot Locomotive 1278 did not have fusible tamper with fusible plugs, also called “drop” plugs. plugs, as they can with low-water alarms. Fusible plugs consist of a short, pipe-shaped brass body that is screwed into the crown- Oversight and Regulation of Steam sheet at specified locations. (See figure 17.) Locomotives Within the brass body is a brass plug held in Observers have long recognized the place by a ring of fusible alloy metal that dangers inherent in employing steam to softens or melts at temperatures between power industry and transportation. In 1863, 500 and 575 °F. Once the crownsheet British Royal Astronomer George B. Airy reaches the critical temperature, the ring calculated that at a pressure of only 60 psi, melts and allows the brass plug to fall into every cubic foot of boiler water has the same the firebox, allowing steam to spray the fire, destructive energy as a pound of (black) attracting the crew’s attention, and relieving gunpowder.34 steam pressure. Depending on the number

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The first steam-locomotive boiler ex- opposed by the railroads. The railroads’ plosion occurred on June 17, 1831, when the greatest objections were to provisions that South Carolina Railroad’s Best Friend of required government inspection but left Charleston blew up because a man annoyed responsibility for safety and accountability by the sound of the safety valve sat on it to for accidents solely with the carrier railroad. prevent it from hissing. Boilers continued to Finally, a compromise was reached. An blow up or fail for a variety of reasons, amended version of locomotive inspection including poor construction and/or design. dropped requirements for specific safety With the introduction of the firebox into the devices and no longer required direct boiler, however, the most spectacular and government inspection. Instead, the carriers deadly forms of failures have been those that were required to file inspection rules with have resulted from a crownsheet that has the ICC and to do their own inspections. The been overheated and weakened because of a government inspectors only spot checked low level of water in the boiler—as in this and oversaw the process and investigated accident.35 accidents. Essentially, this level of oversight remains in effect today, with the FRA, rather Regulation and Oversight--The types of than the ICC, taking the regulatory role. The boil-er explosions that could affect the bill that required “Railroads to equip their public were regulated quickly and early. locomotives with safe and suitable boilers Congress passed a steamboat inspection law and appurtenances thereon” was passed on in 1838 after the steamboat Moselle blew up, February 17, 1911, and became law 4 killing 300 people. The first State boiler- months later. Federal inspection started with inspection law went into effect in 1867 in fiscal year 1912.37 New York after stationary boiler explosions in the 1850s killed scores of people. There are now three sources of boiler Historically, the public risk from steam- regulation and oversight in the United locomotive boiler explosions has been States, one of them private and the other two minimal. Unlike steamboat- and stationary- governmental. Insurance companies are the boiler explosions, generally the only people private source. The insurers, such as the affected by steam-locomotive boiler ex- Hartford Steam Boiler Inspection & plosions have been, as in this accident, the Insurance Company, the insurer in this trainmen and enginecrew. Consequently, it accident, will generally inspect a boiler to was not until 1909 that the first bills to determine whether it is safe enough to be regulate locomotive safety were introduced insured and, if so, at what risk level. in Congress.36 However, the insurer is not required to inspect. Although the Hartford Steam Boiler Specifics of the locomotive safety bill, Inspection & Insurance Company insured such as the provision requiring water glasses, were supported by labor and

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the accident locomotive, it never inspected inspection forms are filed according to the it. regulations--in the 1912 tradition set by the ICC. The FRA is not required to inspect a Some local and most State governments steam-locomotive boiler unless an extension regulate, inspect, and license the operation of the 4-year boiler-and-flue-tube inspection of stationary boilers, such as those used in is requested, nor is such an inspection heating and power plants, but generally not possible without the cooperation of the steam-locomotive boilers. This is primarily steam-locomotive maintenance personnel, because the FRA already has regulatory since a hot pressurized boiler cannot be authority over steam locomotives. State inspected on short notice because it may boiler inspectors may, however, be respon- require several days to cool down. The rest sible for steam-locomotive boilers operated of the steam locomotive is subject to FRA on railroads that do not fall under FRA inspection at any time, as is most other jurisdiction, such as small tourist lines not railroad equipment. However, given the connected to the railroad interchange sys- limited number of FRA inspectors, not to tem. Steam railroads that are not regulated mention the limited number of inspectors by the FRA are not required to file a form with steam-locomotive expertise, and the No. 4. The FRA has discussed bringing high demands of commercial interchange these lines under its jurisdiction. railroad inspection, FRA inspectors are able to inspect steam locomotives only infre- As discussed above, the Federal quently at best. regulations involving steam locomotives are found in 49 CFR Part 230. This title is no Steam locomotives for commercial- longer published each year as the rest of the railroad motive power had all but CFR is, but must be requested separately disappeared by the early 1960s because most from the FRA or other sources. Most of the major carriers had finished converting to standards, specifications, and procedures in diesel-electric locomotive power. The last 49 CFR Part 230 are from earlier railroad common carrier railroad steam locomotive38 industry standards or early regulations of the was replaced by a diesel-electric locomotive ICC and date from between 1912 and 1916. in September 1970. Consequently there are The last major revision of the material was no FRA and few railroad inspectors whose in 1946, long before the FRA was created expertise is based on first-hand knowledge (1966) and the Rail Safety Act of 1970 was of steam locomotives; FRA inspectors now passed. gain their expertise from limited classroom instruction. Unfortunately, many of the FRA Responsibility--Generally, FRA FRA’s regulations are written in such a way motive power and equipment (MP&E) that the inspector’s ability to adhere to them inspectors inspect a steam-locomotive boiler depends heavily on his subjective experience only if the locomotive’s owner files for an and practical expertise. Testing for broken extension of the 4-year boiler-and-flue-tube crown stays by tapping and listening for inspection required by 49 CFR Part 230.10. broken crown stays as required by 49 CFR At that time, the FRA inspector must inspect 230.21 through .24 is one example of a the boiler; but otherwise, boiler inspection is largely a self-certifying process, with the FRA checking to make sure that required 5:/QDKNG"(")WNH"4CKNTQCF"4/8/2"0Q0";90

36 procedure that requires an inspector who can inspectors who have steam-locomotive rely on some level of continuous daily operations in their territory. experience. Industry Efforts--In 1990, members of the The regulations in 49 CFR 230.102 and tourist-railroad industry who owned and op- 103 assign the responsibility for inspection erated steam locomotives became concerned and repairs and define the term “inspector.” that steam-locomotive inspection and safety standards were slowly degenerating. Twelve 230.102 Responsibility for inspection representatives formed an unofficial, ad hoc and repairs. group to formalize some type of recom- The mechanical officer in charge, at mended practice for the repair of steam-lo- each point where repairs are made, comotive boilers. (The 12 representatives will be held responsible for the included people from tourist-railroad inspection and repair of all parts of mechanical departments and insurance in- locomotives and tenders under his spectors, Class I railroad steam operators, jurisdiction. He must know that and experts knowledgeable in the theory and inspections are made as required and practice of steam-locomotive boiler con- that defects are properly repaired struction.) The group contacted the before the locomotive is returned to NBBPVI, the private agency that publishes service. and administers the National Boiler Inspec- tion Code applicable to all boilers used in 230.103 Term “inspector.” industry other than railroads. In 1990, the The term inspector as used in the rules group of 12 representatives began as the and instructions in this subpart means Engineering Standards Committee for Steam unless otherwise specified, the railroad Locomotives (ESC) to develop standards for company’s inspector. the repair and alteration of steam-locomotive boilers. Guidance was provided by NBBPVI The regulations do not specify the level as to modern engineering practices for of education or experience needed by boilers. someone who inspects steam locomotives or repairs and maintains them. The regulations In 1995, the National Board Inspection assume that an individual with extensive Code Committee adopted the standards practical experience in boiler construction developed by the ESC as an American and maintenance will be available to do the National Standard for the repair and work. alteration of steam-locomotive boilers that are repaired or altered by NBBPVI-certified According to the FRA, the agency has boiler engineering firms.39 In 1995, the ESC attempted to maintain some level of inspec- also became an official task group of the tion proficiency by organizing two 1-week NBBPVI. Appendix 3 of the 1995 National seminars, which are taught by industry and Boiler Inspection Code contains the operating museum experts on boilers and NBBVPI rules for steam-locomotive boiler steam locomotives, about steam locomotives and boilers, including maintenance and in- spection. The FRA gives priority for steam- locomotive seminars to those MP&E 5;6JGUG"CTG"HKTOU"JQNFKPI"CP"K4L"UVCOR"KUUWGF"D[ VJG"0$$28+"HQT"DQKNGT"TGRCKT0 37 repair. These rules, however, are only Since the accident, the FRA has formed a voluntary for railroads under FRA Steam-Locomotive Safety Improvement jurisdiction, since 49 CFR Part 230 makes Committee, which began meeting in no reference to any national standard or the September 1995. The ESC became a part of NBBVPI Code. In lieu of Federal standards, the committee and has met with the FRA in the ESC and the NBBVPI have volunteered an initial step to update 49 CFR Part 230. to provide a tailored training program on The ESC also has a representative on a steam-locomotive boiler inspection and larger FRA committee looking into all repair to the tourist-railroad industry. aspects of rail safety.

38 ANALYSIS

General 10 minutes as the train climbed the grade until the second fireman took over at the top The phenomenon of crownsheet failure of the grade, near Gardners. The distance has been well known and understood for between the start of the grade and Gardners many years. That such a failure had occurred was about 2 miles; and according to the in this accident was evident from the start of engineer, while the train was going up the the investigation. All parties to the grade, it was “working hard,” using more investigation agreed that the nature of the steam and, consequently, more water than damage, the statements of the locomotive usual. The first fireman said that as steam crew, and the postaccident examination of was used during the ascent, the pressure in the boiler confirmed that the crownsheet the boiler dropped from about 230 psi to 175 failure was due to low water. The Safety psi. The firemen were unconcerned about Board therefore concludes that the explosion the drop in pressure because they assumed in locomotive 1278 resulted from crown- that the water glass would warn them if the sheet failure caused by having too little level of water in the boiler became water in the boiler. dangerously low, thus allowing them to The investigators found that it was not a correct the problem. single event or condition that caused the Even before the water was cut off, its water to be too low. It was too low because level had been purposely kept low as a of the cumulative result of a number of matter of standard operating procedure. The steam-locomotive boiler-maintenance and engineer told Safety Board investigators that operational factors that resulted from a lack he normally kept the level of water so low of training, knowledge, and application. The that the water glass was only 1/3 to 1/2 full following is a brief synopsis of the accident even while the train ascended the grade to chronology and the inherent factors Gardners. The second fireman testified that involved. Each of these factors will be the highest water-glass level that he explained in greater detail in the rest of the remembered was “3/4 at most with analysis. fluctuation.” The engineer said that keeping The events leading to the crownsheet the water low in the boiler was a way of failure began when the locomotive stopped minimizing the chance of water entering the at Wolf Pit to pick up the helper. There, the cylinders (working water). He also said that first fireman shut off the feed pump, thus having less water in the boiler made for preventing any water from entering the “good steaming,” or the rapid creation of the boiler. He turned off the feed pump because steam that the train needed to climb the a one-way check valve between the feed grade to Gardners. However, keeping the pump and the boiler was leaking to the water so low reduced the layer of safety over extent that he believed that the locomotive’s the vulnerable crownsheet, particularly as drivers (wheels) might slip on the rail. The the water level changed with changes in feed pump remained off for about the next grade and terrain.

39 As the locomotive moved uphill, the totally blocked the already restricted orifices water maintained its level, moving to the of the water-glass spindles. The firemen’s back of the boiler, which was tilted up statements that the water-level movement in grade. Since the crownsheet was at the back the water glass was 1/2 to 1 inch, rather than of the boiler, the water should have covered the 4 to 5 inches that the engineer said was it even more deeply than when the train was normal, show that there was some form of on level track. Accordingly, the water glass, restriction, or blockage, probably from scale, which was on the back of the boiler, should in the already restricted spindles. have shown the level of water as higher than it was when the train was on level terrain. The Safety Board investigation focused on why the water in the boiler had been However, according to the crew, when allowed to drop to such a low level. The the locomotive tilted up grade, the water investigation found locomotive mechanical glass was still only 1/2 full (unchanged from conditions, maintenance practices, and crew the start at Wolf Pit), which should have training practices and procedures that warned the firemen that either the boiler individually or in combination allowed the held very little water or that the water glass low-water condition to develop. was inaccurate. With the feed pump shut down and the locomotive working hard and using steam, the water level continued to Investigation drop. At some point, the boiler held so little Water-Monitoring Devices--Since the water water that the highest point of the crown- glass was the primary tool that the engineer sheet became uncovered and, as a result, and firemen had to monitor the level of failed. By the time the locomotive crested water in the boiler, the investigators the grade at Gardners, where the second examined the glass and its related valves and fireman turned the feed pump back on, it spindles to determine their condition at the was already too late to prevent the inevitable time of the accident. The passages of the failure. valves had significant deposits. Hard scale plugged about 75 to 85 percent of the The firemen should have seen a spindles. It could not be determined how progressive drop in the water-glass level but much, if any, soft deposit or scale had been did not. The restricted condition of the blown out during the explosion, but steam- spindles leading to the water glass was locomotive experts agreed that it is affected by one or both of the following reasonable to believe that soft scale and/or circumstances: a higher-than-normal water scale flakes further restricted or blocked the head (a false head) at the back of the boiler spindle passages. The Safety Board con- and/or free floating scale. A false head may cludes that because the water-glass spindles have been created by the increased were restricted, the water glass could not momentum of water moving upward as the accurately represent the water level in the formation of steam became progressively boiler. more violent because the level of water was dropping. The more violent formation of The lowest gage cock was totally plugged steam and water flow may also have freed by deposits; the middle gage cock was half and/or picked up scale from the encrusted plugged; and the highest gage cock was boiler deposits, which then partially or clear. Again, steam-locomotive experts who

40 participated as investigators were convinced head phenomenon and did not present a that such a large amount of scale could not readily apparent indication of the level of the possibly have accumulated between monthly boiler water as the water glass did. Govern- boiler washings. The pattern of deposits in ment and industry knew that the water col- the gage cocks also suggested that the umn was the optimal solution but did not re- engineer was accurate when he said that the quire the use of a water column. Instead, the level of water in the boiler was routinely CFR said, “Every boiler [must] be equipped low. The amount of scale in each gage cock with at least one water glass and three gage appeared to correlate with the amount of cocks.” In 1920, the U.S. Railroad Admini- time it spent in the boiler water: the bottom stration’s Committee on Standards recom- gage cock was always covered with water, mended the adoption of the water column as the middle gage cock about half the time, a recommended practice. The Safety Board and the highest gage cock almost never. believes that the FRA now should require that, at a minimum, each operating steam lo- Both the first fireman and the engineer comotive have in addition to the required acknowledged that their method of washing water glass and three gage cocks, either the boiler was not thorough and that the another water glass or a water column. spindles were not cleaned and reamed out on While it can be argued that inadequate a monthly basis as, according to the FRA’s maintenance, as in this accident, would regulations, they were supposed to be. The eventually allow any and all water-monitor- gage cocks were also not cleaned and ing devices to become plugged with scale, reamed. The amount of scale and mineral the Safety Board believes that the chance deposit found in the spindles and the gage that all the devices will be plugged at the cocks supported the engineer’s admissions same time is remote and that, therefore, two that he did not follow the monthly cleaning devices provide a degree of redundancy and requirements. The Safety Board concludes accuracy that the currently required single that although the engineer had signed the water glass and gage cocks do not. FRA’s forms No. 1, certifying that the work had been done, the spindles and gage cocks Water-Glass Lighting and Conspicuity--Title were not cleaned on a monthly basis. 49 CFR Part 230.42, “Water Glass Lamps,” requires that all water glasses be supplied Investigators also examined the adequacy with a suitable lamp that is located where it of the water-monitoring systems (water glass enables the engineer to easily see the water and gage cocks) in this accident since the in the glass. In the accident locomotive, the systems would have been crucial in light for the water glass did not work. The detecting the level of the water before the firemen indicated that they carried no other crownsheet failed. At the turn of the century, light source, such as a flashlight, with which both the government and the railroad to check the water glass. The second fireman industry had recognized the shortcomings of said that at night the crew used the cab lights gage cocks by requiring the use of a water powered by the gasoline generator on the glass, thus relegating gage cocks to the tender and that they had an electric lantern status of a redundant back-up system. that sat on the floor by the seat of either the engineer or the fireman. The Safety Board Government and industry knew that gage concludes that the water glass was not cocks were particularly subject to the false- illuminated as required.

41 Although it was not possible to determine representatives of Gettysburg Passenger the preaccident conspicuity of the water Services showed that water treatment for glass, both firemen testified that they had no locomotive 1278 was, at best, undocu- trouble seeing the water glass. The cab of mented and inconsistent. the locomotive was an all-weather enclosed one of the type commonly found on steam The attempts at water treatment appeared locomotives used in northern climates. The to be irregular, rather than part of a planned cab had side doors and other features that and researched policy. According to his limited the entrance of light and air. Given testimony, the engineer sent boiler- and/or the lengthening shadows and the light of supply-water samples to Water Chem for early evening, it is possible the amount of testing. However, Water Chem has no light in the cab and on the water glass was record of doing any testing for Gettysburg restricted. Passenger Services. The engineer told Safety Board investigators that he did his own While the Safety Board does not dispute water testing with a kit and that he kept a the claims of the firemen that they had no journal of his testing. There was no problem reading the water glass, the Board documented evidence that this was done on believes that a working light on the water a regular, program-type basis or that glass, as required by the regulations, would anything was done with any test result have made reading the water glass easier and information. Investigators were unable to might have yielded more accurate infor- determine the effectiveness of such irregular mation about the action of the water level in water treatment, since no test results were the water glass and, thus, the amount of found or provided. The Safety Board water in the boiler. A working light might concludes that Gettysburg Passenger Ser- also have allowed the engineer, who indi- vices did not have a comprehensive water- cated that the water-level movement was treatment program. The Safety Board normally 4 to 5 inches, to see that the level believes that the FRA should require steam- was moving only an inch or less before the locomotive operators to have a documented accident. He might have realized that some- water-treatment program as a basis for boiler thing was wrong and been able to take maintenance and operation. preventive action. Boiler Washing--The first fireman’s tes- Water Treatment--Since scale, particularly timony about boiler washing described the as it affected the water-monitoring devices, manner in which Gettysburg Passenger became a factor in the investigation, Safety Services personnel washed the boiler. Board investigators explored how Gettys- Contrary to the regulatory requirement that burg Passenger Services treated its water in all washout plugs be removed, the fireman order to control the mineral content. removed only 4 of the boiler’s 29 washout According to experienced steam-locomotive plugs. With only four plugs removed, it is operators and historical railroad documenta- doubtful that even the most conscientious tion, water treatment is critical to the effort to wash out the boiler would have maintenance and safe operation of steam been very effective in removing a significant locomotives. Testimony from steam-lo- amount of sediment. comotive experts and investigators, from the owner of Gettysburg Railroad, and from

42 There was also a discrepancy between the water entered the boiler. As soon as the train method the fireman said he used to wash out began moving, the first fireman said, the a boiler and the methods described in main- feed pump was turned back on. However, tenance literature or described by the Stras- the second fireman testified that when he burg Railroad CMO. The fireman did not relieved the first fireman at Gardners, the use any special nozzles or equipment, which feed pump was still turned off and that he the ARA had adopted as recommended (the second fireman) turned it on. The Safety practice in 1915. His casual description of Board believes the feed pump was off on the the procedure displayed his lack of knowl- ascent to Gardners. edge and training in this critical procedure. The Safety Board concludes that the boiler On the fireman’s side of the locomotive washing procedure described by the fireman cab, three gages had been removed from a was inadequate to ensure that the boiler was mounting plate, leaving only a stoker-engine properly and thoroughly cleaned as required steam-pressure gage and a boiler-pressure by FRA regulations. gage. Gages displaying stoker-jet pressure, steam-heat pressure, and feed-pump pressure Although the CFR requires boiler wash- had been removed. Firemen use the feed- ings, it does not describe the procedure. pump pressure gage to ensure that heated When all railroads depended on steam, the feed water is overcoming boiler pressure and railroad industry had detailed methods and flowing into the boiler. Consequently, the special equipment for boiler washing; how- investigation steam-locomotive experts were ever, much of this expertise has disappeared. concerned to find locomotive 1278 lacked Despite TRAIN’s recent efforts to promote the gage. the proper boiler washing methods, it is ob- vious from this accident that some steam-lo- When the accident firemen were asked comotive operators do not have the initiative how they could tell whether the feed pump or the resources to find and employ proven was working, they both said they relied upon and accepted boiler washing methods. the sound and movement of the feed-pump Therefore, the Safety Board believes that the rod. Yet without a feed-pump gage to show FRA should describe the proper boiler wash- that the pressure was high enough to force ing methods and techniques in its regulat- water into the boiler, the feed-pump rod ions in order to set some basic safety could have been moving only because standard for steam-locomotive operators. pressure was being relieved by the leaking of the check valve. The Safety Board concludes Feed Pump and Gage--According to testi- that because the feed-pump gage was mony from the two firemen, they did not use missing, the traincrew had no reliable way to the water injector during the accident trip— determine whether the feed-pump pressure they used only the feed pump. When the was overcoming the boiler pressure and train left Aspers with the helper, the first delivering water into the boiler. fireman stated, the feed pump was shut off to prevent the locomotive drivers from Malfunctioning Check Valve--Investigators slipping on the wet rail, which was wet al-so examined another defect in the water- because of the leaking check valve between supply system. A check valve between the the feed pump and the boiler. Consequently, feed pump and the boiler had been leaking for the time the feed pump was shut off, no all day, although the valve had recently been

43 returned from repair. While it is not known steam-locomotive engineer), the helper fire- how much water was leaking from the valve, man, another Gettysburg Passenger Services it was enough water to necessitate clearing employee (who was qualified as both a half an open-decked observation car when steam-locomotive fireman and an engineer), the locomotive was pulling in reverse. If and the owner of Gettysburg Railroad each nothing else, the leak reduced the efficacy of described and demonstrated how he would water delivery to the boiler. It should also be blow down and verify the water glass. Only noted that had the accident locomotive been the owner of Gettysburg Railroad, the equipped with a feed-pump gage, the gage engineer’s father, demonstrated the correct would not have provided an accurate pres- method of blowing down. All the Gettysburg sure indication, since it would have been Passenger Services employees had been connected between the feed pump and the taught by the engineer. No one said that he leaking check valve, which was relieving also tested the gage cocks when he blew pressure. down the water glass, as required by regulation. The Safety Board therefore The leaking of the check valve indirectly concludes that the firemen did not know, contributed to the lack of water in the boiler. because they had not been properly taught, Because the valve leaked, the feed pump how to blow down the water glass or test the was shut down, cutting off the water supply gage cocks. The lack of knowledge about to the boiler and contributing to the cause of such basic procedures reflects the lack of an the crownsheet failure. effective training program at Gettysburg Passenger Services. Injector--The other means of water de- livery to the boiler was the injector, which Delineation of Responsibilities--According was not used, according to the locomotive to the testimony of the two firemen, re- crew. Postaccident examination of the in- sponsibility was not clearly divided among jector showed that it had the wrong type of the members of the crew, particularly be- steam valve disk. Such a disk would make it tween the two firemen. Each fireman felt he difficult to prime the injector, and if a lifting had a firm grasp of the tasks that needed to injector cannot be primed, it will not operate be done and how to do them; however, correctly. It would be possible for the neither was totally aware of who was injector to function, but only with some responsible for what tasks. The situation is difficulty. Although the injector does not much the same as the one in which two appear to have been involved in the crown- baseball outfielders run toward a fly ball. sheet failure, it is typical of another device Each may know how to catch the ball, but on locomotive 1278 that either did not unless there is a clear understanding of function or functioned marginally. The responsibility, each may expect the other to Safety Board concludes that because the catch the ball, and the ball may fall to the wrong type of disk had been installed in the ground. Or each may attempt to catch the injector, it would have been difficult to use ball, resulting in a collision and the ball’s the injector to add water to the boiler. being dropped. In either case, delineation of responsibility is critical. In this case, instead Water-Glass and Gage-Cock Testing--During of a ball, the critical item “dropped” was the the testimony, both accident firemen, the feed pump. The Safety Board concludes that helper engineer (who also worked as a there was no clear division of responsibility

44 among the members of the crew in this as co-owner of Gettysburg Passenger Serv- accident, particularly between the two fire- ices, had duties and responsibilities beyond men. running and maintaining the entire opera- tion. Unlike modern electric and diesel-electric locomotives, which may be operated with While the Safety Board acknowledges some degree of safety by the engineer alone, that it is up to the FRA to enforce the Hours operating a steam locomotive requires the of Service Act,40 the work-rest routine of close coordination of both fireman and Gettysburg Passenger Services train person- engineer. Such coordination is impossible nel exceeds the intent of the legislation and unless everyone involved has a clear under- might threaten the safety of the public. The standing of his responsibilities. While 49 Safety Board concludes that Gettysburg Pas- CFR 230.40 states that before each trip, the senger Services management was not aware water glass must be blown out and each gage of the Hours of Service Act. The Safety cock must be tested, the regulation does not Board believes that the FRA, in cooperation assign anyone this specific responsibility. with TRAIN, should promote awareness of The Safety Board believes that the FRA and compliance with the Hours of Service should delineate such basic levels of Act. responsibility and duties, since close coordination between and among the Training--Based on the description pro- engineer and fireman (firemen) is critical to vided of the formal training given to Gettys- the safe operation of the steam locomotive. burg Passenger Services employees, the The Safety Board also believes that until the training was a 1-day recurrent or refresher FRA specifies who is responsible for what, training module, rather than a comprehen- Gettysburg Passenger Services should sive training program. The closest thing that specify. Gettysburg Passenger Services had to a com- prehensive training program was a generic Hours of Service--Although fatigue does fill-in-the-blank document from the not appear to have been a factor in this acci- American Shortline Association used to sat- dent, the Safety Board is concerned that the isfy FRA engineer certification requirements cumulative and consecutive hours worked of 49 CFR 230.101. by employees, particularly part-time em- ployees, of tourist railroads such as Gettys- Gettysburg Passenger Services employees burg Passenger Services, may make such said they received their training through employees susceptible to accidents caused at OJT. But the company’s OJT program was least in part by fatigue or sleep deprivation. not organized enough to be comprehensive Such an accident exposes the public to dan- or complete. The greatest failing of the OJT ger. The members of the enginecrew of lo- comotive 1278 had worked a full day, taken a 2-or 3-hour break, and then returned at 62(KTUV" GPCEVGF" KP" 3;29." VJG" *QWTU" QH" 5GTXKEG" #EV 5:00 p.m. expecting to work until midnight. YCU"UWDUVCPVKCNN["TGXKUGF"KP"3;8;"D["2WDNKE".CY";3/ 38;0" (WTVJGT" COGPFOGPVU" YGTG" GPCEVGF" CU" RCTV" QH Whether part-time or full-time, such a day- VJG" (GFGTCN" 4CKNTQCF" 5CHGV[" #WVJQTK\CVKQP" #EV" QH to-day pattern can easily cause sleep depri- 3;98." 2WDNKE" .CY" ;6/56:." CPF" VJG" 4CKN" 5CHGV[ +ORTQXGOGPV"#EV"QH"3;::."2WDNKE".CY"322/5640"6JG vation and tiredness. This is particularly RWTRQUG" QH" VJG" NCY" KU" KVQ" RTQOQVG" VJG" UCHGV[" QH disturbing in the case of the engineer who, GORNQ[GGU" CPF" VTCXGNGTU" WRQP" TCKNTQCFU" D[" NKOKVKPI VJG"JQWTU"QH"UGTXKEG"QH"GORNQ[GGU0L 45 was that it was built upon either misunder- Steam-Locomotive Maintenance Expertise-- stood instructions or misinformation that The Safety Board is concerned that the had come second- or third-hand from a certi- incorrect injector disk, the leaking check fied or professional commercial-railroad valve, the missing feed-pump gage, the source. Thus, misunderstood, incomplete, or inoperative dynamo, and the non- incorrect information was continually passed functioning water-glass light together reflect on until it became the norm. Therefore, the a disturbing pattern of poor maintenance Safety Board concludes that Gettysburg Pas- and/or improper repair. Such maintenance, senger Services had no effective formal in the opinions of the investigation steam- training or certification program and that its locomotive experts, clearly indicated a lack OJT was dependent on second- and third- of knowledge and expertise on the part of hand expertise. the locomotive owners and crew. As previously noted, steam-locomotive Progressive Crown-Stay Failure--Although expertise is gone from most modern not a warning or preventative device, the de- commercial railroads, and generally only a sign of the accident locomotive boiler small number of experts and a limited appeared to mitigate the effects of the supply of knowledge and skill remain. crownsheet failure. As previously discussed, Today, many operating steam locomotives the locomotive had alternating rows of are in the hands of a generation who have straight-thread and button-head crown stays had to develop steam-locomotive mainte- to help ensure that any crownsheet failure nance and operation second- or third-hand, due to low water would occur relatively much like the personnel of Gettysburg gradually and in stages, rather than instanta- Passenger Services. One way to establish a neously and catastrophically. minimum level of steam-locomotive ex- pertise and thereby better ensure the safety The design was suggested in the 1922 of operators and the public would be to Master Boiler Association manual report. It establish an education and certification appears to have been unique to the Canadian program that establishes and enforces basic Locomotive Company, Ltd. and may well standards for steam-locomotive operation have prevented a more sudden catastrophic and maintenance. failure of the crownsheet, which could have sent the boiler rocketing off the frame, The NBBPVI and the tourist-railroad in- killing or injuring the crew and passengers. dustry steam-locomotive operators have The Safety Board believes such a design agreed to establish a program for the safe may be worthy of further study for maintenance and operation of boilers. The incorporation in steam locomotives when Safety Board supports such efforts and be- they are repaired or rebuilt. The Safety lieves that the FRA, in cooperation with the Board also believes that the FRA, in NBBPVI and the tourist-railroad industry cooperation with the NBBPVI and the steam-locomotive operators, should develop tourist-railroad industry steam-locomotive certification criteria and require steam-lo- operators should explore the feasibility of comotive operators and maintenance per- requiring progressive crown-stay failure sonnel to be periodically certified to operate features in steam locomotives. and/or maintain a steam locomotive.

46 The Safety Board believes that the FRA, techniques and technologies, to minimize in cooperation with the NBBPVI, should interpretation based on empirical experience, update 49 CFR Part 230 to take advantage of and to maximize the use of objective accepted practical modern boiler-inspection measurable standards.

47 CONCLUSIONS

1. The explosion in the locomotive resulted 7. Because the feed-pump gage was from crownsheet failure caused by missing, the traincrew had no reliable having too little water in the boiler. way to determine whether feed-pump pressure was overcoming boiler pressure 2. Because the water-glass spindles were and delivering water to the boiler. restricted, the water glass could not represent the water level in the boiler 8. Because the wrong type of disk had been accurately. installed in the injector, it would have been difficult to use the injector to add 3. Although the engineer had signed the water to the boiler. Federal Railroad Administration’s forms No. 1, certifying that the work had been 9. The firemen did not know, because they done, the water-glass spindles and gage had not been properly taught, how to cocks were not cleaned on a monthly blow down the water glass or test the basis. gage cocks.

4. The water glass was not illuminated as 10. There was no clear division of required. responsibility among the members of the crew in this accident, particularly 5. Gettysburg Passenger Services, Inc., did between the two firemen. not have a comprehensive water- treatment program. 11. Gettysburg Passenger Services, Inc., management was not aware of the Hours 6. The boiler washing procedure described of Service Act. by the fireman was inadequate to ensure that the boiler was properly and 12. Gettysburg Passenger Services, Inc., had thoroughly cleaned as required by no effective formal training or Federal Railroad Administration certification program, and its on-the-job regulations. training was based on second- and third- hand expertise.

48 PROBABLE CAUSE

The National Transportation Safety ger Services, Inc., management to ensure Board determines that the probable cause of that the boiler and its appurtenances were the firebox explosion on steam locomotive properly maintained and that the crew was 1278 was the failure of Gettysburg Passen- properly trained.

49 RECOMMENDATIONS

As a result of this special investigation, operate and/or maintain a steam loco- the National Transportation Safety Board motive. (R-96-58) makes the following recommendations: In cooperation with the National --to the Federal Railroad Administration: Board of Boiler and Pressure Vessel Inspectors and the Tourist Railway Require that each operating steam Association, Inc., update 49 Code of locomotive have either a water column Federal Regulations Part 230 to take or a water glass in addition to the advantage of accepted practical mod- water glass and three gage cocks that ern boiler-inspection techniques and are already required. (R-96-53) technologies, to minimize interpreta- tion based on empirical experience, Require steam-locomotive operators to and to maximize the use of objective have a documented water-treatment measurable standards. (R-96-59) program. (R-96-54) --to the National Board of Boiler and Describe basic responsibilities and Pressure Vessel Inspectors: procedures for functions required by regulation, such as blowing down the Cooperate with the Federal Railroad water glass and washing the boiler. (R- Administration and the Tourist Rail- 96-55) way Association, Inc., in exploring the feasibility of Federal regulations re- In cooperation with the Tourist quiring progressive crown-stay failure Railway Association, Inc., promote features in steam locomotives. (R-96- awareness of and compliance with the 60) Hours of Service Act. (R-96-56) Participate with the Federal Railroad In cooperation with the National Administration and the Tourist Rail- Board of Boiler and Pressure Vessel way Association, Inc., in developing Inspectors and the Tourist Railway criteria to be used in the periodic certi- Association, Inc., explore the feasibil- fication of steam-locomotive operators ity of requiring a progressive crown- and maintenance personnel. (R-96-61) stay feature in steam locomotives. (R- 96-57) Participate with the Federal Railroad Administration and the Tourist Rail- In cooperation with the National way Association, Inc., in updating 49 Board of Boiler and Pressure Vessel Code of Federal Regulations Part 230 Inspectors and the Tourist Railway to take advantage of accepted practical Association, Inc., develop certification modern boiler-inspection techniques criteria and require that steam-loco- and technologies, to minimize motive operators and maintenance interpretation based on empirical personnel be periodically certified to experience, and to maximize the use

50 of objective measurable standards. (R- the Federal Railroad Administration 96-62) and the National Board of Boiler and Pressure Vessel Inspectors in devel- --to the Tourist Railway Association, oping criteria to be used in periodi- Inc.: cally certifying steam-locomotive op- erators and maintenance personnel. In cooperation with the Federal Rail- (R-96-65) road Administration, promote aware- ness of and compliance with the Hours Encourage its members who operate of Service Act. (R-96-63) steam locomotives to participate with the Federal Railroad Administration Encourage its members who operate and the National Board of Boiler and steam locomotives to cooperate with Pressure Vessel Inspectors in updating the Federal Railroad Administration 49 Code of Federal Regulations Part and the National Board of Boiler and 230 to take advantage of accepted Pressure Vessel Inspectors in explor- practical modern boiler-inspection ing the feasibility of Federal regula- techniques and technologies, to mini- tions requiring progressive crown-stay mize interpretation based on empirical failure features in steam locomotives. experience, and to maximize the use (R-96-64) of objective measurable standards. (R- 96-66) Encourage its members who operate steam locomotives to participate with

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL Chairman

ROBERT T. FRANCIS II Vice Chairman

JOHN A. HAMMERSCHMIDT Member

JOHN J. GOGLIA Member

GEORGE W. BLACK, JR. Member

November 15, 1996

51

APPENDIX A

APPENDIX A

Investigation and Sworn Testimony Proceeding The accident occurred about 7:30 p.m. edt on Friday, June 16, 1995, and was reported to the Coast Guard’s National Response Center (NRC) in Washington, D.C., the following morning at 7:17 a.m. The NRC incident report number was 295913. The incident report was electronically sent to the National Transportation Safety Board (NTSB) at 7:39 a.m. on Saturday, June 17, 1995.

The NTSB investigator arrived at the Gettysburg Railroad about 10 a.m. on Tuesday, June 20, 1995, and initiated the accident investigation. The Gettysburg Railroad, Gettysburg Passenger Services, Inc., the Federal Railroad Administration, the Hartford Steam Boiler Inspection and Insurance Co., and members of the Tourist Railway Association, Inc., participated and assisted in the investigation.

As part of the investigation, a 2-day sworn testimony proceeding was held at the Holiday Inn in Gettysburg, Pennsylvania, on September 27 and 28, 1995. Parties to the proceeding included the Gettysburg Railroad, Gettysburg Passenger Services, Inc., the Federal Railroad Administra- tion, the Hartford Steam Boiler Inspection and Insurance Co., the National Board of Boiler and Pressure Vessel Inspectors, Inc., and members of the Tourist Railway Association, Inc. Twelve witnesses testified.

53

APPENDIX B

Abbreviations Used in this Publication

ARA: American Railroad Administration

CFR: Code of Federal Regulations

CMO: chief mechanical officer

ESC: Engineering Standards Committee for Steam Locomotives

FRA: Federal Railroad Administration

ICC: Interstate Commerce Commission

MP&E: motive power and equipment

NBBPVI: National Board of Boiler and Pressure Vessel Inspectors

OJT: on-the-job training psi: pounds per square inch

TRAIN: Tourist Railway Association, Inc.

53