Runaway on CIMA HILL David Le Roy Totten was a young Californian engine-driver who worked on the Union Pacific Railroad until 1980 - to be precise, until 14.29 hours Pacific Standard Time on Monday 17 November 1980. David's employer is prominent in the history of the United States of America. David is virtually unknown but he too has his place in railway history. A great company, a great and proud system, the Union Pacific Railroad is a name known across the world. UP was the railroad famed for opening up the American West, reviled for destroying the prairie buffalo and a complex Indian society. Train enthusiasts know UnPac of old for having the world's biggest engines , the longest trains, the densest intercity freight traffic. The modern UnPac is famous for its superb infrastructure,equipment, and management, its marketing, and its profitability in a difficult business. "If only we were as good as UnPac", Australian managers might well say, "our industry would have it made" And that would be true. What then if a Telivision drama or a novel had a 4000-tonne five-diesel superfreighter being driven at breakneck speed down a 1 in 45 grade in a desperate attempt to outrace a runaway train behind it? The script would surely be dismissed as fanciful. And what if the death of the hero was attributed to a disregard of safety by the railway management? Would that be pure fiction? Both these things happened on the fabled Union Pacific Railroad. They happened only eight years ago, and they killed three men, facts documented by no less an authority than the US Government's National Transportation Safety Board.Few government reports contain such hair-raising drama, tragedy, and sense of sheer waste. THE SETTING Most mountainous sections of railway are located so the steep grade follows a winding river valley, a staircase of alpine glacial basins, or, as in the Blue Mountains of NSW, a narrow, rising ridge. In such settings, the natural rise sets the overall grade, and the engineering works follow. More subtle and rare but not less steep is the open desert plain tilted to the horizontal. Although the tilt may he imnercentible to the naked eye it can be formidably steep for a labouring main-line train. AN's eastern climb up to the Nullarbor is an example - a gentle 1 in 70 rise. The bottom of the Bolan Pass in Baluchistan is another such place, but here Pakistan Railways rise at 1 in 25 grades. Another lies in the Mohave desert, where the Los Angeles-Las Vegas leg of UPac's transcontinental main line climbs Cima Hill on an unbroken 1 in 45 for some 30km. The section is in San Bernadino County but is not in the San Bernadino mountains. Cima Hill is in tilted desert, still essentially open country. On Cima Hill the curves are few, the straights up to 5km long. THE TRAIN Five minutes after midnight on Monday 17 November 1980, a 26-car UP freight train arrived at Las Vegas, Nevada. One car was the yellow caboose, one was loaded with beer, and the remaining 25 cars were bulkhead flats from UPac's sleeper treatment works at The Dalles, Oregon. Built in 1956 for plasterboard traffic, these sleeper- wagons were 16.3m long with a tare mass of 30.5t. Heavy? Yes, these flats had cast steel underframes that alone weighed nearly 16t, bolt-on cast steel end bulkheads, and extra side framing to constrain the transversely-loaded sleepers. Twenty of the wagons carried main track sleepers 2.7m long and five carried short 2.4m siding-track sleepers, the latter cars being mixed in the train. The main track sleepers were urgently needed at Yermo, California. So by 07.45 the night shift had removed the beer car, added another caboose and assembled a 21-car train headed by No 3119, a single EMD-GM Model SD-40 diesel of 3300hp. Due to a mix up with numbers in the dark, however, the five cars with siding sleepers were coupled in the rake. Getting the people, locating the right cars, and unscrambling the muddle took some time. But the staff were lashed by an angry yardmaster. The perway special was remarshalled,given its pre-trip train examination and brake-tested for continuity and leakage rate by 09.42. It was fine autumn high-country weather in Vegas and to the west, with near perfect visibility, 17 deg C and a light wind. At 10.00 precisely, the perway special, now designated by its UP engine number as Extra 3119 pulled out of Las Vegas yard bound for Yermo, 275km to the west. On board were nearly 11000 sleepers and a youthful four-man crew. Engineer (driver) David Totten was the oldest at 31, accompanied on the footplate by the youngest, head brakeman Wallace Dastrup, 22. In the caboose, conductor David Branson, 26, was in charge of the train, with rear brakeman Thomas Faucett, age 30. BREAKS NOT WORKING. On this perfect late-autumn morning, the compact little train of heavily -laden cars climbed the long 32km rise to Erie, Nevada, holding a bit over 30km/h on the 1 in 100 climb. The special then dropped down an undulating descent to Borax, Nevada. The speed limit for the special was 80km/h, but it briefly reached 90km/h after David Totten found that 3119's dynamic brake was not working. As required by the UP rules, he radioed this to the despatcher (train controller) at the Salt Lake City Control Office. While he was able to control the train on the 1 in 100, it was clear to David that they would have to set the grade control valves (retainers) before he could bring the train down the long 1 in 45 Cima Hill on air brakes alone. After Borax, the train settled into another long, steady uphill slog at 32km/h across the state line into California and up the 1 in 100 into Cima, the summit station. Extra 3119 arrived at Cima and swung right on to the northbound loop track at 13.29, having averaged around 40km/h for the first part of the trip. While the SD-40 ticked over up front, Dave Branson and Tom Faucett moved forward along each side of the train, setting grade control valves. They met Wally Dastrup, who was walking backwards from the engine, doing the same. Branson and Faucett heard no air leaks, and they reported no defects. While events were to show that their examination could only have been perfunctory, there was no special reason why it should not have been. The car department in Las Vegas had examined and passed their train, and the upward chain of responsibility was train examiners, yardmasters, operations management. Train inspection wasn't the train crew's job. Twenty minutes behind Extra 3119, a long train of loaded grain hoppers had 73 cars and was pulled by a string of SD-40s. Extra 3135 followed the perway special westward across the desert at its regulation 80kin/h, down and up the 1 in 100 banks and at 13.35 took the loop points at Cima, swinging left on to the northern loop track. Then, like the crew of Extra 3119, the grain train's crew moved down their long train setting the grade control valves. A THIRD TRAIN At 12.05, a third westbound train had also clattered out of the Las Vagas yards on to the UP main line, heading for LA. But extra 8044 was a very different train from the perway special and the grain train. Extra 4044 had rolled in from the East on a priority schedule with 50 cars on : 49 loaded, extra-length 25m piggyback and automobile cars and a caboose. A long, tall, high-windage train, Extra 8044 represented a solid block of profitable cargo wrestled by UPac's marketing department from the trucking competition. With some $8m worth of cargo aboard, nothing was allowed to delay trains like this. So five GM diesel units had been coupled on to crack this freighter over the 1 in 100 grades. And the leading unit was the biggest diesel in the world - a 6600 hp, 8-axle Centennial class engine. EMD model DD40X was a 1967 design, custom-built for the UP's transcontinental fast freight run, a twin- V16 engined Do-Do monster weighing nearly 248 tonnes. Compared with the 6946, the other four units on the fast freighter were mere babies: 6-axle SD-40s, Co-Co, 3300 hp, 1771 each, single V16 ,brothers under the bonnet of Australian V/Line's lighter G Class and Westrail's L Class Clydes. Except for the Centennials, this division was an SD-40 railway. So with the line cleared for it , with nearly 20000 hp of locomotives available for 3290 tons of train, and with fuel pouring into cylinders at the rate of a garden hose, Extra 8044 found no problem in maintaining a cracking 77km/h average from Las Vegas up to the summit at Cima - despite two climbs totalling 68km of rising 1 in a 100. Approaching the occupied Cima loops, the locos were throttled back, but 8440 did not need to stop. The crews exchanged waves as an unending string of long, high cars banged and rang their way through. between the two standing westbound trains. The track circuits wired the event back to the CTC machine at Salt Lake City, which timed it at 13.46. But this fast freight was nearly 1.5km long; it took over four minutes to roll through the lonely little summit station. Then with the long, mostly straight 1 in 45 descent before him, the driver set the power control on the Centennial on DYNAMIC, and step by step notched the five big yellow locomotives up to full notch-8 retardation. The 32 traction motors dug the wheels in, checking the downhill surge of the train; the driver applied the air brakes carefully. With engines in fast idle, the dynamic brake fans howling at full revs, and 400 brake blocks clamped firmly against 400 wheels, Extra 3044 stabilised at exactly the regulation 40km/h and the freighter's crew settled back in their seats for a steady, uneventful 30km run, a 633m drop down Cima Hill. They would pass the unoccupied Chase, Elora, Dawes, and Hayden loops before reaching Kelso, California, where the 1 in 45 ends and the grade eases to a continuing descent at 1 in 100. The points were aligned from Salt Lake, the perway special was cleared by radio as next in the queue,and ten minutes later the signal block changed from red to yellow. David Totten realeased the independent brake and gently powered-up his SD-40, notch by notch, looking back, easing the 21-car train on to the main line. Then he throttled back as the cars coasted over the loop points. GOING DOWN At 13.59, the yellow caboose clattered clear of the Cima loop at 27km/h and the train began its descent of the 1 in 45. But unlike the 8044 ahead, its dynamic brake fans were not howling. On Engine 3119 David Totten had to bring his train down in exactly the same way as a steam driver would have done 70 years earlier. Ten minutes later again, at 14.09, the bulk grain train followed. But it plays no real part in this story. After Branson's caboose cleared the loop points, David Totten braked his train down from 27 to about 21km/h. Obedient, the train slowed - but then it reaccelerated to 26km/h. Two more full-service brake applications were needed to take command of the train. Sensing trouble, David Totten radioed the Salt Lake City despatcher: "I keep setting air, and it won't slow down". What could be wrong? They had brake continuity. They had set the grade control valves. They were following their instructions and training. Yet speed was gently rising. At 14.13, it was 31.4km/h and accelerating at 2.6km/h every minute. David radioed that he now had 210 kPa of air in the loco brake cylinders. Back in the caboose, Branson, the 26-year-old conductor, heard this, and opened his emergency brake valve ; he said nothing on the radio. The despatcher heard David's radio message but he did and said nothing. Just two minutes later, at 14.15,several things happened simultaneously. The following grain train's engine crew noted that the block signals at Chase, the next crossing loop down the hill, changed rather rapidly from red to yellow, then green. And the perway special 4.7km ahead of them, seem to be smoking rather heavily. Branson and Faucett were making a futile attempt to uncouple their caboose. Their train, which had stabilised briefly at 32km/h, had started to reaccelerate at the high rate of 8km/h per minute after Branson pulled the air from the rear. The train had already run 8km of unbroken and mostly straight 1 in 45. David Totten had again radioed Salt Lake reporting a full service application, 40km/h speed, and a train that was still accelerating. The CTC board now showed the train had clattered past the unattended Elora loop,so the despatcher asked David whether he planned to stop at Dawes to cool the brakes. David replied that he didn't think he'd be able to stop. The despatcher said and did nothing. He did not set the CTC to sidetrack the express freighter further down the hill, and give the perway special a clear track. He did not slow the express freighter so that rear-end crew could bale out safely, set the points to derail the perway special at a still (relatively) low speed. In short, that despatcher failed totally to ask the right questions, to use his head, and to react. RUNAWAY TRAIN The driver of 8440 certainly reacted to the radioed exchanges, for the tempo of action was rising on Cima Hill. He realised that just 8km behind him there was a now runaway train doing - at 14.17 - 63km/h, when he was holding the regulation 40 and still in full dynamic braking. He released his superfreighter's air brakes, eased the dynamic brake back to "idle", and radioed Salt Lake for permission to exceed the speed limit. It was granted. So he set POWER and punched the throttle open. With five diesels in notch 8 unleashing 19800 hp pulling, the 50-car freighter unbunched its coupler slack and surged down the 1 and 45. By 14.21, the 40001 automobile train was running at 105km/h. But the runaway, too, had gathered speed and with virtually no retardation, it was now accelerating at nearly 14km/h per minute. David Totten sat in his cab broadcasting his rising indicated speed: 100-110-120-130 kilometres an hour. Behind him, the old three-piece bogies under the fiat cars kicked and bucked and bounced at way above their critical speeds. Regrettably, UPac's superb track kept them on the rails. And not at 130km/h - for that was only the indicated speed. The speedometer on the SD-40 didn't read or record anything higher, even though the perway special was by then running very much faster than 130. Two trains with total masses of over 60001 were racing towards Kelso down the I in 45. Near the bottom of the hill, Extra 8044 was galloping for its life, full-tilt at 121km/h, her diesels fiat out, her crew now becoming confident they could outrun the runaway. It was then that the overspeed trip on the big Centennial operated, knocking out traction power. The engines wound back to idle; 50 angry wagons surged in against the locomotives; somehow the driver forestalled a penalty brake application. His mate broke into the speed recorder instrument, desperately forcing its needle back so that traction power could be restored. The speed had dropped to ll0km/h before they got their locomotives back on to power, and wound up to notch 8 again. But the check had probably saved their lives;investigators found that the big DD-40X with its 8-wheel probably would not have taken the approach curve much faster than ll0km/h. Thus did everyone stay on the rails, all the way down Cima Hill. With a clear, straight road ahead the express freighter thundered off the 1 in 45 and through Kelso yard on maximum throttle and doing ll0km/h. Then it was on to the 1 in 100 - still descending, still accelerating. Four kilometres west of Kelso, the automobile train was back to 120km/h. Faster, ever faster it went, still on notch 8 - for its crew knew that behind them was David Totten's runaway sleeper. And that was still accelerating, too. The runaway rocketed through Kelso with the SD-40 on red hot wheels, past the horrified crew of a freight train that had been sidetracked and was waiting to climb the big hill, with the old flatcars still on the rails at an unbelievable 177km/h. The waiting railwaymen had heard David Totten's warning on the radio, heard the 3119's warning horn. They were the last people to see David Totten alive - seated in his cab, microphone in hand, broadcasting his indicated speed of 130km/h and a calm estimate of the narrowing distance to the caboose of the automobile special clearly visible ahead. THE COLLISION At 14.29,just 30 min and 37km after it had left Cima summit, the runaway train finally overtook the speeding express freighter. Both trains were running on dead straight track, still dropping at 1 in 100. The automobile freighter was running at 135km/h when they hit. And hotbox detector records confirmed that the runaway was doing around 118 miles an hour - an incredible 190km/h. A series of four cataclysmic, multiple-impact rolling collisions followed. The express freighter's caboose was instantly lifted, derailed, uncoupled and thrown clear to the left, fatally injuring the conductor and badly injuring the rear brakeman. The air hose opened, the express freighter went into emergency braking as David's perway train smashed in the coupler slack at the train's rear and savaged, in rapid succession, three tri-level automobile cars. In this grinding maelstrom of flying steel the automobile car structures held, and they too, were thrown clear. But the superstructure of UP loco 3119 did not: except for the diesel engine, it was wholly demolished. The rails then spread under the headless perway train, and in a few terrifying seconds of dust and thunder in the desert, all 20 bulkhead flatcars derailed, uncoupled and dug in. They ejected 11000 sleepers into the desert, sideways and forwards at 180km/h, scattering them like broken matchsticks amid indestructible General Steels underframes and a scrapyard of wheelsets, couplers and bogie components. Ahead of this, the wrecked SD-40 ran on for nearly 700 metres before it too stopped, upright,in line with the roadbed, and reduced to scrap metal. This terrible collision was reconstructed by NTSB investigators , who established that David Totten and Wally Dastrup were killed instantly, still at their posts when the third-last auto rack car finally demolished their locomotive. But for at least 10 minutes the men must have known that they faced almost certain death. Branson and Faucett were derailed but survived. David Totten had been in Union Pacific's service for six years. He had joined as a shunter, and passed his driver training course with a final score of 96 per cent. He was described as "a very apt student", "very capable". After an experience period in which he was recorded as meticulous in following rules, he had been driving the big yellow diesels for 22 months when he was killed. He comes through the cold prose of the official US Government report on the Kelso wreck as a dedicated railwayman and a fine product of the company's recruitment and training program. On the material side, the bill was one SD-40, 20 old wagons and four newer ones, plus track damage and service disruption: A modest $USI.2m bill in all. And no doubt some Californians had to wait a while for Detroit to make them another new car. INVESTIGATION But how, the industry asked, could such an unthinkable runaway occur on a modern railroad like the Union Pacific? The task of answering this fell to four people - the National Transportation Safety Board's vice-chairman Elwood Driver, Messrs Francis McAdams and Patrick Bursley, and Ms Patricia Goldman. They flew from Washington, examined the wreck, and took testimony from witnesses. They did tests. They called for laboratory analysis of wreckage. They took their time - nine months - to do the job thoroughly, because their 70-page report would reveal a shocking state of affairs and attitudes on the Union Pacific Railroad. There had originally been 55 vehicles in the UP's 1956 model F-70-1 class fiatcar fleet. Twenty of the survivors were pulled out of sleeper -distribution service for brake tests, and assembled in Las Vegas yard to replicate the wrecked special. Six had wholly ineffective brakes when presented for test and 10 had only partially effective brakes, largely due to maladjusted cylinder travel. The NTSB felt this indicated the likely condition of the brake equipment on the 20 identical fiatcars that had been wrecked. It took UPac's car department at Las Vegas more than two days to fix them and achieve a testable train; fifteen minutes, not two days, had been allowed for the examination of David Totten's train. Inspection of the wreck had shown that four of its 20 wagons had their brakes cut out at the branch cock -an automatic loss of nearly 20 per cent in wagon brake power. The wagon wheelsets recovered showed relatively little heat damage and the recovered brake blocks were no more than half worn. Yet David Totten's locomotive had no brake shoes left at all, and its wheel rims had burned blue with the heat of a full-service application at 190km/h. So the NTSB wasn't in much doubt about the condition of the air brake equipment on Union Pacific's Maintenance of Way Dept wagons. Then there was the question of actual train weight. The wagons had been carded by the UP sleeper- treatment plant with a "standard and nominal" load of 27.21 (60,000 pounds) per car, so the young crew had left Las Vegas believing their train weighed 12901. Analysis and weighing showed that the payload was more than double that carded. The actual trailing load was in fact over 18001. Loaded, the wagons had a braking ratio of under 15 per cent - this with fade-prone phosphorus-iron blocks, and on a 1 in 45 grade. David Totten's train had been been inadequately inspected before the train left Las Vegas, by one man and not two (the norm). The imposed limit of 15 minutes was not an aberration but standard practice, for written instructions had been issued that brake inspections should take no longer than this, regardless of train size, the amount of examination and rectification work needed, or the number of people available to do it. The trains had to be cracked through. There was definite evidence that the yard superintendent had hustled the brake inspection and the despatch of the ill-fated perway train. On 2 January 1980, the superintendent of the UP's California Division had issued orders that diesel units were not to be despatched from mechanical points (of which Las Vegas was one) without functional speed recorders, recorder tapes and dynamic brakes on the lead unit. After only seven months, this same official cancelled his order without explanation. That was on 12 August; the special crashed only three months later, and the NTSB could find no explanation of the circumstances. UPac's executives were not talking. A dynamic brake is just that -dynamic. A driver cannot test it standing still, but only on the road,when it either brakes the train or it doesn't. And when David had tested the dynamic on 3119 between Las Vegas and Cima, he had found it ineffective. He had radioed this to the despatcher, following rules. But the despatcher had done nothing. He had not, for example, ordered the exchange of 3119 for an identical SD-40 from the multi-unit grain train lashup also waiting at Cima Summit By this sad chain of events, David Totten was put in the situation of having to bring a string of heavy, under-braked cars down 31km of 1 in 45 grade behind one locomotive without dynamic brakes. He had air brakes and grade control valves (retainers) alone. Those brakes had little enough margin at the best of times, and they were terribly defective. LAXER RULES But every railway has rules that are supposed to prevent situations like this. What did the Union Pacific's air brake rules include that insured that they complied with the relevant AAR Interchange rules and Federal regulations for air brake operation. The Federal investigators established that UP's rules for mountain working were laxer than those of other major railroads operating on comparable grades, laxer than the recommended practice of industry's Air Brake Association, and simply did not comply with Federal Railway Administration requirments, which happened to be the law. When the investigators ran the replica test train, it was shown that a very experienced driver could bring the train, with operative air brakes, safely down the 1 in 45 of Cima Hill with grade control valves alone. But the emphasis was on "very experienced", for a driver had been brought out of retirement for the test. And nobody dared touch the caboose emergency valve to fully replicate the circumstances of the runaway - not even on a train with air brakes that worked, not even with a cleared road ahead, not even on a loco with unused dynamic in reserve. Air brake training up to this level of train handling had not, the NTSB found, been given to David Totten. And conductor David Branson had received no instruction on air brakes that would be of any use to him in the management of a train like Extra 3119 on a mountain grade like Cima Hill - even though working over this mountain grade was normal. A background to the case, not given in the report, was the Union Pacific Railroad's continuing drive to increase operating productivity, reduce manning and eliminate wasteful featherbedding. All this had been bitterly resisted by the unions, with the Federal Railroad Administration field inspectors stuck in the middle, with rules and regulations that most people seem to have ignored. Management might well have claimed that as technology leaders, using modern cars with modern air brake equipment, trip inspections every 800km were not justified at all. Or that even if they were, continuity and leakage tests Coupled with a quick visual check by teams of examiners on golf buggies carrying repair materials were perfectly adequate. But the runaway train at Kelso was not modern. It was a string of nniFnrrnl,tr nlH rnrnn~nv wnonnq in non-interchange service. And Las Vegas was the last train examination point before a mountain descent - a descent almost as steep as that from the Blue Mountains of NSW. But given UP's record of runaways,the company view cut no ice with the NTSB. UPac's RECORD. A record of runaways? On the Union Pacific? Yes. In criticising the UPac management, the NTSB cited four other accidents in only two years, 1979 and 1980, in support of its devastating statement that "runaway and the difficult-to- control trains" have become a problem relatively unique to the UPac in the past few years One case was at Granite, Wyoming,just 16 months before Kelso. A bulk grain freighter comprising three SD-40-2 diesels, 81 bogie covered hopper wagons and a caboose - 82 on for 87501 - had run away on the famous Sherman Hill and crashed at 120km/h. This destroyed two late-model diesels and all the grain cars, most of them brand new, in a $5m pile of wreckage just one-sixth of the train's previous length. The lead diesel ran ahead for five more kilometres before it was stopped. And the wreck brought down an overbridge on Interstate Highway 80, thus ensuring maximum publicity. Miraculously, nobody was hurt. The cost should have excited serious management attention, but it seems not to have. In all, 28 findings covered three pages of the Kelso report. The 28th was that "the Federal Railroad Administration is not adequately enforcing the Federal Power Brake Law on the Union Pacific Railroad". There is a footnote to this accident, and it is perhaps the most terrible indictment of all. The NTSB reported that even after the Kelso wreck, UPac trains had continued to be operated over the California Division without proper inspection. In fact just three months after Kelso, a trainmaster, acting under orders from an assistant superintendent, ordered a crew to take their train from Yermo to Las Vegas, up the Cima Hill, despite defective brakes and under threat of dismissal. The union complained and the NTSB investigated. The Feds verified the complaint. And this in 1980, not 1880. It is, however, possible to track after 1981. One former senior operations executive now appears to be allocating wagons. So in 1988, this great American railroad is once again under a management with a more enlightened attitude to safety. THE LESSONS for our Railways. What are the lessons from Kelso and the unhappy Union Pacific of eight years ago for Australia? We have similar and even steeper grades than the Sherman and Cima hills. We have had freight train runaways. We use very similar models of diesel-electric locomotive, equipped with basically the same WABCO 26L air brake outfit. And although (the Pilbara excepted) our freight wagon brakes are Australian-developed and different from the American AB and ABW systems, they are functionally similar: single-pipe, direct-release, automatic air brakes with retainers (grade control valves) for retarded release. The first key difference is maintenance: no Australian railway would dare to skimp on essential air brake maintenance. A car might slip through the net occasionally, but never a complete train, let alone a fleet. And there are a number of other important technical differences. [1] Almost all heavy-load wagons in Australia today have empty/load brake control gear, to augment the braking effort and compensate for the extra mass of a loaded car. David Totten's train didn't.Some very old Australian equipment doesn't, either. [2] All new Australian freight wagons today have fully rubber-seated air brake distributor valves, which leak off far more slowly than the old metal-seated valves on the Kelso cars. But some old cars here s/ill have metal-seated triple valves. They include some vintage tourist equipment. [3] Most Australian wagons have automatic slack adjusters to take up and correct for block wear, and thus keep piston travel at the desired 100mm maximum. The NTSB report suggests that Totten's wagons did not. [4] Almost all Australian wagons today use non-metallic brake shoes. These wear more slowly and give near-constant friction. At high speed,they have only a fraction of the fade of David Totten's cast-iron blocks. [5] UP engine 3119 was unusual, by our standard, in its not being fitted with a brake pipe flowmeter. Almost equipped, and they have been for more than 20 years. A flowmeter is a cheap, simple device - a two-needle pressure gauge tapped across a venturi fitting in the feed to the brake pipe. It is a valuable aid, showing not only that there is pressure at the front-end of the train brake pipe but, by indicating how fast the air is rushing into that pipe, whether or not the pipe is open. This identifies situations that call for particular brake-handling responses by the driver. These differences did not just happen. They were the result of decisions to equip the railways safely. The air brake rules of Australian railways are tough, and they are enforced. The training is good, and most systems have a Westinghouse brake engineer and technical staff dedicated to the subject. And while the industrial structure of our government rail systems and the power of the unions are often criticised, one thing is sure: no Australian railway manager would dare to order his people to shortcut safety rules under penalty of dismissal. DOOMED TRAIN. The technical circumstances of David Totten's near-total brake failure are complex. In essence, the unexamined, over-stroke brake cylinders on the perway cars meant low cylinder pressures after the check application at the top of the hill. The retainers (grade control valves) were unable to hold effective cylinder pressure after two service re-applications, and the pressure-maintaining feature of the 26L equipment on the one engine could not compensate. Once the conductor's valve was opened, the train was doomed, for with no flowmeter to guide him and inadequate training, David Totten was unable to take the only step that might just- only just - have saved the train. For given no dynamic brake on the engine,low braking ratio, cast-iron blocks vulnerable to high speed fade,and, above all, cut-out cars and maladjusted equipment, that train was all but doomed before it set out from Las Vegas. The UPac arrangements made this adverse technical combination routinely probable; the same combination is just - barely just -possible given an exceptional combination of deferred maintenance, short cuts, sloppy marshalling, very inept brake handling, breaking of rules and sheer bad luck. In reviewing the technical elements of the Kelso wreck, one is reminded not so much of recent accidents but of the classic train runaways of half a century ago. Substitute David Totten's SD-40 for an old steam engine, and you have all the stuff of early-1930s railroading: Heavy cast-steel frame fiatcars, plain journal bearings,metal-seated AB triple valves,and the neglected maintenance of desperate times in the Great Depression. All that radios and CTC and speed recorders did 50 years later was to tell more people what was happening, to raise the speed (and severity) of the final crash, and to better record the circumstances. The humans failed to use these modern tools to mitigate the results of the runaway. And, in Australian terms, the Traffic was every bit as much to blame as the Loco. So Kelso was a "human", rather than a "technical" accident, meaning that there must be lessons for other humans. They are these. SAFETY FIRST. Every railwayman on the ground could usefully ponder David Totten's story when he or she waves to the enginemen who are bringing their 3000 tonnes of train down from Katoomba, or Mount Lofty,or Ingliston, or down the Toowoomba or Kuranda ranges. When radios crackle or lights wink in a CTC office and people monitor these movements, they should think, and think safety. If it is our job to maintain and test brakes, to marshall and examine trains, to set grade control valves, or to bring these trains down the mountains, we should be not careful. We should be meticulous -always. We should never cry wolf, or close our eyes to, or misuse for purposes of advantage or leverage, a matter that significantly affects safety, no matter on which side of the industrial-relations fence we sit. And if all of us are always just that little bit more thoughtful about what we do,what we direct, what we pass on as instruction to the next generation, then our trains will continue to be brought down these formidable grades. The dynamic fans will howl and the air will slowly hiss from retainers, and there will be no need for young Australians to die as David Totten and Wally Dastrup died, so bravely, so unnecessarily, at the bottom of Cima Hill in the lonely Mohave Desert on 17 November 1980. AN EXTRACY FROM RAILWAYS OF AUSTRALIA NETWORK MAGAZINE December 1988