July 11, 2006
NTSB Number: RAR-07-02
NTIS Number: PB2007-916302
Adopted September 11, 2007
On Tuesday, July 11, 2006, about 5:06 p.m., central daylight time, the last car of northbound Chicago Transit Authority Blue Line train number 220 derailed in the subway between the Clark/Lake and Grand/Milwaukee stations in downtown Chicago, Illinois. About 1,000 passengers were on board the eight-car rapid transit train. Following the derailment, the train came to a stop, and electrical arcing between the last car and the 600-volt direct current third rail generated smoke. The single operator in the lead car received a number of calls on the train intercom. The operator exited the control compartment, stepped onto the catwalk, and walked beside the train to investigate.
Electrical power was removed from the third rail, and most passengers walked to an emergency exit stairway about 350 feet in front of the train that led to the street level. Some passengers had to be assisted in their evacuation by emergency responders. The Chicago Fire Department reported that 152 persons were treated and transported from the scene. There were no fatalities. Total damage exceeded $1 million.
The National Transportation Safety Board determines that the probable cause of the July 11, 2006, derailment of Chicago Transit Authority train number 220 in the subway in Chicago, Illinois, was the Chicago Transit Authority's ineffective management and oversight of its track inspection and maintenance program and its system safety program, which resulted in unsafe track conditions. Contributing to the accident were the Regional Transportation Authority's failure to require that action be taken by the Chicago Transit Authority to correct unsafe track conditions and the Federal Transit Administration's ineffective oversight of the Regional Transportation Authority. Contributing to the seriousness of the accident was smoke in the tunnel and the delay in removing that smoke.
As a result of its investigation of this accident, the Safety Board identified the following safety issues:
As a result of its investigation of this accident, the National Transportation Safety Board makes safety recommendations to the Federal Transit Administration, the State of Illinois, the Regional Transportation Authority, the Chicago Transit Board, and the Chicago Transit Authority.
As a result of its investigation of the July 11, 2006, derailment of Chicago Transit Authority train number 220 in Chicago, Illinois, the National Transportation Safety Board makes the following safety recommendations:
To the Federal Transit Administration:
Modify your program to ensure that State safety oversight agencies take action to prompt rail transit agencies to correct all safety deficiencies that are identified as a result of oversight inspections and safety reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term. (R-07-9)
Develop and implement an action plan, including provisions for technical and financial resources as necessary, to enhance the effectiveness of State safety oversight programs to identify safety deficiencies and to ensure that those deficiencies are corrected. (R-07-10)
Schedule the Chicago Transit Authority as a priority for receiving the maintenance oversight workshop and the training course to be developed for track inspectors and supervisors that will address the unique demands of track inspection in the rail transit environment. (R-07-11)
Inform all rail transit agencies about the circumstances of the July 11, 2006, Chicago Transit Authority subway accident and urge them to examine and improve, as necessary, their ability to communicate with passengers and perform emergency evacuations from their tunnel systems, including the ability to (1) identify the exact location of a train, (2) locate a specific call box, and (3) remove smoke from their tunnel systems. (R-07-12)
To the State of Illinois:
Evaluate the Regional Transportation Authority's effectiveness, procedures, and authority, and take action to ensure that all safety deficiencies identified during rail transit safety inspections and reviews of the Chicago Transit Authority are corrected, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term. (R-07-13)
To the Regional Transportation Authority:
Determine if track safety deficiencies on the Chicago Transit Authority's Dearborn Subway in the area of the derailment have been adequately repaired. (R-07-14)
Strengthen your followup action on Chicago Transit Authority system safety reviews to ensure that the Chicago Transit Authority corrects all identified safety deficiencies, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term. (R-07-15)
To the Chicago Transit Board:
Direct the Chicago Transit Authority to correct all safety deficiencies identified by the Regional Transportation Authority in its most recent and future safety inspections and reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term. (R-07-16)
To the Chicago Transit Authority:
Correct all safety deficiencies identified by the Regional Transportation Authority in its most recent and future safety inspections and reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term. (R-07-17)
Examine all of the elements in the American Public Transportation Association's "Standard for Rail Transit Track Inspection and Maintenance" and incorporate all appropriate elements of this standard in your system safety program. Specifically, include the regular use of track geometry vehicle inspections and the inspection of rail for internal defects in your system safety program. (R-07-18)
Evaluate all territories to determine the number of inspectors and the amount of time needed to ensure that adequate track inspections are conducted, and implement appropriate changes. (R-07-19)
Schedule as a priority the maintenance oversight workshop and the training course that the Federal Transit Administration plans to develop for track inspectors and supervisors that will address the unique demands of track inspection in the rail transit environment. (R-07-20)
Perform a comprehensive computational study of the existing ventilation system using various fire and smoke scenarios to identify potential deficiencies, and make improvements to the ventilation system and smoke removal procedures based on the findings of the study. These actions should address reinstalling fan 108 and replacing unidirectional fans (including fan 133) with dual direction fans as needed. (R-07-21)
Examine and improve, as necessary, your ability to communicate with passengers and perform emergency evacuations. (R-07-22)