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 . Illlr 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Safety Board is concerned that these hazards may be becoming more significant because Federal regulatory controls are outdated and because expertise in operating and maintaining steam locomotives is diminishing steadily.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