Report of the director of the Bureau of safety in re investigation of an accident which occured on the Pennsylvania rail...

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Title:
Report of the director of the Bureau of safety in re investigation of an accident which occured on the Pennsylvania railroad at Altoona, Pa., on November 29, 1925
Physical Description:
11 p. : ; 23 cm.
Language:
English
Creator:
United States -- Interstate Commerce Commission. -- Bureau of Safety
Borland, W. P
Publisher:
U.S. Govt. Print. Off.
Place of Publication:
Washington
Publication Date:

Subjects

Subjects / Keywords:
Railroad accidents -- Pennsylvania -- Altoona   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

General Note:
Caption title.
General Note:
At head of title: Interstate Commerce Commission.
General Note:
"December 28, 1925."
General Note:
Signed, W.P. Borland, director.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 004954780
oclc - 660057140
System ID:
AA00012225:00001


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'/ I ** / 4


L rNIV. OF FL. LIS.




U.S. nEPOyDTO.Y

REPORT OF THE DIRECTOR OF THE BUREAU OF SAFETY IN RE
INVESTIGATION OF AN ACCIDENT WHICH OCCURRED ON THE
PENNSYLVANIA RAILROAD AT ALTOONA, PA., ON NOVEMBER 29,
1925
DECEMBER 28, 1925.
To THE COMMISSION:
On November 29, 1925, there was a derailment of a freight train
on the Pennsylvania Railroad at Altoona, Pa., which resulted in
the death of two employees and the injury of one employee.

LOCATION AND METHOD OF OPERATION

This accident occurred on that part of the Pittsburgh Division
extending between Pittsburgh and Altoona, Pa., a distance of 113.8
miles. In the vicinity of the point of accident this is a four-track
line over which trains are operated by time-table, train orders, and
an automatic block-signal system. The tracks are numbered from
north to south as follows: 4, 3, 2, and 1; the train involved started
to run away while on track 1, was diverted to track A, which
parallels track 1 on the south, at BO block station, at which point
one pair of wheels was derailed, and was running on this track
when it was entirely derailed nearly opposite JK block station, ap-
proximately 1 mile distant. Approaching JK block station from
the west the track is tangent for a distance of 5,900 feet, while the
grade for the' distance of nearly 12 miles between Gallitzin and
Altoona is descending for eastbound trains, the greater part of this
grade being between 1.5 and 2 per cent.
The weather was clear at the time of the accident, which occurred
at 7.46 a. m.
DESCRIPTION

Eastbound freight train symbol VL-4 consisted of 58 cars and a
caboose, hauled by engine 1282, and was in charge of Conductor
Perry and Engineman Scheline. It departed from Sharpsburg,
Pa., on the Conemaugh Division, at 5.45 p. m., November 28, and
made several stops en route, including one at Conemaugh, on the
Pittsburi Division. It left Conemaugh at 1.30 a. m., assisted by
helper engine 4587, started down the grade at Gallitzin, at which
77056-26





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point the helper engine was cut off, and had nearly reached GY
block station, 3.3 miles from Altoona, when the train was stalled
by an application of the brakes due to some cause which was not
determined. After a delay at this point of 30 or 35 minutes the
train proceeded, passed GY block station according to the train
sheet at 7.41 a. m., got beyond control of its crew and ran away,
being derailed at Altoona while traveling at a speed estimated to
have been about 60 miles an hour.
The first mark of derailment was at a frog located just west of
BO block station, and there were wheel-flange marks on the outside
of the left rail and on the inside of the right rail, about 4 or 5
inches from the base of the rail, extending from this point to the
point where the final derailment occurred. The engine and 39 cars
were derailed, the majority of the cars being demolished. The
employees killed were the engineman and fireman.

SUMMARY OF EVIDENCE

Conductor Perry said his train, which was what is known as a
relay train, was received at Sharpsburg from the west, and that, as
is customary with such trains, he received from the clerk the mani-
fests and also a slip showing the number of cars in the train and the
fact that the air brakes were 100 per cent operative, and he said he
gave the original copy of this air-brake report to the engineman.
No terminal tests are made with these relayed trains before depart-
ing, the instructions being to make a road test, which merely shows
that the air is coupled through to the caboose. At Conemaugh,
about 23 miles from Gallitzin, the engine was cut off for the purpose
of taking on coal and cleaning the fire, another road test of the air
brakes being made when the engine was recoupled. When the train
reached Cresson near the summit of the ascending grade approach-
ing Gallitzin, he left the caboose and went out on top of the train,
and he said that prior to leaving the caboose he noted that the brake-
pipe pressure was then between 65 and 70 pounds. Conductor Perry
began turning up the retaining valves and he said that when the
train started down the grade extending from Gallitzin to Altoona
all the retaining valves on the train were turned up with the excep-
tion of four on the rear end of the train, and that in addition hand
brakes were applied on six cars at the head end of the train. He
stated the number of hand brakes to be applied is left to the judg-
ment of conductors, and when at Conemaugh he had told the head
brakeman how many hand bakes to apply on the head end of the
train. It further appeared from Conductor Perry's statements that
before starting down the grade east of Gallitzin a brake-pipe pres-
sure of 85 pounds is required on the head end of the train, with not





ACCIDENT AT ALTOONA, PA.


less than 75 pounds on the rear end; if there is a pr)esIsre of less
than 75 pounds on the rear end the engineman of the helper engine
is supposed to sound a stop signal before cutting off from the
train at that point. When the train passed AR block sit:tion
practically at the summit of the grade, Conductor Perry heard a
whistle signal, which he thought was sounded by the eniigviniian of
the helper engine, this signal indicating that it was all right for the
train to proceed. and he said he transmitted a proceed silnal to the
engineman.
No trouble was experienced in handling the train down the grile
at a moderate rate of speed, and from his place in about the middle
of the train he had not noticed any heavy applications of the brakes
just before the train stalled, a short distance west of GY block
station, although prior to this time he had noticed that the brakes
were sticking on about six cars. After the train had stalled Con-
ductor Perry turned down some of the retaining valves and found
five or six which would not release. He then turned up the retainers
again and bled the air from some of the auxiliary reservoirs, after
which he went to a telephone for the purpose of notifying the oper-
ator that his train had stopped and giving the operator information
concerning the number of hours his crew had been on duty, after
which he started ahead and met the head brakeman, who said he
had been arguing with the engineman about overcharging the train
line, the engineman claiming that the train line had not been over-
charged. He did not, however, go up to the head end of the train
and talk with the engineman for the purpose of finding out what
had caused the train to stall, having met the brakelian at a point
about 2- car lengths from the engine; and he said that while talk-
ing with the brakeman the engineman took the slack three or four
times, finally succeeding in starting the train, although the brakes
still were sticking to some extent. Conductor Perry did not notice
any application of the air brakes after the train started, and as it
passed GY block station, at about which time he heard the engine-
man sound a whistle signal calling for hand brakes, he applied the
hand brakes on two cars and shortly afterwards was able to apply
the brake-; on three more cars; and he said that while he did not
know what was wrong he tupp,'sed at the time that the pumps on
the engine were out of order. He estimated the speed of the train
when passing BO block station to have been about 30 or 35 miles
an hour and said he remained on the train, near the rear end, until
it was derailed after the engine had passed JK block station. Con-
ductor Perry further stated that when his train stalled west of GY
block station he did not think that. there was anything wrong other
than the overcharging of the train line; although required when





4 INTERSTATE COMMERCE COMMISSION

a train has stopped on the grade for some unknown reason to turn
down all retaining valves and make a road test, yet such a test. was
not made in this case.
Head Brakeman Pincuspy said he left the engine at Cresson, pre-
vious to which the enginem~I n heid had no difficulty with the air
brakes, and started back over the train, turning up the retaining
valves on the first 20 or 22 cars, and that when the train finally
stalled west of GY block station lie had also applied the hand brakes
on five cars at the head end of the train; he said that the train
stalled with the engine working steam and the air brakes applied in
emergency. After the train stopped he went over the cars toward
the head end of the train, turning down the retaining valves and
then turning them up again: he said he did not get any blow when
he turned them down while the pistons remained out, causing him
to think that the train line was overcharged, and when he reached the
head end of the train he began bleeding the auxiliaries, not drain-
ing them, but, according to his statements, taking some of the strain
off the brake shoes. In doing this, at which time the retaining valves
were in the holding position, he did not bleed the auxiliaries on all
the cars but would occasionally skip one or two cars, and he estimated
that he opened about 12 or 15 bleed cocks; the pistons, however,
would not release after this had been done. It also appeared from
his si atements that uanth'er rc: i:ution wavas made and that the brakes
again applied in emergency. After bleeding the auxiliaries Head
Brakeman Pincuspy returned to the engine and had an argument
with the engineman, who had gotten off the engine and had started
back along the train looking at the bleed cocks; he said this argu-
ment was as to reasons for the stalling of the train, that he told the
engineman he must have overcharged the train line while the engine-
man said the trouble was located on the train and not on the engine.
Brakeman Pincuspy said that when a train stops for unknown rea-
sons the crew is supposed to locate the trouble, make a road test to
see that the air is working through the train, and then wait until
the air pressure is restored before proceeding. This procedure was
not followed, however, in this case. According to his statements, the
flagman was recalled by the engineman, a proceed signal was given
by the conductor, and the train was started with the brakes sticking
throughout the train. Although the speed began to increase, yet he
did not realize that the train was out of the control of the engine-
man until he saw the fireman on top of the first car in the train and
at about the same time he heard the engineman calling for hand
brakes, this being after the train had passed GY block station, and
he said he then began applying hand brakes, working toward the
rear end of the train, and had succeeded in setting the brakes on six





ACCIDENT AT ALTOONA, PA.


cars. He estimated the speed of the train to have been about 75 or
80 miles an hour immediately prior to the time the derailment
occurred n,,;ir JK block station. Head Brakeman Pincnispy further
stated that while the train was standing at the point where it had
stalled he did not notice any clo-ed angle cocks or any leaks in the
train line, ;nd he was unable to offer any explanation as to why the
train got beyond control after pa-ing GY block station.
The .stit.iiinis of Flai man Si r:y;ier conclerninL' the movements
of his train prior to the time it reached Gallitzin brought out noth-
ing additiorial of imploranc. He said the pre.ssire a'e wording to
the <.:ho.se gange w-as about 70 pounds when the helper engine was
cut off at Gallitzin and that the enginemnan of the helper engine
whistled off at that time; he afterwards qualified this statement,
however, to the extent of saying that he was busy with other duties
and did not notice whether the en!,'inieniiian of the helper engine
whistled for the train to be stopped or for it to proceed. He said
the brn;kes were working properly from Gallitzin to the point
where the train stalled and that he then went back to protect his
train. When recalled he returned to the caboose and glanced at the
gauge, but he said he was unable to say whether or not it indicated
there was any brake-pipe pressure. He then rode in his usual posi-
timn. on the forward platform of the caboose, and he said he did
not hear anything to indicate that the brakes were sticking, neither
did hle hear anything to indicate that the air brakes had been ap-
plied by the engineman, and finally when the speed began to in-
c.'reaset he went inside the caboose and reaclled for the release valve.
Findin no air at that point he went balk to the forward platform
and broke the air hoe between the caboose and the rear car and he
s:id that there was nothing to indicate the presence of any air in
the train line. He did not open the conluictor's valve, which was
located on the outside of the (abnoo-e, saying that he reached for the
first available mean, of opening the train line. When asked to ex-
plain why there was no air in the train line he suggested that it
mighlit have leen due to the action of some one in closing an angle
cock or to tlie fact that the pumps on the engine might have been
out of order. Flagman Strayer further stated that when the train
was in the vicinity of GY block station, at which time it was run-
nin,- away, he had looked ahead but had not seen any fire flying
from the brake shoes.
Engineman Beiter, in charge of helper engine 4587, stated that
when he coupled to the rear of the train at Conemaiigh the gauge
showed a brake-pipe pressure of 62 pounds. The engine was cut
off at NY block station, 11 miles west of Gallitzin. for the purpose
of taking water, and when it had recoupled to the train the pressure





INTERSTATE COMMERCE COMMISSION


was once more pumped up to 62 pounds. He said that 62 pounds
was the pressure at the time the train stopped at MO block station,
about 2 miles west of Gallitzin, and that when the train finally
reached the summit of the grade at Gallitzin the same brake-pipe
pressure %was registered and that he sounded one blast on the whistle
as a stop signal, at the same time gradually closing the throttle.
The speed of the train was reduced and he thought it was going
to be brought to a stop, but his statements indicated that his engine
was cut off and that train VL-4 started down the grade without
having the rejulired brake-pipe pressure, which he said should have
been between 75 and 85 pounds. Engineman Beiter further stated that
the automatic brake had been used in mniking the various stops en
route, that the brakes applied and released properly, and that in each
case the brake-pipe pressure was pulliped up iminediately. Fireman
Fenwick said he had not noticed the brake-pipe pressure until
Enginemiin Beiter sounded a stop signal, at which time the pressure
was slightly less than 65 pounds, and that he did not see any mem-
ber of the train crew when he cut off the helper.
Oprantor Sease, on duty at GY block station, said train VL-4
was moving at a .peed of about 25 miles when the engine passed that
point. He did not see any fire flying from the wheels nor did he hear
the engineman calling for hand brakes, but he said there were two
members of the crew on top of the train setting the hand brakes,
one of these men being located on about the fifteenth car from the
engine while the other apparently was about 30 or 35 cars back
of the engine. Operator Sease did not realize at this time that the
train was beyond control, but as a matter of precaution he notified
the operator at BO block station to be watching for the train.
Operator Chappell, on duty at BO block station, said he had in-
tended to detour train VL-4 from track 1 to track A, and this
arrangement was not changed. As the train went through the
crossover the engine seemed to sway to one side but righted itself,
and he did not know until some time afterwards that any portion of
the train had been derailed at that point. He estimated the speed
of the train to have been about 50 miles an hour, and said that there
were two men on top of the train applying hand brakes. Operator
Chappell further stated- that the only fire.he saw was coming from
the driving-wheel brake shoes and that the tires on the driving
wheels seemed to be red-hot.
An eyewitness who was standing at JK block station said that
as the train approached that point he could see that the pony-truck
wheels were derailed, while fire was flying from under every car
in the train. He estimated the speed of the train to have been about
35 or 40 miles an hour.





ACCIDENT AT ALTOONA, PA.


L. F. Axe, assistant foreman car inspector, said that as soon as he
reached the scene of the ac cident, at about 8.15 a. m., he exll1,inced the
brakes on the last 19 curs and the caboose and found that only five
of the brakes were still holding, the balance having released. Later
a terminal test vwa. nadllc, and it was filund that all the briakes ap-
plied properly except in the ca.se of one car on which the brakes were
cut out and another on which the brake was inoperative, on a'cmci0nt
of a leaky cylinder-piacking leather; this test w\\a made from a brake-
pipe pres.siire of 70 pouJlnl. Car In:pecttor Brannen stltedl it was
about. 9.30 a.'m., when in companyy with Mr. Axe and one other em-
ployee. a yard engine was coupled to the rear of the 19 cars and ;.ai-
)bouse. the ti-r:in line char- i1 to 70 pounds brake-pipe pressure, and a
20-pound reduction mcde, nd he said that on examining these cars
they found four on which the brakes w.rre not working. Two\ of these
were the cars previously referred to by Mr. Axe, the other two in-
volving release valves which had stuck in the open position. These
were closed and the test was thin repeated and on this occasion there
were only two cars on which the brakes did not apply. These two
employees were ;iked for their opinion as to what (caiuedl the train to
run away, and Mr. Axe said from what he had seen he judged that
the train did not have efficientt pressure when coming down the
grade, otherwise there would have ,be-n air in the auxiliaries when
they were examined after the occurrence of the accident, while the
brakes on all of the cars which were not damaged would have re-
mained applied as it was, while the air was still applied on several
of the cars, yet it was just barely holding.
The air-brake test which was made of the 19 ca rs and ;aboo ,e
which remained on the rails after the occurrence of the accident
showed that in addition to the two cars on which the brakes were in-
operative, as noted by Assistant Foreman Axe, there were two other
cars on which the piston travel w is 81 inches, ne on which the pis-
ton travel was !91. inches, and one on which the travel was 10Y/
inches. It was also noted about 30 or 35 minutes after the occurrence
of the accident that there were only five cars on which the pistons
were out of. the cylinders, one of these being the car on which the pis-
ton t ravel was 101/ inches.
Chief Car Inspector Walker said he understood that train VL-4
was assembled at Columbus and relayed at Dennison, Ohio, and again
relayed at Sharpsburz, and that at the two stations last named
the instructions, in effect, were to make only a road te.,t of the air
brakes in the case of a relayed train; should a train be a-:embled at
Sharpsburg, however, it would receive a terminal test. Mr. Walker
also sain that the air-brake instructions provided that on starting
down grades a brake-pipe pressure of at least 85 pounds should be
carried on the engine, in the case of a light-tonnage train, such as





INTERSTATE COMMERCE COMMISSION


the train involved in this accident, and in case a train stops for a
reason unknown to the crew the train is to remain at that particular
point until the crew is satisfied that the brakes are in condition to
control the train; after turning down the retaining valves and re-
leasing the brakes, the valves are to be turned up again and the
brake-pipe pressure restored before proceeding. He considered it to
be practical for trains of the size involved in this accident to start
down the gradc without stopping at the summit for a test either of
the air liralts or of the retaining valves, provided it is known that
the brnket are in ;:.,l cmlition and also provided that the requli'ted
pressure is maintained; in fact, he stated that the only difficulty ex-
perienced on this grade was due to trains breaking in two or stall-
ing due to the extra attention paid to keeping up the brake-pipe
pressure and keeping down the speed. He further stated no re-
taining-valve tests are made in this particular territory other than
to see that tlhe pipes are intact and coupled to the valves and that the
valves appear to be in working order.
Assistant Trainnimster Gerard, located at Sharpsburg, said that
in the case of relayed trains the clerk who handles the waybills
;se.'res information ias to the niiumber of operative air brakes either
from the conductor or the yardmaster; he then writes down this
information on a blank form and turns it over, together with the
waybills, to the ronliictor who is to have charge of the train when it
leave Sharpsburg. No terminal or retaining-valve tests are made
on such tra in.-, the condl tor of the incoming train being expected
to know of any inoperative brakes and to furnish information con-
cerning them. If there are any cars on which the brakes are in-
operative, it is provided in the instrnitions that these cnrs are to
be cut out of the train and repaired before being forwarded to their
destination. In this connection it might be .tated that the car in-
:.pectors at Sharpsburg shopped one car on account of a broken arch
bar and another car on account of a broken truss rod.
Train VL-4 had been made up at Columbus, Ohio, on the after-
noon of November 27, at which time a terminal air-brake test was
mnlde by car inspectors. These inspectors stated that the air brakes
on the train were in good condition, with a piston travel of between
6 and 8 in:lies, but that they did not make any te.t of the retaining
valves other than to see that they were open. These inspectors also
stated that a road test was made after the engine was coupled to the
rniin for the purpose of determining that the air brakes were
working through to the caboose. The. terminal tet was completed
ait aloit 5.45 p. m. and the road test at, about (;.S p. m.
Malchiinist Gilchrist, located at Slihrp :1, ur, said lit had worked
on the air brakes on engine l.92 on November 27, prior to its depar-





ACCIDENT AT ALTOONA, PA. 9

ture on train VL-4 on Novenmber 28. The reservoir pressure was all
right but he changed tihe brake-pipe pressure -ettilig froni 75 pouInds
to 70 pounds. He said he had a report that the air gauge registered
improperly, but on testing it he found it to be only 1% picounds out
of the way, and therefore did not make any repairs. He did, how-
ever, find that the pi. ton travel of the driving-wheel br:;ike was about
7 inches and said lie adjusted this travel to about' 5" inch]'-. He
did not notice an ytlhing wrong with the operation of the pulnp and
said he considered the air-brake eqiuiplinnt on the engine to be in
good condition. Examination of engine 1]82, which is of the
2-8-2 type, showed that the driving-wheel tires had been ladIly ovc -
heated, four of them being loosened. Careful examination of such
parts of the air-brake equipllent, of the engine as could be te ted
failed to develop anything wrong with the exception of a slight
leak to the atmosphere at the rotary valve when in the rekl;-ce po d-
tion, but in this case the valve handle and stem !ore evidence of
having been struck by something when the engine was wrecked.
The work reports show that considerable trouble. had; been experi-
enced with the air compressor and that finally on November 24 it
had been removed and another compressor applied which had
neen previously inspected and tested.

CONCLUSIONS

This accident was caused by failure to know that the air-brake
system was in proper condition to control the train before allowing
it to proceed from the point at which it had stalled on a heavy de-
scending grade, for which Conductor Perry and En:ineminn Scheline
are primarily responsible.
The investigation developed that after the train had stalled, at
a point where the grade was about 1.70 per cent descending, the
only thing (done by the members of the crew was to endeavor to
release the brakes so as to allow the train to proceed, no attempt
being made to ascertain the nature of the trouble responsible for the
stalling of the train. The engineman had to take the slack several
times before he finally succeeded in starting the train, at which time
many of the brakes still were sticking, and it appears that after the
train had once been started it never again was under the enginenan's
control. The reason for the stalling of the train was not definitely
ascertained. However, all the evidence indicates that the emergency
application which stalled the train was due either to undesired quick
action ofa triple valve at some point in the train or to an open brake
pipe probably caused by a burst hose. The theory of an overcharged
brake pipe, advanced by Brakeman Pincuspy and Conductor Perry,
is not tenable.





INTERSTATE COMMERCE COMMISSION
*


Conductor Perry turned down a few retaining valves and bled
a few auxiliaries at the rear of the train, and then went directly to
the telephone, from which point he proceeded toward the head end
of the train and met the brakenian at a point about.25 car I ngths
from the engine. While Conductor Perry was talking with the
brakemtan at this point, the engineiflan was taking -lack on the train
in an effort to start it, the brake- still sticking, and finally got it
moving while the conductor and brakeman were still engaged in
conversation. No member of the train crew had an opportunity to
know anything about the condition of the train behind the twenty-
fifth car from the head end. After the train once started it was
absolutely beyond control. When Flagman Strayer in ,ntedl the
caboose after being allied in he did not notice the brake-pipe pres-
sure indication on the air gauge, but when the speed of the train
increa.-ed unduely he broke the air hose between the caboose and
rear car and found no air in the brake pipe.
This accident very forcibly calls attention, not only to a woeful
lack of rule olb_-ervia nce' on the part of the re-plon:ible members of this
train crew, but al. o to lack of adequate safeguards by the Pennsyl-
vania Railirad Co. to insure that trains shall be safely operated on
this decenlding grade.
In the first place, this train broke ov r the summit of the grade
with the rear end not charged to the pre.-l re required by rule. The
nonnchl aane with which this fact was treated when attention was
called to it by the designated .-ignal from the engineman of the
helper engine indicates that the rule is more honored ih its breach
than in its ob-trvance. Next, this train was moved from Columbus,
Ohio, to the point of accident, a distance of approximately 300 miles,
pa.-sing through two established terminals at which the engines and
crews were changed, without any test of the brakes other than the
ordinary road te4.t to determine that the brake pipe was open
throughout the train. No infornimaion as to the efficiency of the
brakes on this train was had by the crew which took charge of it
at Dennison or at Sharpsburg. It was particularly essential that full
in form action about brake conditions should have been furnished the
crew which took the train at Sharpsbllrg, the last terminal passed
before descending the grade on which the accident occurred. The
evidence is that it is the regular practice of the Pennsylvania Rail-
road Co. to operate trains of this character as this train was oper-
ated. This is a bad practice which should be corrected.
The test which was made of the brakes on the cars which remained
intact after the accident disclo-ed brakes with unduely long piston
travel, and at least two that were wholly inoperative. It is reason-





ACCIDENT AT ALTOONA, PA.


able to asiuniw, that this was typical of the brake conditions on the
entire train, a state of affairs which would not have existed had a
proper brake test lieen made at Sharpsburg and the necessary repairs
made.
It is a ]',rcertta;Ible circumstance that serious accidlenis such as the
one herein considered often seems to be the only .means of effecting
a correction of unsafe practices of long standing. While the opera-
tion of trains on Gallitzin grade is nominally by means of air brakes,
it has long been the practice not only to permit but to encourage the
use of hand brakes in connection therewith, the number of hand
brakes used being left to the judgment of enginemen and conductors
in charge of trains. The control of trains on this grade, therefore,
is partly by air brakes and partly by hand brakes. This practice,
like all practices which involve a division of responsibility, leads
to a reliance upon one method to correct deficiencies in the other,
leading to the result that, sooner or later, both methods will inevi-
tably fail when most urgently needed.
The lesson to be learned in this connection is that if trains are to
be controlled by means of air brakes they must be so controlled ab-
solutely and without reservation. This means that the air brakes
must be maintained in an efficiently operative condition at all times,
and employees must be properly instructed in their use. The con-
verse is true of the hand-brake method. Both methods can not
safely be used together; and in this connection it may be proper to
observe that the use of hand brakes to control the speed of trains is
unlawful.
The employees involved were experienced men. At the time of
the accident they had been on duty about 14 hours after about 10
hours off duty, with the exception of Head Brakeman Pincuspy,
who had been off duty about 24 hours.
Respectfully submitted.
W. P. BORLAND, Director.





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