NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


NTSB DETERMINED ENGINEER'S INACCURATE INTERPRETATION OF SIGNAL LED TO CAUSE OF AN AMTRAK ACCIDENT IN CHICAGO

March 31, 2009

Washington, D.C., - The National Transportation Safety Board today determined that the probable cause of a collision of an Amtrak (National Railroad Passenger Corporation) train with the rear of a Norfolk Southern Railway Company (Norfolk Southern) train 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 the signal across the different territories over which he operated.

"As we discovered in this accident investigation, the comprehensive training and evaluation of the train crews is extremely critical," said NTSB Acting Chairman Mark V. Rosenker. "Ensuring that we have the most qualified and prepared crew at the controls can prevent accidents like this from occurring."

On Friday, November 30, 2007, about 11:23 a.m., CST, Amtrak passenger train 371, consisting of one locomotive and three passenger cars, struck the rear of standing Norfolk Southern freight train 23M. 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 5 crewmembers were transported to hospitals; 2 passengers and 1 crewmember were admitted.

In today's report, the Safety Board found that as the Amtrak train traveled closer to the first signal at Englewood interlocking, the engineer made a significant error when he misinterpreted the meaning of the red over yellow signal aspect. The red over yellow aspect was a restricting indication that required the crew to operate the train at a maximum speed of 15 mph and to be prepared to stop for any trains or obstructions ahead.

The report states that the engineer misinterpreted the signal as a slow approach, which would have allowed him to operate at a maximum speed of 30 mph while being prepared to stop at the next signal. It is important to note that a slow approach signal indication would have meant that there was not a train within the next block.

The Board determined that 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 the engineer 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.

It is stated in the report that the relief engineer asserted herself after the engineer accelerated the train to 40 mph rather than immediately after she was aware of the miscalled signal at Englewood. Also, she never declared to the engineer that she believed that the Englewood signal was a restricting signal that limited their speed to 15 mph.

Therefore, the Safety Board concluded that the relief engineer failed to communicate effectively and in a timely manner to the engineer that he had miscalled the restricting signal at Englewood interlocking. She also failed to then take action herself to stop the train after the engineer did not slow or stop the train when challenged.

Further contributing to the accident was the absence of a positive train control (PTC) system that would have stopped the Amtrak train when it exceeded restricted speed. The Board concluded that had a PTC system been in place, it would have intervened by stopping the Amtrak train when the engineer failed to comply with the restricted speed.

As a result of its investigation of this accident, the Safety Board made recommendations to the Federal Railroad Administration, Amtrak, 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 in the following areas: uniform signal aspects to communicate meanings more effectively, wayside signal indication training and proficiency programs, crewmember communication and action in response to operating concerns, and inadequate locomotive cab emergency egress and rescue access. A synopsis of the Board's report, including the probable cause, conclusions, and recommendations, is be available on the NTSB's website. The Board's full report will be available on the website in several weeks.

NTSB Media Contact:
Keith Holloway
(202) 314-6100
hollowk@ntsb.gov  

 

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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.