Collision of Metrolink Train 111 with Union Pacific Freight Train LOF65-12

Chatsworth, California
September 12, 2008

NTSB Number: RAR-10/01
NTIS Number: PB2010-916301
Adopted January 21, 2010
PDF

Executive Summary

About 4:22 p.m., Pacific daylight time, on Friday, September 12, 2008, westbound Southern California Regional Rail Authority Metrolink train 111, consisting of one locomotive and three passenger cars, collided head-on with eastbound Union Pacific Railroad freight train LOF65-12 near Chatsworth, California. The Metrolink train derailed its locomotive and lead passenger car; the UP train derailed its 2 locomotives and 10 of its 17 cars. The force of the collision caused the locomotive of train 111 to telescope into the lead passenger coach by about 52 feet. The accident resulted in 25 fatalities, including the engineer of train 111. Emergency response agencies reported transporting 102 injured passengers to local hospitals. Damages were estimated to be in excess of $12 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the September 12, 2008, collision of a Metrolink commuter train and a Union Pacific freight train was the failure of the Metrolink engineer to observe and appropriately respond to the red signal aspect at Control Point Topanga because he was engaged in prohibited use of a wireless device, specifically text messaging, that distracted him from his duties. Contributing to the accident was the lack of a positive train control system that would have stopped the Metrolink train short of the red signal and thus prevented the collision.

The safety issues identified during this accident investigation are as follows:

  • Inadequate capability, because of the privacy offered by a locomotive operating compartment, for management to monitor crewmember adherence to operating rules such as those regarding the use of wireless devices or the presence of unauthorized persons in the operating compartment.
  • Lack of a positive train control system on the Metrolink rail system.

Recommendations

As a result of its investigation of this accident, the National Transportation Safety Board makes recommendations to the Federal Railroad Administration.

New Recommendations

To the Federal Railroad Administration:

Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. (R-10-1)

Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. (R-10-2)

Previously Issued Recommendation Reclassified in This Report

To the Federal Railroad Administration:

R-07-3
Require the installation of a crash- and fire-protected locomotive cab voice recorder, or a combined voice and video recorder, (for the exclusive use in accident investigations and with appropriate limitations on the public release of such recordings) in all controlling locomotive cabs and cab car operating compartments. The recorder should have a minimum 2-hour continuous recording capability, microphones capable of capturing crewmembers' voices and sounds generated within the cab, and a channel to record all radio conversations to and from crewmembers.

Safety Recommendation R-07-3, previously classified "Open-Acceptable Response," is reclassified "Closed-Unacceptable Action/Superseded." Safety Recommendation R-07-3 is superseded by Safety Recommendation R-10-1.