1916-056: 18 September 1916

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378

In re Investigation of accident which occurred on the Missouri Pacific Railway near Stuart, Colorado, September 18, 1916.

October 27, 1916.

[¶1]  On September 18, 1916, there was a head-end collision between two freight trains on the Missouri Pacific Railway near Stuart, Colo., which resulted in the death of 3 employees and the injury of 4 employees. After investigation of this accident the Chief of the Division of Safety reports as follows:

[¶2]  The division on which this accident occurred is a single track line; no block signals are in use, trains being operated by time-table and train orders. The track is straight on either side of the point of collision for several miles, while the grade is .79% descending for eastbound trains. There was a dense fog at the time of the accident.

[¶3]  Eastbound freight train extra 6414 consisted of 35 cars and a caboose, hauled by locomotive 6414, and was in charge of Conductor Dickey and Engineman Westfall. It left Pueblo, Colo., at 11:00 p.m., having been given a schedule on a Form 31 train order. This train order, No. 60, read as follows:

“To C. and E., all west except first class, at Horace station. Engine 6414 will run extra, leaving Pueblo Sunday, September 17th, as follows, with rights over all except first class trains.”

This was followed by the schedule, which provided that it should leave Pueblo at 11:00 p.m., and arrive at Horace at 6:56 a.m. Extra 6414 left Eads, the last open telegraph office, at 6:10 a.m., 15 minutes late on its schedule, passed Stuart at 6:12 a.m., 2 minutes late, and while running at a speed of about 35 miles an hour collided with westbound extra freight train 1223 at a point about one mile east of Stuart.

[¶4]  Westbound freight train extra 1223 consisted of 37 cars and a caboose, hauled by locomotive 1223, and was in charge of Conductor Gibbons and Engineman Isbester. This train was en route from Horace, Kans., to Pueblo, Colo. When Conductor Gibbons went to the telegraph office at Horace for his orders he received train order No. 13, of September 18th, which contained his running order from Horace to Pueblo, train order No. 12 of September 18th, and train order No. 13 of September 17th, the last two orders being orders annulling [Page 2 - Top of Report] certain second-class freight trains, together with slow order No. 44B, and a clearance card calling for these four orders. He did not, however, receive a copy of train order No. 60, of September 17th, which order contained the schedule for east-bound extra 6414. The orders received by him were made complete at 4:54 a.m., and the train departed from Horace at 5:15 a.m., colliding with extra 6414 near Stuart.

[¶5]  Both locomotives were very badly damaged, and 16 cars in extra 1223 were destroyed by fire. The engineman and fireman of extra 1223, and the fireman of extra 6414, were killed in the collision.

[¶6]  Conductor Gibbons, of extra 1223, stated that when ready for his orders at Horace he went to the telegraph office and told the operator that he would be ready to leave at about 5:15 a.m. He then picked up the file of westbound train orders. The order on top, No. 41, was a schedule for extra 1224 east, and as that train was shown by the register as having passed, he remarked to the operator that the train had arrived and that he did not want that order. He stated that when he looked at the westbound orders in the file they were in the customary place, that he read them all and that train order No. 60 was not among them. He was positive that there were only three orders in the westbound file. He then checked over his bills and stayed there, waiting for the operator to give him his orders. Finally he told the dispatcher to that he was waiting for orders. The operator then got his orders and he signed for what the operator gave him; order No. 13, of September 17th, and orders 12, 13 and 445, of September 18th, all of which he signed personally; he also received a clearance card showing the numbers of his orders. He stated that among the orders which the operator presented to him for signature was an annulment order applying east of Horace, and, after signing it, he saw that it did not apply to him and handed it back, this order, together with the order relating to extra 1224, which had already passed Horace, being the two orders which he rejected as not applying to his train. In all, there were three orders on the shelf when he picked them up, and the operator afterwards received two more for him. He stated that the operator overlooked train order No. 13, of September 17th, and afterwards inserted it on the clearance card in pencil. Conductor Gibbons further stated that while he was in the office the operator seemed to be having trouble in making out some reports, and spoke to him, asking if he knew about them.

[¶7]  Train Dispatcher Marshall stated that at about 4:40 a.m. he transmitted order No. 11, which applied from Horace east. This order was sent to four stations, Horace being the first [Page 3 - Top of Report] to repeat it. After repeating the order, Operator Lunbeck started to sign “Gibbons,” and he broke in and said: “No, Hoisington go ahead,” Hoisington being the next station which was to repeat the order. The other three stations then repeated the order, and as soon as the last operator had closed the wire Operator Lunbeck at Horace began to give him the numbers of train orders, form 31, giving Nos. 11, 445 and 60, and something like “41.” At this point he broke in and said: “Sig.” The operator again started in the same manner, giving the numbers of the various orders, and again he broke in and said “Sig.” He stated that Operator Lunbeck then started for the third time to give the numbers of orders and that he again broke in and said: “Sig.” Dispatcher Marshall stated that it was his custom to make the operators give him separate signatures after each order, and that he broke the operator when he was giving the train order numbers all together, for the purpose of having him give a number and then a signature, then another number, another signature, etc. He further stated that Operator Lunbeck then signed: “HR,” the office call for Horace, and he supposed that the operator was again attempting to sign “Gibbons” to train order No. 11, which applied only east of Horace, and he said: “That order, No. 11, not for Gibbons, that is east,” Conductor Gibbons being on a train which was westbound. He then sent train order No. 12, and as soon as it was repeated by the operator at Horace the latter again started to sign “Gibbons,” and he broke in and said that there was another order. He then issued train order No. 13, the running order for extra 1223, after which Operator Lunbeck signed “Gibbons,” “445, Gibbons;” “60, Gibbons;” “12, Gibbons.” Train Dispatcher Marshall stated that he then said: “Old 13,” and the operator replied: “13, Gibbons.” Dispatcher Marshall further stated that after being notified of the occurrence of the accident he called Operator Lunbeck and asked for his clearance, showing the orders delivered to Conductor Gibbons, and Operator Lunbeck replied: “No. 445, 12 and 13.” He then asked about order No. 60 and old 13, and he stated that Operator Lunbeck replied “Conductor Gibbons said they did not affect him and he did not want them.” The operator did not say whether or not he had a copy of the clearance.

[¶8]  Operator Lunbeck, on duty at Horace from 11:00 p.m., September 17th, stated that he delivered to Conductor Gibbons a copy of train order No. 13, of September 17th, and copies of train orders Nos. 12, 13, and 445, of September 18th. He stated that he had train order No. 60, but did not deliver a copy of it to the conductor. In explaining his failure to deliver this order he stated that there were two shelves in the office, one for westbound and one for eastbound train [Page 4 - Top of Report] orders. At the time Conductor Gibbons came into the office for orders he was busy, took down all of the orders in the westbound file and told Conductor Gibbons to pick out those which affected him. The conductor did so, and then placed them on the desk in front of the telegraph instrument, and he repeated them, train orders Nos. 41 and 60 not being among them. In making out the clearance he placed the orders in front of him, completed the signatures, made out three copies of the clearance, one each for the conductor, engineman and flagman, and gave all of them to the conductor, not keeping a copy of the clearance for his file. In completing the signatures he gave the numbers of three orders, and then the conductor’s signature. He stated that the dispatcher did not interrupt and have him give the conductor’s signature after each order, also that No. 60 was not among the numbers he gave to the dispatcher. He afterwards stated that when he first gave the numbers of the orders to the dispatcher, the dispatcher started in and sent him one or two orders before he completed them. Operator Lunbeck also said that he did not read the orders to the conductor and the conductor did not read them to him, and that when he signed the transfer book before going on duty he checked off the orders by number and to whom addressed, but did not read the orders and did not know what they contained. The conductor was given three orders, and returned for the fourth order, which was No. 13, of September 17th. He also stated that he did not remember Conductor Gibbons signing for any order, and then handing it back to him, saying that it did not affect him, and he was positive that order No. 60 was in the westbound file when Conductor Gibbons examined the file, as, after the accident, he looked in the file and the order was there, and it was also there before Conductor Gibbons examined the file. Operator Lunbeck further stated that in addition to his duties as operator, he had to sell tickets, check any baggage which needed to be handled, attend to the mail pouches and look after the yard.

[¶9]  This accident was caused by the failure of Operator Lunbeck to deliver to Conductor Gibbons a copy of train order No. 60, which was the running order of extra 6414 and provided a schedule for that train between Pueblo and Horace.

[¶10]  The statements of the three men directly involved, Operator Lunbeck, Conductor Gibbons and Train Dispatcher Marshall, are conflicting, as regards the manner in which the train orders were handled. Operator Lunbeck claimed that train order No. 60 was in the westbound file, that Conductor Gibbons picked out what orders related to him, and that he repeated the numbers to the dispatcher, and that No. 60 was not among the numbers of the orders which he repeated to the [Page 5 - Top of Report] dispatcher. Dispatcher Marshall stated that he was having difficulty in making Operator Lunbeck properly repeat the numbers of the orders, and that as they were finally given to him they included No. 60, with the signature of Conductor Gibbons. On the other hand, Conductor Gibbons claimed that train order No. 60 was not in the westbound train order file when he looked at it, that he took what orders were given to him by the operator, and that the only orders which he returned to the operator as not affecting him was an annulment order applying from Horace east and the order which applied to extra 1224 east, which was shown by the train register as having passed Horace, and that he never saw train order No. 60.

[¶11]  In view of these conflicting statements it is impossible to say whether or not Operator Lunbeck repeated order No. 60 to the train dispatcher, as claimed by the dispatcher. While the dispatcher’s train order book shows the signature of Conductor Gibbons to train order No. 60, it is to be noted that Conductor Gibbons stated that he did not see the order, and Operator Lunbeck was positive that he did not give the conductor’s signature to the order to the dispatcher. There is no way of definitely determining when the name of Conductor Gibbons was placed on the dispatcher’s train order book, and if the operator is correct in his statement, and did not include that order among those repeated, then the dispatcher is also at fault for failing to detect the error. The operator says that train order No. 60 was in the westbound file, that the conductor picked out the orders which affected him and that he repeated the numbers to the dispatcher, while the conductor claimed that he took the what orders that were given to him by the operator and that he also looked through the westbound file and that train order No. 60 was not there. Regardless of the conflicting statements, however, the fact remains that Operator Lunbeck was in possession of train order No. 60, and it was his duty to see that it was delivered to Conductor Gibbons, and not to entrust to the conductor, as he claimed he did, the duty of picking out which orders related to him.

[¶12]  Operator Lunbeck was employed in September, 1911, as an operator, and was off duty for six months in 1913. In November, 1914, he was granted leave of absence, and dismissed at the end of 60 days for failure to report at the expiration of his leave of absence. He was re-employed in May, 1916. At the time of the issuing of the orders to Conductor Gibbons he had been on duty about six hours, after a period off duty of about 48 hours. Dispatcher Marshall had had three years’ experience as a telegrapher and 17 years’ experience as a dispatcher, having been employed at four different times by [Page 6 - Top of Report] the Chicago, Rock Island & Pacific Railway, also on the Union Pacific Railroad, the Atchison, Topeka & Santa Fe Railway, the Cincinnati, Hamilton & Dayton Railway, the Detroit, Toledo & Ironton Railroad, and the Cleveland, Cincinnati, Chicago & St. Louis Railway. He entered the service of the Missouri Pacific Railway in October, 1910, as a dispatcher, and resigned in January, 1913. He re-entered the service as a dispatcher in January, 1914, and had been in the service since that time as dispatcher and chief dispatcher. Conductor Gibbons had just gone on duty when he received his orders, and at the time of the accident had been on duty about two hours, after a period off duty of about 11 hours.

[¶13]  Although Horace is a division terminal, this investigation developed unsafe conditions surrounding the handling of train orders and other duties performed by the operator. Several years ago the station at this point was destroyed by fire, and since that time the business of the company has been transacted in two box cars placed on the ground beside the track. There is no railing to separate the operator and his instruments from employees who have occasion to go into his office, whether for orders or for other purposes. There is also much work to be performed by the operator besides the handling of train orders. He handles commercial messages, sells tickets, checks baggage, places mail on trains, makes out several reports, makes empty car records, report of all “red ball” cars passing through, and checks way-bills of trains leaving Horace. Under such conditions as these particular car should be exercised in the handling of train orders, and instead of an arrangement which allows any employee to pick up and read over the train orders at will, a proper regard for safety should require the furnishing of suitable facilities for the handling of train orders.