Blame the dead guy?!
This is the final look at the Southern Pacific Tunnel 26 accident of 19 November 1941, involving the Extra 4193 West.
Readers probably noticed that the official accident investigation by the Interstate Commerce Commission did not consider as many parameters as a modern multi-disciplinary accident investigation would today.
Essentially, the report said the accident occurred because:
1) The train stalled in the tunnel.
2) No one turned off the oil supply after this happened.
My post which includes the ICC's report can be found here:
All of the previous Southern Pacific-related posts can be found
by pressing the Short Subjects 02 radio button (in the top banner)
and scrolling down alphabetically until your reach the 'SP ... ' items.
* * *
The engineer and the young fireman (the 'engine crew' responsible for the oil supply) both died in the accident. The ICC investigators provide a neat, factual conclusion. It places no responsibility on the railroad, anyone in company management, or anyone who is alive.
In an earlier post, I tried to describe the economic boom being experienced in California in 1941 ... created by the 'wartime economy' which immediately preceded the US entry in World War 2.
We do not know if this boom contributed to the loss of experienced railroad workers to more stable and 'family friendly', well-paying industrial work ... or if increased traffic demand resulted in a wave of new employee hiring.
The short period the fireman had been employed is cited in the investigation. After unpaid student trips with practical instruction (of variable quality) in the cab of a working engine ... and self-study (no formal classroom instruction) ... the fireman would have been judged ready to begin work under the normal supervision of an engineer.
The ICC report does not address the issue of new employee training.
... In the 1940s, is it likely that a newly-hired fireman would be empowered - during any of this casual training - to 'shut down' the locomotive of his own volition if he had identified a safety emergency?
* * *
This post will look at five factors:
1. Train crew members.
2. Engine crew members.
3. The Extra 4193 West and the timetable.
4. The role played by maintenance of way equipment.
5. Decision making, task saturation and situational awareness.
* * *
We do not know if there were any professional consequences for the four surviving crew members.
Similarly, we do not know if the railroad officials supervising these employees, or other aspects of railroad operations, were subject to company sanctions.
We do not know how the survivors' lives were affected by this tragedy.
* * *
1. Train Crew Members (4)
The conductor is responsible for conducting the movement over the line. On this train, there was a brakeman on the engine and two brakemen in the caboose with the conductor. Traditionally, the conductor would work collegially with the engineer - rather than trying to 'pull rank' on general decision-making.
With the advent of more powerful motive power and 100-car trains, this traditional arrangement breaks down. In 1941, there was no end-to-end radio communication on SP trains. How could a conductor instruct or confer with the engineer? The crew in the caboose could only give physical signals along the side of the train to relay instructions - assuming the engine crew was looking back to see them at precisely that moment.
... Or ... the conductor could 'pull the air' if there was a rules-based justification for it. The act of slamming on the emergency brakes - if not reasonable in the engineer's eyes - would send a shockwave through the local engineer community on the same day it happened. Only a micro-managing conductor who didn't respect engineers would put the whole train into emergency!
(In fact, I think I remember seeing old caboose brake valves which allowed a range of increasing brake pipe reductions. However, I think it was necessary to stop the train before any graduated brake pipe reduction by the conductor could be reversed.)
In any case, there was a strong social disincentive to using the conductor's valve to 'communicate'.
Consequently ...
In most cases, the engineer had all the responsibility of ... supervising the fireman; protecting the company's valuable capital investment in the motive power (and steam locomotives were very labour-intensive to operate); ensuring the movement follows all the rules and speed limits; do all the 'driving'; and thus take sole responsibility for all of the rolling stock and its contents for most of the trip.
To oversimplify: With a 100-car train in the 1940s, the conductor is just along as a passenger who handles company paperwork, and who leads and supervises the train crew when the train has stopped to conduct switching moves.
As an example: This conductor was not aware of the conditions at the locomotive inside Tunnel 26. Consequently a tailend brakeman was sent toward the headend with a verbal movement directive for the engineer. This messenger died from the lack of oxygen just a few car-lengths into his long trip in darkness to the headend.
2. Engine Crew Members (2 + 1 student)
To become an engineer, one must first work as a fireman. A fireman's work leaves little room for error. A fireman's mistake which the engineer does not notice can precipitate a wide variety of consequences: from merely expensive for the company ... to catastrophic with the loss of life.
In addition to the 24-year-old fireman with 2 months' experience, this engineer had a second 24-year-old student fireman in his cab.
A fireman whose skills are not fully developed can undermine the outcomes the company expects of the engineer. The 'in real time' supervising railroad official (i.e. the dispatcher) expects the train to get over a busy subdivision in the normal time. It is up to the engineer to achieve this - new fireman or not.
At some point or another, the engineer on the Extra 4193 West had to: think of ... monitor ... coach ... or compensate for ... two inexperienced firemen working on his engine.
Further adding to the engineer's cognitive workload, the experienced brakeman on the headend provided unsolicited input en route on the need to stop and repair a faulty cylinder cock observed on his side of the engine. The engineer declined to do this, citing the delay this repair would cause.
ICC report: "According to the statement of the student fireman who was on the engine the engineer experienced difficulty with the throttle throughout the trip."
It is unclear whether the engineer's problems with throttle control were the result of:
- A basic ergonomic failing of the cab design and the throttle lever.
- A physical or medical problem the engineer had.
- A defect the company shop had not repaired on this essential control.
The throttle control problems contributed significantly to the loss-of-life accident, according to the ICC investigation.
* * *
The Assigned Crew
Considering this train - an extra freight running at night - we may conclude that these crew members are not a 'regular crew'. That is, they are not regularly assigned to work together on a particular job at the same time each day.
They are working out of the Los Angeles 'hub' - from which radiate many subdivisions, and industrial and switching work assignments. Perhaps only the headend brakeman, conductor and engineer (all with years of service) know each other well.
The fireman and the tailend brakemen may have been called from their spareboards ... where low-seniority workers waited for a call to work: 24 hours per day, 7 days a week.
It is only in modern investigations that the following foundation for performance is documented:
That each member of the crew is fit, rested and qualified for duty. None of this was considered in the ICC report.
* * *
3. The Extra 4193 West and the Timetable
- Below, is the timetable in force at the time of the accident.
- Traffic on the Ventura Subdivision is controlled by timetable, train orders and an automatic block system.
- Extra 4193 West is 96 cars + caboose in length, 3550 tons (the maximum rating for the engine here was 3650 tons).
- It departs from Los Angeles yard at mileage 479.7 at 2315hr on 18 November 1941.
- The siding capacities and subdivision mileages are shown on Page 2, below. Page 3 is supplied only for completeness and to show that there are no scheduled westbound freights which could help us calculate the expected progress our extra would make over the subdivision. While Train No 373, the Coast Merchandise Westbound, originates at LA Yard, it transports LCL freight, fresh produce and other perishables. Special rolling stock allows it to travel at passenger train speeds.
- We do not know anything about the traffic on the railroad that night. The only thing that I can assume is that Train 812 - a Second Class eastbound train - is running, and that it is on time.
- As the Extra 4193 West must clear for Train 812, the responsibility for calculating and organizing this meet falls on the shoulders of the engineer. The conductor cannot participate collegially in this decision from the isolation of the caboose, 100 cars back.
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| from: The employee timetable collection of the California State Railroad Museum, Sacramento. archive.org https://archive.org/details/cscrm_2021_02_001478/mode/1up |
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| from: The employee timetable collection of the California State Railroad Museum, Sacramento. archive.org https://archive.org/details/cscrm_2021_02_001478/mode/1up |
* * *
The Engineer Calculates the Meet
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| screencaps from: Southern Pacific employee timetable 183, Los Angeles Division, 8 July 1945. archive.org https://archive.org/details/cscrm_2021_02_001553/page/n19/mode/1up |
- The map above is identical to the map published with the 1941 timetable.
- My yellow dots and labels show the route. The times are from the ICC report.
- The red dot is the accident location.
- The red labels show the expected scheduled progress of Train 812 against Extra 4193 West.
- The three green dots show the only sidings in which the Extra 4193 West will fit.
- My guess is that Moorpark would be the chosen location to clear ... if the extra makes normal progress.
- Once the extra passes Santa Susana siding, the engineer is committed to clearing at Moorpark. Stopping at Santa Susana would probably result in the conductor 'collegially' stomping up the ballast and demanding to know why they are waiting for an hour on a siding.
- Completely clearing at Moorpark would typically be 5 minutes before the 0135hr scheduled time of No 812. This means the extra is stopped in the siding, with its headlight off, and with the switch behind the caboose lined and locked for the passage of No 812. No 812 will be governed by the ABS signals indicating track occupancy (if the Extra has not cleared) as it approaches the siding.
- While this meet is a laboured calculation for me, it would be a routine decision for an experienced engineer.
- We cannot know if aiming for the target of Moorpark influenced the engineer's decision not to stop to repair the cylinder cock.
- Similarly, we cannot know that the cylinder cock defect was definitive in the stalling of the train in Tunnel 26.
I would be very surprised if only these two trains were operating that night. Given the increased demand to move 'wartime' traffic, it seems much more likely that additional extra movements ... and/or routine dispatcher modifications to the schedule through train orders ... were added to the engineer's mental model of the subdivision traffic that night.
* * *
4. The role played by maintenance of way equipment.
In the footnotes at the back of the timetable is this text.
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| from: The employee timetable collection of the California State Railroad Museum, Sacramento. archive.org https://archive.org/details/cscrm_2021_02_001478/mode/1up |
Automatic mechanical flange (rail) lubricators were intended to decrease friction between the wheel flanges and the 'gauge face' of the rails on curves.
As a maintenance of way device, they decreased rail wear - reducing the familiar flange-squealing sound. They could also help prevent derailments on curves when gauge face friction was so great that a wheel would climb over the rail and cause a derailment.
Below, is text from a 300-page book published by Imperial Oil/Esso on all aspects of railroad lubricants, circa 1950. (Imperial Oil/Esso was a Canadian subsidiary of the former Standard Oil - Exxon.)
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| from: Railway Lubrication; circa 1950; Imperial Oil. |
The design of the flange lubricators used by the SP in 1941 was probably of a less efficient, earlier design from the 1930s.
Even in the 1970s and 1980s these devices always seemed to be sitting in a black wasteland of fugitive grease. The deep grease reservoir in the diagram (above) suggests that maintenance of the device is not going to be a daily task during which the section gang comes by with a roll of paper towels and wipes away any grease which has fouled the top of the rail.
Continuing with flange-rail friction ... the 4193 did not need any blind driving wheels (i.e. none were flangeless) because its two eight-driving-wheel 'engines', were articulated to move independently of each other. Among the driving wheels, some axles were also designed to accept lateral motion. This engine probably cornered like it was on rails.
Below is a wonderfully helpful section of a 'track profile' from Multimodalways (linked below). It is from 1992. However, the mileage of Chatsworth 445.5 is identical to the 1941 employee timetable (numbered from Santa Barbara) so the curves and tunnels can be assumed to have the same mileages as well.
I have added polka dots to make it festive.
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| from: Multimodalways - SP Lawrence-Burbank Jct Track Chart 1992 (PDF) https://www.multimodalways.org/archives/rrs/SP/SP%20Track%20Charts/SP%20Track%20Charts.html |
- On the line near the top with all the labels, you can see Tunnel 26 labelled, then 27, 28 and Chatsworth at 445.5 .
- The next line down is the track mileage graduated in tenths of miles, i.e. 440, 440.1, 440.2 etc., type of rail, ballast, etc.
- The bottom line shows gradient (and/or ruling grade), coming eastbound from Santa Barbara ... so minus 1.0 ( ... or +1.0 % for the 4193 as it approaches Tunnel 26 westbound, purple dot).
- The line above gradient shows curvature. My blue dots show the two distinctive ~90 degree curves east of the tunnel are identified as 223 and 224. You'll notice that they straddle very short Tunnel 28.
- Referring to the timetable note above: lubricators are at 442.7, 443.7 . These are marked with red dots on the track profile.
At the top of Page 6 of the ICC report, it says:
"When the engine was at a point about 5,000 feet east of the east portal of tunnel No. 26 the engine slipped and the train stalled. After the slack was taken twice the train proceeded and when the engine entered the tunnel the speed was between 10 and 12 miles per hour. At a point 3,899 feet west of the east portal, or approximately half way through the tunnel, the engine again slipped and the train stalled."
... As the engine slipped and stopped inside Tunnel 26 ... the train slack ran in from inertia ... and back out from gravity ... and when the runout of slack reached back 75 cars to the steel gondola loaded with steel ... it broke its knuckle and the train brakes went into emergency. This locked up the wheels on the whole train. This emergency brake application marked the beginning of the fatal accident.
* * *
If you notice the mileage and location of the first lubricator the engine passed over (the red dot at the right, above) ... "5000 feet from the portal" is consistent with a point reached shortly after the engine ran over the first lubricator. The engine slipped here twice.
I have tried to accurately transcribe the two red dots on the track profile above to a current GoogleMaps view of this track section as it appears today.
The 4193 passed over the second lubricator as it was entering Tunnel 26.
But if the 4193 slipped and the train stalled at the first lubricator, why didn't the train stall at the second lubricator just outside the tunnel?
And how was the 4193 able, after passing that second lubricator, to pull the whole train onto the 1% grade inside Tunnel 26 before slipping and stopping?
(The ICC diagram of Tunnel 26 gradient appears below.)
Having slipped ... stalled ... taken slack twice in order to restart the train ... knowing he was approaching a second lubricator ... and knowing he would be running his train up a 1% grade ... while pulling 3550.5 tons (of a rated 3650 tons for the engine in this territory) ... the engineer would perhaps be taking no chances with traction and he might be sanding heavily.
As we saw in a recent post about pre-trip locomotive inspection, taking slack, cylinder cocks and sanding ...
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| from: Locomotive Management; AB Carson; 1928, 1937; International Textbook Co. |
I have read many books about railroad operating procedures but I had never encountered this paradoxical side effect of sanding before.
Since the long-ago adoption of diesel-electric power, with its high tractive effort and good adhesion at low speed, it seems possible this 'stalling because of sand' might be a 'lost railroad phenomenon'. Given how frictionless shaped steel wheels on steel rails are, this unexpected effect of sanding is yet another fascinating aspect of wheel-rail physical science.
We will never know whether the flange lubricators and reactive sanding were significant factors in this accident.
The ICC investigators were extremely diligent in their review of the local physical forensics inside the tunnel: measuring and locating the roof damage from the exhaust and safety valve discharge ... and the rail burns from slipping ... to recreate the engine's movement within Tunnel 26.
However, they made absolutely no mention of the two lubricators' locations, state of repair, or functioning at all.
They did not analyze the train dynamics and traction at the point of the first slipping (twice) and gathering of slack (twice) at/near the first lubricator.
* * *
Train Handling
When knuckles break and trains stall on grades, investigations have typically looked at the performance of the engineer and his 'train handling'. The 75th car of 96 was a gondola car constructed of steel which was loaded with steel. It was a slack runout which broke the knuckle on this car and precipitated the accident.
The conductor denied that there had been any problem with harsh slack action in the train up to that point. The marshaling of loads/empties in the train is not discussed in the ICC report.
The investigators suggest that because the independent brake was found in the applied position after the accident, this had probably caused the slack runout and the breaking of the knuckle on the steel gondola.
* *
Those Onboard the Engine
The accounts given by the participants to newspapers immediately - during the first 24-48 hours after the accident - are not always the same as the actions and accounts which were taken under oath and included in the ICC report.
Speaking from his hospital bed, the student fireman stated:
"When the engine stalled I went out one side of the cab with [the brakeman] while the other two climbed out the other side."
... then ... his 5-word gift to the journalists: "like being lost in hell" ... then ...
"[The brakeman] and I made our way to the end of the tunnel - and after we got our breath we went back in to find out what happened to the engineer and the fireman."
Prescott Evening Courier (Arizona), 19 November 1941.
... Having struggled in the dark for 3529 feet to reach the west portal, the brakeman and student fireman had narrowly escaped death. At the upper (west) portal of the tunnel, where most of the gases would naturally flow and accumulate, no reasonable person would expect them to retrace their steps back into the tunnel.
Standard Code of the AAR, 1940, General Rules, Rule L:
"In case of danger to the Company's property employe[e]s must unite to protect it."
The headend brakeman and the engineer probably knew each other from their years of service. In reading the newspaper accounts of the accident, I have always wondered about the terms on which these two veterans parted ...
Nowhere is there any account that the engineer told the brakeman and student to leave the equipment to save themselves.
If the brakeman and student exited one side of the cab and the engineer and fireman the other, was the engineer aware that the brakeman had made the bold and appropriate decision to save his life and that of the student's by abandoning the train?
* * *
On these engines, I believe the pull-handle-cable-linkage to release the spring-loaded oil cut-off inside the tender was always located on the backhead cab wall - that is, behind the engineer and fireman. It was located here so either member of the engine crew could easily reach it to cut the fuel when any emergency required a quick response. The ICC report stated that it had not been triggered, but that it worked flawlessly during the investigation.
What are the possible reasons why the fuel was not turned off in this manner?
5. Decision making, task saturation and situational awareness.
Earlier, I suggested that the fireman (with two months' experience) would not consider it being within the realm of his authority to decide that the engine must be shut down.
The ICC report notes the failure to move the fireman's oil regulator valve to the 'drifting' (i.e. like 'idle') setting ... or to close the oil regulator valve entirely.
However, as I understand it, closing the fireman's oil regulator valve would shut the engine (fire) down ... having the same effect as if the fireman had actuated the emergency cutoff via the cable leading to the tender valve.
Having a '100-car freight train going into emergency in the centre of Tunnel 26' would not have been covered in the fireman's training materials or his trial trip instruction. When this happened, he would look to the engineer ... in order to follow his instructions in this emergency situation.
* * *
It was the engineer's fault.
... That is the conclusion the ICC investigation leaves us with.
I think the engineer did not turn off the oil supply using the cable-linked tender valve
because he could not.
The reasons might include:
A) He had a medical crisis (eg. a heart attack) before he could act.
B) He was injured in the cab or as he exited the cab (eg. he was scalded, or he fell from the cab ladder, or he fell into one of the tunnel drains).
C) He was trying to solve the problem in a 'conventional railroad way' - which would cause the least delay to his train and to the traffic on the railroad.
He may not expect that the young fireman (or the student) has left the oil regulator valve in a low 'working engine' fire setting which is creating choking smoke. This is because the 'working fire' is not being drafted by the exhaust of a working engine.
He expects he will be 'examined' by management over his train-handling, so he is working efficiently to add as little delay as possible. With the brakeman unable to reach the tender to cut the power off the train, it is up to him to wait out the safety valve steam, uncouple the engine, and run it out of the tunnel.
The 'correct' answer from the safety of a 2026 blog post is 'to stop the fire to preserve life' ... and get the engine out of the tunnel and out of the way (for the moment) by using the steam pressure in the boiler. But ...
... Perhaps the engineer was well aware that everything on an oil-fired engine needs high pressure steam. The tender tank heater to keep the heavy bunker oil flowing, the oil superheater to get it to burning temperature, the atomizer to break the heavy oil into fine a mist which can burn, the blower to draft the fire of a stationary locomotive, the injector to keep the boiler filled with water.
... If the fire was extinguished and boiler steam was consumed to run the engine out of the tunnel, an extended delay might occur because remedial efforts would have to be made to re-light the stubborn heavy oil with diminished steam pressure. Next, would come the work to nurse the boiler back to operating temperature to produce adequate quantities of steam.
... The ICC report suggests cutting the oil supply (they are as smart as a 2026 blogger) ... or leaving the oil regulator in the drifting setting. However, the ICC offers no estimate on life expectancy for the workers in the small air volume of the tunnel even with this lighter fire setting. The reason for the emergency air brake application would have to be found and corrected while the fire burned away inside the confined area of the tunnel with the crew members present.
Speaking of the emergency air brake application. As far as the headend knows, uncoupling the engine would leave all 96 cars at rest on a 1% grade. If the air bleeds off and the tailend crew did not take the precaution of applying an adequate number of handbrakes, an eastbound runaway of the entire train might occur.
D) Task Saturation. I won't drag you through the list again. But see if you can imagine and/or recall all the information, calculations and functions the engineer has had to consider and perform ... from his usual pre-trip responsibilities as an engineer ... up to this point ... one hour (37 miles) into his 108-mile workday.
Hi-lites: After leaving Los Angeles yard, he's had two inexperienced fireman working on his engine. He's had problems with the throttle, traction, and with stalling the train (three times). He is aware of the probability of discipline by company management because of the situation he now finds himself in ... in Tunnel 26. He can't account for the whereabouts of the brakeman and the student who were in his cab. He's trying to imagine the best way to handle whichever mystery problem has caused the emergency brake application. He has no idea what the tailend crew is doing.
E) Loss of Situational Awareness. Because of the engineer's task saturation with 'conventional railroad procedures' it is impossible for him to recognize that in only a few minutes he and his fireman will become unconscious and then die. That is why he does not extinguish the fire.
* * *
The End
* * *
By way of being constructive and preventing this type of occurrence from happening again in 1941, I would look at the following issues:
1. While the ICC details all of the engineer's cab control settings as they were found ... and shows that there was adequate sand ... and that the emergency oil cutoff worked ... and the impractical and irrelevant observation that no respirators were signed out of the shop in Los Angeles - i.e. a full hood with a hose coming out the top which attaches to the air brake system. Their investigation DOES NOT comment on the proper functioning of the throttle lever. Was there a defect which the shop left uncorrected? The report DOES NOT explain (if it might account for a loss of traction in Tunnel 26) WHY an engine is leaving the shop with an constantly open, malfunctioning cylinder cock.
2. The ICC offers a short sentence in recognition of the fact that the fireman "involved had but little experience". However, it makes no pronouncement on the training of that fireman. Should new firemen be trained that crew safety is paramount and that, in the event of an emergency in a long tunnel, the FIRST CONSIDERATION MUST BE to ask the engineer: 'Should the oil regulator valve be closed or should the emergency oil cutoff be engaged until the reason for the emergency brake application is known?'
3. The ICC does not comment on how having an inexperienced fireman AND a student fireman in the cab at the same time affects the efficiency and safety of locomotive operations. It does not address how this might create unnecessary distractions for the engineer.
4. The ICC notes the location of the first loss of traction, wheel slip and train stalling (twice at that location). It does not mention the fact that this loss of traction was at the site of a flange lubricator. It does not record the STATE OF MAINTENANCE of that flange lubricator, or the second flange lubricator at the east portal of Tunnel 26. Were the traction surfaces of the rails found to be fouled with grease at either lubricator location? Are there better places to locate these devices?
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