The Derailment

of the Sunset limited

September 22, 1993
Big Bayou Canot, Alabama

TECHNICAL
RESCUE
INCIDENT

Federal Emergency Management Agency

This document was scanned from hard copy to portable document format (PDF)
and edited to 99.5% accuracy. Some formatting errors not detected during the
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 This report is part of a series of reports on technical rescue incidents across the United
States. Technical rescue has become increasingly recognized as an important element in
integrated emergency response. Technical rescue generally includes the following rescue
disciplines: confined space rescue, rope rescue, trench/collapse rescue, ice/water rescue, and
agricultural and industrial rescue. The intent of these reports is to share information about recent
technical rescue incidents with rescuers across the country. The investigation reports, such as this
one, provide detailed information about the magnitude and nature of the incidents themselves;
how the response to the incidents was carried out and managed; the impact of these incidents on
emergency responders and the emergency response systems in the community; and the lessons
learned. The U.S. Fire Administration greatly appreciates the cooperation and information it has
received from the fire service, county and state officials, and other emergency responders while
preparing these reports.

This report was produced under contract EMW-94-C-4436. Any opinions, findings,
conclusions, or recommendations expressed in this publication do not necessarily reflect the views
of the U.S. Fire Administration or the Federal Emergency Management Agency.

Additional copies of this report can be ordered from the U.S. Fire Administration, 16825
South Seton Avenue, Emmitsburg, MD 21727.
 The Derailment of the
Sunset Limited
Big Bayou Canot, Alabama
September 22, 1993

Local Contact: Chief Edward A. Berger

Fire Chief
City of Mobile Fire Department
701 St. Francis Street
Mobile, Alabama 36602

OVERVIEW

This report details the response of the Mobile, Alabama Fire Department (MFD) to the
derailment of a passenger train in a remote section of the Big Bayou Canot, nine miles north of
Mobile. Two-hundred and twenty people were on board the train when it derailed, caught fire,
and, in the case of some cars, became submerged in the Bayou. One-hundred and seventy-three
people survived the derailment of the Sunset Limited.

The majority of the “rescue” work was accomplished in under four hours. However, the
incident was protracted because the MFD had to oversee recovery of the 47 deceased. This
required sending divers into zero-visibility, subsurface, confined-space conditions. Furthermore,
surface operations to support the body recovery required personnel to work in extreme heat and
humidity for hours on end.

Use of the Incident Command System permitted the MFD to run a safe and efficient
operation in the face of extremely adverse conditions. While the “technical” operations are not
especially illuminating, this incident is extremely instructive in understanding the value of tight
incident control that is afforded through the Incident Command System.
 Key findings of this investigation are:

The Incident Command System worked extremely well. It allowed control over
resources that were spread over a wide geographic area.

Mutual aid was critical to handle an incident of this magnitude. Having formal
agreements in place before the need occurred was important.

Preparation of documentation for the National Transportation Safety Board was very
time-consuming. Good documentation, initiated early, is key.

Communications were difficult. Cellular phones helped more than portable radios. Large
quantities of back-up batteries were needed.

Morgue duty was exceptionally emotionally draining. Personnel should be rotated

through this assignment frequently.

Rehabilitation of personnel was a top safety consideration. This was especially necessary
because of the work environment and the high heat and humidity.

Many of the extrication tools that are designed for automobiles are ineffective on trains.
The AMTRAK Emergency Evacuation Procedures guide lists alternative means of
emergency access.

Technical Rescue Incident Investigation Project Explained

The Technical Rescue Incident Investigation Project is an effort of the U.S. Fire
Administration to document case studies of certain technical rescue incidents. The project seeks
to produce documentation in a “lessons learned” format in order to provide local emergency
responders, trainers, federal and state agencies, and other interested groups enhanced knowledge
about technical rescue response and safety.

Applicability to Sunset Limited Derailment

The derailment, in the early hours of the morning, of a fully loaded passenger train into a
remote waterway in an area without vehicular access might be thought to be the product of the
imagination of a disaster exercise planner run wild. Unfortunately, this “worst-case scenario” did
occur and tested the mettle of the MFD and emergency responders from several neighboring
jurisdictions. While the actual technical operations were more directed towards recovery rather
than rescue, the experiences of the incident managers and responders are instructive about the
value of pre-incident planning, exercise, and the use of the Incident Command System.

Investigation Methodology

The research for this report was conducted through face-to-face interviews with many of
the people who had incident command and operational responsibilities during the response to the
derailment of the Sunset Limited. In addition to the interviews, documentation provided by the
1
MFD and the National Transportation Safety Board (NTSB) was reviewed. Finally, a site visit
was made to view the scene of the derailment.

1
The sections of this Technical Rescue Incident Investigation which deal with the sequence of events involved in the
derailment of the Sunset Limited borrow heavily from the NTSB’s report, NTSB/RAR-94101, “Derailment of AMTRAK
Train No. 2 on the CSXT Big Bayou Carrot Bridge Near Mobile, Alabama, September 22, 1993.” Sections of this report
are taken verbatim from that report and are indicated with bold Helvetica print. All times from the NTSB report have
been converted to military time.

iii
Acknowledgements

This report could not have been written without the invaluable assistance of the Mobile
Fire Department. Specific thanks are accorded to Chief Edward Berger for the hospitality he
afforded and the resources he made available to complete the investigation. An equal measure of
appreciation is due to Steve Huffman, the MFD Public Information Officer, who arranged and
facilitated the numerous interviews necessary for the writing of this report. Finally, Boatswain’s
Mates Rooks and Tucker, of the U.S. Coast Guard Marine Safety Office/Mobile, provided
marine transportation to and from the crash site.

iv
I. Introduction

Mobile (population 265,000) is a heavily industrial port on Mobile Bay, in southwest

Alabama, 31 miles north of the Gulf of Mexico. The city has a central business district which
lies adjacent to the port area. Low-, medium-, and upper-income residential areas surround the
central business district, and many square miles of unusable swampland comprise an irregularly
shaped “panhandle” which follows the Mobile River to the northeast. Because Mobile is a port
and because paper production is a major industry, there is a large amount of hazardous material
transported through and around the city.

MFD is the area’s largest fire department. It serves an area of approximately 210 square
miles. MFD has 432 personnel, 18 engine companies, five truck companies, seven ambulances,
a fire boat, and several other specialized units. The department answers approximately 18,000
calls per year, of which about 12,000 are EMS-related.

On September 22, 1993 at 0253 hours, Amtrak Train No. 2, the Sunset Limited, with 220
people on board, derailed on a railroad bridge which crosses the 300-foot-wide Big Bayou Canot
(pronounced “can-not”), in the Mobile Delta, approximately nine nautical miles from the mouth
of the Mobile River. The ensuing crash caused the submersion of two passenger cars and fire to
break out in a dorm-coach car, the baggage car, and a fuel cell. Forty-two passengers and five
train crew members died, 111 passengers and crew members sustained injuries, and 62 people
escaped without injury.

II. Sequence of Events

On September 21, 1993, the Sunset Limited, proceeding from Los Angeles to Miami, was
delayed 34 minutes for repairs at a normally scheduled stop in New Orleans. The train departed
New Orleans at 2334 hours. It arrived in Mobile at 0230 hours, where it stopped for about three
minutes to drop off and pick up passengers.
 The following table describes the train as it left Mobile. Beginning with the lead
2
locomotive, cars are listed in the position which they occupied in the consist. AMTRAK floor
plans are reproduced in Appendix A.

Train Car Description

Locomotive 819 These Model F40PH diesel-electric locomotives deliver 3000

horsepower and operate on #2 diesel fuel (stored in a storage
tank on the underside of the locomotive). They are equipped
with a 480 Volt AC power generator in the rear of the engine
room.

Locomotive 262 Same as Unit #819.

Locomotive 312 Same as Unit #819.

Baggage Car 1139 These cars transport passenger baggage. All baggage cars
are equipped with a stretcher in addition to standard
emergency equipment.

Crew Dorm 39908 These two-level cars have eight crew bunks and seating for
40 passengers on the upper level, and crew lounges and
bathrooms on the lower level.

Superliner Coach 34083 These two-level cars seat 75 passengers.

Superliner Coach 34068 Same as Unit #34083.

Superliner Coach 34040 Same as Unit #34083.

Superliner Lounge 39973 These two-level cars provide casual seating, tables, and bar
space for 68 passengers.

2
The term “consist” refers to the string of cars which comprise the train.

2
 Train Car Description

Superliner Diner 38030 These two-level cars combine a dining area for 72 passengers
on the upper level and a food preparation area on the lower
level.

Superliner Sleeper 32067 These two-level cars have sleeping quarters and daytime
private rooms. The upper level houses five duplex and ten
economy roomettes; the lower level houses one large family
bedroom, four economy roomettes, one large handicapped
toilet, and five public toilets.

At 0055 hours, the towboat Mauvilla departed the National Marine Fleet, heading upriver
from mile 5 on the Mobile River. A dense fog soon settled in, reducing visibility to almost
nothing. Fog in the region is notorious for its thickness and the speed with which it descends on
the river. The pilot of the Mauvilla stated that he could barely see the fore end of the load he was
pushing. Although the Mauvilla was equipped with radar, the NTSB found that the pilot was not
trained in its use.

In the heavy fog, and given the extremely winding nature of the Mobile River (see the
map of the Mobile River Delta and the inset enlargement - Figures 1 and 2, below), it is
understandable how the Mauvilla wound up in the Big Bayou Canot instead of the Mobile River
when it attempted to find a place to tie off to shore and wait for the fog to lift.

At 0245 hours, in the Big Bayou Canot, the Mauvilla struck an object (later discovered to
be the CSXT railroad bridge which crosses the Bayou at that point). The towboat pilot was
unable to see the object which he hit, and he later stated that he thought he had run aground.
Inspection of the bridge after the derailment showed the south end of the girder span had been
displaced 38 inches to the west; this caused the east girder to protrude into the path of the Sunset
Limited.

3
Figure 1 -- Map of the Mobile River Delta

4
Figure 2 -- Inset enlargement showing the Big Bayou Canot

5
 After departing Mobile, the Sunset Limited continued on its journey to Miami. There
were 202 passengers and 18 crew on board; however, the exact passenger count would not be
3
known until well after the derailment. Traveling about 72 miles per hour, the Sunset Limited
struck the displaced bridge girder and derailed at milepost 656.7 about 0253 hours (Figure
3 is an NTSB diagram of the bridge and the train.)

Figure 3 -- NSTB Diagram of Crash Site

Following the collision, the first seven cars of the train derailed into the waters of the Big
Bayou Carrot. The lead locomotive, 819, was buried in about 46 feet of mud, and the part
protruding above the embankment burned. The second [engine], 262, also burned. The
fuel tank of the third [engine], 312, separated from it, and all equipment along the bottom
of the unit below the frame was sheared off.

3
This was because AMTRAK policies did not require infants riding free of charge to be “ticketed.” The problems this
caused during the rescue/recovery operations will be discussed in a later section of this report.

6
 Baggage car 1139 and dorm-coach 39908 . . . were gutted by fire, and parts of both
cars sustained major structural damage. About half of coach 34083, which rested against
the bridge after the accident, was submerged, and coach 34068 was almost totally
submerged. The next four cars, coach 34040, lounge 39973, diner 38030, and sleeper 32067,
remained on the bridge. All passenger cars were double-decker cars. (See Appendix A for
applicable AMTRAK floor plans; see Figure 4 for a diagram of the wreckage).

Figure 4 -- Diagram of Wreckage (based on a sketch by Capt. GA Foster)

Notification

[A]bout 0256 hours, [the] assistant conductor made a “Mayday, Mayday” transmis-
sion over the railroad-designated radio that was heard by CSXT train 579, waiting at
[milepost] 660.4, whose crew repeated it to the yardmaster at the Sibert Yard, Mobile. Also
about 0256 hours, the assistant terminal trainmaster at Sibert Yard heard [the Sunset
Limited] transmitting Mayday over the radio. The yardmaster at Sibert Yard notified the
train dispatcher in Jacksonville, Florida, at 0257 hours and the Mobile Police Department’s
9-l-l operator about 0300 hours that [the train] had derailed. (See Appendix B for the
transcript of the 9-1-1 notification.)

The bridge tender at the Mobile River Bridge and the engineer of train 579 also
radioed the train dispatcher in Jacksonville about 0256 hours that [the Sunset Limited] was
transmitting a Mayday call. Immediately thereafter, the train dispatcher tried to contact
[the train] but was unsuccessful. Train 579’s engineer advised the dispatcher that [the
Sunset Limited] had derailed at the Mobile River Bridge, which is where the assistant
conductor said he thought the train was when he made his Mayday call, and was on fire.
The Mobile River Bridge is about 3.2 miles north of the actual accident site.

Between 0302 and 0305 hours, the Mobile Police Department’s 9-l-l operator
contacted the Mobile Fire Department and the Coast Guard. Police, fire, and Coast Guard
personnel began notifying other emergency responders; more than 60 local departments
eventually responded. [The Sunset Limited's On-Board Service (OBS)] supervisor, using a
cellular telephone, called the Mobile 9-1-1 operator about 0305 hours and provided
additional information about the accident location and what was taking place at the site.
The OBS supervisor did not know the exact location of the derailment, however. For about
18 minutes - from 0302 to 0320 hours, confusion ensued as the Mobile, Saraland, and
Chickasaw 9-l-l operators tried to locate the accident site. Exactly where [the train] had
derailed was unclear, and no roads lead into the area, which is heavily wooded swampland.
First Response

At 0320 hours, 18 minutes after the initial call to 9-1-1, the MFD Fireboat, MFD Engines
1, 14, and 21, Truck 4, Rescue 14, the District 1 Chief, and the Medical Shift Commander were
dispatched to the call. After the initial dispatch, the following agencies were notified: Mobile
Police Department; Prichard Fire Department; Mobile County Sheriffs Department; the U.S.
Coast Guard; the police and fire departments from Saraland, Chickasaw, Creola, and Mount
Vernon; and the Mobile County Emergency Management Agency.

The initial dispatch location (Bayou Sara Drawbridge) was checked without finding
anything. It was later determined that the location given the 9-1-1 operator was incorrect (see
Appendix B for the 9-1-1 transcript).

The MFD Fireboat, the Ramona Doyle, departed its dock at 0320 hours. Navigation was
clear until the fireboat reached the Cochran Bridge, at which point the visibility was reduced to
zero by the same fog which had caused the pilot of the Mauvilla to become lost. From that point,
the Ramona Doyle was forced to navigate by radar and slowed to about six knots.

While en route to the scene, Captain Randall Smith, the medical shift supervisor, called
University of South Alabama Medical Center (the area’s Level 1 trauma center). He requested
that they put their helicopter, SouthFlite, on standby and that they notify all the other hospitals of
a possible mass casualty incident. Captain Smith also notified Newman’s Ambulance Service,
the largest private ambulance service in the region at that time. He requested that they notify the
other two private ambulance services and that they send units to stage at Saraland. Following the
notification of the private ambulance services, Captain Smith contacted the communications
center and ordered all off-duty paramedics called in. Finally, he gave orders for arriving units
not to do CPR, not to perform endotracheal intubation, and not to give aggressive Advanced
Cardiac Life Support, given the potential for large numbers of injured passengers.

9
Initial Actions -- Fireboat

The fireboat arrived on scene at about 0400 hours and confirmed the location of the crash
as the Big Bayou Carrot. Heavy fire was showing in the baggage car, a crew dormitory car, two
engines, and on the bridge itself. Twenty-eight survivors of the derailment had been plucked
4
from the water by the crews of the Mauvilla and the Scott Pride. After determining that no
other people remained in the water, the Ramona Doyle began fighting the fires.

Scott Paper Command Established

Response personnel made several attempts to locate the crash site and a route for land-
based vehicles to reach it. After determining that there was no road access, District One Chief
V.E. Hall established command at the Scott Paper Company at 0420 hours. This site was
chosen for a command post because it was the closest land location with both vehicular and rail
5
access to the crash site. For this reason, the Scott Paper Company also became the land-based
staging area for the initial operations and the anticipated triage, treatment, and transportation site,

Accessing the Scene

Because it was an undetermined distance up the tracks from the staging area to the crash
site (certainly further than walking distance), a “rescue train” was arranged to carry the initial
wave of emergency responders to the scene. At 0455 hours, a three-car train carrying “Task

4
The Scott Pride is a towboat which had been operating in the area and which responded to the U.S. Coast Guard’s
“Urgent Marine Information Broadcast” concerning the derailment (0324 hours).
5
Beyond the paper mill, travel into the Mobile Delta could only be accomplished by boat or train.

10
 6
Force One" departed from the command post, with Captain Seth Peden from Engine 14 in
charge.

Aboard the train, Captain Peden used the 30-minute travel time to organize and prepare
the personnel with him. The first car (a dining car) was to be used to treat the injured (because
there were tables upon which they could be placed). The middle car carried all the medical and
rescue equipment. (All potentially useful medical and rescue equipment had been stripped from
the vehicles and placed on the train.) The third car was to be used for the “walking wounded.”
Captain Peden stated that “it helped a lot to set up the operations and talk about the plan prior to
our arrival on scene.”

Initial Actions - Task Force One

Upon arrival, at 0525 hours, Task Force One commenced a primary search of the area and
took a head count of the victims brought onto the train. The search was hampered because the
only available light was from the fires burning on the bridge and in the train cars, and the fog
which blanketed the area. Rescuers checked the cars on the bridge, the railbed, and the
surrounding accessible areas. Once the primary search had been completed and all of the known
patients had been taken on board, Captain Peden ordered the rescue train to depart. He sent two
paramedics and two defibrillation-trained EMTs back on the train with 125 patients (mostly
walking wounded). The total on-scene time for the first train was less then 20 minutes.

Once the train left, Task Force One personnel initiated a secondary search of the shore
and the railbed areas. This search, however, failed to locate any more survivors.

6
Task Force One comprised the crews from Engines 14, 1, and 21; Truck 4; and Rescues 14 and 3 (a “rescue” is an
advanced life support ambulance), for a total of 17 responders.

11
Search Activities

The crew from Ladder 4 boarded a bass boat which had arrived at the scene of the wreck.
They proceeded to the above-water portion of the partially submerged car, and searched without
success for survivors. They then boarded the Ramona Doyle and assisted with fire suppression
activities.

As soon as the fires had been extinguished and the train had cooled to a temperature
which permitted entry, the crew dormitory was searched, and the badly burned bodies of two
crew members were recovered.

At this point, it became clear that aside from those people who had already been
transported from the scene, there would be no more survivors. Hence, a command decision was
made to move from a “rescue mode” to a “recovery mode.”

Triage, Treatment, and Transport of Patients

At approximately 0550 hours, the rescue train arrived at the Scott Paper triage area on the
west side of the river. MFD EMS personnel handled the triage, treatment, and transport of the
125 patients from the rescue train. Some patients were taken by ambulance; the less serious were
transported by city transit bus.

Word was received that 28 passengers who had been pulled from the Bayou were being
transported downriver by a towboat to the Scott Paper Company docks which are on the east side
of the river. The Director of Mobile County EMS System (MCEMSS), Dirk Young, was sent
with eight MCEMSS ambulances to the Scott Paper docks to handle the patients on that side of
the river. None of the 28 patients had sustained serious injuries, and they were all transported to
the hospital.

12
 The U.S. Coast Guard airlifted five passengers to Bates Field, and SouthFlite flew two
patients directly from the crash site to the hospital.

The last patient was transported by 0800 hours from the Scott Paper treatment area on the
west side of the river. MCEMSS personnel triaged, treated, and transported all 28 survivors on
the east side by 0830 hours.

Body Recovery Efforts

About 0430 hours, SCUBA divers from the Mobile Police Department and the Mobile
County Sheriffs Flotilla arrived on scene and began to prepare for recovery operations. A diving
team from the U.S. Marine Corps also showed up - its personnel actually did the body removals.
At 0545, divers began the process of removing the dead from the train cars. Later, divers from
the state bridge inspections diving team arrived on scene. They had extensive experience diving
in sub-optimal conditions, and the expertise to conduct the search for additional victims.

After fire suppression was completed, the Ramona Doyle became a floating forward com-
mand post and rehabilitation station. Due to an error at the dispatch center, MFD’s Chief,
Edward Berger, was not immediately notified of the derailment. By the time he had responded,
the Scott Paper command post had already been established, and Chief Berger decided to proceed
to the crash site. A boat from Daphne Volunteer Fire Department ferried him up to the scene.
He arrived at the crash site at 0615 hours and took charge of all MFD activities at the scene.

A temporary morgue was established on a barge in the Bayou. The MFD Chaplain was
called to the scene, and MFD Engine 14’s personnel were placed in charge of coordinating the
activities associated with preparing the bodies for transport back to a temporary morgue.

13
Train Removal/Recovery of Engineers

In the crash, the lead locomotive drove into the muddy banks of the north end of the
Bayou Canot. The front 45 feet of it was buried in the mud at about a 30-degree angle. It was
believed that three AMTRAK engineers were in the first locomotive.

The two submerged passenger cars were removed from the bayou by a barge crane during
the afternoon hours of September 23. All victims had been removed from them by the divers.
There was one major concern in removing the trains from the Bayou; a fiber optic cable which
ran through the Bayou, alongside the CSX railroad tracks. This cable was a major
communications link serving thousands of users, including computer networks and 9-1-1
systems, from Jacksonville, Florida to Los Angeles, California. Severing the fiber optic cable
would mean a devastating loss of communications for the users of the cable. MFD personnel
rigged a rope system in an effort to pull the cable out of the way. Despite a few tense moments,
the MFD rigging system succeeded in saving the cable while the train cars were removed. The
train cars were subsequently moved by barge downriver to the Alabama State Docks.

The next morning, after the other cars had been removed, a 700-ton barge crane pulled
the 240-ton locomotive out of the mud. MFD personnel used a handline to wash the mud out of
the engineer’s compartment and removed the bodies of the three engineers. This brought the
final death toll to 47.

By 2000 hours on Friday, September 24, the train cars and locomotives had been cleared
and all the victims accounted for. The forward command post was shut down, and all personnel
were released. The final MFD operations at the crash site were limited to retrieval of the train’s
“black box” and passenger effects by the crew of the Ramona Doyle the next day, Saturday,
September 25.

14
III. Discussion

Several aspects of the rescue and recovery operations of the MFD at the Big Bayou Canot
warrant further discussion at this point. In order to understand the critical role that the ICS
played in this incident, it is important to get a sense of the obstacles that the MFD and the other
responding agencies needed to overcome.

Response Difficulties

The most obvious problem was locating and gaining access to the crash site. Several
factors combined to hamper emergency response to the derailment.

The crew members who would have known exactly where the train had derailed were in
the lead locomotive and all three had all been killed on impact. The location reports for the crash
site were inexact because there were no landmarks readily visible to the surviving train crew and
the Mobile Delta swamp all looks the same (especially in the fog at night). Train personnel
thought that they were farther away from Mobile than they actually were and initially reported
that the train had derailed at the Mobile River bridge. Later reports described the crash site as
Bayou Sara (about 1.5 miles closer to Mobile). For about 18 minutes, 9-1-1 center personnel
tried to determine where the crash was and who to send based on the conflicting information they
received.

Based on observations made during the clear day and on the descriptions of people
interviewed who are familiar with the Mobile River and its tributaries, the area is confusing and
inchoate - even in daylight. Given that it was a foggy night, responders would have been hard-
pressed to arrive much faster even if they had had a verifiable location of the incident.

Although the MFD was dispatched in the initial group of emergency responders, the
premise was that the MFD was responding on a mutual-aid basis to the Saraland Fire
Department’s response area. It was not until the following morning that it was determined that

15
the crash site technically lay within the city limits of Mobile and the MFD had jurisdiction over
the scene.

Finally, the few roads and paths into the Mobile Delta are spread out over a wide area,
and are not well mapped or marked. After making a number of attempts to locate the crash site
by land, the responding crews realized that road access was an uncertain means, and that the best
chances for success would be via the railroad itself.

Scene Safety Considerations

7
The crash site itself was dangerous to rescuers and survivors alike.

The Bayou was 300 feet wide and about 20 feet deep where the submerged cars
lay. There was an ever-present possibility of falling into the water.

The railbed was elevated, and footing was unsure because the sides of the railbed
were steep, gravel-covered embankments. In addition, railroad ties and other
obstacles presented constant tripping hazards.

The accessible portion of the bridge was obstructed by the train. The northern
half of the bridge was mangled and on fire.

The only light was from the fires which burned and the few spotlights on the
Ramona Doyle, the Mauvilla, and the Scott Pride.

The scene was 30 minutes by rail (and about the same by boat) from the nearest
land access point, making emergency evacuation of any personnel who became

7
Contrary to the rumors which circulated in the media, there was no danger present from snakes or alligators.
Although both are known to inhabit the Mobile Delta, they are characteristically timid animals. The noise, fire, and
commotion associated with the derailment and the response frightened away most the swamp’s denizens.

16
 injured more difficult than would otherwise be acceptable. This also posed
problems for resupply operations.

There was no landing zone big enough to accommodate a helicopter. Personnel

and supplies that were airlifted to the scene had to be raised and lowered using a
hoist.

The wreckage of the Sunset Limited itself posed several hazards - glass, twisted
metal, fire, and fuel were all present.

During the day, temperatures reached the mid-nineties. This, combined with the
high humidity and the extended exposure of rescuers, posed real problems for
ensuring that personnel would not suffer heat prostration.

Dive Operations

The first-arriving rescuers made a limited search of the above-water portion of one of the
cars in the Bayou. Beyond that attempt, the lack of lighting made further sub-surface attempts to
search impossible. The “technical” aspects of the response were limited to providing underwater
recovery operations inside the AMTRAK cars. This necessitated the use of highly trained divers
to conduct a methodical search for and recovery of bodies. A commitment to safety dictated that
precautions be taken to assure that no divers were injured performing body recoveries.

The water in the Bayou was a dark brown (one person interviewed described it as coffee-
colored) from all the mud which had been stirred up. Visibility inside the train cars was less than
one foot. This created an extremely hazardous environment in which to run recovery operations.
Because of the cramped space and loose debris inside the cars, divers had to work alone, with a
back-up rescue diver positioned at the entrance to each car in case the search diver got into
trouble. The bodies that were located were brought out to a “shuttle” diver at the window of the

17
car. The body would then be taken to the surface and placed on the morgue barge for
identification.

Some of the divers used “Kirby Morgan” helmets. These specialized helmets have a
tether which delivers surface-supplied breathing air, acts as a safety line, and facilitates
communications with the surface and other divers. The use of these helmets permitted longer
dive times and better communications. Some divers were also equipped with helmet-mounted
cameras.

IV. Incident Command

Initial Establishment of Command

District One Chief Vernon Hall established command at the Scott Paper Company
beneath the Cochran Bridge at 0403 hours. He immediately established Staging, Operations, and
Medical Sectors.

Chief Hall directed District Chief Mike Byrd to assume responsibility for the Operations
Sector. Chief Byrd was flown by helicopter to the Ramona Doyle, from where he directed the
on-scene operations.

Scott Paper Command Post

At 0440 hours, Chief Hall transferred command to Deputy Chief Stephen Dean, who
expanded the ICS organization to include Triage and Transportation Sectors. The Mobile
County Emergency Management Agency’s Communications Unit arrived on scene and was
placed into service as the command post.

The Medical Sector Officer, Captain Randall Smith, prepared a patient triage and
treatment area near the railroad tracks and the command post, and initiated staging of the many

18
ambulances which would arrive at the staging area. Two helicopter landing zones were also
established.

John Owen, Chief Hall’s aide, was placed in charge of personnel accountability.

Decision to Move Command

Because of the necessity of moving operational and command personnel between the
operations area and land, it became obvious that a command post/staging area with water access
would be more advantageous. For this reason, at 0800 hours the command post was moved to
the North Star Lumber Pier in the Port of Chickasaw. The move was completed and the new
command post activated by 0845 hours.

Port of Chickasaw Command Post

The new command post offered several advantages. First, access to the site could be
restricted. Second, it relieved the Scott Paper Company from having the congestion and
logistical problems associated with having a large, 24-hour operation in front of its main gate.
Third, there was water access for shuttling personnel to and from the incident site. Fourth, it was
the receiving point for bodies and had ample room for use as an interim morgue.

The new command post also allowed the Public Information Officer to establish a press
briefing area and to stage the press in between briefings.

Finally, the Port of Chickasaw had ample room for support services (such as food and
lavatories) to be established.

19
Forward Command Post

Because the scene of the derailment was so far isolated from any accessible roads, a
forward command post was established on the Ramona Doyle. This provided the Operations
Sector an area from which to manage the scene while the Port of Chickasaw command post was
used to coordinate the overall activities of the response.

The fireboat offered several inherent advantages for the operation. First, it offered shelter
from the sun and had air conditioning and a refrigerator aboard (this was critical as the daytime
temperatures hovered in the high-nineties). Second, it had radio communications which were not
dependent on batteries (although the Big Bayou Carrot was in somewhat of a radio “dead zone”).
Third, it offered a private place for command personnel to conference.

Difficulties of Command

The ICS had never been used on such a large scale, except in a drill. According to
Deputy Chief Dean, the MFD uses the Incident Command System on a daily basis, but this was
by far the largest incident the MFD had ever run. Chief Dean attributes the ability to use the ICS
in such extreme circumstances to the department’s constant exposure to ICS in the course of
routine operations. Most others agreed that familiarity with the ICS was the main reason that
incident management was not overly problematic.

An additional difficulty was that because of the location of the crash and the darkness, it
was impossible to be sure exactly who had jurisdiction over the incident. As stated earlier, the
MFD had been dispatched on the assumption that it was providing assistance to Saraland Fire
Department or the County Sheriff. Institution of the ICS by the MFD was not done in an effort
to gain command of the incident, but rather as a standard operating practice use by the MFD to
manage incidents of all types.

20
 Chiefs Hall and Berger were proceeding on the rationale that the incident was in Mobile
County and that the Sheriff had jurisdiction. It was not until midday that it was actually
determined that the incident was in the “panhandle” portion of the City of Mobile which extends
along the railroad tracks well into the Mobile Delta. According to Chief Berger, he “eased into
command” about noon the next day.

The MFD was the only agency which had been trained in and used ICS. This meant other
agencies which responded to the derailment needed to be brought into the ICS organization
without their having a proper understanding of how the system worked. Accordingly, the ICS
organization remained staffed by MFD personnel but utilized the personnel and resources of the
other agencies to complete incident objectives. While this approach worked reasonably well,
most agreed that incident command would have been easier had officers from other agencies
been able to dovetail into the ICS structure.

Number of Victims

“Not knowing” the exact number of victims was a source of considerable stress for the
incident command staff. A number of rescue personnel cited the inability to determine consistent
and reliable numbers of people on board as a major problem.

This problem arose because AMTRAK ticketing policies in place at the time of the
derailment did not require that certain children traveling with revenue passengers or employees
8
be ticketed. This meant that they did not appear on the passenger manifest. Accordingly, there
was no way to know when all the people had been accounted for. One responder was assigned
the full-time task of coordinating the passenger count with the AMTRAK liaison. It was not
until well into the recovery effort that AMTRAK was able to provide a comprehensive passenger
list.

8
AMTRAK is presently working to implement an on-board, computerized system which will allow complete and
accurate passenger lists to be obtained in the event of a similar emergency. This system is projected to be available by
sometime in 1996.

21
ICS Organizational Chart

Figure 5 shows the fully expanded ICS structure used for the incident.

Interagency Liaison/Unified Command Structure

Deputy Chief Dean was the Incident Commander. There was a high level of interagency
cooperation with representatives of other agencies assigned to liaison positions at the command
post.

Officials from each of the responding agencies as well as representatives from AMTRAK
and CSX were on site at the Port of Chickasaw command post. The Operations Sector made
frequent use of the technical expertise of AMTRAK’s Chief Mechanic, especially during the task
of lifting the cars and locomotives.

Media Liaison

Control of the media was a major task. By noon Thursday, there were over 300 news
reporters and 75 tractor-trailer TV news trucks which created a line of parked vehicles over l/4-
mile long on the access road to the Port of Chickasaw command post.

Working together, the public information officers from the Mobile Fire and Police
Departments, Steve Huffman and Tom Jennings, ensured that the media was kept from
endangering themselves or interfering with the operations. The two held hourly briefings near
the command post to keep the media fully informed of developments and supplied with accurate
information that had been approved for release.

22
 Sunset Limited Derailment
ICS Organization

Figure 5 -- ICS Organization at peak expansion

23
 The media was kept in a media staging area at the Port of Chickasaw command post.
Media personnel were taken by boat in groups of ten to the crash site. To ensure fairness, the
groups were chosen by lottery, with an even representation from print, TV, and radio outlets. All
the media eventually did get to visit the scene.

Media representatives were afforded access to the portable latrines set up at the Port of
Chickasaw and the food and drinks provided by the Salvation Army and the Red Cross. The
media was asked to make contributions to a food fund. This was used to help the Salvation
Army and Red Cross offset their expenses. This was not viewed as unreasonable by the media
(who had large budgets to be there anyway). In retrospect, some responders thought that
separating the media food and latrine facilities from those for emergency personnel might have
been beneficial.

An additional consideration was the number of media helicopters which were circling the
area. In order to avoid potential mid-air collisions and reduce the noise which was associated
with the helicopters, Chief Dean had the air space in the area declared off-limits to non-essential
aircraft by the Federal Aviation Administration.

Morgue Operations

Two morgues were established - one on a barge in the Bayou and one at the Port of
Chickasaw command post. After initial recovery, the bodies would be lifted onto the barge,
where they were placed in body bags. When a sufficient number of bodies were ready for
transport, they were taken by boat to the Port of Chickasaw dock.

At the second morgue, the Identification Section of the Mobile Police Department
photographed and made tentative identification of the bodies. Personal effects were secured by
the police department, and the bodies were handed over to the Medical Examiner’s Office for
transportation to Mobile.

24
 The crew from Engine 14, which had been on the initial rescue train with Task Force
One, was initially assigned to handle the on-scene morgue. By all accounts, this crew worked
the longest at the morgue. In retrospect, it was felt that a more frequent rotation of personnel
through morgue duty would have relieved some of the emotional stress which morgue duty
placed on those who performed it.

V. Major Findings

The following are some recurrent themes that emerged in the interviews:

ICS Saved the Day

By all accounts, ICS is credited as providing an organizational framework which created

a systematic approach to handling this very chaotic scene. All MFD personnel interviewed
indicated that the ICS worked the way it was intended to work.

The Mobile Police Department later commented on the functionality of the ICS and how
well organized the MFD was. Since the incident, all public safety agencies in the area have
adopted ICS and sought ICS training. The MFD has provided ICS training to a number of the
area’s public safety agencies.

Earlier Disaster Drill Was Helpful

On June 17, 1993, MFD personnel and equipment engaged in a disaster drill in
conjunction with Mobile County Emergency Management Agency and Mobile County EMS
System. The exercise tested the response to an airplane crash into Mobile Bay and simulated 90
survivors and 57 victims.

25
 Many rescuers commented that the drill had been beneficial in refreshing their familiarity
with disaster operations and that they felt that their ability to handle the train derailment had been
enhanced by participation in the drill.

Rescue Operations Were Limited in Scope

Because the derailment occurred when most people were sleeping, there was no way for
most of the passengers who died to escape their cabins once the cars became submerged in the
murky water of the Bayou. Accordingly, by the time that the first rescuers arrived on scene,
those who had been able to escape had been moved to safety. The “walking wounded” were the
only survivors.

With the exception of the entry into the above-water portion of the partially submerged
car, a fuller “search and rescue” effort was not feasible. For many rescuers, the frustration of
“not being able to do anything” was the most traumatic aspect of the two-day operation.

The Limited Numbers of Seriously Injured Helped

Most rescuers agreed that the relative speed with which people were cleared from the
patient receiving areas was due, in part, to the fact that so few people had serious injuries. Had
there been greater numbers of injured, the EMS function would have been under much more
pressure. Nonetheless, everyone interviewed felt that the Medical Sector had been properly
established and was prepared to handle large numbers of seriously injured patients, had it been
necessary.

Critical Incident Stress Management Played an Important Role

According to Chief Edward Berger, “[The wreck of the Sunset Limited] was the most
traumatic incident any of us had ever been on.” In recognizing and responding to that concern,
Critical Incident Stress Management (CISM) was instituted to help responders deal with the

26
emotional impact of the tragedy. Assistant Chief Pitt was assigned to oversee the provision of
CISM.

At the time of the incident, only two of MFD’s personnel had been formally trained in
CISM.

Emergency responders were monitored on-scene for signs of traumatic stress; however,
only one responder needed to be removed from the scene. All responders who continued to work
on the incident underwent CISM.

Two phases were used. First, all responders were debriefed as they left the scene. Next,
a formal debriefing was done on three dates in the week following the crash. All MFD personnel
were required to attend one of the sessions. All personnel were paid for their time in debriefing
sessions, thus facilitating acceptance and participation. In addition, the sessions were opened to
personnel from any of the agencies involved.

The CISM activities were viewed as extremely successful. No MFD employee has been
referred by the department to the Employee Assistance Program (although some may have
sought help of their own volition). Only one MFD employee has subsequently left the
department for reasons connected with the incident. No other individuals have reported major
problems.

Preparedness for Future Responses

As mentioned earlier, agencies which had been involved in the response to the Sunset
Limited derailment have subsequently decided to adopt the use of the Incident Command
System. There is widespread belief that this incident demonstrated both the need for, and
efficacy of, the ICS.

27
 Subsequent to the incident, Mobile County EMS System recognized the need to have a
large quantity of extra EMS equipment available for rapid deployment in future major
emergencies. Through the efforts of its Director, Dirk Young, MCEMSS has purchased a trailer
which is equipped with backboards and disaster supplies. Should large amounts of medical
equipment ever be needed again, the trailer can be attached to the supervisor’s vehicle or an
ambulance and brought to the scene. This will help avoid the necessity of stripping ambulances
for their equipment cache.

The MFD’s communications system has been upgraded to an 800 mega-Hertz trunking
system, and cellular phones have been purchased for use by ambulances, the hazardous materials
team, select command staff, and the fireboat. By all accounts, the radio “dead space” problem
appears solved. In addition, spare batteries for all communications equipment have been
acquired.

VI. Lessons Learned

The following are lessons learned from this incident, as suggested by the personnel who
were involved in its mitigation.

Incident Management

It is essential to get an accurate count of the passengers. Without knowing how many
people were on board, it was impossible to make a decision about when to discontinue
searching for survivors or recovering victims.

The use of the Incident Command System was what differentiated the fire department
from all the other agencies which responded to the derailment. All agencies with
emergency response duties should receive formal training in the use of the ICS, should
use it on a daily basis on all incidents regardless of size, and should drill with other local

28
agencies on its use. This will ensure that all personnel are comfortable and familiar with
operating under the ICS when a major emergency occurs.

The MFD needed to assure response capability to the rest of the city while it was
handling the derailment. Incidents of this size quickly outpace the capabilities of even
the largest departments. Without a formal mutual aid system in place, there would have
been no way to get adequate numbers of personnel to the scene and ensure that additional
calls were answered. The need for formal mutual aid agreements is especially applicable
for small departments. This is demonstrated by the fact that the MFD, which has many
more resources than other departments in the area, used mutual aid to effect the initial
response.

Work out bugs in the response system by drilling frequently with all other agencies which
would be involved. Don’t wait until the real thing to find out what works and what
doesn’t work.

Initiate complete and accurate documentation early in the incident. On big incidents such
as this, post-event investigations will be time-consuming and expensive. Proper
documentation of the actions of the departments involved as well as the scene conditions
will shorten the amount of time that needs to be spent reconstructing the paperwork
afterwards.

Coordination with other agencies is both helpful and problematic. Use the resources of
other agencies to your advantage, but do not allow interpersonal issues to interfere with
the mitigation of the incident. Work around problems and ensure that they receive
adequate attention during the post-incident analysis.

29
Communications

Good communications equipment is essential. After-action reports indicate that inter-

agency frequency coordination was problematic. Personnel require a common channel
for inter-jurisdictional or inter-agency communications. Radio dead zones need to be
identified and written into pre-incident plans. Cellular telephones can provide a viable
alternative means of communications.

Have back-up batteries fully charged and ready to go at all times. Nickel-cadmium
batteries should be “exercised” to prevent them developing a “memory.” It is a good idea
to have a bank of portable rapid-charge battery chargers and spare batteries available.

This type of incident causes a heavy reliance on quality communications center

personnel. Departments should ensure that they have adequate supervision in dispatch
centers, that the personnel assigned there are well trained, and that they are included in all
disaster exercises. Dispatch should be viewed as an integral part of the response team.

While the initial responders assumed that it was too early in the morning for the incident
to have been a drill, some expressed concern that some might have thought that they were
being sent on a drill, had the incident occurred during the day. Communications policies
should be to have all drills “dispatched” and run on a channel other than the main
communications channel. In addition, an identifier should be used during the initial
dispatch to ensure that responders understand that the incident is an exercise. This could
be as simple as saying, “ATTENTION, THE FOLLOWING IS A DRILL” prior to, and
after, the dispatch. This holds especially true for those agencies lacking alternate
communications channels.

Ground communications were hampered by the helicopters operating in the area.

Minimize the number of unnecessary aircraft by implementing an airspace restriction

30
 around the incident. This can be done by contacting the closest air traffic control center
(the phone number should be included in your agency’s emergency operations plan).

Personnel Safety

Personnel working on or around water must wear appropriate personal flotation devices
(PFDs).

Rotate crews and pace activities to avoid premature exhaustion. Don’t let them get
burned out in the initial stages of an incident - especially if it is likely to be an extended
incident.

Relieve the initial response personnel and remove them from the immediate operating
area as soon as feasible. Critical Incident Stress Management (CISM) is an absolute
must! The MFD personnel who were involved in the incident report that their
participation in CISM was of significant benefit to them.

Rehabilitation, although difficult to establish in the tight operational environment of the

scene, was an absolute necessity. Given the high temperatures, constant exposure to the
sun, and dangerous working conditions, it was critical to ensure that personnel were
rehabilitated on a regular, formal basis. Use a large tarp or parachute cloth to set up a
shaded area for rehabilitation.

Personnel should be rotated through various jobs on an extended incident to prevent them
from being unduly subjected to too much of any particular sight, sound, smell, etc.
Ensure that this rotation occurs even if they are being adequately rehabilitated with rest
periods, fluids, and nourishment.

Personnel must receive ample food and liquids. This will prevent dehydration (which is
the most likely source of fatigue) and loss of energy. Care must be taken to ensure that

31
 responders do eat and drink as they may have a tendency to ignore sustenance in favor of
continuing to work. Personnel must not eat on scene or prior to thoroughly washing their
hands.

In swampy areas, have ample supplies of mosquito repellent on hand. When working in
the sun, make sure that sunblock is available to all personnel.

Logistics

Resupply of food, water, and other supplies to the scene was difficult. Several hours
often elapsed between the time that a need for supplies was recognized and the time those
supplies could be delivered to the scene. This highlights the need for a planned logistics
component within the ICS organization and for the early recognition of such needs.

Don’t underestimate the difficulty or importance of logistics. The MFD considered this
an important enough function to assign to one of its top command staff. Whomever is
designated to head the logistics sector should be reliable, capable, and knowledgeable.

Having pre-packaged multiple-casualty incident supplies would eliminate the need to

strip ambulances of their medical equipment.

Technical Rescue Considerations

Rescuers should familiarize themselves with the emergency access techniques outlined in
the AMTRAK Emergency Evacuation Procedures guide. The MFD quickly discovered
that its extrication tools would not work on the train. Several of its power tools were
damaged trying to force entry. This is to be expected. In fact, AMTRAK’s emergency
guide states, “Rail passenger cars and locomotives are constructed to withstand extreme
stresses under all conditions. Forced entry is not easily accomplished.” Copies of the
booklet can be obtained by contacting AMTRAK’s Safety Department at (202) 906-4949.

32
 Highly specialized teams, such as divers, require time and assistance to initiate
operations. Involve these teams in pre-incident planning and drills so all department
personnel understand how they function, their limitations and capabilities, and what
assistance and resources they will require.

Triage and Treatment

The proper and early alerting of the hospitals proved to be quite helpful. Although area
hospitals did not receive the 200+ patients they had prepared to receive, they were ready
and had been able to call back additional personnel because they received advanced
warning. Be sure to notify the hospitals, in a timely manner, when they are clear to stand
down from their disaster plan.

Distribute patients to avoid overload at any one hospital. Keep the Level 1 trauma
facilities available for the most critical patients. The medical control officer ensured that
the area’s Level 1 trauma center did not receive patients simply because of the nature of
the incident. Patients were transported to other area hospitals, leaving trauma beds free
for critical trauma patients. This decision, while not easily undertaken or executed,
would likely have meant the difference between receiving proper care and not, had
critical trauma patients been found at the scene of the derailment.

After saving the living, it is necessary to have a plan for the removal of the dead. Proper
search, documentation, and recovery procedures are crucial for identifying the dead and
investigating the cause of the incident. Morgue operations is a continuation of this
process. It is advisable to have a mass fatalities procedures annex outlining these
procedures in your Emergency Operations Plan. Following a mass fatalities incident, you
need to handle the dead properly and address the needs of the family and friends of the
victims as well as the needs of the responder. The National Emergency Training Center
through the State Emergency Management Training Offices offers the Mass Fatalities

33
 Incident Response Course (G386). Contact your State Training Office for course
information.

If it is a hot day, don’t place victims in body bags until they are to be transported. Don’t
attempt to identify victims on the scene. Morgue personnel should be rotated out as often
as possible. Have law enforcement personnel secure the morgue. Keep it sheltered from
view and from the weather, if possible.

Handling the Media

Anticipate media from your area as well as national and even international reporters, if
the incident is big enough. Organize and control the media to avoid serious operational
problems.

The Public Information Officer is a critical member of the Command Staff. Without a
PIO, the media will seek out anyone willing to talk with them. This could result in them
getting incorrect or restricted information. The worst possible circumstance would be
that the media hamper the Incident Commander or operational personnel.

Understand that the media have a constitutional right to report on what is happening.
More importantly, they are competitive and value getting a “scoop.” If you ignore the
media, they will find a way to get the story. It is better to enlist their cooperation by
making accommodations for them than to try to keep them in an adversarial position.

Establish media ground rules early on in the incident. If certain areas are restricted, tell
the media where they cannot go and why (i.e., safety considerations, public health, etc.).
If news crews violate the rules, have law enforcement escort them off site. If necessary,
remind the media that they are being granted special access and that, in return, they need
to abide by certain rules.

34
 A rotation system was used to ensure that all the media got an opportunity to visit the
crash site. While this worked well, it may not always be practical. When access to the
scene is limited or unsafe, consider the use of a “pool reporter.” Under this system, one
reporter and one camera operator are selected to go to the site. All the media who are
there when the pool is established are then given full rights to any reporting or footage
produced by the pool crew.

Know the facts, and know what information can and cannot be released. Anticipate
questions and the flow of events. When the media area is remote, maintain constant
contact with the operations site to obtain updated information.

Consider utilization of a “unified” PIO function (fire, law enforcement, EMS, emergency
management, etc.) - it distributes the work and the stress by allowing for rotation of the
spokesperson. This will require that PIOs in an area know each other, train together, and
use a unified PIO function on normal incidents and in exercises. Have the Incident
Commander assign assistants to the PIO.

When an incident revolves around an organization (such as AMTRAK), have one of its
representatives available at the command post to get and give information which only that
organization can provide.

VII. Conclusion

The tragic wreck of the Sunset Limited presented emergency responders with a complex
and unusual set of challenges. It was in many respects, the worst-case scenario come true. As
one responder said, “If you had asked me whether I’d ever go to a train derailment in the middle
of the night, in the middle of the swamp, I’d have thought you were crazy.” It is important to
note that trains characteristically travel through remote and inaccessible places. As evidenced by
the wreck of the Sunset Limited and numerous other train crashes, emergency responders need to
anticipate and plan for these types of incidents.

35
 Considering that there was virtually no visibility or land access, that responders had large
numbers of patients to triage, treat, and transport, that access to fatalities was technically difficult
and dangerous, and that extreme heat made recovery and processing of fatalities an unpleasant
and emotionally tortuous task, it is to the credit of all those there that the only responder injury
was a cut arm.

By all accounts, training and the use of ICS contributed heavily to the ability of the MFD
to handle the obstacles which confronted them in Big Bayou Canot.

VIII. Post Script: Mobile Revisited

Just before 0700 hours on March 20, 1995 (approximately one week after this incident
investigation was completed) the MFD responded to a series of motor vehicle collisions on the I-
10 Bridge over the Mobile River. Upon arrival units discovered that five separate car crashes
involving 193 vehicles had occurred in the fog on the 7-mile-long bridge. Seventy-one people
were injured, one fatally. Victims were located on both the east- and west-bound sides of the
bridge.

MFD instituted its multiple casualty incident plan. Over 230 emergency personnel from
MFD, Baldwin and Mobile Counties, various private ambulance services, and assorted law
enforcement agencies responded to the scene. Forty-nine patients with varying degrees of injury
were transported by ambulance; transit buses transported the remaining 18 walking wounded
patients. Both lanes of the bridge were reopened approximately five and one-half hours after the
first crash occurred.

As with the Sunset Limited incident, the ICS was used. This time, however, assisting
agencies were well-versed in its use. Because of the 800 mega-Hertz radio system, a common
radio frequency was available for incident coordination. While two radio channels were used, a
third was available had it been necessary to use it.

36
 According to PIO Steve Huffman, “The lessons learned from AMTRAK resulted in us
being able to handle this incident without problem.” This is perhaps the lasting legacy of the
Sunset Limited.

***

37
 APPENDIX A

APPLICABLE AMTRAK FLOOR PLANS

 APPENDIX B

TRANSCRIPT OF 9-1-1 CALLS

9-1-1: 9-1-1

CARR: This is Warren Carr-, the CSX Railroad.

9-1-1: Yes, sir.

CARR: We got a passenger train at Bayou Sara drawbridge, has derailed. I understand
that there’s people in the water. The bridge is on fire. I need all.

9-1-1: Wait a minute 507, where?

CARR: Bayou Sara drawbridge.

9-1-1: Where is this? Where is that located?

CARR: It’s off the Mobile River.

9-1-1: Um-hm.

CARR: It’s north of Chickasabogue draw.

9-1-1: You can’t?

CARR: You can’t get there, can’t get there by vehicle.

9-1-1: Okay, is that going to be, is that going to be in Prichard, north of Chickasabogue?
Is that going to be it?

CARR: It’s north of Chickasabogue.

9-1-1: Um-hm.

CARR: I’m talking to 9-1-1, Tommy. (speaking with another CSX employee)

9-1-1: Okay.

CARR: It’s a passenger train. I got people in the water. I got cars on fire.
9-1-1: Okay, but . . .

CARR: It’s a derailment.

9-1-1: Okay, a derailment, but is it in Prichard, there by Chickasabogue Creek?

CARR: No, it’s on the river.

9-1-1: On the Mobile River?

CARR: You can’t get to it over the road.

9-1-1: Okay.

CARR: You’re going to have to get some helicopters and boats and Coast Guard and all
those people.

9-1-1: 507 drawbridge, on the Mobile River.

CARR: On CSX Railroad.

9-1-1: (unintelligible)

CARR: No, it’s, it’s south of Mobile River, north of Chickasabogue River.

9-1-1: South of.

CARR: North of Chickasabogue, at the next, next major creek, north of Chickasabogue.

9-1-1: And south of, what other river was that?

CARR: South of Mobile River. It’s right along beside Mobile River, where Bayou Sara
comes off the Mobile River.

9-1-1: Bayou Seven?

CARR: Get me ahold of the Coast Guard.

9-1-1: Okay, sir. We’re going to get someone out there. What’s your callback number,
sir. You calling from 4-3-4?

CARR: 4-3-4.

9-l-l: 1300?
CARR: No, 1390 or 1375.

9-1-1: What’s your name sir?

CARR: Carr, C-A-R-R.

9-1-1: And you’re with the C and X railroad?

CARR: That’s right. You need all the emergency vehicles that you can get, too.

9-1-1: Okay, you got a derailment with people in the water?

CARR: That’s right.

9-1-1: Okay.

CARR: Bayou Sara draw.

9-1-1: All right.

CARR: Bridge, on CSX Railroad.

9-1-1: Okay.

(end of call)

9-1-1: Emergency, 9-1-1.

SEYMOUR: This is Ronnie Seymour, with CSX Transportation.

9-1-1: Uh-huh.

SEYMOUR: AMTRAK has derailed at Bayou Sara drawbridge. I need any available
assistance. I need boats in the water. I need them as soon as possible.

9-1-1: Okay, stay on the line just a moment. I’ve got an operator working on that. Can
you hold the line just a moment?

SEYMOUR: Yes.

9-1-1: Just a moment.

9-1-1: Ma’am. (this is the same 9-1-1 operator from the Carr call)
UNKNOWN FEMALE: Hold on a minute, please. Yeah.

9-1-1: Can you tell me what the train?

SEYMOUR: Hello?

9-1-1: Sir.

SEYMOUR: Yes.

9-1-1: Can you tell me what the train was carrying?

SEYMOUR: The passengers.

9-1-1: Passengers? Linda, so it’s not a . . .

UNKNOWN FEMALE: It’s going to be Saraland, but it’s a passenger train that’s derailed,
(unintelligible) crew in water; the train’s on fire.

9-1-1: So it is a passenger train?

SEYMOUR: Yes, ma’am.

9-1-1: Okay, sir. It’s going to be Saraland’s, but we have notified the proper authorities,
okay?

SEYMOUR: Thank you very much.

9-1-1: You’re welcome, bye-bye.

9-1-1: Carol, I can’t get Marine Police to pick up.

(sound of dial tone)

(end of call)

9-1-1: 9-1-1.

AMTRAK: Yes, listen, this is AMTRAK train, a supervisor. We’re on, we’re on the Mobile
River. The bridge has gone out. We got cars burning, people in the river, can’t
swim.
9-1-1: Okay.

AMTRAK: We need help. Any kind of help you can get down here.

9-1-1: Okay, sir, just stay on the line with me. Sir?

AMTRAK: Yes.

9-1-1: Okay, you’re with the AMTRAK train?

AMTRAK: Yes, ma’am. I’m the supervisor on board. We’re on the Mobile River.

9-1-1: You’re on the Mobile River?

AMTRAK: On the Mobile River. We’ve got cars burning. They’re over the bridge is out.
There’s people in the water. We’re trying to help them, but.

9-1-1: So the bridge is out?

AMTRAK: We need all kind of help. Yes, ma’am, we need help, send help, please.

9-1-1: Okay, just stay on the line, okay? We got someone en route to you. It has been
called in before, but I need you to stay on the line, okay? AMTRAK train. Hello,
sir?

AMTRAK: Yes, ma’am?

9-1-1: Just hold on the line, okay?

(AMTRAK placed on hold, comes back on the line)

AMTRAK: Location, we can use them.

9-1-1: Okay, sir?

AMTRAK: Yes, ma’am.

9-1-1 : We do have help on the way.

AMTRAK: Okay.

9-1-1: Sir, listen to me, what, you, hello, sir?

AMTRAK: Yes, ma’am.

9-1-1: This is the bridge that’s out?

AMTRAK: Yes, ma’am. The bridge is out. Yes, ma’am.

9-1-1: Okay, which bridge is this that’s, that’s out?

AMTRAK: Ma’am. I don’t know. We’re on the Mobile River.

9-1-1: You’re on the Mobile River?

AMTRAK: That’s all I know.

9-1-1: But you don’t know what bridge it is?

AMTRAK: No ma’am. No, ma’am. I haven’t been informed by the conductor. John, John?

9-1-1: Okay, Sir?

AMTRAK: Yes, ma’am.

9-1-1: Can you give me some information on where this train was coming from?

AMTRAK: Was coming from New Orleans, sir.

9-1-1: New Orleans,

AMTRAK: Be careful, watch your step. (speaking to passengers) It’s left New Orleans.
Ma’am, I have to go and assist these folks.

9-1-1: Okay, sir.

AMTRAK: All right, then.

(end of call)

***
 APPENDIX C
LESSONS LEARNED FROM THE
AMTRAK/CONRAIL DERAILMENT IN
CHASE, MARYLAND, JANUARY 1987

Reproduced courtesy of the Charles McC. Mathias, Jr.

National Study Center for Trauma and Emergency Medical Systems
© 1989, University of Maryland at Baltimore
All Rights Reserved

Following is a summary of the recommendations made in the post-incident analysis

report of the AMTRAK/CONRAIL derailment which occurred January 4, 1987 at Chase,

Maryland. Although there are many similarities between this incident and the derailment of the

Sunset Limited, there are also crucial differences - the two most important being that this

incident occurred over land and in cold weather. Sixteen (16) people died; 177 others were

injured.

The reader should note that some of the recommendations reproduced below are specific

to the Maryland EMS system as it was in 1987, when the derailment occurred. Many of the

recommendations have been subsequently implemented. Where appropriate, explanatory notes

appear in parentheses.

1. For incidents involving multiple fatalities, the Medical Examiner and his office need to
be included in the appropriate notification call list. It was by chance that they were
contacted for this incident and were able to respond as they did.

2. Removal of, care for, and discussion pertaining to the deceased or their families should be
accomplished with the assistance of a representative of the Medical Examiner’s Office, as
they are aware of all considerations needed for these operations.
3. Arrangements need to be made for the purchase and storage of disaster pouches and for
regional storage locations from where they could be more readily transported to the
scene.

4. The purchase of a refrigerated trailer for use as a mobile morgue should be investigated.

5. Accessibility was a severe problem, as there were many checkpoints on access roads and
fire and rescue apparatus blocked narrow roads that led to the scene. More easily
recognized identification needs to be investigated along with appropriate transportation
plans for Medical Examiner’s Office to respond to the scene.

6. There should be designated persons from each jurisdiction in the region to respond to the
command post to act as a liaison and also control the units from that person’s jurisdiction.

7. There needs to be a mechanism to control individuals responding on their own to the

scene.

8. Preparation for environmental conditions such as low temperature needs greater attention.

9. Great care needs to be taken in the movement of uninjured passengers. A large group
was escorted past the active treatment areas at the scene. Changes in their emotional state
could be recognized immediately due to the additional stress of seeing fellow passengers
who were injured.

10. “GO teams” (Maryland hospital-based disaster teams) should be used more extensively in
triage areas.

11. Staging should be utilized to a greater extent.

12. Hourly updates should be given to hospitals, even if the message is “no new
information.”

13. EMS Communications System should be improved.

14. Interhospital communications should be established to centralize patient identifi-

cation/condition list at MIEMSS (statewide communications center).

15. Clearer designation of command personnel is needed.

16. Traffic should be directed well out of the area.

17. Suggestions from civilian experts (i.e., AMTRAK workers) should be considered.
18. There is a need for distinct identification of CIP (Crisis Intervention Preparedness) team
members. Clear identification emblems and acronyms on outer garb (vests, jumpsuits,
jacket) that specifically identify CIP team members are necessary.

19. Communications on-site between CIP team dyads (pairs working together) and the team
leader must be improved. Simple walkie-talkie equipment would solve the problem.

20. The capabilities of organizations like Dogs East (a search dog team) should be considered
earlier in future incidents which may involve the possibility of trapped victims.

21. Dogs East normally utilizes a second dog team to confirm the findings of a single team.
If the team is to be utilized in the future, arrangements should be made to allow the
transport of more than a single team.

***

*U.S. GOVERNMENT PRINTING OFFICE: 1996-719495/82752