The main branch rises in eastern Cambria County, along the western slope of the Appalachian ridge separating the watersheds of the Ohio and Susquehanna rivers.
The river flows through scenic mountainous areas but is considered severely degraded by abandoned mine drainage, most notably the Hughes bore hole,[1] from the long exploitation of the region's coal resources.
The headwaters of the Little Conemaugh form on the western side of Tunnelhill, Pennsylvania, at Cresson Pass in northern Cambria County, which is transited by the line of the Eastern Continental drainage divide.
The river's upper valley falls off gradually enough that the terrain forms a natural transportation corridor navigable by muscle-powered vehicles such as Indian travois and Conestoga wagons.
On May 31, 1889, the dam holding back this reservoir failed during a period of extremely heavy rainfall, sending a wall of water up to 60 ft (18 m) high down the Little Conemaugh at 40 mph (64 km/h), causing massive flooding in the towns along its banks, including Johnstown, and resulting in the loss of 2,209 lives in the worst civilian disaster of the 19th century in the United States.