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Safety Recommendation Details

Safety Recommendation R-05-012
Synopsis: On October 12, 2003, about 4:38 p.m., central daylight time, westbound Metra train 519 derailed its two locomotives and five passenger cars as it traversed a crossover from track 1 to track 2 near Control Point 48th Street in Chicago, Illinois. The train derailed at a recorded speed of about 68 mph. The maximum authorized speed through the crossover was 10 mph. There were about 375 passengers and a crew of 3 on board. As a result of the accident, 47 passengers were transported to eight local hospitals. Of these, 44 were treated and released, and 3 were admitted for observation. Damages from the accident exceeded $5 million.
Recommendation: Based on its investigation of the October 12, 2003, Metra train derailment in Chicago, Illinois, the National Transportation Safety Board makes the following safety recommendations to Metra: Require your train crews to call out all signal indications over the radio, including clear signals, at all locations that are not equipped with automatic cab signals with enforcement or a positive train control system.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Railroad
Location: Chicago, IL, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA04MR001
Accident Reports: Derailment of Northeast Illinois Regional Commuter Railroad Train 519
Report #: RAR-05-03
Accident Date: 10/12/2003
Issue Date: 11/23/2005
Date Closed: 11/28/2006
Addressee(s) and Addressee Status: Metra (Northeast Illinois Regional Railroad Corporation) (Closed - Acceptable Alternate Action)
Keyword(s): Positive Train Control

Safety Recommendation History
From: NTSB
To: Metra (Northeast Illinois Regional Railroad Corporation)
Date: 11/28/2006
Response: The Safety Board notes that on January 4, 2006, Metra issued General Order (G.O.) No. 15. In part, the rule instructs an engineer who is the sole occupant of the control compartment of a train to verbally communicate all absolute signals (including clear signals), all signals governing the approach to absolute signals, and all signals displaying an approach or less favorable signal indication where the maximum authorized speed is greater than 30 mph. The G.O. applies to the entire Metra system. Rock Island G.O. No. A-14, issued the same day and applying specifically to the Rock Island District, specifies that “The provisions of System Special Instruction 1.47D (calling signals) do not apply east of Chicago Terminal-Bridge B; milepost 1.1 and 0.0.” (Prior to the accidents and the issuance of this G.O., the exemption applied between mileposts 3.9 and 0.0.) On January 13, 2006, Metra issued G.O. No. 19, which specifies that engineers must call all absolute signals displaying an aspect less favorable than clear. A designated crewmember elsewhere in the train shall acknowledge the transmission and confirm or take action to ensure the safety of the train, including stopping the movement, if appropriate. This G.O. was issued because calling clear signals resulted in substantial additional radio traffic (Metra operates 700 weekday trains) and created confusion with possible unintended consequences. The Safety Board notes that Metra is also installing speed limit signs (round white retro-reflective background with black numerals) throughout its system at approach signals in advance of locations where a diverging route may be encountered. Although the Safety Board recommended that train crews call out all signal indications, Metra’s efforts constitute an acceptable alternate means of addressing the recommendation. Accordingly, Safety Recommendation R-05-12 is classified Closed Acceptable Alternate Action.

From: Metra (Northeast Illinois Regional Railroad Corporation)
Date: 12/14/2005
Response: Letter Mail Controlled 12/19/2005 3:30:26 PM MC# 2050573:Metra intends to implement, in the territories designated in the Board’s report, the calling of all signal aspects at absolute signals and the approaches thereto, except at downtown terminals where speeds are 20 mph or less. We will implement the procedure in January 2006. Metra feels that calling all signals would result in radio congestion and this may, in fact, create other safety issues such as impacting the urgent need to communicate grade crossing malfunctions and other safety critical issues. While we appreciate the Board’s recommendation to call all signals, we are concerned about our ability to safely and efficiently adopt the recommendation in its entirety in the Chicago Terminal District. Metra’s proposal expands on the provisions of EO#20 by calling signals as noted above. Being the locations where trains are controlled in both velocity and direction, we believe calling all aspects at these locations will alert other crewmembers and other trains particularly if one failed to be called. While intermediate signals do protect occupied blocks, switches and broken rail conditions the calling of these signals would not have prevented the 2003 derailment. Calling all signals including intermediates in territories where train movements can be in excess of 100 trains per day could have unintended consequences. Metra takes your recommendations seriously. We trust that the information provided in this letter meets with your approval.