Railroad Accident Report

Collision of Amtrak Passenger Train 371 and Norfolk Southern Railway Company Freight Train 23M

Chicago, Illinois
November 30, 2007

NTSB Number: RAR-09-01
NTIS Number: PB2009-916301
Adopted: March 31, 2009
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Executive Summary

On Friday, November 30, 2007, about 11:23 a.m., Amtrak (National Railroad Passenger Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck the rear of standing Norfolk Southern Railway Company freight train 23M near Chicago, Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and five crewmembers were transported to hospitals; two passengers and one crewmember were subsequently admitted. The weather was clear, and the temperature was 30º F. Estimated damage was $1,299,000.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the November 30, 2007, collision of Amtrak train 371 with the rear of Norfolk Southern Railway Company train 23M near Chicago, Illinois, was the failure of the Amtrak engineer to correctly interpret the signal at Englewood interlocking and Amtrak's failure to ensure that the engineer had the competency to correctly interpret signals across the different territories over which he operated. Contributing to the accident was the relief engineer's failure to immediately communicate to the engineer that he had miscalled the signal at Englewood and to stop the train when he did not respond to her expressed concern. Also contributing to the accident was an absence of effective crew resource management between the relief engineer and the operating engineer which led to their failure to resolve the miscalled signal prior to the collision. Further contributing to the accident was the absence of a positive train control system that would have stopped the Amtrak train when it exceeded restricted speed.

As a result of its investigation of this accident, the Safety Board identified the following safety issues:

Recommendations

As a result of its investigation of the November 30, 2007, collision of Amtrak train 371 with the rear of standing Norfolk Southern Railway Company train 23M near Chicago, Illinois, the National Transportation Safety Board makes the following recommendations:

To the Federal Railroad Administration:

Establish uniform signal aspects that railroads must use to authorize a train to enter an occupied block, and prohibit the use of these aspects for any other signal indication. (R-09-1)

Study the different signal systems for trains, identify ways to communicate more uniformly the meaning of signal aspects across all railroad territories, and require the railroads to implement as many uniform signal meanings as possible. (R-09-2)

Require that emergency exits on new and remanufactured locomotive cabs provide for rapid egress by cab occupants and rapid entry by emergency responders. (R-09-3)

To Amtrak:

Identify engineers and engineer trainees who have not consistently demonstrated competency in interpreting signals, and provide them with enhanced training, supervision, testing, and evaluation necessary to determine that signal proficiency has been achieved and maintained. (R-09-4)

Use the circumstances of the November 30, 2007, accident in Chicago, Illinois, during crew resource management training to reemphasize the necessity of any qualified person on the leading locomotive or car to immediately communicate any disagreement on a called signal and to immediately take action necessary to ensure that the train is operated safely. (R-09-5)

To the Association of American Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the American Public Transportation Association:

Use the circumstances of the November 30, 2007, accident in Chicago, Illinois, during crew resource management training to reemphasize the necessity of any qualified person on the leading locomotive or car to immediately communicate any disagreement on a called signal and to immediately take action necessary to ensure that the train is operated safely. (R-09-5)