Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation R-13-034
Details
Synopsis: On September 30, 2013, at 7:42am central daylight time, an unoccupied CTA train consisting of four cars collided with a CTA train in revenue service that was stopped at the Harlem Station on the Blue Line. There were about 40 passengers on the in-service CTA train. CTA reported that 33 passengers were transported to three local hospitals. All were treated and released. There were no fatalities. The unoccupied train had been stored at Forest Park Repair Terminal awaiting repairs when it began moving under power and departed the terminal entering main line track. The train traveled almost one mile downhill through five mechanical train stop mechanisms before reaching the Harlem Station. The emergency brakes were applied and the train was momentarily stopped several times by the mechanical train stop mechanisms as it proceeded to the Harlem Station. Following each stop, train movement resumed because the master lever on the operator console had been left in a setting that allowed the train car brakes to recover and reset from the emergency brake application and proceed through a mechanical train stop mechanism after a momentary stop. The investigation into the cause of unintended movement continues. The investigation has raised concerns about the need for improved protection against unintended movement.
Recommendation: TO THE CHICAGO TRANSIT AUTHORITY: Review your operating and maintenance procedures for stored unoccupied cars to ensure the propulsion and brake systems are left in a condition that would not facilitate unintended movement. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Forest Park, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA13FR014
Accident Reports: ​Railroad Accident Brief: Collision of Two Chicago Transit Authority Trains
Report #: RAB-15-02
Accident Date: 9/30/2013
Issue Date: 10/4/2013
Date Closed: 2/10/2014
Addressee(s) and Addressee Status: Chicago Transit Authority (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Chicago Transit Authority
Date: 10/31/2016
Response: You state in your letter that, since you adopted our safety recommendations in 2013, there has not been an incident of unoccupied train movement in your facilities. We note that you have taken additional measures to prevent unintended movement of unoccupied rail cars in your facilities, such as the required use of rail chocks, and safety and risk management audits to ensure procedures are being followed as per your hold-car storage in rail yard rules. As stated in our February 20, 2014, letter to you placing the above-mentioned safety recommendations in a CLOSED—ACCEPTABLE ACTION status, we appreciate learning about your efforts to improve the safety of your rail operations, and we believe that all rail operations, not just those involving unoccupied cars, could benefit from the safety improvements specified in these recommendations. Accordingly, we urge you to continue your efforts to improve all your rail operations.

From: Chicago Transit Authority
To: NTSB
Date: 8/19/2016
Response: -From Reginald A. Mason, Chief Safety and Risk Management Officer: On September 30, 2013 the Chicago Transit Authority (CTA) had a train collision and derailment of a northbound unoccupied train with a southbound revenue train run # 11 0 at Harlem Station on the Congress Branch of the Blue Line. As a result of this incident the National Transportation Safety Board (NTSB) proposed two urgent recommendations (R-14-034 and R-13-035) in a Safety Recommendation letter dated October 4, 2013 to prevent unmanned train movement. The CT A adopted and implemented the NTSB recommendations and the following additional measures listed below: 1. Revised Hold Car Storage in Rail Yards Procedures (SOP 8248) (Attached) 2. Identified Specific Hold Car Tracks 3. Installed derail devices on hold tracks 4. Required the use of wheel chocks when storing trains 5. Retraced Electric Couplers 6. Opened Main Motor knife switch to prevent current to train 7. Applied Parking brakes (calipers) 8. Rail Operations, Rail Maintenance, Rail Engineering along with Safety and Risk Management collaboratively conducts Hold Car Audits to ensure the procedures are being followed. By choosing to install the derail devices in June of 2014 the CTA introduced an additional hazard to Rail Yard employees. There has been an increase in collisions with hold track derail devices since installation. The CTA would like to mitigate and eliminate the collision hazard by removing the derail devices from the yards. The CTA asserts that without hold track derail devices its existing physical measures, hold car storage procedures, and increase in safety assurance audits have been reliable, successful, and are adequate enough to prevent unmanned train movement. Since the 2013 incident there have been no unmanned train movements. In closing, the CTA will continue to make every effort to improve the performance of its rail car storage practices, and we are confident that the adoption of the provisions outlined above including the redundant use of wheel chocks will allow the CTA to migrate towards a safer system as recommended by the NTSB.

From: NTSB
To: Chicago Transit Authority
Date: 2/10/2014
Response: We are pleased that you issued Rail Operations Service Bulletin R1235-13 and Rail Maintenance General Bulletin RMGB 1-13A, which state that all unmanned consists must be shut down and the motor cabs secured to ensure that unoccupied CTA trains are not powered up while stored or on hold for service and to ensure that the propulsion and brake systems are left in a condition that would not facilitate unintended movement. We note that this new policy was fully implemented on December 5, 2013. We are also pleased that you issued Rail Operations Service Bulletins R1178-13 and R1226-13, requiring the use of wheel chocks and other operating safeguards against unintended train movements. We note that you have identified 39 locations at 10 yards where you will install derails to stop unintended rail car movements, that all CTA rail cars have a set of wheel chocks in their toolboxes, and that you have issued two additional bulletins regarding the washing of rail cars and rail car components. Accordingly, Safety Recommendations R-13-34 and -35 are classified CLOSED—ACCEPTABLE ACTION.

From: Chicago Transit Authority
To: NTSB
Date: 12/19/2013
Response: -From David Kowalski, Chief Transit Operations Officer: The Chicago Transit Authority continues to work towards full implementation of the operations and safety procedural changes discussed in the November 1, 2013 initial response letter. The following outlines the status of items discussed in the response letter as well as additional procedural changes that have been implemented in response to the September 30th incident (NTSB Case# DCA 13 FR 014). CTA RMGB 1-13 Rail Maintenance General Bulletin RMGB 1-13 delineates the procedure for "hold car" storage to ensure that the propulsion and brake systems are left in a condition that would not facilitate unintended movement. (Full bulletin was provided with the November 1, 2013 response letter.) The bulletin directs Rail Maintenance staff to take the following action when a car is identified by Rail Maintenance as having an electrical or mechanical defect and is to be stored outside the shop for any length of time and for any reason: • Affix hold tags to the corner grab irons of the #1 ends of each car of the unit • Retract the electric coupler buttons on each rail car of the defective unit • Cut out main motor knife switch on each rail car of the defective unit • Ensure all parking brakes (calipers) are cut-in (in the applied position) Status Updates: • The first draft of RMGB 1-13 was issued to Rail Operations and Maintenance personnel on October 31, 2013. A final version was distributed to maintenance and operations personnel for full implementation on December 5, 2013. CTA R1178-13 Rail Operations Service Bulletin R1178-13 provides directive on procedures to be completed by Rail Operations personnel in the yard once Rail Maintenance personnel have placed a car on " hold" and secured it according to the aforementioned Rail Maintenance Bulletin (RMGB 1-13). These procedures will not only further ensure that the brake systems are left in a condition that would not facilitate unintended movement, but also require the use of wheel chocks as specifically stated in NTSB recommendation (R-13-035). This bulletin directs Rail Operations personnel in the yard to take the following actions (also see attached bulletin): • Rail hold cars will be stored on designated yard tracks that will not be used for any other purpose. • Prior to moving a hold car switchman must; o Ensure parking brakes (calipers) are cut-in (in the applied position) before coupling with a horse o Remove the wheel chocks immediately prior to coupling the hold car with a horse o Ensure the parking brakes are in the cut-out position (in the unapplied position) after coupling with a horse • Once the hold cars are stored, switchmen will use two wheel chocks that will be placed on the non-third rail side of the #1 truck and the #1 and #2 axles on the odd numbered rail car. Status Updates: • The CTA has identified thirty-nine (39} designated "hold tracks" across its ten (10} operating yards. • Permanent derailers will be installed on each hold track as well as on the lead to the yard at the heavy maintenance facility (Skokie Shop). A product (see Photo A below) and vendor have been selected and approved by the Safety, Rail Operations and Track Maintenance departments. The CTA is currently in the process of procuring the derailers and installation will begin upon receipt. • All CTA rail cars are currently outfitted with a set of wheel chocks in the car toolbox. The procedure outlined above is being implemented with the wheel chocks from each car's tool box. In order to streamline this process, wheel chocks that will be designated for use with hold cars in the yard (see Photos Band C below) have been selected and approved by Safety, Rail Operations and Rail Maintenance departments. The CTA is currently in the process of procuring 800 additional wheel chocks. • In addition to the placement of wheel chocks, the CTA will require the placement of a blue flag with a yellow "C" on the end doors of each hold car (see Photos D and E). The blue flag will be an additional indicator to yard personnel that the train wheels have been 'chocked'. This procedure will be included in the 2014 revised Rail Rule Book. Additional Bulletins: The CTA has created two (2} additional bulletins in response to the investigation findings: 1} Rail Maintenance Bulletin 2-13 (RMGB 2-13} which eliminates the washing of cars while they are on hold for maintenance. This bulletin is intended to reduce the risk of additional failures by limiting the movement of hold cars. 2} A new Rail Maintenance Bulletin is in development which will prohibit power washing of electronic components (or components within their direct proximity) without prior approval from a rail maintenance foreman or supervisor. This bulletin is intended to eliminate the risk of maintenance personnel compromising the integrity of electronic components. Yard Audits: The CTA began preliminary audits of rail yards on October 16, 2013 to ensure that hold car procedures were being consistently implemented. Following the distribution of RMGB 1-13 (referenced above), a full audit procedure was launched in November 2013 to ensure that all rail operations and maintenance personnel are consistently applying the procedures laid out in the bulletin. The Safety Department performs weekly audits of all rail yards and the Rail Maintenance Quality Assurance Department performs the same audit bi-monthly. The Safety Department assumes final responsibility for the tracking and reporting of all audit findings. Comprehensive Standard Operating Procedure tor Hold Car Storage in Rail Yards: A final Standard Operating Procedure (Hold Car Storage in Rail Yards) is still in process. The SOP incorporates the procedures outlined in the three bulletins submitted to the NTSB on November 1, 2013 (R1226-13, R1235-13 and R1178-13} and will supersede these bulletins upon its final release. Status Updates: • The final SOP will make adjustments to the procedures outlined in Rail Maintenance General Bulletin RMGB 1-13 for 5000 series rail cars only. Due to the engineering of the battery system, the 5000 series cars will require the battery switch to be cut out with the main motor knife switch to avoid draining the car battery. • The final SOP will be included in both new hire and refresher training for all Rail Operations personnel.

From: Chicago Transit Authority
To: NTSB
Date: 11/1/2013
Response: -From David Kowalski, Chief Transit Operations Officer: CTA appreciates the recommendations made, and has worked diligently since their issuance to implement procedures which address the underlying concerns. Immediate steps were taken while the NTSB investigation team was still on site and concurrent with the release of the recommendations. To date, CTA has released three Rail Operations Service Bulletins and one Rail Maintenance General Bulletin and is in the process of drafting one comprehensive Standard Operating Procedure (SOP) that encompasses the directives provided in the bulletins. The bulletins were an expedient means of responding to the recommendations made by the NTSB so as to safeguard against future occurrences of a similar nature. As CTA develops and finalizes the comprehensive SOP, we continue to analyze and assess the solutions identified in the issued bulletins to ensure there are no new significant hazards being created by the new processes, and that we are utilizing industry best practices. The following bulletins are CTA's immediate response to the NTSB recommendations. CTA R1235-13 Rail Operations Service Bulletin R1235-13 states that 11AII unmanned consists must be shut down and the motor cabs secured ." (See attached bulletin) The intention of this bulletin is to ensure that unoccupied CTA trains are not powered-up while stored or on hold for service. CTA RMGB 1-13A Rail Maintenance General Bulletin RMGB 1-13A delineates the procedure for "hold car" storage to ensure that the propulsion and brake systems are left in a condition that would not facilitate unintended movement. (See attached bulletin) The bulletin directs Rail Maintenance staff to take the following action when a car is identified by Rail Maintenance as having an electrical or mechanical defect and is to be stored outside the shop for any length of time and for any reason: • Affix hold tags to the corner grab irons of the #1 ends of each car of the unit • Retract the electric coupler buttons on each rail car of the defective unit • Cut out main motor knife switch on each rail car of the defective unit • Ensure all parking brakes (calipers) are cut-in (in the applied position) CTA R1178-13 Rail Operations Service Bulletin R1178-13 provides directive on procedures to be completed by Rail Operations personnel in the yard once Rail Maintenance personnel have placed a car on "hold" and secured it according to the aforementioned Rail Maintenance Bulletin (RMGB 1-13A). These procedures will not only further ensure that the brake systems are left in a condition that would not facilitate unintended movement, but also require the use of wheel chocks as specifically stated in NTSB recommendation (R-13-035). This bulletin directs Rail Operations personnel in the yard to take the following actions (also see attached bulletin): • Rail hold cars will be stored on designated yard tracks that will not be used for any other purpose. • Prior to moving a hold car switchmen must; o Ensure parking brakes (calipers) are cut-in (in the applied position) before coupling with a horse o Remove the wheel chocks immediately prior to coupling the hold car with a horse o Ensure the parking brakes are in the cut-out position (in the unapplied position) after coupling with a horse • Once the hold cars are stored, switchmen will use two wheel chocks that will be placed on the non-third rail side of the #1 truck and the #1 and #2 axles on the odd numbered rail car. CTA R1226-13 Rail Operations Service Bulletin R1226-13 addresses the proper operating cab configuration for trains at all times. Proper cab configuration, as prescribed below, will also safeguard against unintended movements. The bulletin calls for the following (also see attached bulletin) : • Operators must keep the cab door closed and locked at all times while operat ing. • When leaving the operating cab to perform duties (non-shut down), operators must place the Master Controller in the "B2" position and must place the Control Positive toggle in the "off' position and then fully secure the operating cab door. • Employees must dress all other cabs in the train to permit passage between cars. • Employees must dress the rear cab of t he train to permit access to the end door. In order to ensure compliance with all of the issued bulletins, CTA is conducting regular audits of each rail yard and is tracking the compliance rate in its overall performance metrics process. Any noncompliance identified during the course of an on-site audit is immediately addressed. Additionally, CTA is in the process of procuring de-railers for the yards where "on hold" cars are stored to further guard against unintended movements. When CTA finalizes and issues the comprehensive Standard Operating Procedure, which will encompass the various bulletins, a copy will be sent to NTSB for your records. Please advise if any additional information is necessary at this time to complete the required response to the October 4, 2013 NTSB recommendations.