Steam Locomotive Firebox Explosion on the Gettysburg Railroad ...

CONCLUSIONS
1. The explosion in the locomotive resulted
from crownsheet failure caused by
having too little water in the boiler.
2. Because the water-glass spindles were
restricted, the water glass could not
represent the water level in the boiler
accurately.
3. Although the engineer had signed the
Federal Railroad Administration’s forms
No. 1, certifying that the work had been
done, the water-glass spindles and gage
cocks were not cleaned on a monthly
basis.
4. The water glass was not illuminated as
required.
5. Gettysburg Passenger Services, Inc., did
not have a comprehensive watertreatment
program.
6. The boiler washing procedure described
by the fireman was inadequate to ensure
that the boiler was properly and
thoroughly cleaned as required by
Federal Railroad Administration
regulations.
7. Because the feed-pump gage was
missing, the traincrew had no reliable
way to determine whether feed-pump
pressure was overcoming boiler pressure
and delivering water to the boiler.
8. Because the wrong type of disk had been
installed in the injector, it would have
been difficult to use the injector to add
water to the boiler.
9. The firemen did not know, because they
had not been properly taught, how to
blow down the water glass or test the
gage cocks.
10. There was no clear division of
responsibility among the members of the
crew in this accident, particularly
between the two firemen.
11. Gettysburg Passenger Services, Inc.,
management was not aware of the Hours
of Service Act.
12. Gettysburg Passenger Services, Inc., had
no effective formal training or
certification program, and its on-the-job
training was based on second- and thirdhand
expertise.
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