National Transportation Safety Board
Office of Public Affairs
Washington, DC - The National Transportation Safety Board determined today that the probable cause of the September 17, 2005 derailment of Northeast Illinois Regional Commuter Railroad Corporation (Metra) train 504 in Chicago, Illinois, was the engineer's inattentiveness to signal indications and his failure to operate the train in accordance with the signal indications and speed restrictions for the crossover at Control Point (CP) 48th Street.
Contributing to the accident was lack of recognition by Metra of the risk posed by the significant difference between track speed and crossover speed at the accident location and its inaction to reduce that risk through additional operational safety procedures and other means. Also, contributing to this accident was the lack of a positive train control system.
"This is another example of a tragic accident that could have been prevented if the train was equipped with a positive train control system," said NTSB Chairman Mark V. Rosenker. "The system would have prevented overspeed through the crossover by overriding the engineer's failure to slow the train."
Train 504 departed Joliet, Illinois traveling eastbound on track two to downtown Chicago, Illinois. Track two is designated by Metra as a class four track with a maximum operating speed of 70 miles per hour (mph) for passenger train between milepost (MP) 7.0 and MP 3.9. The train, operating in a push mode from a cab control car at the lead end, was traveling 69 mph at MP 4.7 as it entered a crossover from track two to track one when a locomotive and five cars derailed. There were 117 injuries and two fatalities.
Signal data logs indicate that when train 504 passed the signal at 53rd Street, the signal was displaying an approach diverging indication and that the next signal at CP 48th Street was displaying a diverging clear indication, which tells the train engineer to proceed on a diverging route at prescribed speed through the turnout. The prescribed maximum operating speed, which is intended to provide for a safe transition through the crossover was 10 mph.
Postaccident inspection of the train's seats by the Safety Board showed some of the seats had sustained extensive damage.
As a result of the accident, the safety Board made the following recommendations:
To the Federal Railroad Administration:
1. Immediately require all rail passengers car seat backs be secured to the seat assembly. (R-06-24)
2. Revise the language in 49 Code of Federal Regulations 238.233 to define seat to include all components of seat assembly, such as seat cushions and seat backs, that could become dislodged when subjected to accelerations specified in that section. (R-06-25)
3. Require all rail passenger seat assemblies to be dynamically tested to withstand accelerations specified in 49 Code of Federal Regulations 238.233, and require both upward and downward vertical acceleration tests. (R-06 26)
4. Establish crashworthiness standards for passenger car body floor structure systems. (R-06-27)
To the Northern Illinois Regional Commuter Railroad Corporation (Metra):
5. Conduct a risk assessment of all crossovers on your system and determine those that pose an unacceptable level of risk due to the speed differential between maximum allowed track speed immediately before the crossover and maximum allowable speed through the crossover. For those crossovers where an unacceptable level of risk is determined, develop guidelines and procedures to effectively manage those risk, including procedures for communication those risks with train crews. (R-06-28)
The Board's full report will be available on the website soon at: www.ntsb.gov.
NTSB Media Contact:
Terry N. Williams
The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.