NATIONAL TRANSPORTATION SAFETY BOARD

Public Meeting of September 11 , 2007

(Information subject to editing)

Railroad Accident Report
Derailment of Chicago Transit Authority Train Number 220
Between Clark/Lake and Grand/Milwaukee Stations
Chicago, Illinois, July 11, 2006
NTSB/RAR-07/

This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations.  Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing. 

EXECUTIVE SUMMARY

• Poor track conditions,
• Ineffective management and safety oversight,
• Difficulty locating the train, and
• Problems with tunnel ventilation and smoke removal.

CONCLUSIONS

1. The following were not factors in the accident: the operator’s qualifications, his operation of the train, or drug or alcohol use.
2. There was no preaccident mechanical or component failure on any of the train’s cars.
3. The tie plates and fastener system failed to maintain the track gage because of the effects of corrosion and/or wear on the rails and rail fastener system, and degraded half-ties.
4. The dark area on the inner rail of the curve, the abrasion on the tie plates and ties, the broken lag screws, the tie plates’ elongated fastener holes and poor drainage in the area of the derailment were all readily observable and should have been documented during walking inspections.
5. Track inspectors in the Dearborn Subway did not have sufficient time allotted for inspecting all of their assigned territory twice a week as prescribed.
6. The Chicago Transit Authority track inspection training program did not adequately prepare inspectors to perform their required duties and it did not address the unique demands of inspecting and maintaining elevated track structures or track structures located inside tunnels.
7. The use of a track geometry strength and condition test vehicle would have simulated train loads and better identified areas of poor track gage and the need for corrective action.
8. Because the Chicago Transit Authority failed to establish an effective track inspection and maintenance program, unsafe track conditions and deficiencies were not corrected.
9. Because the Regional Transportation Authority failed to follow up with the Chicago Transit Authority and prompt action to correct safety deficiencies identified in the triennial report, unsafe track conditions continued to exist that should have been corrected.
10. The Federal Transit Administration’s oversight of the Regional Transportation Authority’s Rail Safety Oversight Program was inadequate and failed to prompt actions needed to correct track safety deficiencies on the Chicago Transit Authority’s rail transit system.
11. Because a train indication system had not been installed on the Dearborn Subway and the Chicago Transit Authority’s control center could not identify the location of an emergency call box used to report the accident, the specific location of train 220 could not be determined, which delayed the emergency response and the activation of emergency exit lights and announcements at the closest accessible emergency exit.
12. The initial efforts to remove smoke were inefficient because the fans were pulling against each other from opposite sides of the smoke source.
13. Had fan 133 been capable of dual direction (reversible), the smoke could have been removed in a direction opposite that of the path of evacuation.
14. If fan 108 had been reinstalled and operational, the smoke could have been eliminated faster and in a direction opposite that of the path of evacuation.

PROBABLE CAUSE

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.

SAFETY RECOMMENDATION

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Transit Administration:

1. 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.
2. 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.
3. 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.
4. 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.

5. 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.

6. Determine if track safety deficiencies on the Chicago Transit Authority’s Dearborn Subway in the area of the derailment have been adequately repaired.
7. 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.

8. 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.

9. 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.
10. 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.
11. 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.
12. 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.
13. 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.
14. Examine and improve as necessary your ability to communicate with passengers and perform emergency evacuations.