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Unit Train Derailment Site Case Study:

Emergency Response Tactics

Incident Details

Published by: Renewable Fuels Association

Authored by: International Association of Fire Chiefs

March 2015

PREFACE

This document was prepared by the International Association of Fire Chiefs (IAFC) for the

Renewable Fuels Association (RFA). The information, though believed to be accurate at the time

of publication, should not be considered as legal advice or as a substitute for developing specific

company operating guidelines. IAFC or RFA makes no warranty, expressed or implied, or

assumes any legal liability or responsibility for the accuracy, completeness, or applicability of the

information presented in this document.

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Handling Instructions

Hazardous Material - Unit Train Related Transportation Incidents Case Study

The information gathered in this CASE STUDY is classified as open source

and should be used as a reference in reviewing the potential hazards of

your community.

At a minimum, the attached materials will be disseminated through the

Renewable Fuels Association (RFA).

Points of Contact:

Renewable Fuels Association:

Kristin Moore

Vice President, Technical Services

425 Third St. SW, Suite1150

Washington, DC 20024

International Association of Fire Chiefs:

James Rist

Program Specialist

4025 Fair Ridge Dr.

Fairfax, VA 22033

Richard Miller

Program Manager

John Woulfe

Assistant Director Programs and Technology

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Table of Contents

Case Study #1……………………………………………………………………………….4

Case Study #2………………………………………………………………………………15

Case Study #3………………………………………………………………………………24

Case Study #4………………………………………………………………………………34

Case Study #5………………………………………………………………………………39

Appendix: Events Summary Table………………………………………………………47

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Case Study #1

Title: Lynchburg Derailment

Incident Background and Locality Contact: Conference Call

Interview – Conducted on Wednesday, 4 June 2014

Lynchburg Fire Department, Fire Chief Steven B. Ferguson

(steven.ferguson@lynchburgva.gov)

800 Madison Street

Lynchburg, VA 24504-2545

Rail Line: CSX Transportation / CSX Corporation (CSX)

Date: Monday, 30 April 2014

Location: Lynchburg, Virginia

Narrative: Written by James Rist and Richard Miller

Weather: Source – Weather Underground (www.wunderground.com)

Photos: Various Sources

Emergency Plan/ Fire Pre-Plan: Yes

Supporting Documentation:

Lynchburg Narrative

Lynchburg is an independent city in the Commonwealth of Virginia. As of the 2010 census,

the population was 75,568. Located in the foothills of the Blue Ridge Mountains along the

banks of the James River, Lynchburg is approximately 120 miles west of Richmond. Other

nearby cities include: Roanoke (southwest), Charlottesville (northeast), and Danville (south).

The Lynchburg Fire Department, established in April of 1883, provides fire suppression and

prevention services, emergency medical services, technical rescue, hazardous materials

response, and confined space emergency response for approximately 76,000 Lynchburg

residents, as well as the thousands who enter the area daily to work and shop. The

department is staffed with 192 personnel, including civilians, firefighters and emergency

medical personnel operating with eight stations, an administrative office, a specialized repair

shop, and a fire training facility.

The City of Lynchburg uses the Commonwealth of Virginia Department of Fire Programs for

fire service certifications. All Lynchburg personnel are Hazardous Materials Level Awareness

and Operations certified, with many certified at the Technician-Level.

HazMat Team

The Lynchburg Fire Department's HazMat Team provides the citizens of Lynchburg with an

innovative approach for resolution of life safety situations involving hazardous materials.

Fire department employees provide advanced planning and management services for

chemical releases in the Lynchburg area. By developing partnerships and enacting written

mutual aid agreements with other localities, the hazmat team provides the ability to take an

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offensive approach to unplanned releases of hazardous materials.

Some incidents may require the response of the regional hazmat team; however,

Lynchburg’s team effectively decreases critical time delays before more aggressive actions

can be taken. This will favorably change the outcome of a chemical release in the

Lynchburg area.

HazMat Team Capabilities

Ability to:

Control a hazardous substance spill or

leak.

Assess and manage container damage.

Detect and monitor hazardous

atmospheres.

Work at transportation or fixed facility

emergencies.

Use advanced chemical protective clothing.

Decontaminate personnel during exposures.

Perform advanced hazmat life support medical services.

The hazmat team operates in compliance with governmental regulations and professional

standards. Members of the hazmat team offer additional hazmat related training for other

Lynchburg public safety departments.

HazMat Team Profile

The Lynchburg HazMat Team was developed in 1999 and operates a Level III self-contained

response unit from Lakeside Drive Fire Station #7. The team consists of 30 technicians and

specialists who perform these special operations in addition to their firefighting and EMS

duties with the Lynchburg Fire Department.

Rail Background

Lynchburg has pre-plans for the railways in their area, as both CSX and Norfolk Southern

have rail yards. Lynchburg also sees passenger rail as Amtrak shares rail time with freight rail.

In addition to the normal freight and passenger rail train traffic, Lynchburg experiences a unit

train of either Bakken crude oil or ethanol daily. These trains, operated by CSX, transport

these products through Lynchburg southeast to Yorktown, VA to the Plains All American

Pipeline LP. At that location these products are transloaded (Transloading is the process of

transferring a shipment from one mode of transportation to another) into either pipeline or

aboard barges or ships moored on the York River. Besides crude oil and ethanol, products

such as butane, biodiesel components and other petroleum products, will also come and go

by rail and water; therefore some of these products may pass through Lynchburg heading

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westward.

Free access mapping system: http://www.mapsofworld.com/usa/states/virginia/virginia-railway-map.html

Incident

On Wednesday afternoon, 30 April 2014, at 1400 hours a CSX Bakken crude oil unit train was

transiting through downtown Lynchburg when it derailed. The 105-car train had 17 of its DOT-

111 rail cars derail. Three cars landed in the James River where one leaked product into the

river, but another car breeched and burned. A local business called 9-1-1 reporting a vehicle

fire.

Initial fire department response consisted of three engines, truck (ladder), a Battalion Chief

and EMS. Upon arrival after initial determination of a rail incident, an additional two engines

and truck were dispatched to the assignment. Incident command post was established at a

nearby intersection and a defensive posture to protect exposures was initially established.

Regional Mutual Aid called to provide backfill coverage. A Lynchburg Fire Department

recall was activated for off-duty staff to report (overtime) for backfill to maintain adequate

emergency service protection. The incident command post location was relocated in the

first hour to a parking lot that allowed the incident command post to safely continue

operations. The command post operation was unified with

police and city management. According to Lynchburg EMS,

there was no CSX representation at the command post until

the end of the incident and command was never able to meet

or talk with the train crew. A second fire department

Command Battalion Chief had to be dispatched to the CSX rail

yard within the city of Lynchburg to acquire the train’s consist,

which was attained and brought back to the command post.

Product identification: Incident command identified the

products involved by the DOT placards (DOT 1267) and utilizing

the DOT 2012 Emergency Response Guide (ERG), command

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made efforts to verify that information with the train’s consist.

Incident command established a staging area a few blocks from the second command

post. No additional fire department resource units were required for the incident as

command decided to conduct a nonintervention mode of operation. Therefore, fire

department resources never totaled more than six engines, two trucks, hazmat, and

additional command staff on the scene.

Command established a James River water operations boat crew to gain an assessment of

the rail cars in the water and deploy containment booms. A half mile evacuation of the

downtown area was established as outlined in Public Safety Section of the 2012 DOT ERG

Guide 128.

Command continued to monitor the situation and allowed the product involved to burn off

before deciding to transition into offensive operations. An Initial foam fire attack was used to

extinguish the remaining product. Complete extinguishment and overhaul operations

continued with assistance from the CSX rail operators until termination of the incident.

Utilizing a tag or passport accountability system with a Rescue Intervention Team format, all

personnel wore their structural gear with self-contained breathing apparatuses except

hazmat at who wore Level-B suits while performing air sampling.

Key Factors of Operations:

The City of Lynchburg municipal water supply adequately met the needs of the

incident.

Foam concentrate and foam supply was adequate for this incident.

Lynchburg Fire Chief Ferguson assessed that the fire department resources met the

need for this incident.

Lynchburg’s Emergency Operations Center (EOC) was activated, and an Incident

Action Plan (IAP) was written. There were “zero” problems with communication. There

were no injuries.

The following outside agencies on scene were: Virginia’s Department of Environmental

Quality (VDEQ), Coast Guard, U.S. DOT, U.S. EPA, National Transportation Safety Board

(NTSB), as well as CSX. By 2100 hours, CSX had approximately 150 railroad-related

personnel and contractors on scene, including a full hazmat unit.

The incident was terminated after a few operational periods with units standing by until

all train-related equipment was removed. Only one rail car burned for 1–1.5 hours and

only one of the three rail cars in the river leaked product. Product from those three

cars as well as the other derailed cars was pumped off before the cars were righted.

Cost recovery was billed to CSX for the incident that included: personnel and

apparatus costs, equipment replacement – fire hose, approximately 50 gallons of

alcohol resistant – aqueous film forming foam (AR-AFFF), and oil containment and

recovery boom. At time of this report there has not been an assessment conducted

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as to the physical damage to the property adjacent to where the train derailed.

Weather – Lynchburg, Virginia

Wednesday - April 30, 2014

Mean Temperature 64 °F

Max Temperature 76 °F

Min Temperature 52 °F

Dew Point 54 °F

Average Humidity 63%

Maximum Humidity 100%

Minimum Humidity 26%

Precipitation 0.00 in

Sea Level Pressure 29.84 in

Wind Speed 4 mph (SW)

Max Wind Speed 18 mph

Max Gust Speed 22 mph

Visibility 9 miles

Lynchburg Emergency Operation Plan:

The plan identifies railroad incidents as a

potential but did not have the specific

rail carrier information and resources

listed in the plan.

Based on fire department reports and

interviews, the rail carrier CSX chose not

to actively engage the Lynchburg Unified

Command Operation for the initial

operational period.

City of Lynchburg, Virginia Emergency

Operations Plan Record of Changes

“Public Document from Lynchburg”.

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Operations

There are several types of incidents involving hazardous materials: Incidents at fixed facilities,

roadway or rail transportation accidents, incidents involving household hazardous materials

and known materials on the water, railway or roadway. The Emergency Operations Plan

(EOP) states that for all railroad incident the Hazardous Materials Team (HMT) prepare

economic impact analysis covering the following areas, as appropriate, and as directed by

DES:

Infrastructure: (i.e. damage/disruption of commuter rail lines, transportation systems,

telecom switching stations, electrical substations, cable, etc.)

The HMT should be dispatched to any of the following incidents, or any incidents that field officers deem

necessary for a HMT response:

- Gas leaks (commercial and residential).

- Any hazardous materials or chemical leak that could potentially cause personal injury.

- Fuel spills greater than 25 gallons, or any spill that exceeds the safe cleanup of the initial response of

an Engine Company and Rescue 1.

- Any hazardous material that involves contaminating a water system.

- Any motor vehicle accident involving a vehicle containing hazardous materials.

- All railroad emergencies.

- Any large scale fire operation that requires detection and monitoring for air quality.

- Any other emergency deemed to have hazardous materials involved in the incident.

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The document states that certain emergency support functions are established for each

major incident.

The Incident Action Plan (IAP) includes a unified command operation and is defined within

the plan.

Unified Incident Command

When multiple response agencies or organizations have major management roles in

response to a complex incident, collective management and coordination of response

services is most effectively achieved through unified incident command. Unified command

occurs through joint decision-making that establishes common incident objectives or

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management by objectives. For an incident, clearly delineated objectives and strategies are

agreed upon and documented in a formal fashion.

This document forms the basis of the City of Lynchburg IAP. Unified command provides

relatively equal management participation by the departments involved, but it is recognized

that a lead agency must be the final arbiter within the unified command team (i.e., one of

the represented agency managers is recognized as having the final say in all matters).

This lead agency authority is determined by the specific incident type and circumstances

and is clearly defined at the outset of the incident command process. The decision support

tool for determining the designated lead agency authority for each type of hazard event is

described in the upcoming table.

To accomplish this common operating system in a City of Lynchburg response, unified

command includes:

A single integrated incident organization.

Shared or co-located command facilities.

A single planning process and incident action plan (a single set of strategic goals and

objectives) managed through the EOC Planning Team.

An operations section leadership that replicates the organizational makeup of the

incident’s unified command, with the lead agency’s representative designated as the

Operations Chief. A similar organizational composition may be established for the

Logistics section.

A coordinated process for resource ordering and management for the City of

Lynchburg through the EOC.

The response organizations that may be included in a unified incident command:

o Fire Department

o Police Department

o Department of Human

Services

o Department of Water

Resources

o Department of Public

Works

o Department of

Emergency Services

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Lessons Learned

Fire Department Assessment:

Expand the Incident Command System (ICS) early to include logistics and finance sections.

Incident command utilized the EOP but was unable to locate rail personnel to include them

with in a unified command structure.

A. Training CSX is paying all costs for three technicians to go to American Association of

Railroads (AAR) training in Pueblo, CO.

B. Since the derailment there has not been any other new procedures put in place.

Probing Questions:

Based on the interview, information provided to unified command did not included rail

responders and the rail system did not actively engage the first responders during this

incident.

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Case Study #2

Title: Cherry Valley Derailment

Incident Background and Locality Contact:

Rail Line: Canadian National

Date: June 19, 2009

Location: Cherry Valley, IL

Narrative: Written by James Rist and Richard Miller

Weather:

Photos:

Emergency Plan/ Fire Pre-Plan:

Supporting Documentation: Emergency Plan

Cherry Valley Narrative

The village of Cherry Valley, Illinois is a community of 8.72 square miles located in

the Kishwaukee River Valley, which lies primarily in Winnebago County. Approximately 10

percent of the village is located within Boone County. The village is within the Rockford,

Illinois Metropolitan Statistical Area (MSA), and borders the southeast side of Rockford. The

population is approximately 3,200 as of the 2013 census estimate.

Rockford is a city located on both banks of the Rock River in far northern Illinois. Often

referred to as "The Forest City", Rockford is the county seat of Winnebago County. As

reported in the 2013 U.S. census estimate, the city was home to 150,300 people; the

outlying metropolitan area has a population of 290,750 residents. In terms of population,

Rockford is the 160th-largest city in the United States.

Although located close to Rockford, Cherry Valley was far enough away to be considered,

for most of its history, not a part of the Rockford community. However, with the advent of

modern transportation in the later 20th century, Cherry Valley became in essence a suburb

of Rockford. As the city of Rockford grew and expanded its boundaries it came in direct

contact with Cherry Valley. Since that time there have been land control related issues

between the two municipalities. For the most part these issues have been resolved with a

boundary agreement between the two communities.

Their fire departments could not be any more different. Cherry Valley is a small combination

department with two chiefs, one fire inspector, 12 career and 40 on-call firefighters. They

operate out of two stations with two personnel on duty in each station per shift. The career

personnel are State Firefighter III with Hazardous Materials Awareness and Operations

training. Some personnel are trained to Technician-Level. Rockford is staffed with 330 career

personnel working 24 tours with three platoons out of 11 stations. A first alarm assignment will

put 30 personnel on scene. Ninety percent of their personnel are trained to Operations-Level

and 85 are trained to the Technician-Level. Rockford handled 25,900 calls in 2013. Both

departments are part of Mutual Aid Box Alarm System’s (MABAS) Division 8.

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Incident

On Friday, 19 June 2009, strong storms passed through the area dumping in excess of four

inches of rain causing flash flooding in the region. Both departments had been responding to

numerous calls for people trapped in cars due to flooding. The 9-1-1 Center in Rockford,

who dispatches both departments, received calls that the rail bed had washed out on the

train tracks at South Mulford Road. A Canadian National Railway key train with 116 cars, of

which there were 74 DOT-111 tank cars carrying ethanol, was traveling through the area en-

route to Chicago, IL notified its dispatcher that some parts of the tracks were under water. It

had to reduce its speed because of wheel slippage. As the train approached the crossing at

South Mulford Road, cars were stopped on both the northbound and southbound sides as

the crossing signals were activated.

At 2038 hours, Cherry Valley was dispatched for a derailment with explosions at South

Mulford and Sandy Hollow Roads. Due to the multiple calls, Rockford was also dispatched.

Because of the storm calls, both departments with fully staffed personnel responded with

heavy first alarm assignments.

Due to the situation caused by the storms that had gone through the area earlier, the

Emergency Operations Center (EOC) for Rockford Fire Department had been opened and

staffed. As a result, they were able to assist command almost immediately. Units arrived from

both the north and the south. On arrival, Cherry Valley Chief Wilt advised that he had a train

derailment involving multiple cars of unknown product with a major fire. Many pressure relief

valves could be heard operating. Chief Wilt ordered everyone to stage back from the scene

at a safe distance. EMS advised command that they had multiple victims. Command

advised them to get the victims and pull back before beginning treatment. Chief Wilt

formally assumed command of the incident. A unified command was established at this

time. All agencies on scene had representatives at the Incident Command Post (ICP)

located at the rear of Chief Wilt’s vehicle. Command was located at the intersection of

Mulford and Abbington Roads on the north side of the derailment. The incident was then

sectored into north and south, each with their own operational command. Four goals were

established:

Immediately rescue those persons who could be saved.

Evacuate those people most in danger and get them to a safe area away from the

incident.

Expand the evacuation zone to include all of the people living within a half mile of the

incident as per the 2012 DOT ERG.

Get all responder personnel on the scene back to a safe location.

Personnel found four victims on the north side of the railroad tracks: three with minor to

moderate burns. Command was advised by south side personnel that they had two victims

that were critical and one fatality. All victims were treated, stabilized and transported to the

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hospital. Police were notified and added to command as they were needed to control

bystanders trying to get close to take pictures.

At 2058 hours, command requested second alarm for MABAS Box 11. This brought six

engines, two trucks, two squads, one ambulance and four chiefs to the Cherry Valley Mall,

which was designated as the staging area. The mall is a large area, with adequate lighting

and three miles from the incident.

Binoculars were used to try to identify the product placards and the types of tank cars

involved and whether they were pressurized or not. Due to the massive amount of fire,

wreckage and darkness it remained undetermined.

On the north side of the derailment both the east and west sides of Mulford Road were

heavily populated residential areas consisting of approximately 700 homes with 1,500-1,800

residents. Due to the close proximity of these homes, command ordered an evacuation area

of a half mile radius. Police began evacuating the area around 2110 hours. Meanwhile, the

south sector established an unmanned ladder pipe in a parking lot to cool unaffected

tanker cars.

At 2200 hours, a large area still needed to be evacuated so command requested that

MABAS Box 11 be upgraded to a sixth alarm to assist the police. This alarm consisted of an

additional 11 engines, two trucks, two heavy rescues, and eight chiefs from departments in

northern Illinois and southern Wisconsin.

At 2220 hours, the train crew was located and brought to the command post. The engine

and forward portion of the train came to a stop approximately two miles east of the

derailment and the crew was walking back towards the scene setting brakes on the railcars

when they were located. The train’s consist showed that all of the tank cars were carrying

approximately 28,800 gallons of ethanol each. As a result of this, command left the

evacuation radius at half a mile as per the ERG.

Command met with hazmat personnel from Cherry Valley, Rockford and Canadian National

Railway to plan the best course of action. Command made the decision to let the fires burn

down for the following reason: There were 400 gallons of AR-AFFF on scene and the railroad

had 900 gallons en-route. It appeared that the fire could involve up to 15 tank cars

containing up to 30,000 gallons of denatured fuel ethanol each. There wasn’t enough foam

for extinguishment and firefighters could not get close enough to apply it. Many pressure

relief valves on tankcars involved in the derailment were operating at a high pitch. It was

unknown if any relief valves were damaged and not operational or if tank cars were

overturned with relief valves buried. Several tankcars had already failed prior to arrival.

At midnight, the Illinois Unified Command vehicle arrived on scene. Chief Wilt moved

command from the rear of his vehicle to the larger vehicle. Some chiefs were re-assigned to

the command vehicle to fill out the ICS system, write a multi-operational period Incident

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Action Plan (IAP) and prepare for a multi-day event.

At 0230 hours on Saturday, 20 June 2009, command was advised that all evacuations were

complete.

At 0330 hours, command began releasing mutual aid departments from the mall staging

area to return to their stations, with two alarms of units moved to sector staging areas just in

case. All first alarm responders were rotated out at the end of their operational period. This

change of personnel went seamless.

By 1000 hours, the fires on the west side of the crossing began to burn down to a level where

both command and railroad representatives felt the fire could be extinguished. The fire was

extinguished and two unmanned monitors flowing 750 gpm each cooled tank cars for one

hour afterwards. Throughout the day heavy equipment was arriving on the north side of the

incident.

At noon, it was determined that it would be safe for the removal of the south side fatality.

This was accomplished by 1210 hours.

During the afternoon, it was discovered that the truck and wheels from a tank car

penetrated the dirt next to the road to a depth of 10 feet, striking and damaging the outer

casing of a 12 inch natural gas transmission line operating at 288 psi. The inner pipe was bent

but did not leak.

The tank cars on the east side of the crossing started to burn down after 1500 hrs. Using the

same approach as the west side, command decided to extinguish the fires. The difference

was that cooling took two hours. At 1700 hrs, about 20.5 hours after dispatch, command

advised that all fires were extinguished. At this time, all mutual aid companies were released

and all move-up companies were released by 1800 hours. The evacuation order was lifted at

1730 hours.

National Transportation Safety Board (NTSB) arrived around 1300 hours on the 20th and after

the fires were extinguished began their investigation. As they progressed they began

allowing the railroad to begin removing the wreckage. Private contract recovery and

firefighting crews began the process of removing the tank cars by foaming the insides of

each car. Responders continued to provide fire protection for the crews removing the cars

and the crew digging up the natural gas line that was struck.

At 1600 hrs on Sunday, 21 June 2009, it was determined that the fire department presence

was no longer needed and command was terminated. During this operational period,

firefighters continued to protect recovery crews as wreckage was still being removed, and

at one point railroad personnel requested confined space certified firefighters to stand by as

they needed to enter one tanker.

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Statistics: 160 firefighters on scene, police from 35 agencies, 28 engines, nine trucks, seven

squads, six ambulances, two of aqueous film-forming foam (ARFF) units, MABAS Division 8

decon truck, MABAS Division 8 rehab trailer, the Illinois Unified Command Unit, MABAS Division

8 ATV, 750,000 gallons of water, 600 feet of five inch hose, 800 feet of 2.5 inch hose,

estimated damages in excess of $1.5 million dollars, 323,963 gallons of ethanol burned,

107,745 gallons of ethanol recovered, both the Red Cross and the Salvation Army for food,

no foam was used.

This was the largest incident in the history of the Cherry Valley Fire Protection District. The train

was traveling at 34 mph in a 50 mph zone. The train experienced wheel slippage coming out

of Rockford going up an incline because of wet tracks, and the engineer backed off on the

throttle. At the time of the derailment the train was just starting to pick up speed again. One

person died at the scene from burns; their family members were both critically burned. One

of those critically burned was pregnant, and the fetus did not survive. They were in a minivan

on the south side, the first vehicle in line at the crossing waiting for the train to pass. Five

people who were in vehicles on the north side of the crossing received injuries from minor to

moderate and all were treated and released that night or the next day.

Key Factors

Weather – Cherry Valley, Illinois

Friday - June 19, 2009

Mean Temperature 76 °F

Max Temperature 86 °F

Min Temperature 66 °F

Dew Point 68 °F

Average Humidity 83%

Maximum Humidity 100%

Minimum Humidity 65%

Precipitation 04.20 in

Sea Level Pressure 29.69 in

Wind Speed 09 mph (South)

Max Wind Speed 43 mph

Max Gust Speed 52 mph

Visibility 08 miles

Events Fog, Rain, Thunderstorm

Lessons Learned

1. Have experienced personnel brought to the command post to scribe radio, cell

phone, and person-to-person orders including a date/ time stamp. Make sure

important benchmarks are written down. Six radio channels were used during the

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incident, of which only two were recorded channels. An accurate time line, for report

purposes, was difficult to determine.

2. Bring in extra alarms early for evacuation of civilians. The police were given the task to

do this but it became obvious that they could not get the manpower that was

needed together in a short period of time. Reverse 9-1-1 was tried but failed to work

for over an hour due to a software problem. It was a nice evening out after the storm

passed and most people were outside watching the fire and missed the reverse 9-1-1

calls when they began to be made.

3. Bring in extra ambulances to assist with evacuation. Fire department did not

anticipate the number of invalids who could not self-evacuate. Companies assigned

to evacuation who called for an ambulance numerous times for people who needed

removal by stretcher.

4. Bring in 1-2 experienced dispatcher(s) to the command post to handle radio traffic.

5. Make sure a time keeper is assigned to advise command every hour how long you are

into the incident. After 5-6 hours it was easy to lose track of time and some crews were

not getting rotated out as soon as they should have.

6. If you have access to ATVs, have them brought in for shuttling crews from staging

areas to where they are needed. Once key apparatus was in place crews were just

rotated.

7. Make sure food makes it to all staging areas. Portable restrooms were distributed to all

areas but food was not distributed to both sectors in a timely manner.

FAVORABLE CIRCUMSTANCES: Many circumstances worked in the emergency responders

favor by chance that could have gone the other way.

The weather cleared up just before the derailment.

The product involved. No pressurized cars in derailment.

The set of tracks derailment was on the south side and not the north side.

Heavy first alarm dispatch (Cherry Valley and Rockford).

Due to location first arriving units were pretty evenly split between the north and south

sectors.

Rockford Operations Center was still open due to the earlier storm.

SUCCESSES:

All persons who could be rescued were.

There were no injuries or loss of life to civilians after fire department arrival.

There was no additional property loss after fire department arrival.

There were no firefighter injuries.

The transition was smooth during operational periods rotation.

Cost recovery was a good experience as the railroad responded quickly.

NTSB experience was good and professional.

Train dispatcher originally gave the railroad an incorrect consist; realized their mistake

and send a correct consist to command electronically.

New multiple training opportunities arose: could not take advantage of AAR training

at Pueblo, CO, but had the Union Pacific’s version of the “Safety Train”, and had a

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DOT-111 tank car donated to the regional fire training center.

The MABAS system brought in the needed resources quickly and easily. MABAS system

was a key to the success of this incident.

Cherry Valley does not have a railroad pre-plan and still doesn’t. In its place they use a

MABAS Commercial Fire/ Disaster Run Card as their model.

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Case Study #3

Title: Casselton Derailment

Incident Background and Locality Contact:

Conference Call Interview – Conducted on Friday, 6 June 2014

Casselton Fire Department Fire Chief Tim McLean (tmclean@anyconnect.com)

121 North Langer Street

P.O. Box 571

Casselton, ND 58012-0571

Rail Line: Burlington Northern Santa Fe Corporation (BNSF)

Date: Monday, 30 December 2013

Location: Casselton, North Dakota

Narrative: Written by James Rist and Richard Miller

Weather: Source – Weather Underground (www.wunderground.com)

Photos: Various Sources

Emergency Plan/ Fire Pre-Plan: None

Supporting Documentation: Emergency Plan – Purposed Annex to County Plan

Incident Narrative

Casselton is located at 46°54′0″N 97°12′38″W / 46.9°N 97.21056°W (46.900028, -97.210668).

According to the United States Census Bureau, the city has a total area of 1.4 square miles

(3.7 km²), of which, 1.4 square miles (3.7 km²) of it is land and 0.04 square miles (0.1 km²) of it

(2.08%) is water.

Casselton is small town in eastern North Dakota with a population of approximately 2,500

people. It is located in Cass County, 25 miles west of the city of Fargo, ND. Cass County has

over 100 miles of railroad track within the county boundaries. The town itself has Burlington

Northern Santa Fe Railroad (BNSF) tracks that divide the town running east/west and a line

the borders the southern half of town to the west side that links to the Tharaldson Ethanol

plant on the west side of the community. Rail system in Casselton, BNSF has multiple rail lines

running through and around the town. Casselton experiences 70-80 freight rail trains per day,

at all times of the day, seven days a week, traveling at average speeds of 45-60 miles per

hour. There is limited Amtrak service in the area. Interstate route 94, which runs east and

west, is just south of the town. The current local economy does rely on the commercial value

of the rail traffic; the local ethanol plant located 1-2 miles out of town, within the fire

department’s jurisdiction.

Incident Background:

An estimated 11-12 crude oil unit trains depart daily from the oil region in western North

Dakota. The main railroads, BNSF and Canadian Pacific, have tracks through the Twin Cities.

25

Location: 35 ST SE / 154 AVE SE

CASSELTON, ND 58079 , CAST

Dispatch Time: 12/30/2013

14:14:25

Additional Location Info: Arrive

Time: 12/30/2013 14:22:18

Common Name: Clear

Date/Time: 01/01/2014 13:57:05

Phone: Nature Of Call: TRAIN

DERAILED AND ON FIRE

TRAIN DERAILED AND ON FIRE

1/4 MI W OF CASSELTON BTWN

CASSELTON AND

ETHANOL PLANT

12/30/2013 14:14:14 Dispatcher

COMPL IS WITH BNSF

12/30/2013 14:14:30 Dispatcher

CARRYING OIL

12/30/2013 14:14:36 Caller

LOOKS LIKE OIL CARS THAT ARE ON FIRE

12/30/2013 14:14:41 Caller

3 ENGINEERS STILL ON BOARD

12/30/2013 14:15:00 Dispatcher

ENGINE ARE ON FIRE

12/30/2013 14:15:10 Caller

100 CAR TRAIN, APRX 10 CARS ARE ON FIRE

12/30/2013 14:15:35 Dispatcher

NO INJURIES

12/30/2013 14:16:45 Dispatcher

ENGINEER IS WALKING TOWARD CASSELTON.

12/30/2013 14:20:48 Dispatcher

WIND SPEED - N 15 MPH 0 DEGREES HUMIDITY 76%

12/30/2013 14:28:01 Dispatcher

COMMAND POST AT THE CASS SCHOOL

12/30/2013 14:28:15 Dispatcher

STAGING AT MACINTYRE FARM

12/30/2013 14:35:54 CITY AUDITOR,

WOULD LIKE TO BE CONTACTED IF THEY NEED TO NOTIFY THE CITIZENS OF A

HAZARDOUS EVENT

12/30/2013 14:40:44 Dispatcher

FLAMES 100 FT IN AIR - FIRE NOT YET APPROACHED

12/30/2013 14:43:04 Dispatcher

26

111 CARS FULL OF OIL

12/30/2013 14:43:30 Dispatcher

ALL GRAIN WAS WB - OIL WAS EB

12/30/2013 14:51:32 Dispatcher

CODE RED REQUESTED

12/30/2013 14:52:12 Dispatcher

PD IS ENRT TO THE COMMAND POST

12/30/2013 14:53:02 Dispatcher

STAGGING AREA AT THE COMMAND CENTER

12/30/2013 14:59:25 Dispatcher

CODE RED MESSAGE SENT

12/30/2013 15:15:05 Dispatcher

IMMEDIATE ACTION TEAM DEPLOYED VIA CODE RED

12/30/2013 19:30:21 Dispatcher

CODE RED SENT TO EVACUATE ALL OF CASSELTON

12/31/2013 16:30:45

CMD POST AT SCHOOL CLOSED AT 1600 HRS

Special Notifications:

2013-00000039 REDCROSS No RED CROSS Fire

2013-00000048 SALVARMY No SALVATION ARMY Fire

2013-00000358 CARFIR No CASS COUNTY RURAL FIRE Fire

2013-00000778 CAREMS No CASS COUNTY RURAL EMS EMS

2013-00006948 MN0140200 No DILWORTH POLICE DEPARTMENT Police

2013-00015350 FMA No FM AMBULANCE EMS

2013-00016242 ND0090000 Yes CASS COUNTY SHERIFF'S OFFICE Police

2013-00020739 ND0090300 No WEST FARGO POLICE DEPARTMENT Police

Terms:

Key Train:

A "Key Train" is any train with one tank car load of poison or toxic inhalation hazard (PIH or

TIH) (Hazard Zone A, B, C, D) or anhydrous ammonia, or; 20 car loads or intermodal portable

tank loads of a combination of PIH or TIH (Hazard Zone A, B, C, D), anhydrous ammonia,

flammable gas, Class 1.1 or 1.2 explosives, and environmentally sensitive chemicals, or; one

or more car loads of Spent Nuclear Fuel (SNF), High Level Radioactive Waste (HLRW).

First Responders:

First responders include public safety professionals and trained volunteers who respond to

and provide services at emergencies where additional skills and resources may be needed

to bring the incident to a safe conclusion. First responders, often the first trained personnel to

arrive on scene, usually arrive with standard issue protective and tactical equipment, which

may not be adequate for intervention. First responders often provide first detailed scene

information to managing authorities and other responding agencies. As the incident evolves,

27

first responders may assist with establishment of structured incident command. They may

continue to participate in incident stabilization and mitigation under the direction and

supervision of highly trained specialists.

Unified Command:

Applies ICS in incidents involving multiple jurisdictions or agencies. Enables institutions and

agencies with different legal, geographic, and functional responsibilities to coordinate, plan,

and interact effectively.

Unified Command:

Incident management performed by representatives of several agencies to assure that a

consistent response plan is developed and deployed and that all actions are performed in a

safe, well-coordinated manner.

Unity of Command:

A management concept that assures that each responder has only one direct supervisor.

Interview Overview with Fire Chief of Casselton Tim McLean

Fire Department Statistics:

Department Type: Volunteer

Number of Stations: 1

Firefighting Personnel

Volunteer Firefighters: 28

Full-Time Paid Firefighters: 0

Part-time Paid Firefighters: 0

The Casselton Fire Department is an all-volunteer department with 28 personnel, operating

out of one fire station. Fire department’s personnel are all trained to the NFPA 472 Awareness

Level certification, with most trained to the Operations Level. The local hazardous material

team members are trained to the NFPA 472 Technician Level and are from the City of Fargo

Fire Department.

Incident

On Monday, 30 December 2013, at about 1411 hours CST, a BNSF Railway grain train was

heading westbound at 28 mph when it derailed outside of Casselton. The train consisted of

three locomotives (two at the front or head and one at the rear) and 112 cars. Thirteen cars

derailed, with one of the cars - the 45th car from the front of the train, fouling the eastbound

tracks. An eastbound BNSF petroleum crude oil key train traveling at 43 mph collided with

the derailed car, derailing the two front locomotives and the first 20 tanker cars and a

hopper car carrying sand. The crude oil key train consisted of two front-end locomotives, 105

DOT-111 cars, one hopper car carrying sand, and one rear locomotive. Both train crews

28

were not injured and were able to exit their lead locomotives, although both of the

locomotives of the crude oil were lost to fire. The weather was clear with overcast clouds, -1º

F with wind from the north at 15 mph making the wind chill feel like -20º F. It was daylight.

The Red River Regional Dispatch Center received its original 9-1-1 call at 1413 hours, CST. The

Fire Chief arrived on scene a short time later establishing a forward command post a quarter

mile away northwest in a farm yard. He was able to see some placards (UN1267) and was in

contact with the train’s crew within 10-15 minutes. The Fire Chief verified that the tanker cars

were carrying Bakken crude oil. He used the DOT placard system to make the initial

identification. He requested the hazmat team out of the City of Fargo and relayed the

information back to the incident command post and the Sheriff, who was the incident

commander by Cass County Code.

Eighteen tanker cars were breeched (punctured) in the derailment with their product

burning. The initial estimate of released product equaled 400,000 gallons of crude oil.

Coupled with the weather, lack of manpower, water and foam, a decision was made to let

the fires burn out. This is when the Fire Chief called area departments to see how many

gallons they could have brought in through mutual aid. BNSF brought in 20,000 gallons of

water and had fracking tanks with heaters, brought in to hold the water all with warming

blankets. The Fargo HazMat Team was the only fire department mutual aid called. For

perimeter (inner and outer), traffic and crowd control, and evacuation support, the incident

commander brought in 65 deputies. They were all released by 1900 hours, CST.

An EOC was activated and manned, and local officials coordinated a voluntary evacuation

of about 1,400 people. No injuries to the public were reported. The Fire Chief stated that the

snow was dotted with black specs and there were tar balls falling out of the sky eight miles

away.

No Incident Action Plan was written. CHEMTREC was called by the Fargo HazMat Team.

Residents were allowed to return to their homes later that next afternoon. The scene was

turned over to the BNSF representatives when it became safe to do so. Through BNSF, the

department has also received TRANSCAER “Safety Train” training after the incident as a

follow up.

29

Weather – Casselton, North Dakota

Monday - December 30, 2013

Mean Temperature -08 °F

Max Temperature 02 °F

Min Temperature -19 °F

Dew Point -10 °F

Average Humidity 72%

Maximum Humidity 79%

Minimum Humidity 64%

Precipitation 00.04 in

Sea Level Pressure 30.24 in

Wind Speed 07 mph (NE)

Max Wind Speed 18 mph

Max Gust Speed 20 mph

Visibility 05 miles

Events Snow

Cass County Map overview North Dakota

30

Lessons Learned

1. Casselton had no BNSF rail pre fire-plan before the derailment.

a. The fire department does have a pre-plan for the ethanol plant as result of

multiple incidents at the ethanol plant as stated by Chief Tim McLean.

b. The County Emergency Manager has written a plan, which did consider rail as a

hazard. No specific plan for crude oil was available. See below excerpts from

hazard plan.

Note specifics on HAZMAT Team - Regional Hazmat Team: The Regional

Hazmat Team is comprised of members of Fire Departments from the cities of

Fargo and Moorhead. The Regional Hazmat Team has a response services

contract with Cass County. The regional team is responsibilities for Weapons

of Mass Destruction (WMD) and Hazmat incidents which include:

o Respond with persons certified at the technician’s level of hazardous

spill training

o Assist local authorities by taking emergency actions necessary to

protect life, property and the environment from the effects of a release

o Provide technical advice to the incident commander

o Recommend and take mitigation actions to stabilize the stabilize the

situation

2. The command post had both cellular and internet problems.

3. The Cass County command post trailer is too small for an incident of this kind.

4. Need for additional staff members to assist with tracking and taking notes.

5. American Association of Railroads (AAR) Training has offered training after the

incident. Casselton is scheduled to receive more TRANSCAER classes, and

approximately a dozen personnel, in three groups, will travel cost-free to receive

hands-on training in Pueblo, CO.

6. The National Transportation Safety Board (NTSB) was very slow in responding and

would not let the rail line move the car until all the cars were GPS marked.

7. The fire was still burning and NTSB would not let the rail company continue their

mitigation operations.

8. Fire command had no direct communications with any investigators from NTSB. Only

one responder was questions by NTSB because he helped to separate rail cars days

later. A firefighter was in contact with command by radio throughout the operation.

NTSB did have initial communication with the local sheriffs upon arrival.

9. Sheriffs and BNSF cellular traffic was overwhelming the local cell phone system.

a. Note: Responders were not aware of the "Emergency Responder Priority Cell

Phone Card" to access the cell phone system.

10. All rail personnel on this incident were familiar with the National Incident Management

System (NIMS).

11. Having a scribe with incident commanders to capture information.

12. Emergency manager immediately set up the Emergency Management Center

31

Tactical Operation Center for Cass County Rail Road Emergency Plan and phone log,

public Information officer report.

13. Casselton also has an ethanol plant that has a pre-plan, the fire department has

responded to multiple fire calls at the facility with fires and injury. Product is transported

out by rail.

a. Note: The facility has a trailer of foam on site and pre-piped nozzle with self-in

ducting system nozzles, and is available for mutual aid response.

14. New department requirements were established since this derailment that all

command personnel complete NIMS training.

15. Recognize early in rail incidents that the rail companies have significant resources that

can be brought to the site to assist in the mitigation of the incident.

16. Unified command needs to be established for unity of command rail incidents that

includes both municipal and rail Industry responders. Decisions have to be made

jointly and not independently. Communication process between local responders and

rail industry has to be built into local response plans.

32

33

34

Case Study #4

Title: Tiskilwa Derailment

Incident Background and Locality Contact:

Rail Line: Iowa Interstate Railroad

Date: October 7, 2011

Location: Tiskilwa, IL

Narrative: Written by James Rist and Richard Miller

Weather:

Photos:

Emergency Plan/ Fire Pre-Plan:

Supporting Documentation: Emergency Plan

Tiskilwa Narrative

Tiskilwa, IL is a small bedroom community with a population of 830 people. It is located in

south, central Bureau County, 100 miles west-southwest of Chicago, 60 miles east of the

Quad cities, and 45 miles north of Peoria. Approximately one-third of its residences are

occupied by senior citizens. Tiskilwa has a three block long business district with 10 storefronts

open for business.

The Tiskilwa Rural Fire Protection District is an all-volunteer department with 16 firefighters. The

district covers 93 square miles and has two stations, the main station is on the north side of

the town itself and their second station is located in Lake Thunderbird, a rural subdivision

approximately eight miles south of Tiskilwa. Chief Philhower (C-1) stated that upon receipt of

the call at 0215 hrs from the 9-1-1 dispatch page stating that there was a train derailment

with fire showing, but no specific location was given.

Incident

At 0221 hrs, the C-1 requests Princeton Fire for mutual aid.

At 0222 hrs, C-1 arrives on the scene staging one-eighth of a mile southwest of the incident

where he sees a large fire from derailed tank cars. It is still dark with the only light being that

from the burning tank cars. Still from his vantage point, he can see 10-15 tank cars that are

derailed with numerous cars already venting and relief product burning, and the fire is

impinging on adjacent tank cars.

The town was split into two sections due to the derailment location at Bottom Road where it

was blocked by derailed cars, eliminating entry to the town from the east. The Main Street

rail crossing was also blocked by intact uninvolved rail cars, creating a five mile detour

35

around the train to access either section of the town. In addition, the main highway from

the north into town is also blocked at the crossing.

At 0225 hrs, the MABAS Division 25 Hazmat Team is requested for mutual aid.

At 0228 hrs, C-1 calls the Iowa Interstate Dispatch where he receives a breakdown of the

train contents and is told that the engines are free of the train and down the track 1-2 miles.

He calls the Town of Bureau Fire for mutual aid and tasks their chief to locate the engines

and crew and obtain the train consist. C-1 receives the train’s consist in approximately 30

minutes.

At 0234 hrs, C-1 calls the Iowa Interstate Dispatch again to request an engine from the west

to connect to the rear of the train to remove the train from the community opening up the

crossings. He was told that action was already started.

Recognizing that the fire was too large for his department to handle, since he didn't have

the personnel, water or foam (even with the foam caches from the three surrounding

ethanol plants), C-1 made the decision not to fight the fire initially and established four

benchmarks: personnel safety, public safety focusing on community safety and evacuation,

stop the possible progression of the fire and the possible boiling liquid expanding vapor

explosion (BLEVE) towards a residential section of the town that was approximately 250 yards

from the incident scene, and stop the spread of the fire to uninvolved intact tank cars.

At 0239-0256 hrs, C-1 orders his personnel and the town's EMS to start evacuating all residents

east of State Street.

At 0242-0312 hrs, the mutual aid companies establish a water shuttle and set up an

unmanned monitor to start cooling exposed intact ethanol tank cars closest to the fire.

At 0307 hrs, Bureau County deputies are on the scene and C-1 requests the county's incident

command vehicle.

At 0334-0433 hrs, additional local fire mutual aid is requested.

At 0444 hrs, the Bureau County command vehicle arrives and is set up at Main/High Street,

one block from the main fire station which is to be the established staging area. Command is

relocated from the incident scene to the command vehicle at this time. Illinois Law

Enforcement Action System is activated for the transfer of evacuation operations, as well as

incident and town traffic and crowd control.

At 0602 hrs, railroad representatives begin arriving.

At 0718 hrs, the requested engine from the west arrives, railroad and fire personnel uncouple

train leaving three tank cars upright west of the last derailed car and the train rolls out of the

36

town.

At 0800 hrs, the first major meeting of incident leadership at the scene takes place. The

unmanned monitor is temporarily shut down to allow a closer evaluation of the scene. The

decision is to have the Tiskilwa RPFD remain in overall command with turning over the

incident to the railroad for fire containment, extinguishment, then proceeding to cool

tankers for overhaul of the scene. The Iowa Interstate Rail Company will provide a firefighting

contractor to engage the rail cars on fire. Command will establish the required 1,000 gpm

flow water supply for 24 hours to extinguish the fires and cool the uninvolved tank cars. An

Incident Action Plan is completed.

The Iowa Interstate Rail Company provided contractors for rail car removal, railroad

firefighting specialists, digging and removal of contaminated soil and the replacement of

clean fill, and an air monitoring and pollution control.

At 0900-1218 hrs, command contacts MABAS establishing a box alarm for 10 tankers

(tenders) per shift for 12 hour operational periods until further notice; with the initial shift to be

handled by the units already on scene. Next operational period will begin at 1800 hrs. EMS

will be rotated on the same schedule. Two fill sites established, with two 3,000 gallon porta-

tanks and engines to pump relay to extinguishing site.

Extinguishment operation begins at 1218 hrs.

At 1500 hrs, the evacuation order for residents south of the railroad tracks and east of State

Street is lifted.

At 1300 hrs on 8 Oct. 2011, extinguishment operations are winding up with cooling and

overhaul operations to begin.

At 1400 hrs, the remainder of all evacuation orders are lifted.

At 1800 hrs on 9 Oct 2011, all mutual aid operations terminated. Tiskilwa will handle all further

operations.

At 2000 hrs, unified command/ command vehicle operations terminated. Tiskilwa will handle

all further operations.

Total time on scene from 9-1-1 call until release of unified command - 65 hours 45 minutes;

with Tiskilwa on scene for an additional 72 hours.

Train Consist: Train was 133 cars long, a little over 8,000 feet in length. The train derailed and

uncoupled directly behind the two engines which cleared the scene. Cars 3-17 were DDG

hopper cars (grain mash); car 18 was a sand car; cars 19-27 were ethanol tankers which

derailed and were involved in the fire with some of the hopper cars; car 28 was an ethanol

37

car with one set of trucks derailed, and the other set of trucks still on the tracks; this car got

hot but did not vent; cars 29-30 were ethanol cars that were undamaged and still on the

tracks; they became the disconnect point to remove the train to the west. Cars 31-83 were

ethanol cars which extended back through town past the main fire station; cars 84-88 were

empty assorted cars; cars 89-91 were ethanol cars; car 92 was a gluten meal car; cars 93-133

were ethanol cars. Total cars derailed = 26 with 25 on their side; with nine ethanol cars

involved. The engine's rear camera showed a fireball 19 seconds after the derailment

occurred.

Weather – Tiskilwa, Illinois

Friday - October 7, 2011

Mean Temperature 73 °F

Max Temperature 87 °F

Min Temperature 59 °F

Dew Point 53 °F

Average Humidity 53%

Maximum Humidity 77%

Minimum Humidity 29%

Precipitation 00.00 in

Sea Level Pressure 30.23 in

Wind Speed 11 mph (South)

Max Wind Speed 21 mph

Max Gust Speed 28 mph

Visibility 10 miles

Events Clear, Dry

Lessons Learned

1. Initially because of the limited light (visibility) and a very large and hot fire, determining

the total hazards without a train consist was difficult. Tiskilwa did not have a railroad

pre-plan in place.

2. Since the incident, Tiskilwa still does not have a railroad pre-plan.

3. Railroads have been offering additional training to municipalities having derailments; if

offered, Tiskilwa should take advantage of this.

4. Use of the ERG is essential - Guide #127 showed that the product was flammable, cars

were low pressure, product was explosive only for an intermediate distance, product

had a low airborne toxicity, and that water was of little use except for cooling of

uninvolved cars.

5. The defensive decision to let the fire burn allowed the resources on hand to focus on

establishing a perimeter, evacuating the public, and calling for the needed resources

is a sound choice.

6. Tiskilwa personnel are trained to the Awareness-Level. Per NFPA, personnel should be

trained to their appropriate 1000-series level. Regarding hazardous materials,

38

personnel should be Operations-Level for all personnel and higher for all supervisory

personnel.

7. Some of the responding federal partners acted in an intimidating manner upon arrival

at the command post. Relationship building between local, state and federal

partners, prior to any emergency situtaiton, would ease tensions that may be present

under stressful conditions.

8. Tanker (tender) shuttles - Tiskilwa Fire Department and their mutual aid accomplished

a remarkable task bringing adequate water to the incident site. Incident scene was

rural and all water had to be relayed in.

9. The IL MABAS Box Alarm System is one of the best in the nation.

39

Case Study #5

Title: Lester Derailment

Incident Background and Locality Contact:

Rail Line: BNSF

Date: November 4, 2012

Location: Lester, IA

Narrative: Written by James Rist and Richard Miller

Weather:

Photos:

Emergency Plan/ Fire Pre-Plan:

Supporting Documentation: Emergency Plan

Lester, Iowa Narrative

Lester is a city in Lyon County, Iowa, United States. The population was 296 per the 2013

census estimate. The city has a total area of 1.82 square miles, all of it land. Lester sits in the

northwestern corner of Iowa, with the county bordering both Minnesota and South Dakota.

Lester is located approximately 30 miles southeast from Sioux Falls, SD.

Lester has a Burlington Northern Santa Fe (BNSF) rail line that runs north/south with a siding

along its western boundary. The rail line has homes on both sides, and there is an active grain

elevator working at the siding.

The Lester Fire Department is an all-volunteer department and has approximately 17

members. The department operates out of one station manning one pumper, two tankers

(tenders), and a grass firefighting unit. There is a separate local EMS organization sharing the

same facility. Lester Fire Department runs 6–12 calls per year, mainly grass fields, motor

vehicle accidents (MVA), and mutual aid to its surrounding communities. Per the interview

with the Fire Chief, all personnel have met the certification requirements for Firefighter I,

approximately 4–5 personnel are certified to Firefighter II or are currently fulfilling those

requirements, and all have been trained to the Hazardous Materials Awareness level. No

personnel are Hazardous Materials Operations level trained.

Prior to the derailment, the Lester Fire Department did not have a railroad pre-plan. Since

the incident, the Lester Fire Department still doesn’t, but has met with their county-wide

peers to share their individual resource inventories, the county (Lyon) has conducted both

Incident Command System (ICS) and National Incident Management System (NIMS) training,

and through a donation by BNSF Railroad, Lester Fire Department now has a multi-gas

hazardous materials meter.

40

Incident

At approximately 0415 hours on Sunday, 4 November 2012, a BNSF freight rail train derailed

approximately 1-1.5 miles south outside of Lester, IA between 160th and 170th Streets. The train

was headed from Sioux City, SD to Wilmer, MN. The train had 102 cars. Fifty-two were full

loads, 48 were empties, and there were two locomotives. Upon experiencing a jerk and lost

air pressure, the engineer walked back and found that cars 25-50 had derailed. Upon

noticing a pungent odor near a tanker car placarded 1075, the engineer contacted Lyon

County 9-1-1. A Public Information Officer for BNSF released a statement to the press that

one of the damaged cars was carrying propane, but the train’s consist listed the product as

butane; both are classified as Liquefied Petroleum Gas (LPG) and follow the same Guide

#115 in the ERG.1

The Lester Fire Department was paged at 0458 hours. A firefighter/EMT was first on scene

and, very quickly, had communications with the engineer, who provided the train’s consist.

The consist listed derailed cars 25-50 as carrying liquid butane, empty crude oil DOT-111

tanker cars and cement dust. The derailed LPG car was inverted with its valves buried in the

ground. With a strong pungent odor, the car was somehow compromised. The Sioux City

Hazardous Materials Team, as well as the Rock Rapids and Alvord Fire Departments were

paged for mutual aid at approximately 0505 hours. Both arrived shortly thereafter staging at

the command post location.

At 0510 hours, Lester Fire Department sent a six-man recon team into the derailment area.

The team approached the incident from the east and evaluated the east and north side of

the wreckage. The team was out of the derailment area at 0610 hours.

As reports form responding deputy sheriff units and area residents smelling the odorant, at

0610 hours. Command established a one mile perimeter around the incident scene and, in

coordination with the Lyon County 9-1-1 and the Lester Mayor’s Office, evacuated affected

residents. In total, 14 families were affected.

At 0611 hrs, command called the Sioux Falls National Weather Service for weather and wind

information. Weather was forecasted to be overcast; winds were at four mph out of the

east/northeast switching to the south/southeast at six mph at midday.

At 0657 hours Rock Rapids Fire Department was relocated from the incident scene to back-

fill the Lester Fire Station.

At 0700 hours, Lester Fire Department sent a five-man recon team into the derailment area.

The team approached the incident from the east and evaluated the east and south side of

the wreckage. They reported a hole in car 0756 with liquid dripping out onto a cement

powder car. They also reported a green florescent liquid on the ground. The team was out of

1 There are six gases that meet the definition of LPG. They are: Butane, Butylene, Propane, Isobutane, Isobutylene and Propylene.

41

the derailment area at 0750 hours. Command notified BNSF Hazmat of the recon information

with a potentially compromised car.

About this time command was notified by Transportation Security Administration (TSA) Agent

Jim Weisenhorn that he was en-route to their location.

At 0730 hours, Sioux City Hazardous Materials Team arrived on the scene. Throughout the

incident the team assisted command with exacting the evacuation perimeter, providing

recommendations, an entry and back-up teams, and computer graphics, especially plume

modeling.

From 0750-0815 hours, BNSF notified command that they were sending personnel from

Wilmar, MN to the derailment site and that the train master was working on resources to

move the north section of the train. This was accomplished shortly thereafter and opened up

the intersection at Dove Avenue and 160th Street. Lyon County barricaded all gravel and

black top roads in the affected area. Command decided to further enforce the closures

with a firefighter of a mutual aid deputy at each barricade. TSA Agent Jim Weisenhorn

arrived on the scene. His primary duty was to determine if the derailment was or was not an

act of terrorism.

At 0850 hours, command requested the Lyon County Mass Casualty trailer to the scene to

become the incident command post. This was accomplished by 0930 hours.

At 0955 hours, Command notified the Lyon County 9-1-1 Dispatch that Larchwood and Rock

Rapids would cover calls in Lester until further notice.

At 0959 hours, logistics established a schedule for the command post for the next three

operational periods (until Monday, 5 November 2012).

The 1000 hour Sioux City HazMat prepared to enter the derailment area with a three-man

recon team. They were briefed by Lester Fire Department about the punctured car. Lester

Fire Department will be the back-up entry team. The Lyon County Sheriff was briefed by the

Incident Commander; TSA Agent Weisenhorn left the scene. At 1039 hours, Sioux City made

entry with BNSF HazMat personnel and logistics is preparing a multi-operational period rescue

schedule which will be accomplished by Lester Fire Department and Larchwood Fire

Department personnel.

At 1140 hours, the entry team reported that butane was detectable at 20 feet from the 1075

placarded rail car. One farm experienced a strong smell of the odorant.

The Lyon County Sheriff arrived at the scene at 1145 hours. Also at this time the BNSF

command was transferred.

Command received an updated weather report at 1155 hours. Wind shifting to south-

42

southeast at 4-5 mph with evening chance of rain.

Between 1200-1230 hours, command moving both incident staging and command post due

to weather change. Incident staging moved to the Lester Fire Station; the command post

moved to a private residence. This involved all equipment and personnel except for the

equipment truck, grass rig, the rescue truck and two crews of five personnel.

At 1300 hours, with deputies checking people in and out, residents were allowed to return to

their homes for 30 minutes to feed animals, gather medications and clothes.

The Incident Commander and BNSF representatives meet at 1330 hrs. At 1340 hours, a BNSF

HazMat two-man recon team entered the derailment area. This went on with a two in – two

out rotation until 1504 hours. This long timeframe was due to the fact that personnel could

not locate the exact source of the leak due to the tanker rail car being inverted with all its

valves buried in the ground. Once identified BNSF requested a six foot wide 10 foot long

culvert pipe. A neighboring county (Sioux) provided the pipe – it is unknown if it was

resourced or used. The green liquid was identified as antifreeze.

At 1600 hours, a unified command staff meeting was held with command transferring from

Lester Fire Department to BNSF and the Lyon County Sheriff. Lester Fire Department will

maintain a presence within the unified command staff and oversee the rescue team

function but could reduce required staffing. Staffing will be on a four hour shift and logistics

posted schedule of the whiteboard in the command post trailer.

Sioux City Hazardous Materials Team returned to their station at 1630 hrs. Also, the

evacuation perimeter is reduced at this time allowing some residents to return home.

From 1630 hours on Sunday, 4 November to 0600 hrs on Monday, 5 November the incident is

monitored.

Incident command staff to meet at 0630 hours, plan will be to clear the area by 0745 hours

when BNSF will send in a specialized “vent and burn” team in mitigate the event at

approximately 0800 hours. This type of plan requires a hole to be blasted in the side of the

tanker rail car allowing product to be burnt off via pre-positioned lit flares. Area farmers will

be allowed in before to feed their stock and then cleared.

At 0710 hours, the Mayor of Lester notified of the upcoming plan.

At 0800 hours after a failed first device, the second explosive device was successful.

At 1145 hours, it was determined that the situation is secure, Lester Fire Department can

terminate, residents can return to their homes, and all roads are opened.

43

Weather – Lester, Iowa

Sunday - November 4, 2012

Mean Temperature 40 °F

Max Temperature 44 °F

Min Temperature 37 °F

Dew Point 36 °F

Average Humidity 86%

Maximum Humidity 93%

Minimum Humidity 70%

Precipitation 00.14 in

Sea Level Pressure 30.13 in

Wind Speed 05 mph (NE)

Max Wind Speed 10 mph

Max Gust Speed -- mph

Visibility 07 miles

Events Rain

Lessons Learned:

1. There was planning and logistics occurring at the command post – all tracking of

resources was accomplished using a whiteboard. There was no formally written

Incident Action Plan (IAP). Also, there was no cost recovery. Even though there were

no lost or damaged resources, personnel could have been reimbursed for their lost

wages, fuel costs could have been recovered, etc. Railroad compensated the

evacuees, made a monetary donation to the Lester Fire Department and purchased

them a multi-gas meter. The BNSF also offered the fire department future training.

2. There was no railroad pre-plan before the incident. There is none after the incident,

but the county (Lyon) has initiated both Incident Command System (ICS) and National

Incident Management System (NIMS) training for all responders.

3. Recognized the importance of training. All members are farmers and it is a big task

getting people trained or to attend training.

4. Lester experiences a couple of freight rail trains per hour, many with crude oil; there

are no passenger rail trains transiting through the area. Unsure about ethanol transiting

through the area.

5. Lester Fire Department does not have any Class “B” foam, let alone AR-AFFF foam, but

can access to Class “B” AFFF through mutual aid. None requested or used.

6. There is a county-level Emergency Operations Center (EOC), but there is no Local

Emergency Planning Committee (LEPC). The Mayor of Lester opened a community

center for evacuees. Many opted to stay with family or went elsewhere. The Lester Fire

Station was used as the staging area.

7. Lester Fire Department having been a part of the incident never thought as to how

bad a train derailment incident could be if it had not occurred where it did.

44

8. ICS – Even though Lester Fire Department was the initial command authority,

witnessing the raw power of the BNSF in acquiring and gathering resources, felt that

the Lester Fire Department better served as a support organization. The fire

department did not provide any operational support for the actual derailment they

managed.

9. Communication between the unified command staff and railroad personnel slowly

diminished as it became a railroad operation.

10. Since the incident scene was in a field south of the community the incident was seen

as a training event. This is a key issue – getting personnel to understand the scope of

the potential hazmat consequences.

11. Outside agencies, except for the local first responders, included TSA, Iowa DOT

(impact on the roads for the “vent and burn” operation), and Iowa Department of

Natural Resources (on scene to check a dry creek bed for run off pollution).

45

46

47

Appendix: Events Summary Table

[In formulating its analysis, the evaluation team may assemble a timeline of key exercise

events. While it is not necessary to include this timeline in the main body of the CASE STUDY,

the evaluation team may find value in including it as an appendix. If so, this section should

summarize what actually happened during the exercise in a timeline table format. Focus of

this section is on what inputs were actually presented to the players and what actions the

players took during the exercise. Successful development of this section is aided by the

design, development, and planning actions of the exercise design team. Prior to the

exercise, the exercise design team should have developed a timeline of anticipated key

events.

An example of the format for the Events Summary Table is presented below.]

Table D.1: Events Summary

Date Time Event , Time Line Event/Action

02/20/06 0900 Scenario Event Explosion and injuries reported at subway

station 13

02/20/06 0902 Player Action Subway services stopped in accordance with

protocols; notifications started

02/20/06 0915 Player Action Evacuation ordered for planning zone 2A

02/20/06 0940 Simulated Player Inject Traffic at a standstill on major egress route 1

reported to players (Response generated

issue because personnel to staff traffic control

points were not deployed)

ACCIDENTS IN DESCENDING FREQUENCY BY CAUSE ( By CALENDAR YEAR )

***IMPORTANT: Rates calculated are National Level - they do not display for Region or State Geography***

Selections: Railroad - All Railroads State - All States County - All Counties

All Regions

All Causes / All Types of Accidents

All Track Types / All Track Classes

CALENDAR YEAR - 2014

Reporting Level - ALL

End Month of Report - December

48

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

-----GRAND TOTAL....... 6,140 100.0 2,022 1,753 1,797 2.82 2.40 2.40 1,797 568

T110 Wide gage(defective/missing crossties) 310 5.0 97 94 87 0.14 0.13 0.12 87 32

H702 Switch improperly lined 245 4.0 61 75 83 0.09 0.10 0.11 83 26

H307 Shoving movement, failure to control 226 3.7 81 66 59 0.11 0.09 0.08 59 20

H306 Shoving movement, absence of man 223 3.6 75 59 66 0.10 0.08 0.09 66 23

T207 Detail fracture - shelling/head check 167 2.7 52 48 47 0.07 0.07 0.06 47 20

T314 Switch point worn or broken 141 2.3 47 39 40 0.07 0.05 0.05 40 15

H607 Failure to comply with restricted speed 124 2.0 48 37 32 0.07 0.05 0.04 32 7

H704 Switch previously run through 120 2.0 40 41 26 0.06 0.06 0.03 26 13

T220 Transverse/compound fissure 107 1.7 40 32 26 0.06 0.04 0.03 26 9

M411 Passed couplers (automated

classificatio

102 1.7 30 27 39 0.04 0.04 0.05 39 6

M405 Harmonic rock off, etc. 98 1.6 36 28 29 0.05 0.04 0.04 29 5

H318 Kicking or dropping cars, inadequate

pre

96 1.6 31 24 33 0.04 0.03 0.04 33 8

T109 Track alignment irreg(buckled/sunkink) 89 1.4 46 29 14 0.06 0.04 0.02 14 .

H503 Buff/slack action excess, trn handling 87 1.4 30 29 25 0.04 0.04 0.03 25 3

M404 Obj/equip on/fouling track, other 86 1.4 33 22 24 0.05 0.03 0.03 24 7

M599 Other miscellaneous causes 86 1.4 31 29 20 0.04 0.04 0.03 20 6

T111 Wide gage(spikes/other rail fasteners) 82 1.3 30 22 21 0.04 0.03 0.03 21 9

T221 Vertical split head 80 1.3 31 19 25 0.04 0.03 0.03 25 5

M101 Snow,ice,mud,gravel,coal,etc. on trk 79 1.3 32 15 15 0.04 0.02 0.02 15 17

H303 Derail, failure to apply or remove 76 1.2 25 17 30 0.03 0.02 0.04 30 4

T202 Broken base of rail 71 1.2 15 22 25 0.02 0.03 0.03 25 9

H302 Cars left foul 68 1.1 23 23 20 0.03 0.03 0.03 20 2

T404 Catenary system defect 68 1.1 29 18 13 0.04 0.02 0.02 13 8

H018 Fail to secure car hnd brk -rr emp 65 1.1 21 21 18 0.03 0.03 0.02 18 5

T210 Head and web sep(outside jt bar limit) 63 1.0 24 18 16 0.03 0.02 0.02 16 5

T311 Switch damaged or out of adjustment 55 0.9 13 25 13 0.02 0.03 0.02 13 4

T001 Roadbed settled or soft 53 0.9 20 12 16 0.03 0.02 0.02 16 5

H312 Passed couplers 51 0.8 21 12 14 0.03 0.02 0.02 14 4

M105 Extreme wind velocity 51 0.8 13 13 21 0.02 0.02 0.03 21 4

M204 Improperly loaded car 51 0.8 16 16 15 0.02 0.02 0.02 15 4

S016 Classification yard automatic control sy 51 0.8 11 16 16 0.02 0.02 0.02 16 8

T319 Switch pt gap(btwn swt pt & stock rail) 51 0.8 20 17 13 0.03 0.02 0.02 13 1

E61C Broken rim 50 0.8 21 9 15 0.03 0.01 0.02 15 5

T102 Cross level track irreg.(not at joints) 50 0.8 23 13 12 0.03 0.02 0.02 12 2

E53C Journal (roller bearing) overheating 49 0.8 16 10 14 0.02 0.01 0.02 14 9

H020 Fail to apply suff. hand brakes -rr emp 49 0.8 11 17 17 0.02 0.02 0.02 17 4

49

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

M402 Object/equipment (mtr veh) on track 45 0.7 15 12 13 0.02 0.02 0.02 13 5

T108 Trk alignmnt irreg-not buckled/sunkink 42 0.7 10 14 15 0.01 0.02 0.02 15 3

T113 Wide gage (due to worn rails) 42 0.7 16 12 10 0.02 0.02 0.01 10 4

H601 Coupling speed excessive 41 0.7 8 12 15 0.01 0.02 0.02 15 6

T201 Bolt hole crack or break 41 0.7 10 14 14 0.01 0.02 0.02 14 3

H402 Motor car/on-trk rules, fail to comply 40 0.7 14 8 15 0.02 0.01 0.02 15 3

M407 Auto hump retarder failed to slow car 40 0.7 10 12 15 0.01 0.02 0.02 15 3

H703 Switch not latched or locked 37 0.6 12 12 9 0.02 0.02 0.01 9 4

M501 Interference(not vandals)with RR op. 37 0.6 15 9 11 0.02 0.01 0.01 11 2

M507 Investigation complete, cause could

not

37 0.6 8 12 13 0.01 0.02 0.02 13 4

H997 Motor car or other on-track equipment

ru

35 0.6 8 11 10 0.01 0.02 0.01 10 6

E78L Pantograph defect (LOCO) 34 0.6 11 3 17 0.02 0.00 0.02 17 3

M406 Fire, other than vandalism 34 0.6 9 8 12 0.01 0.01 0.02 12 5

E46C Truck bolster stiff 33 0.5 15 7 9 0.02 0.01 0.01 9 2

T101 Cross level of track irregular(joints) 33 0.5 18 8 5 0.03 0.01 0.01 5 2

T299 Other rail and joint bar defects 33 0.5 11 6 11 0.02 0.01 0.01 11 5

T205 Defective or missing crossties 32 0.5 11 11 7 0.02 0.02 0.01 7 3

H599 Other train handling/makeup 31 0.5 11 11 7 0.02 0.02 0.01 7 2

E67C Damaged flange or tread (build up) 30 0.5 8 10 8 0.01 0.01 0.01 8 4

H021 Fail to apply car hnd brks -rr emp 30 0.5 12 5 11 0.02 0.01 0.01 11 2

T199 Other track geometry defects 29 0.5 10 7 11 0.01 0.01 0.01 11 1

T399 Oth frog, switch, trk appliance defect 29 0.5 12 6 10 0.02 0.01 0.01 10 1

S006 Class yard auto control sys switch fail 28 0.5 4 12 10 0.01 0.02 0.01 10 2

H221 Automatic block or interlocking signal d 27 0.4 7 8 8 0.01 0.01 0.01 8 4

H525 Independent brake, improper use 27 0.4 14 6 5 0.02 0.01 0.01 5 2

H999 Other train operation/human factors 27 0.4 10 8 7 0.01 0.01 0.01 7 2

H399 Other general switching rules 26 0.4 8 4 7 0.01 0.01 0.01 7 7

S011 Power switch failure 26 0.4 8 4 8 0.01 0.01 0.01 8 6

H310 Failure to couple 25 0.4 9 5 9 0.01 0.01 0.01 9 2

H524 Excessive horsepower 25 0.4 9 8 6 0.01 0.01 0.01 6 2

S007 Class yd auto ctrl sys retarder fail 24 0.4 7 6 10 0.01 0.01 0.01 10 1

H017 Failure to secure engine- rr empl 23 0.4 8 7 6 0.01 0.01 0.01 6 2

M503 Vandalism of track or track appliances 23 0.4 11 3 6 0.02 0.00 0.01 6 3

E30C Knuckle broken or defective 22 0.4 5 11 4 0.01 0.02 0.01 4 2

M408 Yard skate slid and failed to stop car 22 0.4 5 7 7 0.01 0.01 0.01 7 3

E33C Coupler retainer pin/cross key missing 21 0.3 8 4 9 0.01 0.01 0.01 9 .

E64C Worn Flange 21 0.3 8 6 5 0.01 0.01 0.01 5 2

50

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

H305 Instruction to trn/yd crew improper 21 0.3 8 7 5 0.01 0.01 0.01 5 1

H605 Failure to comply with restricted speed 21 0.3 8 6 5 0.01 0.01 0.01 5 2

T217 Mismatched rail-head contour 21 0.3 7 5 8 0.01 0.01 0.01 8 1

E06C Brake valve malf. (stuck brake, etc.) 20 0.3 10 6 4 0.01 0.01 0.01 4 .

E40C Side bearing clearance insufficient 20 0.3 6 6 7 0.01 0.01 0.01 7 1

H602 Switch movement, excessive speed 20 0.3 5 7 6 0.01 0.01 0.01 6 2

M201 Load shifted 20 0.3 6 5 6 0.01 0.01 0.01 6 3

M409 Lading chains/straps fouling switches 20 0.3 9 8 2 0.01 0.01 0.00 2 1

E39C Oth coupler/draft system defects-car 19 0.3 3 7 8 0.00 0.01 0.01 8 1

E49C Other truck component defects, (CAR) 19 0.3 8 5 2 0.01 0.01 0.00 2 4

H019 Fail to release hand brk - rr emp 19 0.3 4 4 8 0.01 0.01 0.01 8 3

H993 Human factors - track 19 0.3 . 7 9 . 0.01 0.01 9 3

T222 Worn rail 19 0.3 4 9 4 0.01 0.01 0.01 4 2

E04C Oth brk component

dmg,worn,broke,etc.

18 0.3 9 5 4 0.01 0.01 0.01 4 .

T313 Switch out of adj. insuff. anchoring 18 0.3 6 9 2 0.01 0.01 0.00 2 1

E07C Rigging down or dragging 17 0.3 5 7 4 0.01 0.01 0.01 4 1

E21C Center sill broken or bent 17 0.3 5 4 6 0.01 0.01 0.01 6 2

E73L Oil or fuel fire (LOCO) 17 0.3 5 5 5 0.01 0.01 0.01 5 2

H316 Manual intervention of classification ya 17 0.3 7 2 5 0.01 0.00 0.01 5 3

H301 Car(s) shoved out & left out of clear 16 0.3 3 7 5 0.00 0.01 0.01 5 1

H504 Buff/slack action excess, trn make-up 16 0.3 5 6 5 0.01 0.01 0.01 5 .

E4BC Truck bolster stiff (failure to slew) 15 0.2 5 7 2 0.01 0.01 0.00 2 1

E74L Electrically caused fire (LOCO) 15 0.2 5 4 5 0.01 0.01 0.01 5 1

H022 Fail to secure equip - not rr emp 15 0.2 3 7 4 0.00 0.01 0.01 4 1

T212 Horizontal split head 15 0.2 5 4 5 0.01 0.01 0.01 5 1

T403 Engineering design or construction 15 0.2 8 . 5 0.01 . 0.01 5 2

E29C Other body defects, (CAR) 14 0.2 2 4 5 0.00 0.01 0.01 5 3

H099 Use of brakes, other 14 0.2 2 4 6 0.00 0.01 0.01 6 2

H317 Humping or cutting off in motion

equipme

14 0.2 3 4 6 0.00 0.01 0.01 6 1

H507 Lat drawbar force-short/long car combo 14 0.2 3 5 5 0.00 0.01 0.01 5 1

M504 Fail by non-rr empto control spd of car 14 0.2 4 6 4 0.01 0.01 0.01 4 .

E71L Traction motor failure (LOCO) 13 0.2 2 4 3 0.00 0.01 0.00 3 4

H699 Speed, other 13 0.2 3 4 5 0.00 0.01 0.01 5 1

T309 Switch (hand op) stand mechanism

defect

13 0.2 6 3 4 0.01 0.00 0.01 4 .

E09C Other brake defects, cars 12 0.2 4 3 2 0.01 0.00 0.00 2 3

E51C Broken/bent axle between wheel seats 12 0.2 2 4 5 0.00 0.01 0.01 5 1

51

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

E79L Other LOCO defects 12 0.2 3 4 3 0.00 0.01 0.00 3 2

T002 Washout/rain/slide/etc. dmg -track 12 0.2 7 1 4 0.01 0.00 0.01 4 .

T103 Deviate frm uniform top of rail profile 12 0.2 3 4 5 0.00 0.01 0.01 5 .

T206 Defect/missing spike-oth rail fastener 12 0.2 5 4 2 0.01 0.01 0.00 2 1

T308 Stock rail worn, broken, disconnected 12 0.2 2 5 4 0.00 0.01 0.01 4 1

E54C Journal fractured, new cold break 11 0.2 4 3 3 0.01 0.00 0.00 3 1

E69C Other wheel defects (CAR) 11 0.2 4 1 4 0.01 0.00 0.01 4 2

H506 Lat DB force on curve excess, make-up 11 0.2 2 4 4 0.00 0.01 0.01 4 1

H995 Human factors -motive power &

equipment

11 0.2 5 3 2 0.01 0.00 0.00 2 1

M102 Extreme environmental - TORNADO 11 0.2 4 4 2 0.01 0.01 0.00 2 1

M505 Cause under investigation 11 0.2 3 4 . 0.00 0.01 . . 4

M506 Track damage caused by non-railroad

inte

11 0.2 4 2 4 0.01 0.00 0.01 4 1

T112 Wide gage(loose,broke, etc, gage rods) 11 0.2 4 3 3 0.01 0.00 0.00 3 1

T204 Broken weld (field) 11 0.2 . 4 5 . 0.01 0.01 5 2

T211 Head & web separation-in jt bar limit 11 0.2 2 3 6 0.00 0.00 0.01 6 .

E27C Side sill broken 10 0.2 3 4 2 0.00 0.01 0.00 2 1

E34C Draft gear/mechanism broke/defective 10 0.2 5 2 3 0.01 0.00 0.00 3 .

E41C Side bearing clearance excessive 10 0.2 6 2 2 0.01 0.00 0.00 2 .

H210 Radio communication, failure to comply 10 0.2 4 1 3 0.01 0.00 0.00 3 2

H222 Automatic block or interlocking signal d 10 0.2 6 1 3 0.01 0.00 0.00 3 .

H505 Lat DB force on curve xcess trn hndlng 10 0.2 3 3 4 0.00 0.00 0.01 4 .

H519 Dynamic brake, too rapid adjustment 10 0.2 5 3 1 0.01 0.00 0.00 1 1

H706 Switch improperly lined, radio controlle 10 0.2 3 3 2 0.00 0.00 0.00 2 2

M103 Extreme environmental - FLOOD 10 0.2 2 . 6 0.00 . 0.01 6 2

M199 Other extreme environmental

conditions

10 0.2 5 2 3 0.01 0.00 0.00 3 .

M502 Vandalism of on-track equipment 10 0.2 2 2 6 0.00 0.00 0.01 6 .

T305 Retarder worn, broken, malfunctioning 10 0.2 3 3 2 0.00 0.00 0.00 2 2

H309 Failure to stretch cars before shoving 9 0.1 3 4 1 0.00 0.01 0.00 1 1

H401 Failure to stop train in clear 9 0.1 1 4 3 0.00 0.01 0.00 3 1

H514 Fail to allow air brks to release 9 0.1 4 3 2 0.01 0.00 0.00 2 .

T106 Superelevation improper, excessive,etc. 9 0.1 3 3 3 0.00 0.00 0.00 3 .

T213 Joint bar broken (compromise) 9 0.1 2 1 6 0.00 0.00 0.01 6 .

T216 Joint bolts, broken, or missing 9 0.1 4 2 3 0.01 0.00 0.00 3 .

T303 Guard rail loose/broken or mislocated 9 0.1 1 5 3 0.00 0.01 0.00 3 .

T310 Swtch connect/operate rod

broke/defect

9 0.1 4 1 3 0.01 0.00 0.00 3 1

52

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

T316 Turnout frog (rigid) worn, or broken 9 0.1 3 3 3 0.00 0.00 0.00 3 .

T499 Other way and structure defect 9 0.1 3 5 1 0.00 0.01 0.00 1 .

E60C Broken flange 8 0.1 1 2 2 0.00 0.00 0.00 2 3

E62C Broken plate 8 0.1 1 3 2 0.00 0.00 0.00 2 2

E99L Other mechanical/electrical fail(LOCO) 8 0.1 . 3 3 . 0.00 0.00 3 2

H311 Moving cars-load ramp,etc, not in pos 8 0.1 1 2 3 0.00 0.00 0.00 3 2

H701 Spring Swtch not clear before reverse 8 0.1 2 2 3 0.00 0.00 0.00 3 1

H705 Moveable point trk frog improper lined 8 0.1 1 1 6 0.00 0.00 0.01 6 .

T215 Joint bar broken (noninsulated) 8 0.1 1 3 4 0.00 0.00 0.01 4 .

E22C Draft sill broken or bent 7 0.1 2 2 3 0.00 0.00 0.00 3 .

E4TC Truck hunting 7 0.1 4 2 1 0.01 0.00 0.00 1 .

E64L Worn flange (LOCO) 7 0.1 2 5 . 0.00 0.01 . . .

H025 Fail to ctrl car spd use hnd brk-r emp 7 0.1 4 . 1 0.01 . 0.00 1 2

H220 Fixed signal (other than automatic block 7 0.1 5 1 . 0.01 0.00 . . 1

H308 Skate, failure to remove or place 7 0.1 3 2 1 0.00 0.00 0.00 1 1

H522 Throttle (power), improper use 7 0.1 . 2 2 . 0.00 0.00 2 3

T401 Bridge misalignment or failure 7 0.1 2 3 1 0.00 0.00 0.00 1 1

E45C Side frame broken 6 0.1 2 1 3 0.00 0.00 0.00 3 .

E52C Journal (plain) failure from overheat 6 0.1 1 . 2 0.00 . 0.00 2 3

E99C Other mechanical/electrical failures 6 0.1 3 1 2 0.00 0.00 0.00 2 .

H104 Employee asleep 6 0.1 3 2 1 0.00 0.00 0.00 1 .

H526 Failure to actuate off independent brk 6 0.1 3 1 1 0.00 0.00 0.00 1 1

H799 Use of switches, other 6 0.1 3 3 . 0.00 0.00 . . .

H996 Oversized loads or Excess Height/Width c 6 0.1 2 1 3 0.00 0.00 0.00 3 .

M202 Load fell from car 6 0.1 2 1 2 0.00 0.00 0.00 2 1

M203 Overloaded car 6 0.1 3 2 1 0.00 0.00 0.00 1 .

M299 Miscellaneous loading procedures 6 0.1 4 . 1 0.01 . 0.00 1 1

T214 Joint bar broken (insulated) 6 0.1 1 . 5 0.00 . 0.01 5 .

T306 Retarder yard skate defective 6 0.1 . . 5 . . 0.01 5 1

T312 Switch lug/crank broken 6 0.1 3 1 2 0.00 0.00 0.00 2 .

T317 Turnout frog(self guarded)-worn/broken 6 0.1 1 4 1 0.00 0.01 0.00 1 .

E00C Air hose uncoupled or burst 5 0.1 2 1 2 0.00 0.00 0.00 2 .

E0HC Hnd brk link and/or connect defect 5 0.1 4 1 . 0.01 0.00 . . .

E23C Center plate broken or defective 5 0.1 1 1 3 0.00 0.00 0.00 3 .

E35C Coupler carrier broken or defective 5 0.1 3 . 2 0.00 . 0.00 2 .

E44C Truck bolster broken 5 0.1 3 . 1 0.00 . 0.00 1 1

E59C Oth axle/journal bearing defect-car 5 0.1 . 2 1 . 0.00 0.00 1 2

E66C Damaged flange or tread (flat) 5 0.1 . 2 2 . 0.00 0.00 2 1

E68C Loose wheel 5 0.1 1 2 2 0.00 0.00 0.00 2 .

53

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

E69L Other wheel defects (LOCO) 5 0.1 1 1 1 0.00 0.00 0.00 1 2

E85C Bottom outlet car door open 5 0.1 2 2 1 0.00 0.00 0.00 1 .

E86C Bottom outlet door attachment defect 5 0.1 . 2 3 . 0.00 0.00 3 .

H207 Hand signal, failure to comply 5 0.1 3 . 1 0.00 . 0.00 1 1

H313 Retarder, improper manual operation 5 0.1 . 2 3 . 0.00 0.00 3 .

H403 Movement without authority - rr emp 5 0.1 2 1 1 0.00 0.00 0.00 1 1

S099 Other signal failures 5 0.1 . 3 2 . 0.00 0.00 2 .

T099 Other roadbed defects 5 0.1 1 1 3 0.00 0.00 0.00 3 .

T402 Flangeway clogged 5 0.1 1 1 2 0.00 0.00 0.00 2 1

E02C Broken brake pipe or connections 4 0.1 . 3 1 . 0.00 0.00 1 .

E08C Hand brk broken or defective 4 0.1 1 3 . 0.00 0.00 . . .

E24C Ctr plate disengaged from truck 4 0.1 1 2 1 0.00 0.00 0.00 1 .

E65C Worn tread 4 0.1 1 1 1 0.00 0.00 0.00 1 1

E72L Crank case or air box explosion (LOCO) 4 0.1 . . 3 . . 0.00 3 1

H508 Improper train make-up 4 0.1 1 1 . 0.00 0.00 . . 2

H511 Automatic brake, excessive 4 0.1 1 1 1 0.00 0.00 0.00 1 1

H521 Dynamic brake, other improper use 4 0.1 1 1 1 0.00 0.00 0.00 1 1

H606 Train outside yd limits(nonblk),exc spd 4 0.1 1 3 . 0.00 0.00 . . .

H994 Human factors - signal 4 0.1 2 2 . 0.00 0.00 . . .

M206 Trailer/container tiedown eqp improper 4 0.1 1 2 1 0.00 0.00 0.00 1 .

M410 Lading chains or straps fouling wheels 4 0.1 . 2 2 . 0.00 0.00 2 .

S012 Radio communication equipment failure 4 0.1 . 1 2 . 0.00 0.00 2 1

T208 Engine burn fracture 4 0.1 2 1 1 0.00 0.00 0.00 1 .

E32C Coupler drawhead broken or defective 3 0.0 1 . 2 0.00 . 0.00 2 .

E46L Truck bolster stiff (LOCO) 3 0.0 1 . 2 0.00 . 0.00 2 .

E47C Defective snubbing 3 0.0 2 1 . 0.00 0.00 . . .

E48C Broken, missing, or defective springs 3 0.0 . 1 2 . 0.00 0.00 2 .

E51L Broke/bent axle btwn wheel seats-loco 3 0.0 . 1 2 . 0.00 0.00 2 .

H008 Bottling the Air 3 0.0 2 . . 0.00 . . . 1

H218 Failure to comply with failed equipment 3 0.0 . 1 2 . 0.00 0.00 2 .

H510 Automatic brake, insufficient 3 0.0 2 1 . 0.00 0.00 . . .

H513 Automatic brake, other improper use 3 0.0 1 1 . 0.00 0.00 . . 1

H516 Fail to cut-in brake valves-loco 3 0.0 1 2 . 0.00 0.00 . . .

H518 Dynamic brake, excessive 3 0.0 1 . 2 0.00 . 0.00 2 .

H523 Throttle (power), too rapid adjustment 3 0.0 1 . 2 0.00 . 0.00 2 .

H603 Train inside yard limits, excess speed 3 0.0 2 . 1 0.00 . 0.00 1 .

H707 Radio controlled switch not locked effec 3 0.0 3 . . 0.00 . . . .

T307 Spring/power swtch mech. malfunction 3 0.0 2 . 1 0.00 . 0.00 1 .

E10L Computer controlled brake 2 0.0 2 . . 0.00 . . . .

54

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

communication

E25C Center pin broken or missing 2 0.0 . 1 1 . 0.00 0.00 1 .

E29L Other body defects, (LOCO) 2 0.0 1 . 1 0.00 . 0.00 1 .

E36C Coupler shank broken/defective 2 0.0 . 2 . . 0.00 . . .

E37C Failure of articulated connectors 2 0.0 . 1 1 . 0.00 0.00 1 .

E40L Side bearing clearance insuff. (LOCO) 2 0.0 . 2 . . 0.00 . . .

E59L Oth axle/journal bearing defect-loco 2 0.0 . . . . . . . 2

E60L Broken flange (LOCO) 2 0.0 1 . . 0.00 . . . 1

E66L Damaged flange or tread (flat) (LOCO) 2 0.0 . 1 1 . 0.00 0.00 1 .

E76L Remote control equip inoperative

(LOCO)

2 0.0 . . 2 . . 0.00 2 .

E89C Other car door defects 2 0.0 . 1 1 . 0.00 0.00 1 .

H211 Radio communication, improper 2 0.0 . 1 1 . 0.00 0.00 1 .

H212 Radio comm., failure to give/receive 2 0.0 1 . 1 0.00 . 0.00 1 .

H314 Retarder yard skate improperly applied 2 0.0 . . 2 . . 0.00 2 .

H404 Fail to comply with trn order, etc. 2 0.0 . 1 1 . 0.00 0.00 1 .

H499 Other main track authority causes 2 0.0 1 . 1 0.00 . 0.00 1 .

H501 Improper train make-up at init term 2 0.0 1 . . 0.00 . . . 1

S005 Block signal displayed false proceed 2 0.0 1 . 1 0.00 . 0.00 1 .

S013 Other communication equipment failure 2 0.0 . 2 . . 0.00 . . .

S014 Computer system design error (vendor) 2 0.0 . 2 . . 0.00 . . .

S015 Computer system

configuration/management

2 0.0 1 . 1 0.00 . 0.00 1 .

S102 Remote control transmitter, loss of comm 2 0.0 . . 2 . . 0.00 2 .

S104 Radio controlled switch not locked effec 2 0.0 1 1 . 0.00 0.00 . . .

T105 Insufficient ballast section 2 0.0 . . 2 . . 0.00 2 .

T203 Broken weld (plant) 2 0.0 1 1 . 0.00 0.00 . . .

T219 Rail defect with joint bar repair 2 0.0 1 1 . 0.00 0.00 . . .

T223 Rail Condition - Dry rail, freshly groun 2 0.0 2 . . 0.00 . . . .

T301 Derail, defective 2 0.0 2 . . 0.00 . . . .

T302 Expansion joint failed/malfunctioned 2 0.0 1 1 . 0.00 0.00 . . .

T304 Railroad crossing frog, worn or broken 2 0.0 1 1 . 0.00 0.00 . . .

T318 Turnout frog (spring) worn, or broken 2 0.0 . 1 1 . 0.00 0.00 1 .

E00L Air hose uncoupled or burst (LOCO) 1 0.0 1 . . 0.00 . . . .

E02L Broken brake pipe/connections (LOCO) 1 0.0 1 . . 0.00 . . . .

E03C Obstructed brake pipe 1 0.0 . . 1 . . 0.00 1 .

E04L Oth brk parts

dmg,worm,broke,etc.(LOCO)

1 0.0 . 1 . . 0.00 . . .

E09L Other brake defects, (LOCO) 1 0.0 . . . . . . . 1

55

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

E0HL Hnd brk linkage/connect defect-loco 1 0.0 . 1 . . 0.00 . . .

E11C Broken or defective tiedown equipment 1 0.0 1 . . 0.00 . . . .

E20C Body bolster broken or defective 1 0.0 . . 1 . . 0.00 1 .

E26C Center plate attachment defective 1 0.0 . 1 . . 0.00 . . .

E31L Coupler mismatch, high/low (LOCO) 1 0.0 . 1 . . 0.00 . . .

E35L Coupler carrier broken/defective

(LOCO)

1 0.0 . 1 . . 0.00 . . .

E48L Broken/missing/defective springs (LOCO) 1 0.0 . . . . . . . 1

E49L Other truck component defects, (LOCO) 1 0.0 . 1 . . 0.00 . . .

E4AC Gib Clearance (lateral motion

excessive)

1 0.0 . . 1 . . 0.00 1 .

E4TL Truck hunting (LOCO) 1 0.0 . . 1 . . 0.00 1 .

E52L Journal (plain) fail-overheating (LOCO) 1 0.0 1 . . 0.00 . . . .

E65L Worn tread (LOCO) 1 0.0 1 . . 0.00 . . . .

E6AC Thermal crack, flange or tread 1 0.0 . . . . . . . 1

E6AL Thermal crack, flange or tread (LOCO) 1 0.0 . . 1 . . 0.00 1 .

E70L Running gear failure (LOCO) 1 0.0 . . 1 . . 0.00 1 .

E75L Current collector system (LOCO) 1 0.0 . 1 . . 0.00 . . .

E7AL On-board computer - failure to respond

(

1 0.0 . . 1 . . 0.00 1 .

E80C Box car plug door open 1 0.0 . . . . . . . 1

E84C Box car door (not plug) attach defect 1 0.0 . 1 . . 0.00 . . .

H101 Impairment because of drugs or alcohol 1 0.0 . . . . . . . 1

H102 Incapacitation due to injury/illness 1 0.0 1 . . 0.00 . . . .

H199 Employee physical condition, other 1 0.0 1 . . 0.00 . . . .

H205 Flagging, improper or failure to flag 1 0.0 . . 1 . . 0.00 1 .

H208 Hand signal improper 1 0.0 1 . . 0.00 . . . .

H209 Hand signal, failure to give/receive 1 0.0 . 1 . . 0.00 . . .

H406 Trn orders, trk warrants, written err 1 0.0 . . 1 . . 0.00 1 .

H509 Improper train inspection 1 0.0 1 . . 0.00 . . . .

H512 Auto brake, fail to use split reduction 1 0.0 . . 1 . . 0.00 1 .

H991 Tampering - safety/protective device 1 0.0 . . . . . . . 1

H99B Human Factor - Signal - Train Control - 1 0.0 1 . . 0.00 . . . .

M403 Livestock on track 1 0.0 1 . . 0.00 . . . .

S101 Remote control transmitter defective 1 0.0 . 1 . . 0.00 . . .

S103 Radio controlled switch communication

fa

1 0.0 . . . . . . . 1

T104 Disturbed ballast section 1 0.0 1 . . 0.00 . . . .

T107 Superelevation runoff improper 1 0.0 . 1 . . 0.00 . . .

56

Total Total Year

Counts

Total Year

Rates

YTD Counts

Jan -

Dec

Accs Pct of

Total

2011 2012 2013 2011 2012 2013 2013 2014

T218 Piped rail 1 0.0 1 . . 0.00 . . . .

T315 Switch rod worn, bent, broken, etc. 1 0.0 1 . . 0.00 . . . .

57

ACCIDENTS IN DESCENDING FREQUENCY ( By CALENDAR YEAR )

Selections: Railroad - All Railroads

State - All States County - All Counties

All Regions

All Causes / All Types of Accidents

All Track Types / All Track Classes

CALENDAR YEAR - 2014

Reporting Level - ALL

End Month of Report – December

Total Total Year Counts YTD Counts Jan -

Dec

% Change Over Time

Accs Pct of Total 2011 2012 2013 2013 2014 2011

to 2013

2012

to 2013

To Dec

2013

2014

GRAND TOTAL.... 6,140 100.0 2,022 1,753 1,797 1,797 568 -11.1 2.5 -68.4

Texas 695 11.3 211 230 195 195 59 -7.6 -15.2 -69.7

Illinois 584 9.5 191 145 177 177 71 -7.3 22.1 -59.9

California 291 4.7 87 86 99 99 19 13.8 15.1 -80.8

Ohio 249 4.1 79 76 67 67 27 -15.2 -11.8 -59.7

Nebraska 241 3.9 95 71 56 56 19 -41.1 -21.1 -66.1

Kansas 220 3.6 79 67 55 55 19 -30.4 -17.9 -65.5

Louisiana 214 3.5 62 63 70 70 19 12.9 11.1 -72.9

Pennsylvania 196 3.2 57 54 63 63 22 10.5 16.7 -65.1

Indiana 194 3.2 57 62 53 53 22 -7.0 -14.5 -58.5

Missouri 185 3.0 68 45 49 49 23 -27.9 8.9 -53.1

Minnesota 174 2.8 61 43 57 57 13 -6.6 32.6 -77.2

New Jersey 161 2.6 55 50 38 38 18 -30.9 -24.0 -52.6

Iowa 159 2.6 59 51 40 40 9 -32.2 -21.6 -77.5

Georgia 155 2.5 41 51 46 46 17 12.2 -9.8 -63.0

Oklahoma 153 2.5 43 47 54 54 9 25.6 14.9 -83.3

Arkansas 145 2.4 55 44 37 37 9 -32.7 -15.9 -75.7

New York 144 2.3 57 34 42 42 11 -26.3 23.5 -73.8

Tennessee 129 2.1 42 29 50 50 8 19.0 72.4 -84.0

Alabama 124 2.0 29 39 42 42 14 44.8 7.7 -66.7

Montana 113 1.8 47 27 25 25 14 -46.8 -7.4 -44.0

Washington 113 1.8 40 32 33 33 8 -17.5 3.1 -75.8

Virginia 95 1.5 30 30 26 26 9 -13.3 -13.3 -65.4

Colorado 93 1.5 31 33 19 19 10 -38.7 -42.4 -47.4

Kentucky 90 1.5 27 26 24 24 13 -11.1 -7.7 -45.8

Wisconsin 88 1.4 34 25 15 15 14 -55.9 -40.0 -6.7

58

Total Total Year Counts YTD Counts Jan -

Dec

% Change Over Time

Accs Pct of Total 2011 2012 2013 2013 2014 2011

to 2013

2012

to 2013

To Dec

2013

2014

Florida 84 1.4 18 23 32 32 11 77.8 39.1 -65.6

Michigan 80 1.3 27 15 32 32 6 18.5 113.3 -81.3

New Mexico 79 1.3 25 21 29 29 4 16.0 38.1 -86.2

North Dakota 79 1.3 36 18 18 18 7 -50.0 . -61.1

Maryland 78 1.3 28 22 22 22 6 -21.4 . -72.7

Wyoming 76 1.2 28 19 25 25 4 -10.7 31.6 -84.0

North Carolina 70 1.1 20 21 20 20 9 . -4.8 -55.0

Oregon 64 1.0 20 16 22 22 6 10.0 37.5 -72.7

West Virginia 62 1.0 29 13 16 16 4 -44.8 23.1 -75.0

Mississippi 53 0.9 19 19 13 13 2 -31.6 -31.6 -84.6

Arizona 51 0.8 11 18 18 18 4 63.6 . -77.8

Idaho 51 0.8 16 15 17 17 3 6.3 13.3 -82.4

Utah 49 0.8 12 10 21 21 6 75.0 110.0 -71.4

Connecticut 44 0.7 16 10 11 11 7 -31.3 10.0 -36.4

Massachusetts 40 0.7 18 5 15 15 2 -16.7 200.0 -86.7

South Carolina 35 0.6 11 11 9 9 4 -18.2 -18.2 -55.6

South Dakota 34 0.6 15 8 9 9 2 -40.0 12.5 -77.8

Nevada 31 0.5 11 10 9 9 1 -18.2 -10.0 -88.9

Maine 25 0.4 6 6 11 11 2 83.3 83.3 -81.8

Delaware 16 0.3 5 5 5 5 1 . . -80.0

Dist Of Columbi 16 0.3 5 5 5 5 1 . . -80.0

Rhode Island 7 0.1 3 2 2 2 . -33.3 . .

Alaska 6 0.1 4 . 2 2 . -50.0 . .

Vermont 3 0.0 1 1 1 1 . . . .

New Hampshire 2 0.0 1 . 1 1 . . . .

59

ACCIDENTS IN DESCENDING FREQUENCY ( By CALENDAR YEAR )

Selections: Railroad - All Railroads

State - All States County - All Counties

All Regions

All Causes / All Types of Accidents

All Track Types / All Track Classes

CALENDAR YEAR - 2014

Reporting Level - ALL

End Month of Report – December

Trk Cls Total Total Year Counts YTD Counts Jan -

Dec

% Change Over Time

Accs Pct of Total 2011 2012 2013 2013 2014 2011

to 2013

2012

to 2013

To Dec

2013

2014

Total 6,140 100.0 2,022 1,753 1,797 1,797 568 -11.1 2.5 -68.4

1 3,973 64.7 1,280 1,161 1,160 1,160 372 -9.4 -0.1 -67.9

4 637 10.4 228 163 171 171 75 -25.0 4.9 -56.1

2 522 8.5 169 137 172 172 44 1.8 25.5 -74.4

3 376 6.1 127 92 122 122 35 -3.9 32.6 -71.3

X 367 6.0 124 127 99 99 17 -20.2 -22.0 -82.8

5 186 3.0 62 56 52 52 16 -16.1 -7.1 -69.2

7 39 0.6 12 10 13 13 4 8.3 30.0 -69.2

6 23 0.4 11 1 6 6 5 -45.5 500.0 -16.7

9 8 0.1 5 1 2 2 . -60.0 100.0 .

? 6 0.1 4 2 . . . . . .

8 3 0.0 . 3 . . . . . .