NTSB Cites Operator’s Actions in 2003 Chicago Commuter Train Wreck; Calls on Updated FRA Systems

November 28, 2005

The National Transportation Safety Board has adopted a final report on its investigation into the derailment of a commuter train in Chicago in 2003, saying that the train’s engineer failed to observe and comply with signal indications. At the same time, the Board again called on the Federal Railroad Administration to require positive train control systems that would prevent this type of accident in the future.

On Oct. 12, 2003, Metra train 519, from Chicago to Joliet, Illinois, derailed its two locomotives and five passenger cars as it traversed a crossover on the Rock Island Line in Chicago. The train derailed at a recorded speed of 68 mph, where the maximum authorized speed was 10 mph. Three of the 378 persons aboard the train were admitted to a hospital for observation. Damages from the accident exceeded $5 million.

The Board’s investigation determined that the engineer’s cumulative operating concerns – for example, trying to ascertain the location of a maintenance-of-way work crew and where his train would be crossed over from one track to another – likely diverted his attention from safety-critical tasks.

The Board determined that the probable cause of the accident was the engineer’s loss of situational awareness minutes before the derailment because of his preoccupation with certain aspects of train operations that led to his failure to observe and comply with signal indications. Contributing to the accident was the lack of a positive train control system at the accident location.

As with many previous rail accidents, the Board determined that a Positive Train Control (PTC) system would have prevented the accident. PTC requires the engineer to comply with signal indications or the train will automatically be brought to a stop. The Board reiterated a recommendation it had made to the Federal Railroad Administration (FRA) in 2001, to require the implementation of PTC on mainline tracks, and specifically recommended that Metra install such a system on its track. PTC installation is on the Board’s Most Wanted List of safety improvements.

NTSB Acting Chairman Mark Rosenker reacted to the finding: “How many more accidents do we have to see before the railroad industry and the FRA are convinced that PTC is needed on all mainline track in the United States?”

Other recommendations deal with improved training of operating crews, directed at both the FRA and Metra.

Copies of the safety recommendation letters, which will be issued today, can be found later today on the Board’s website, www.ntsb.gov, under Safety Recommendation Letters, Rail. A copy of the Board’s report will appear on the website in several weeks.

On Sept. 17, 2005, another Metra commuter train derailed close to the location of the October 2003 accident, killing two passengers. Safety recommendations related to this accident are anticipated in the near future.

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