NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

RAILROAD ACCIDENT REPORT

 PB2002-916301

NTSB/RAR-02/01

COLLISION OF NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK)

TRAIN 59 WITH A LOADED TRUCK-SEMITRAILER COMBINATION AT A

HIGHWAY/RAIL GRADE CROSSING IN

BOURBONNAIS, ILLINOIS, MARCH 15, 1999

7168A
THIS CORRECTION IS INCLUDED

IN THIS VERSION OF THE PUBLISHED REPORT:

RAILROAD ACCIDENT REPORT 

NTSB/RAR-02/01 (PB2002-916301)

COLLISION OF NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK) TRAIN 59 

WITH A LOADED TRUCK-SEMITRAILER COMBINATION AT A HIGHWAY/RAIL GRADE 

CROSSING IN BOURBONNAIS, ILLINOIS, MARCH 15, 1999

• Page 29 has been updated to include coach car #34089. (11 Sep 2002) 

Coach car #34089 was excluded from the original printed version. Car numbers were also added for the 

sleeping car (32035) and diner car (38020). 

 
Railroad Accident Report

Collision of National Railroad Passenger Corporation (Amtrak) 

Train 59 With a Loaded Truck-Semitrailer Combination at a 

Highway/Rail Grade Crossing in

Bourbonnais, Illinois, March 15, 1999

NTSB/RAR-02/01

PB2002-916301 National Transportation Safety Board

Notation 7168A 490 LíEnfant Plaza, S.W.

Adopted February 5, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2002. Collision of National Railroad Passenger Corporation

(Amtrak) Train 59 With a Loaded Truck-Semitrailer Combination at a Highway/Rail Grade Crossing in

Bourbonnais, Illinois, March 15, 1999. Railroad Accident Report NTSB/RAR-02/01. Washington,

DC.

Abstract: About 9:47 p.m. on March 15, 1999, National Railroad Passenger Corporation (Amtrak) train

59, with 207 passengers and 21 Amtrak or other railroad employees on board and operating on Illinois

Central Railroad (IC) main line tracks, struck and destroyed the loaded trailer of a tractor-semitrailer

combination that was traversing the McKnight Road grade crossing in Bourbonnais, Illinois. Both

locomotives and 11 of the 14 cars in the Amtrak consist derailed. The derailed Amtrak cars struck 2 of 10

freight cars that were standing on an adjacent siding. The accident resulted in 11 deaths and 122 people

being transported to local hospitals. Total Amtrak equipment damages were estimated at $14 million, and

damages to track and associated structures were estimated to be about $295,000.

The safety issues discussed in this report are as follows: truckdriver performance, emergency response, and

signal system performance.

As a result of this investigation, the Safety Board makes safety recommendations to the U.S. Department

of Transportation, the Federal Railroad Administration, all class I and regional railroads, Amtrak, the

International Association of Fire Fighters, and the International Association of Fire Chiefs.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2002-916301 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Railroad Accident Report

Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Truckdriver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Train Operator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Motor Carrier Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Truck Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Track and Signal Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Track Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Roadway and Grade Crossing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Truckdriver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Amtrak Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Postaccident Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Site Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Examination of Gate Arm Mechanism Components . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Sight Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Tractor and Semitrailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Train Air Brakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Grade Crossing Warning System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Grade Crossing Signal Malfunction History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Laboratory Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Fire Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Locomotive Event Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Accident Reconstruction and Computer Simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Current Status of McKnight Road Crossing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Truckdriver Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Truck Speed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Warning Signal System Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Crossing Gate Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Contents iv Railroad Accident Report

Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Motor Carrier Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Flammability of Interior Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Train Evacuation Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Roadway Geometry/Highway Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Reducing Traffic Violations at Grade Crossings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Recommendations Reclassified in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Appendixes

A: Investigation and Hearings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
v Railroad Accident Report

Executive Summary

About 9:47 p.m. on March 15, 1999, National Railroad Passenger Corporation

(Amtrak) train 59, with 207 passengers and 21 Amtrak or other railroad employees on

board and operating on Illinois Central Railroad (IC) main line tracks, struck and

destroyed the loaded trailer of a tractor-semitrailer combination that was traversing the

McKnight Road grade crossing in Bourbonnais, Illinois. Both locomotives and 11 of the

14 cars in the Amtrak consist derailed. The derailed Amtrak cars struck 2 of 10 freight cars

that were standing on an adjacent siding. The accident resulted in 11 deaths and 122

people being transported to local hospitals. Total Amtrak equipment damages were

estimated at $14 million, and damages to track and associated structures were estimated to

be about $295,000.

The National Transportation Safety Board determines that the probable cause of

the collision between Amtrak train 59 and a truck tractor-semitrailer combination vehicle

at the McKnight Road grade crossing in Bourbonnais, Illinois, was the truckdriverís

inappropriate response to the grade crossing warning devices and his judgment, likely

impaired by fatigue, that he could cross the tracks before the arrival of the train.

Contributing to the accident was Melco Tranfer, Inc.ís failure to provide driver oversight

sufficient to detect or prevent driver fatigue as a result of excessive driving or on-duty

periods.

The safety issues identified during this investigation are as follows: 

ï Truckdriver performance;

ï Emergency response; and

ï Signal system performance.

As a result of this investigation, the Safety Board makes safety recommendations

to the U.S. Department of Transportation, the Federal Railroad Administration, all class I

and regional railroads, Amtrak, the International Association of Fire Fighters, and the

International Association of Fire Chiefs. 

1 Railroad Accident Report

Factual Information

Synopsis

About 9:47 p.m. on March 15, 1999, National Railroad Passenger Corporation

(Amtrak) train 59, with 207 passengers and 21 Amtrak or other railroad employees on

board and operating on Illinois Central Railroad (IC) main line tracks, struck and

destroyed the loaded trailer of a tractor-semitrailer combination that was traversing the

McKnight Road grade crossing in Bourbonnais, Illinois. (See figure 1.) Both locomotives

and 11 of the 14 cars in the Amtrak consist derailed. The derailed Amtrak cars struck 2 of

10 freight cars that were standing on an adjacent siding. The accident resulted in 11 deaths

and 122 people being transported to local hospitals. Total Amtrak equipment damages

were estimated at $14 million, and damages to track and associated structures were

estimated to be about $295,000.

Figure 1. Accident Location.

ILLINOIS

ILLINOIS

Bourbonnais

Lake Michigan

Chicago

Bourbonnais

Chicago

INDIANA
Factual Information 2 Railroad Accident Report

Accident Narrative

Shortly after 8:30 p.m. on March 15, 1999, the driver of the truck involved in this

accident picked up his truck tractor semitrailer at Melco Transfer, Inc., (Melco) in

Peotone, Illinois. The driver was operating the vehicle under a 60-day probationary

license that had been issued in January 1999 after his commercial driverís license (CDL)

was suspended for 90 days because of three traffic citations within a 1-year period.1 He

drove the truck to the Birmingham Steel plant in Bourbonnais, Illinois. At the plant, the

semitrailer was loaded with 6 bundles of 60-foot-long, 3/4-inch-diameter steel reinforcing

rods (rebar). When the loading of the flatbed semitrailer was completed, the driver secured

the load and drove the truck over weigh scales. The vehicle gross weight was registered at

74,880 pounds. The truck left the plant compound, turned right onto McKnight Road, and

traveled eastward about 650 feet to the highway/railroad grade crossing. The grade

crossing was equipped with train-activated flashing lights, bells, and automatic gate arms.

Amtrak train 59, the City of New Orleans, originated in Chicago, Illinois, and was

bound for New Orleans, Louisiana. The crew reported for duty at 7:15 p.m. Before the

train departed, the engineer performed an air brake test. No exceptions were taken. The

engineer also stated that he checked the headlight and ditch lights and that they were

working properly. The train departed Chicago at 8:03 p.m. The engineer stated that during

the trip, the ditch lights oscillated properly at the crossings when he activated the train

horn. He also said that the train brakes responded properly each time they were used. At

the trainís first scheduled stop, in Homewood, Illinois, no passengers left the train, while

an unknown number of passengers boarded. The train departed Homewood at 9:27 p.m.

The accident truckdriver stated that the crossing lights started flashing when he

was ìright on top of the track.î He said he did not notice the position of the crossing gates.

The crossing lights had activated on the approach of Amtrak train 59. The truckdriver said

he was concerned about braking hard because decelerating too quickly could cause the

load on the semitrailer to shift forward and strike the tractor cab. He said he believed that

if he attempted to brake moderately to avoid a load shift, he might bring the truck to a halt

on the crossing and in the path of the oncoming train. He said he was thus momentarily

undecided about whether he should attempt to stop or continue across the crossing, but in

the end he ìjust floored it.î He stated that as he traversed the crossing, he looked right and

left and saw that the light of the train ìwasnít too far down the tracks then.î The

truckdriver said he believed his vehicle was in sixth gear and traveling about 20 mph at the

time of the collision.

Meanwhile, an individual who stated that he was in the Bourbonnais area looking

for a used car had mistaken the Birmingham Steel Company parking lot for a used car

dealership. Realizing his mistake, he turned around in the parking lot and attempted to

reenter McKnight Road. He said that after waiting for a truck and a passenger car to pass,

he turned right onto McKnight Road. He said that the car in front of his was stopped

because the lights had begun to flash, and he stopped behind it. He stated that at that time,

1 See the ìPersonnel Informationî section of this report for more information.
Factual Information 3 Railroad Accident Report

the truck ìwas approaching the railî and that ìwhen theÖ [gates] were coming down, the

trailer was already almost on top of the track and, yes, contact was made with one crossing

gate.î He said the gate struck the right side of the trailer about a third of the way back and

that he saw a piece of the gate break off. The witness also stated that the truck moved from

the right-hand lane toward the middle of the roadway. He estimated that the truck was

traveling about 7 mph at the time.

The train 59 engineer, who was the only person in the locomotive cab at the time,

stated that he saw the truck slowly moving over the crossing, and he sounded the train

horn to warn the truckdriver. He said that when he realized that the truck would not clear

the crossing before the train arrived, he initiated emergency braking.2 Traveling at 79 mph,

the train did not have sufficient distance to stop and struck the left rear of the semitrailer.

(See figure 2.) The time was about 9:47 p.m.

The conductor stated that he was walking through the coach behind the diner when

he heard the trainís brakes apply and felt a bump. He believed that the train accelerated,

and then the car rolled over on its side. The conductor stated that at this point he helped a

passenger remove a window and climbed outside; once outside, he communicated by

radio with the assistant conductor and the locomotive engineer. When the engineer said

2 According to the locomotive event recorder, the engineer applied the train brakes, but he did not

activate emergency braking. 

Figure 2. Aerial view of crash scene.
Factual Information 4 Railroad Accident Report

that he was trapped in the locomotive, the assistant conductor said he would go help the

engineer. The conductor remained at the coach and helped passengers evacuate.

At the time of the accident, a crane operator on duty at Simms Metal America,

which is west of and adjacent to the Birmingham Steel plant, had a view of the accident

crossing and the approach. According to a postaccident IC survey, the crane was between

1,600 and 1,800 feet from the crossing, depending on its position along its track. The

crane operator said he was swinging the crane to the northeast when he noticed the grade

crossing lights begin to flash. He looked to the north and, over the tops of rail cars that

were parked on a siding parallel to the main line, he could see the headlight of a moving

southbound train. By his estimate, he could see the train about 1/2 mile from the crossing.

He then made a lift of scrap material and deposited it in a bucket for use by the steel mill.

He stated that it takes between 15 to 20 seconds to pick up material, put it in the bucket,

and turn around.3 He said that when he looked back toward the crossing, he saw the impact

of the train and the truck. He did not remember seeing the crossing gates, nor did he

remember seeing any vehicles at the crossing before the crash.

A truckdriver who was in the steel plant parking lot stated that he first saw the

accident-involved truck through his rearview mirror as it was rolling across the

Birmingham Steel plantís scale on its way out of the parking lot. The accident truck

proceeded directly to the westernmost parking lot exit and turned right onto McKnight

Road. As the accident truck came parallel to the parked truckís position and entered the

roadway, the witness was putting a tarpaulin on his load in the parking lot. The witness

watched the progress of the accident truck because he was interested in the fact that it

carried an oversized load of steel. He stated that he heard the accident truckís jake brake as

it rolled by him on the roadway.4 He also said he saw the truckís brake lights illuminate for

a few seconds, after which the truck proceeded across the tracks with its left tires slightly

beyond the centerline of the roadway. This witness stated that he did not notice flashing

lights as the truck proceeded into the intersection, and that the gates were up. He indicated

that the only time he saw the lights illuminated was after the accident. He also did not

notice any other vehicles on McKnight Road before the accident.

A security guard employed in the scale house of the steel plant knew the accident

truckdriver, and spoke briefly with him shortly before the accident. He indicated that the

truckdriverís behavior and conversation seemed normal, that there was no sign of

drowsiness or other impairment. The security guard looked toward the crossing when he

heard the train horn, but his view was blocked by trucks in the steel plant parking lot. He

stated that he saw the crossing lights begin to flash, and that roughly 5 seconds later the

train arrived at the crossing.

3 Safety Board tests verified the accuracy of this estimate.

4 A jake brake is a compression release braking system, supplemental to the main air brakes, that uses

the engine to provide braking power for the vehicle. When the jake brake is turned on and the driver

removes his foot from the accelerator pedal, the jake brake immediately activates. In some vehicles, the

activation of the jake brake will cause the activation of the brake lights.
Factual Information 5 Railroad Accident Report

The security guardís wife was visiting the scale house at this time. She stated that

she noticed the crossing lights were flashing, and she could see the taillights of the truck.

At that time, she believed the truck cab was past the crossing, but she was unable to

determine the position of the taillights. (See figure 3 for positions of all witnesses at the

time of the collision.)

A motorist driving south on Illinois Route 50 adjacent and parallel to the IC tracks

about the time of the accident said that as he drove down the highway, he noticed a

southbound Amtrak passenger train to his right. He said as he approached the intersection

of Route 50 and McKnight Road, he looked west and saw an Amtrak passenger car

stopped and blocking the crossing. He said he drove to the crossing, where he observed

that an accident had taken place. He said he saw and approached a person walking near the

accident truck. When this person identified himself as the truckdriver, the motorist asked

him if he was injured, and the truckdriver replied that he was not, except for a cut on his

hand. The motorist said that he asked the truckdriver if he had been stuck on the tracks,

and the truckdriver said that he had not been stuck, that he had seen the signal lights and

thought that he could get across the tracks. He quoted the truckdriver as saying, ìI didnít

think the train was moving that fast.î

Figure 3. Aerial view of crash scene showing locations of witnesses to accident: 1. 

crane operator; 2. two people in scale house, 3. truckdriver affixing tarp to his load; and 

4. motorist behind accident truck.
Factual Information 6 Railroad Accident Report

Emergency Response

At 9:48 p.m., the Kankakee County Sheriffís Police 911 communications desk

received the initial request for emergency assistance via telephone from the Birmingham

Steel security office.5

 Shortly thereafter, a second call came from the Birmingham Steel

Company; this was followed by a number of additional calls from various sources. While

the initial call was in progress, the 911 communications dispatch center dispatched units

of the Bourbonnais Fire Protection District to the accident scene and requested an

ambulance response.

About 9:51 p.m., an officer of the Bourbonnais Police Department, who had

overheard the initial radio notification while on routine patrol, arrived at the accident

scene via the unpaved roadway to the west of the tracks. At about the same time, a Bradley

Police Department officer arrived on the east side of the tracks. The Bourbonnais police

officer reported that a locomotive was on fire and that a number of Amtrak passenger cars

had derailed. He observed that the fire was growing, and that it was working its way

toward the rear of the locomotive, where a sleeper car (No. 32035) had come to rest. He

radioed for additional emergency response support, and he and the Bradley police officer

began helping to evacuate the passenger cars. Within a short time, more police units

responded, and officers began evacuating passengers wherever they could.

According to the Kankakee County Sheriffís Department, the Kankakee County

disaster plan was put into effect about the time the first responding police unit arrived on

the scene. The Bourbonnais Police Department established an initial staging area on the

unpaved roadway on the west side of the tracks, in the area adjacent to the wreckage

pileup. The evacuated passengers and traincrew assembled in this area, where responding

ambulances later arrived.

The chief of the Bourbonnais Fire Protection District received the call to dispatch

while on scene at a previous response call. While en route to the accident scene, he

overheard radio transmissions from responders already at the scene. As incident

commander, he radioed a ìbox alarmî to summon emergency equipment and personnel.

He arrived at the accident scene at about 9:52 p.m. Upon arrival, he conducted an initial

assessment of the situation and identified the locomotive fire and the necessity for

passenger evacuation. About 10:05 p.m., he placed a radio call for additional mutual aid

emergency response support. The chief then established a fire department field command

post at the initial staging area.6

In interviews with the Safety Board, emergency responders indicated that the

immediate focus of the response was the extrication of the trapped and injured passengers

and traincrew. Relatively early during the response, emergency responders telephoned

Amtrakís National Operations Center in Wilmington, Delaware, to learn how many

5 Information on emergency response is based on official transcripts from Kankakee County Sheriff

Radio and Fire Band transmissions, interviews by Safety Board investigators, and documentation submitted.

6 Although there is no record of a radio transmission to this effect, incident command participants

reported to the Safety Board that the establishment of the command post was understood.
Factual Information 7 Railroad Accident Report

passengers rescuers could expect to find. At this time, Amtrak responded that the train

could be carrying as many as 400 passengers. When Amtrak management arrived on scene

however, they determined from the contents of the conductorís ticket pouch that the

passenger count was 196; this passenger tally was not considered firm on the following

morning. Several days after the accident, Amtrak and local authorities determined that the

passenger count was 198. Another several days passed before Amtrak could produce a

complete list of passenger names. Subsequent research has shown the correct passenger

count to be 207.

About 9:53 p.m., the first ambulances arrived at the scene. About 9:59 p.m.,

Bourbonnais Fire Protection District Squad 62 arrived at the scene. The squad 62 truck

had a water capacity of 500 gallons dispersed through 1 3/4-inch hose lines. The truck was

also equipped with 5-gallon fire suppression foam containers.7 Firefighters then began

hand-line water and foam application on the burning locomotive, but they were unable to

put out the fire before exhausting their water supply.

About 10:00 p.m., Bourbonnais Fire Protection District Engine 61, a pumper truck

carrying about 2,000 feet of 5-inch hose line, arrived at a water hydrant about 2,600 feet

from the site of the fire. Firefighters laid out the full length of the hose on their truck, then

went to the accident scene. A second pumper truck connected the additional hose line

needed to reach the fire scene.

When the first Bourbonnais Fire Protection District personnel arrived at the

accident scene, they saw that some 30 to 35 employees of Birmingham Steel had

responded to the scene and had begun the rescue effort. These steel plant employees had

cut a hole in the chain-link fence separating the wreckage site from the steel plantís

property and had brought a number of hand-held fire extinguishers and ladders from the

plant to combat the flames. While some of the steel plant employees applied the fire

extinguishers to the flames, others entered some of the damaged passenger cars to

extricate entrapped passengers. These efforts were continued for about 45 minutes, when

the steel plant employees were relieved by Bourbonnais Fire Protection District personnel,

who continued the extrication efforts.

Because the derailed train cars blocked McKnight Road at the grade crossing,

three separate staging areas were established. The first, as noted above, was on the

unpaved road to the west of the tracks, near the wreckage pileup. About 10:13 p.m., a

second fire department field command post was established at the southeast corner of the

intersection of McKnight Road and Route 50 at a vacant lumber yard. This was referred to

as the ìeast staging area.î A police department field command post was established

shortly thereafter at the northeast corner of the same intersection.

About 10:22 p.m., incident command issued a radio request to responding agencies

seeking fire suppression foam. Several units responded, but each carried a small number

of 5-gallon containers of foam and eductor systems designed to mix the foam with water

for application to a fire.

7 Refers to 5-gallon containers of aqueous film-forming foam or similar foam concentrate.
Factual Information 8 Railroad Accident Report

About 10:24 p.m., the 5-inch hose supply line that was laid along the unpaved road

was fully charged and supplying water at the west side of the site. Fire suppression on the

burning locomotive recommenced shortly thereafter.

Upon evacuation, displaced passengers and traincrew were taken to one of two

triage areas initially established at the scene. Because the temperature that night was

estimated to be in the low 20s, however, the incident commander became concerned about

the threat of hypothermia, since most of the evacuees lacked warm clothing. A local retail

store offered its facility as a temporary shelter, and starting about 10:28 p.m., responders

used this facility both as a shelter and as a triage site for several persons who were later

found to have sustained injuries.

About 10:30 p.m., incident command requested that a medical trauma team

consisting of physicians and medical equipment from local hospitals respond to the scene.

About this time, police officers were extricating passengers through the emergency exit

windows of an overturned coach car (No. 34089) that lay on the eastern side of the pileup.

A Manteno Fire Department pumper truck depleted its water tank by supplying a stream

of water to the top of this car in an effort to cool it. About 10:34 p.m., Manteno firefighters

made a radio request to incident command that water be applied to the ìtop of the trainî

because they were out of water. Incident command, on the western side of the pileup,

mistakenly understood the request to originate from personnel inside sleeper car 32035

(the car that was wrapped around the locomotive), and the Bourbonnais Fire Protection

District chief responded with a master stream water application8

 onto the west end of that

car. Continuing attempts were made to set up a hydrant flow to resupply the Manteno fire

trucks on the east side of the scene.

About 10:38 p.m., the Braidwood Fire Department heavy rescue truck arrived at

the east side staging area. It was directed to proceed to the west side staging area.

About 10:39 p.m., the trauma team arrived, and they were directed by incident

command to the west side staging area.

A responding Braidwood Fire Department officer, who was also the emergency

response administrator of a petrochemical operation in Elwood, Illinois, said that shortly

after he arrived on scene about 10:40 p.m., he recognized that the fire suppression foam at

the scene was almost exhausted. He said he also realized that the fire suppression effort

had not been effective in extinguishing the locomotive fire. The fire, as he observed it, was

ì3-dimensionalî and petroleum-based, and it remained entrenched within the upper

confines of the locomotive carbody wreckage, which made suppression access particularly

difficult. He stated that he believed the strategy being used up to that point was having

only limited success, because the fire would be extinguished in one location, only to reignite in an adjacent location and flash back to the original location. Further, the fire was

directly impinging upon and passing beneath the still-occupied sleeper car 32035.

8 A master stream is an application of a large volume of water (about 350 to 1,000 gallons per minute),

typically using a vehicle-mounted ìdeck gun monitorî nozzle.
Factual Information 9 Railroad Accident Report

From this, the Braidwood officer concluded that the application of a large volume

of fire suppression foam might be an effective attack strategy and that, therefore, a heavy

foam tanker truck from the nearest available facility should be used. The Braidwood

officer discussed with the incident commander the possibility of organizing a mutual aid

heavy foam tanker truck response to the scene.

The incident commander concurred with this proposed strategy, and the

Braidwood officer immediately placed a cellular telephone call asking that a heavy foam

tanker truck and personnel from the Stepan Chemical Company near Joliet, Illinois, be

dispatched to the accident site. The officer arranged for a similar request to be made to a

Mobil Oil refinery. Both facilities are about 35 miles away from the accident scene, and

the officer anticipated that the trucks might require about 45 minutes to arrive.

About 10:44 p.m., a radio transmission went out requesting that the Chicago

combined agency response team (CART) immediately respond to the east side of the

pileup because, according to the transcript, two people were trapped inside a rail car and

fire was impinging. The CART is a tactical rescue squad composed of fire and rescue

departments across the suburban Chicago area.

About 10:47 p.m., the Braidwood Fire Department heavy rescue truck arrived at

the west side staging area. It was then used as a fire suppression field command post.

About 10:55 p.m., incident command issued a request to all responding agencies

for all available water tanker truck support.

About 11:19 p.m., incident command radioed that the main body of the fire on the

east side of the scene appeared to have been ìknocked down,î which suggested that the

fire was somewhat in control, although not extinguished, in that area.

About 11:30 p.m., a heavy foam tanker truck from Stepan Chemical Company

arrived and was directed to the west side staging area. About 11:45 p.m., the foam tanker

truck reached the west side staging area and set up near the wreckage pileup. The

Braidwood Fire Department officer who organized the Stepan response directed that water

supply connections be made to one of the pumper trucks stationed at that location and that

fire suppression by hand-line commence immediately. Fire suppression water/foam

solution was applied to the main body of the fire in the proximity of the locomotive and

the sleeper car until the fire was extinguished; the fire was out within a few minutes.

Water/foam solution application continued periodically thereafter, because firefighters

were concerned that hot metal in the wreckage might re-ignite the fire.

About 12:05 a.m. on March 16, an emergency shelter established at a nearby

school building began to receive the uninjured displaced passengers who were transferred

from the temporary shelter established earlier at the retail store. This shelter, staffed by the

American Red Cross and by the Bourbonnais Police Department, remained open until

2:30 a.m.
Factual Information 10 Railroad Accident Report

Several minor rekindle events occurred in the wreckage at times throughout the

night; the fires were quickly extinguished by firefighting crews that remained on the

scene. The fire was completely extinguished by dawn on March 16.

About 6:30 a.m. on March 16, a temporary morgue was established at the vacant

lumber yard located at the intersection of McKnight Road and Route 50.

About 11:00 p.m. on March 19, the Bourbonnais Fire Protection District incident

command post that had opened at the onset of the event was closed.

Injuries

Train 59 carried 207 passengers, 17 on-duty Amtrak crewmembers, and 4 off-duty

Amtrak and IC railroad employees. According to hospital records, 121 of these passengers

and railroad employees, as a result of this accident, were transported to local hospitals for

medical treatment. Thirty-five of the transported patients were examined and released

without receiving documented medical treatment. One train crewmember was airlifted

from Provena St. Maryís Hospital to the Loyola University Medical Center in Chicago. In

addition, the driver of the truck involved in the accident, a responding firefighter, and a

responding sheriffís deputy reportedly sustained minor injuries; they were treated and

released at a local hospital. Eleven train passengers, all of whom were located in sleeper

car 32035, sustained fatal injuries. (See table 1.)

The Safety Board was unable to definitively establish how many individuals were

in the sleeping car at the time of the collision, nor could it determine the precise

whereabouts of those who were in the car. The degree of injury sustained by the carís

Table 1. Injuries

Type

Amtrak 

Crewmembersa

Amtrak 

Passengers Other Total

Fatal 0 11 0 11

Serious 5 29 0 34

Minor 4 51 0 55

None 12 116 0 128

Total 21 207 0 228

49 CFR 830.2 defines fatal injury as ìany injury which results in death within 30 days of the accidentî and serious injury

as ìan injury which: (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the 

injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes 

severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree 

burns, or any burn affecting more than 5 percent of the body surface.î

a

Included in these totals are two off-duty Amtrak employees and two off-duty IC Railroad employees.
Factual Information 11 Railroad Accident Report

occupants ranged from minimal or none, up to fatal. The fatally injured occupants were in

the portions of the car at the vertex of the carís bend, where the crush and intrusion were at

a maximum. This portion of the car was also later consumed by fire. Rescuers reported

that they were unable to immediately extricate some of the individuals they believed to be

entrapped within the wreckage; the Kankakee County coroner tentatively attributed

injuries of 5 of the 11 fatally injured occupants to the effects of the fire. The coroner was

unable to determine whether any of these 5 might have succumbed to their traumatic

injuries had they not been exposed to the fire.

The Safety Board disseminated a questionnaire to the accident survivors, but

relatively few forms were returned; for this reason, it is not possible to determine which

car any individual was occupying at the time of the accident. Five cars on the train were

deadheading (not in service). These cars, in addition to the second locomotive and the

baggage car, were reportedly unoccupied at the time of the collision.9 The occupants of the

other passenger cars in the consist sustained injury severities ranging from no injury to

critical injuries.

Personnel Information

Truckdriver

The accident-involved truckdriver, aged 58, had been driving commercial vehicles

since about 1960. He had been traversing this crossing 5 days per week for about 7 years

at the time of the accident. The truckdriver had worked for Melco Transfer, Inc., as an

owner-operator since 1990.

According to the accident truckdriverís motor vehicle record as certified by the

Illinois Secretary of State, the accident driver was cited and had convictions entered for

the following speeding violations before the accident: 

9 Because of the order of the cars in the consist, passengers in car 13, in order to reach the lounge car or

the dining car, would have had to pass through two of the deadheading cars.

Date Reason State License cited

February 9, 1992 70/60 mph zone Illinois CDL

June 12, 1996 70/60 mph zone Illinois CDL

August 20, 1997 70/60 mph zone Indiana CDL

June 18, 1998 75/60 mph zone Indiana CDL

February 9, 1998 1-10 mph over Indiana CDL
Factual Information 12 Railroad Accident Report

The accident driverís CDL was suspended for failure to pay the fine associated

with the June 18, 1998, speeding citation, but it was reinstated on September 29, 1998.

Illinois has a uniform citation form that indicates whether a violator holds a CDL and

whether the violator was operating a commercial vehicle. This information is entered in

the driverís motor vehicle record. Illinois also enters violation information from other

States. Because of this information interchange, the State of Illinois noted that the

truckdriver had received three citations within 1 year in Indiana. On this basis, in the fall

of 1998, the State of Illinois informed the truckdriver that his CDL would be suspended

after 90 days, effective January 25, 1999. When the truckdriver was notified that his CDL

was subject to suspension, he enrolled in the National Safety Councilís driver

improvement program. Following the truckdriverís successful completion of this course in

January 1999, the State of Illinois issued the accident driver a probationary license for a

period of 60 days beginning on January 25, 1999, and ending on March 25, 1999.10

In May 1999, following the accident, the truckdriverís license was again

suspended for 60 days, because he was convicted of two serious traffic violations during a

3-year period (two of the four speeding violations). The driverís CDL was reinstated on

August 1, 1999. In November 1999, the same truckdriver was cited for a moving violation

and received court supervision. He was not convicted, and his license was not suspended.

The citations instigating the initial license suspension were related to speeding,

and not to grade crossings. However, in 1999, the U.S. DOTís Federal Highway

Administration added a regulation creating a new category of offenses for which a CDL

holder may be disqualified from operating a commercial motor vehicle. The rule

specifically covers convictions for six types of offenses, including failure to obey traffic

control devices at grade crossings. Under the rule, conviction for one of six specific

violations at a grade crossing results in an automatic CDL suspension of not less than 60

days. Upon the second conviction within a 3-year period (for a separate incident), the

driver must be disqualified for 120 days. Following a third and subsequent violation

within a 3-year period, a driver must be disqualified for not less than 1 year. The accident

truckdriver was not charged with a grade crossing violation as a result of this accident.

Following the accident, however, the Federal Office of Motor Carrier Safety11 conducted a

compliance review of Melco Transfer, Inc., that resulted in fines for both the motor carrier

and for the accident truckdriver. The Federal Motor Carrier Safety Administration has

elected not to pursue the case further, but instead has turned the case over to the DOTís

Office of the Inspector General, who is conducting a criminal investigation into

circumstances surrounding this accident. In October 2001, the accident-involved

truckdriver was indicted by a Kankakee County grand jury on two counts. One count of

the indictment alleges that he falsified his logbook. The second alleges that he violated the

hours of service regulations. Both are felony charges.

10 Under the Motor Carrier Safety Improvement Act of 1999, effective January 23, 2000, States are now

prohibited from awarding a probationary license to a CDL holder while he or she has been disqualified from

operating a commercial motor vehicle.

11 On January 1, 2000, the Office of Motor Carrier Safety was redesignated the Federal Motor Carrier

Safety Administration.
Factual Information 13 Railroad Accident Report

The truckdriver possessed a valid medical examinerís certificate at the time of the

accident. The certificate indicated that the driver was qualified for his duties only when

wearing corrective lenses. The driver stated that he wears glasses for reading and while

driving, although his driverís license has no vision restrictions. He stated that he wears the

glasses when he drives because they are light-sensitive lenses. He was wearing the

glasses, which corrected his vision to R=20/20 and L=20/30, at the time of the accident.

He reported that his hearing is normal. 

The truckdriver characterized himself as a social drinker. He said he had never been

treated for alcohol or other substance abuse, and he said he had never used any illicit

drugs.

Shortly after the accident, Safety Board investigators compiled the activities of the

truckdriver for the 72-hour period before the accident using the truckdriverís statements,

his logbook, and materials from the Illinois State Police investigation. A preliminary

compilation indicated that the truckdriver had been driving for about 10 hours and had

been on duty for another 2 hours in the 24-hour period before the accident. However,

during the accident investigation, investigators discovered a fuel receipt that contradicted

the driverís account of his whereabouts on the day before the accident. When confronted

with the evidence by investigators, the truckdriver submitted a revised statement. Based

on the driverís revised statement, the driverís logs, fuel receipts, mileage/speed estimates,

and interviews with shippers and receivers involved in the truckdriverís deliveries on the

day of the accident, the Safety Board compiled the following list of activities for the

truckdriver for the 72-hour period before the accident: (The times listed are approximate.)

Friday, March 12, 1999

8:00 p.m.: Arrived at home near Peotone, Illinois, after loading his truck with steel

at Birmingham Steel in Bourbonnais. The driver parked his truck at

Melco Transfer, about 2 miles from his home. On his way home, he

stopped at a tavern in Manteno, Illinois, where he ate dinner and had

several beers.

10:00 p.m.: Went to bed after falling asleep while watching television.

Saturday, March 13, 1999

7:00 a.m.: Awoke, ran errands during the day, and stayed at home. Slept during the

night at home.

Sunday, March 14, 1999

7:00 a.m.: Awoke, and stayed at home throughout the day attending to personal

matters.

9:30 p.m.: Went to bed.

Monday, March 15, 1999

12:00 a.m.: Awoke and got ready for work.
Factual Information 14 Railroad Accident Report

2:00 a.m.: Arrived at Melco Transfer in Peotone, Illinois, checked truck and

departed for Dayton, Ohio.

3:20 a.m.: Stopped in Rensselaer, Indiana, (62 miles, see figure 4) for fuel and a

coffee break. 

3:45 a.m.: Departed Rensselaer.

7:30 a.m.: Arrived at Dayton, Ohio, (210 miles) where rebar was off-loaded by

others. (The driver reported that he rested in the sleeper of his truck

while the off-loading was taking place.) 

8:45 a.m.: Departed Dayton en route to Canal Winchester, Ohio, to pick up a load

of lift-trucks and various accessories.

10:25 a.m.: Arrived in Canal Winchester, (87 miles) where his truck was loaded.

(The driver reported that he rested in the sleeper berth during loading,

but the shipper indicated that drivers usually participate in the loading

of their trucks.) 

11:00 a.m.: Departed Canal Winchester en route to Country Supply in Peotone,

Illinois.

1:10 p.m.: Stopped in Eaton, Ohio, (112 miles) for food and fuel. 

2:30 p.m.: Departed Eaton.

7:00 p.m.: Arrived at Country Supply (251 miles) and assisted with off-loading. 

8:00 p.m.: Departed Country Supply and went home, about 2 miles from Country

Supply. (The driver stated that he slept at home.)

8:30 p.m.: Departed home en route to Birmingham Steel.

8:45 p.m.: Arrived in Bourbonnais (10 miles). Went off duty for about 45 minutes

while his truck was being loaded with rebar. 

9:30 p.m.: Secured the cargo on his trailer.

9:45 p.m.: Departed the steel mill, just before the accident. 

Train Operator

Title 49 Code of Federal Regulations (CFR) 217.11 stipulates that each railroad

must periodically test and train its employees on the companyís operating rules. Title 49

CFR 240 requires that locomotive engineers be certified every 3 years.
Factual Information 15 Railroad Accident Report

In testimony at the Safety Boardís public hearing, the train engineer, aged 52,

stated that he had worked as a railroad engineer for almost 25 years before this accident.

Records indicate that he was hired by Amtrak on March 18, 1987. According to his

testimony, the engineer had operated over the territory in which the accident occurred for

12 years before the accident date, and records showed that his original qualification date

over that territory was December 2, 1988. Amtrak terminated the engineerís employment

on July 18, 1989, for passing a stop signal. He was reinstated on August 10, 1989. He was

again terminated on March 26, 1990, for incurring three rules violations.12 Amtrak

subsequently rehired the engineer on October 1, 1990. Records showed that the engineer

was recertified in 1990, 1994, and 1996. His most recent engineer evaluation before the

accident occurred on August 1, 1998.

The engineerís most recent medical examination before the accident was on

October 13, 1998. His most recent vision and hearing test before the accident took place

on September 23, 1996. No restrictions were placed on the engineer relating to his hearing

or vision.

The Safety Board was not able to obtain from the train engineer a description of

his activities, including a detailed work/rest history for the 72 hours before the accident.

The engineer was hospitalized with injuries sustained during the collision and could not

recall his activities beyond the fact that he slept much of the day on March 15, 1999, and

that he went on duty that evening at 7:15 p.m. He also stated that he had been off duty

Figure 4. Truckdriverís route on Monday, March 15, 1999

12 The violations involved derailing cars, failure to observe and obey speed limit, and violations of

operating rules and instructions. 
Factual Information 16 Railroad Accident Report

Saturday and Sunday, March 13 and 14. He was unable to provide specific information

about the duration of his sleep periods over those 2 days. He did state that he felt rested

when he reported for duty on the evening of the accident. Records indicate that he was in

compliance with Federal hours-of-service regulations.

No adverse driverís license information was developed about the engineer during a

search of the national driverís register. The engineer said that he was not

overtasked/overworked on the evening of and before the accident, nor was he distracted or

preoccupied before the accident.

Train Information

Amtrak train 59 consisted of 2 locomotive units, a baggage car, and 13 passenger

cars of various types.

The Safety Board examined the derailed locomotives in order to determine the

extent to which the locomotiveís design provided for the survival of the traincrew

members. Both locomotive units were GE model P-40 Genesis locomotives and were

operating in the cab-forward position. This model locomotive is equipped with two

collision posts immediately behind the front fascia panel. The impact with the truck

occurred at the front of the lead locomotive, the only locomotive occupied by traincrew

(the lone engineer). The front fascia panel of this locomotive sustained about 12 inches of

intrusion. Despite this impact damage, however, the collision posts remained intact.

Following the collision, the lead locomotive unit separated from the second, continued

along the right-of-way for about 560 feet, and came to rest almost fully on its right side.

The baggage car came to rest partially on top of the lead locomotive, crushing the aft end

of the locomotive carbody and frame.

Directly behind the two locomotives followed a baggage car, a crew dormitory

(transition sleeper) car, and sleeping car 32035. The accidentís 11 fatalities were sustained

in car 32035. As a result of the derailment and subsequent pileup, the sleeping car came to

rest bent and wrapped around the aft end of the second locomotive unit. The carbody, bent

an estimated 56 degrees, sustained substantial crush damage and a large breach area where

it made contact with the second locomotive. In addition, the aft end of the car experienced

a longitudinal twist of about 50 degrees. The left front sidewall was displaced and crushed

inward about 6 feet through impact with the forward end of coach 34089, a following car.

A length of running rail also longitudinally penetrated the lower level of the carbody,

piercing several of the sleeping compartments. In addition to the crush and deformation

damage caused by the derailment, a fire, ignited in fuel that spilled from the second

locomotive and that migrated underneath the sleeping car, impinged on this car, which

then itself ignited. An inspection of the interior of the sleeping car revealed that most of

the partitions, fittings, and fixtures in the forward two-thirds of the car were

catastrophically crushed and consumed by fire; the material in the aft one-third showed

evidence of smoke damage.
Factual Information 17 Railroad Accident Report

The Federal Railroad Administration (FRA) requires locomotives to receive a

daily inspection. The locomotives of train 59 received this inspection in Minneapolis/St.

Paul at 7:00 a.m. on March 15. The locomotive units, fueled and serviced in Minneapolis,

were scheduled to be refueled at Memphis, Tennessee. An initial terminal air brake test

and an equipment inspection, as required by 49 CFR 232.12, were performed on train 59

by Amtrak mechanical personnel (carmen, machinists, and electricians) at Chicago Union

Station at 6:50 p.m. on March 15. No defects were noted.

While train 59 was operating over IC track, its movements were governed by

Illinois Central Railroad System, Operating RulesSecond Edition, effective November 1,

1998. The accident occurred on the Chicago District, which was a single main track

controlled by a train dispatcher at Homewood, Illinois, according to a traffic control

system.13 The trains were authorized by signal indication through a centralized traffic

control (CTC) system, whereby train movements over routes and through blocks is

directed by signals controlled from a single point.14

Motor Carrier Information

The truckdriver was an owner-operator and owned the accident truck tractor, while

Melco owned the trailer. The accident load was being transported under Melco authority.

Melco is an authorized for-hire interstate carrier that was established in 1986. At the time

of the accident, the carrier operated 41 trucks and owned or leased 55 trailers, primarily

hauling steel throughout the Midwest. According to the company, about 95 percent of

Melco drivers were owner-operators. Melco vehicles accumulated a total of 2,926,355

miles in the 12 months ending February 28, 1999.

After the accident, on March 17, 1999, the Federal OMC conducted a compliance

review of Melco. The five evaluation areas and the final ratings were as follows:

ï General (49 CFR Parts 387, 390): RatingSatisfactory

ï Driver Qualification (49 CFR Parts 382, 383, 391): RatingSatisfactory

ï Operational Driving (49 CFR Parts 392, 395): RatingUnsatisfactory

ï Vehicle Maintenance (49 CFR Parts 393, 396): RatingConditional

ï Accidents (1.367 per million miles): RatingSatisfactory

13 According to 49 CFR Part 236, a traffic control system is a block signal system under which train

movements are authorized by block signals whose indications supersede the superiority of trains for both

opposing and following movements on the same track.

14 Association of American Railroads. 1991. Recommended definitions for technical terms used in

railway signaling. Washington DC. 
Factual Information 18 Railroad Accident Report

Title 49 CFR Part 395 requires motor carriers to maintain driversí log records for a

period of 6 months. The OMC compliance review determined that the company had not

kept accurate records of duty status15 for about one-half of the drivers reviewed.16 As

noted above, this category was rated ìUnsatisfactory.î The OMC review of the carrierís

maintenance records revealed that the carrier had failed to maintain records of repairs and

maintenance. The OMC noted that the carrier also lacked a means to indicate the nature

and due dates of these repairs and maintenance.

Melco Transfer, Inc., was given a ìConditionalî rating and fined $4,050 as a result

of the review. The driver was also fined $2,000 for falsifying his records of duty status.

The OMC conducted a return review in August 1999; this review indicated that Melco had

corrected the majority of the violations for which it had been cited. As a result, the motor

carrierís rating was upgraded from ìConditionalî to ìSatisfactory.î

Previous OMC reviews of Melco were as follows:

ï August 26, 1987, Safety Review: No Rating;

ï July 31, 1989, Compliance Review: RatingSatisfactory;

ï August 5, 1995, Compliance Review: RatingSatisfactory.

On the day of the accident, the truckdriver delivered a load of steel from

Birmingham Steel in Bourbonnais, Illinois, to Dayton, Ohio. The driver then transported a

ìback-haulî of lift trucks from Princeton Products in Canal Winchester, Ohio, to Country

Supply in Peotone, Illinois. The driver had begun his third trip of the day, with a load of

steel, when the accident occurred.

During the investigation, Melco officials indicated that the company had

contracted for the two loads of steel and had assigned those loads to the truckdriver;

however, these officials stated that they were unaware of the back-haul load. Further

investigation revealed that Country Supplythe recipient of the back-haul of lift

trucksand Melco had a routine business relationship and that Melco owned Country

Supply until 1997. The two businesses were located in the same industrial complex.

Driver and billing records showed that Melco drivers, including the accident driver,

frequently transported loads between Princeton Products and Country Supply, and

Country Supply was billed by Melco for transportation services associated with these

deliveries. According to the records, these shipments were always arranged by Country

Supply. According to Country Supply representatives, the company never received a bill

for the back-haul load on the day of the accident. 

15 Title 49 CFR Part 395(e) Failure to complete the record of duty activities of this section or 395.15,

failure to preserve a record of such duty activities, or making of false reports in connection with such duty

activities shall make the driver and/or the carrier liable to prosecution.

16 Since no verifiable records were available for checking the accident truckdriverís records of duty

status, scale tickets were acquired from Birmingham Steel Corporation near the accident site. About 80

percent of the freight transported by this truckdriver came out of this plant destined for Dayton, Ohio.
Factual Information 19 Railroad Accident Report

Investigators attempted to determine how the companies for whom the truckdriver

delivered loads on the day of the accident scheduled their loads for movement.

Birmingham Steel indicated that it would not load or off-load trucks between 11 p.m. and

7 a.m., but otherwise the company did not prescribe specific pick-up or deliver schedules.

Likewise, neither Country Supply nor Princeton Products, the companies involved in the

back-haul load, prescribed specific schedules. A review of Melco records showed that

loads involving the carrier were assigned and scheduled in a variety of ways. Melco

specifically scheduled some loads, others were generally scheduled (to be accomplished

during some time period), and still other loads were assigned to drivers but were selfscheduled by the drivers themselves. Some drivers called in for loads, and others picked

up loads on their own and then notified the company. The Safety Board was unable to

ascertain who determined the schedule for the back-haul load on the day of the accident.

Truck Information

The accident truck consisted of a truck tractor and semitrailer. The truck tractor

was a 1994 Navistar 9400, which is a conventional cab with a sleeper berth. The

semitrailer was a 1991 Reitnouer 48-foot aluminum spread-axle flatbed.

The semitrailer was loaded with six bundles of rebar, with each bundle containing

88 bars. The bundles were loaded three-over-three across the center of the bed, with 4 x 4

timbers placed laterally underneath and between the two layers. The 60-foot lengths of

rebar extended 5 feet beyond the front and 7 feet beyond the rear of the 48-foot trailer bed.

The load was secured with six nylon straps spaced 8 to 10 feet apart. The 46,000 lbs. of

rebar, added to the truck semitrailer unit empty weight of 28,880 lbs., brought the gross

vehicle weight to 74,880 lbs. The estimated payload weight over the axles of the truck

tractor (21,500 lbs.) and the semitrailer (24,500 lbs.) was within the rated capacity of the

unit (80,000 lbs.). The overall length of the vehicle, with the load extending over the rear

of the semitrailer, was estimated at 77 feet.

Track and Signal Information

Track Information

Two parallel IC tracks, oriented geographically in a northerly to southerly

direction, intersected McKnight Road at the grade crossing where the accident occurred.

The westernmost track was the main track, and the easternmost track was a passing siding.

At the point of collision, the distance between the two tracks, centerline to centerline, was

14 feet. A scheduled total of 4 Amtrak passenger trains, 4 Norfolk Southern Railroad

freight trains, and 16 IC freight trains operated over the crossing each day. In addition, a

local switch engine makes several moves daily in the vicinity of the crossing.
Factual Information 20 Railroad Accident Report

The IC railroad owned, operated, inspected, and maintained the tracks and track

structure. The main track met FRA standards for class 5 track, allowing a maximum

operating speed of 79 mph for passenger trains, 70 mph for intermodal17 trains, and 60

mph for freight trains. The siding track was designated class 2, allowing a maximum

operating speed for all trains of 20 mph.

To the north and south of the McKnight Road crossing were additional siding

tracks that paralleled the IC tracks on the west side of the main track. To the north of the

crossing were two siding tracks owned by Lambert Grain Company. To the south were

two tracks owned by Birmingham Steel. The freight cars involved in this accident were

standing about 464 feet south of the centerline of McKnight Road on Birmingham No. 1

track, which was the nearest of the two siding tracks to the IC main track.

Train engineers are required to sound the train horn in a standard blast sequence

upon the approach to a grade crossing. To notify the engineers when they should begin the

horn blast sequence, the railroad installs signs on the railroad wayside, known as whistle

posts. In the case of the McKnight Road crossing, for a southbound train movement, the

whistle post is located about 4,000 feet north of the crossing and about 1,400 feet north of

the St. George Road crossing. The whistle post is described as a multiple crossing whistle

post and bears a sign with the letter ìWî above the number ì3.î The sign instructed the

traincrew to sound the train horn for the next three crossing: St. George Road, McKnight

Road, and Larry Powers Road.

Signals

Railroad Traffic Control Signals. Train traffic in the accident area was governed

by color light signals controlled by electronic coded track circuits. A hot box/dragging

equipment detector18 equipped with an event recording device was located about 5 1/2

miles to the north of the accident crossing. A computer-aided train dispatcherís log located

in Homewood, Illinois, recorded the movement of trains in the accident area.

Grade Crossing Signal System. The McKnight Road crossing was an active

grade crossing protected by bells, flashing lights, and gate arms. The crossing predictor

(the activation control mechanism for the crossing signal and gate system) was a Safetran

Model GCP-3000, which had been installed on January 23, 1992, to replace an older

system. The GCP-3000 is a micro-processor controlled system that detects the speed and

location of an approaching train and uses time and distance calculations to predict the

trainís arrival time at the crossing. The system then activates the crossing signal devices to

provide a preset amount of warning time before the arrival of the train at the crossing. The

system is designed to provide a relatively constant warning time at the crossing, regardless

of the speed of the approaching train.19

17 Intermodal trains include flat cars carrying truck trailers or shipping containers and are referred to as

trailer-on-flat-car (TOFC)/container-on-flat-car (COFC) trains.

18 A hot box detector determines whether any journal bearings are overheating. A dragging equipment

detector determines whether any equipment, such as brake rigging or mechanical connections, is dragging or

whether any debris that can damage the track connections, ties, or switches has become lodged under the

train.

19 The time-and-distance calculations assume a constant-speed train. If the train should slow or

accelerate appreciably after detection by the GCP system, warning time at the crossing would vary slightly.
Factual Information 21 Railroad Accident Report

The number of seconds of warning time provided by the GCP-3000 can be set via

a keyboard/display assembly located in the signals bungalow near the crossing. Maximum

warning time is a function of the length of the track circuit and the maximum speed of

trains using the circuit. In this case, the speed of the train was assumed to be the maximum

authorized speed of 79 mph, and the programmed circuit warning time was 30 seconds;

this was the setting for the GCP-3000 at the McKnight Road crossing. Because the system

requires up to 4 seconds to determine the speed of the train and make its calculation, a 30-

second setting will actually activate the warning lights about 26 seconds before the train

arrives at the crossing. The McKnight Road signal system event recorder indicated that the

system delivered 26 seconds of warning time.

A data recorder module was installed in the GCP-3000 at McKnight Road.

Safetranís Data Recorder Module 80015 allows information pertaining to train movement

events and system status messages to be stored in memory. The module maintains a dateand time-stamped record of train warning times, speed of the train when prediction

occurred, average train speed (speed of train averaged over entire time train is sensed),

and island speed (speed of train when entering the crossing). Additionally, any errors

normally detected by the GCP, either internally or in the track circuit, are also recorded.

The data recorder module 80015 recorded the information shown in table 2 at the

time of the collision.

The module memory can hold data on about 3,000 events; when memory is full,

the oldest data is overwritten by the new data.

The signal system was also equipped with a data recorder interface assembly,

80025, which monitors and records changes of the input state on 16 channels external to

the GCP-3000. All 16 inputs on the 80025 assembly are electrically isolated from each

other allowing direction to vital circuits. Input changes must typically consist of voltage

level changes similar to those produced by relay contact closures.

The crossing underwent an annual inspection on February 3, 1999, during which

some buried wires were determined to no longer meet requirements. These wires were

replaced with other wires that were present in the same bundle of wires. Following the

accident, the Safety Board, in cooperation with the IC railroad, tested the wires in place at

the time of the accident; the wires were within specifications at the time of testing. The

last monthly inspection before the accident was on February 24, 1999. No exceptions were

noted.

Table 2. Data recorded at the time of the collision by the crossing signal system data 

recorder module.

Warning Time 26 seconds

Speed at Train Detection 73 mph

Speed at Crossing 68 mph

Average Speed 71 mph
Factual Information 22 Railroad Accident Report

Roadway and Grade Crossing Information

Roadway. McKnight Road is a two-lane, 22-foot-wide highway running in an

east-west direction. Its easterly terminus is at Illinois 50, a four-lane north-south State

arterial with a left-turn center median. At one time, McKnight Road continued in a

westerly direction. In the 1970s, it was truncated because of construction of the nearby

Interstate 57 and now dead ends about 2,000 feet west of the crossing.

Between the western edge of the railroad right-of-way to a point about 800 feet to

the west of the crossing, the roadway is owned by the Village of Bourbonnais. Between

the eastern edge of the railroad right-of-way and the intersection of McKnight Road and

Illinois 50, the Township of Bourbonnais owns the road. The village maintains the entire

road by informal agreement with the township. No speed limit is posted on McKnight

Road. In Illinois, the speed limit on unposted roads is considered to be 55 mph.

The pavement was last resurfaced in 1992 and was in good condition. The

shoulders were unpaved gravel shoulders, with grass embankments and drainage ditches

on both sides of the traveled way. The northern ditch extended to the crossing, with the

drainage continuing underneath the tracks via a 30-inch-diameter corrugated steel culvert.

Both the eastbound and westbound approaches to the grade crossing are straight,

but each meets the tracks at a slightly different angle. The angle of intersection on the east

side is about 80 degrees, while on the west side, the angle of intersection is 82 degrees.

McKnight Road has a descending 0.75 percent grade from a point 600 feet west of the

crossing to a point 200 feet west of the crossing. From this point to the crossing, the grade

raises slightly at an average rate of 0.2 percent.

McKnight Road had no street lighting; however, railroad security luminaires at the

railroad signal control building in the northwest quadrant of the intersection provided

some illumination of the crossing. In addition, lighting from the steel plant parking lot

southwest of the crossing provided some illumination of the eastbound highway approach.

It also provided some light to the northwest quadrant. Security lighting on two industrial

buildings in the northeast quadrant also provided some illumination.

Birmingham Steel was the primary traffic generator on McKnight Road. The

facility operated three work shifts that generated about 150 automobile roundtrips (300

one-way trips) per day. Trucks bringing steel scrap into and taking steel products out of the

facility generated about 400 to 600 one-way trips per day. Incoming and outgoing trucks

were typically loaded to near their maximum load limits.

Traffic Control Devices. The Manual on Uniform Traffic Control Devices

(MUTCD), published by the Federal Highway Administration and adopted as law by the

States, requires special pavement markings in each approach lane of all paved approaches

to grade crossings where automated signals are present.20 The required markings are an

20 According to the MUTCD, these markings may be omitted at minor crossings or in urban areas if

engineering study indicates that other devices installed provide adequate traffic control.
Factual Information 23 Railroad Accident Report

ìX,î the letters ìRR,î a no-passing-zone marking, and certain transverse lines. With the

exception of no-passing-zone markings, none of these markings were present on the

McKnight Road approach to the accident crossing. The no passing zone on the eastbound

approach to the tracks extended 315 feet but was in poor condition. According to Village

of Bourbonnais officials, the practice of the village was not to stripe roads of this type and

function, and the no-passing-zone markings had not been repainted since the village

acquired ownership of the road.

The MUTCD also prescribes the use of certain signs on the approaches to and at

grade crossings where deployment of such signs is not made impossible by physical

conditions. At the McKnight Road crossing, a 36-inch-diameter railroad crossing sign for

eastbound traffic was posted 512 feet west of the most westerly rail. An identical sign for

westbound traffic was posted 414 feet east of the most easterly rail. Reflectorized

crossbucks were mounted on the railroad masts for east- and westbound traffic. The

crossing signs and crossbucks were in good condition. According to the MUTCD, an

auxiliary sign indicating the number of tracks at a crossing is optional at crossings

equipped with automatic gates. Such signs were not present at the accident crossing.

A driver or pedestrian approaching the grade crossing would have been warned of

an approaching train by bells, flashing red lights, and crossing gate arms. To the driver

involved in this accident, the west gate was on the approach side of the crossing, and the

east gate was on the departure side. The crossing gate masts were 12 feet from the nearest

rail.

According to the State of Illinois, a motorist must stop at a grade crossing if the

crossing is equipped with a ìStopî sign, if a train is approaching and/or gives a warning, if

a flagman indicates a stop is required, or if a train-activated warning device is activated.

When approaching a crossing equipped with flashing lights, the driver is required to

ìalways stop until it is safe to proceed.î21 If the flashing lights are accompanied by an

automatic gate arm, then the motorist is required to stop and remain stopped until the gate

is raised again.

Following the collision at McKnight Road, the Canadian National/Illinois Central

railroad installed video cameras and recording equipment at McKnight Road and several

nearby crossings. Several events at these crossings have since been called to the attention

of the Safety Board. In one, occurring in August 2000, a truck queued in traffic at St.

George Road, the crossing immediately to the north of McKnight Road, stopped on the

tracks. While the truck was stopped on the tracks, a train approached, activating the

signals; the gate lowered behind the truck cab. The truckdriver succeeded in backing off

the tracks but damaged the signal gate. In other instances at McKnight Road, local police

received reports that the signal provided inadequate warning time. Review of the video

tapes has shown that only one of these reported incidents was truly a delayed activation,

which was caused by a broken bond wire in a switch south of the crossing. In the other

instances, review of the tapes shows either warning times in excess of the Federally

required minimum time, or truckdrivers entering the crossing in violation of the already

activated signals. 

21 State of Illinois Secretary of State. 2000. Illinois Rules of the Road. 
Factual Information 24 Railroad Accident Report

Meteorological Information

The National Weather Service in Chicago, Illinois, reported unrestricted visibility

at 10 statute miles and no precipitation at the time of the accident. The temperature was

reported to be 33° F. The train engineer and other witnesses indicated that visibility was

good, other than the darkness of the night.

Toxicological Information

Truckdriver

Postaccident drug and alcohol testing of the truckdriver was directed by the motor

carrier in accordance with Federal requirements. The tests were negative for alcohol,

cocaine, marijuana, phencyclidine, amphetamines, and opiates.

At the request of the Safety Board, the Civil Aeromedical Institute (CAMI)

Toxicology and Accident Research Laboratory of the Federal Aviation Administration

tested the blood and urine specimens submitted by the truckdriver following the accident.

The CAMI tests detected tramadol, a narcotic-like painkiller, both in the urine and

at very low levels in the blood. Verapamil, an antihypertensive medication, was detected

in the blood and urine, and norverapamil, a metabolite of verapamil, was also detected in

the blood and urine. Ephedrine, pseudoephedrine, and phenylpropanolamine, which are

primarily used as decongestants but are also found in many nutritional supplements, were

detected in the blood and urine, and salicylate (aspirin) was found in the urine and at low

levels in the blood. The truckdriver stated that he had taken prescribed medications daily

for hypertension and rheumatoid arthritis for a period of 6 years before the accident. He

said he also used a painkiller as needed for a pulled leg muscle.

Amtrak Crew

Federal regulations do not require postaccident toxicological testing22 of train

crewmembers involved in highway/rail grade crossing accidents; thus, the crewmembers

of train 59 were not tested. The engineer stated that he had not used alcohol or drugs,

including over-the-counter and prescription medication, before the accident. 

Postaccident Inspection

Site Inspection

Postaccident inspection of the crossing on March 16 revealed a black tire mark

about 18 feet long on the rails and on the crossing timbers between the rails of the siding

22 Title 49 CFR 219.201(b).
Factual Information 25 Railroad Accident Report

track. (See figure 5.) One end of the tire mark began just west of the west rail north of the

centerline of the roadway. It ran over the west rail and continued diagonally between the

rails to the edge of the crossing timbers near the east rail and ended on the east rail, about

4 feet from the edge of the timbers. 

Two additional tire marks were found on the passing siding track rails south of the

crossing timbers. The first of these was found on the west rail about 12 feet from the

timbers. The second mark was found on the east rail about 18 feet from the timbers.

The northerly end of the black tire mark on the timbers of the easterly track

indicates the position of the tires when the truck was hit by the train. The only tires

showing sideways sliding were those on the left side of the fourth axle. It was therefore

concluded that the marks were made from the left tires of the fourth axle. A 10-foot

measurement (distance between the fourth and fifth axles) indicated that the fifth axle had

to be at the center of the southbound tracks at impact. This was confirmed by noting the

damage to the left outside wheel of the fifth axle, which was consistent with the geometry

of the locomotiveís front coupler. (See figure 6.)

Figure 5. McKnight Road grade crossing showing damage features and tire marks.
Factual Information 26 Railroad Accident Report

The tire marks on the rails indicate the path of the rear of the trailer on its way to

its point of final rest. The accident reconstruction study (discussed later in this report) used

these marks and the tire mark noted above, among with other inputs, to determine the

placement and speed of the truck at the time of collision, and its path to its point of final

rest.

Examination of Gate Arm Mechanism Components

The base of the west crossing gate signal mast was cracked. This was the gate that

was on the approach side of the crossing from the perspective of the accident truckdriver.

The front edge of a flange on the case metal base and a section of the base itself bore a

series of indentations. Witness marks on the concrete under the base of the crossing signal

mast indicated that the cast-metal gate mast base had been moved about 1 inch to the west

and south of its original position. (See figure 7).

Figure 6. Left-side fifth axle of semitrailer at point of impact.
Factual Information 27 Railroad Accident Report

An area of missing paint, where the outer coat was removed while the base or

primer coat was left, was found on the west face of the gate at the tip. The gate

counterweight, three of the four large signal lights, and the bell had broken off the signal

mast. In addition, the gate arm was fractured but not broken off; the mountings for the

three lights on the gate arm were broken; and the tip light and base light remained hanging

from the gate arm. (See figure 8.) Safety Board investigators were unable to locate the lens

for the gate arm center light. The east crossing gate was broken off, in an inward and

downward direction, at a point 19 inches from the tip.

As a part of the accident scene cleanup, the IC replaced the damaged west gate arm

mechanism. The gate mechanism was discarded and remained in outside storage in

Gilman, Illinois, until September 15, 1999, when the Safety Board asked that it be sent to

Washington, D.C., for testing. The Safety Board received the mechanism on October 5,

1999. Details of the initial testing and examination of the gate arm mechanism are

discussed in further detail in the ìTests and Researchî section of this report.

Figure 7. Cracked cast metal base of the west-side crossing gate.
Factual Information 28 Railroad Accident Report

Sight Distance

Sight distance, in this instance, refers to the distances along the highway and along

the railroad tracks needed by a motorist to detect the presence of a train in time to stop and

avoid a collision. According to the American Association of State Highway and

Transportation Officials (AASHTO), which establishes guidelines for the geometric

design of roadways, a grade crossing should be designed so that an approaching motorist

is able to perceive the train, react to its presence, and stop the highway vehicle before

reaching the crossing.

Once the necessary distance is determined, a ìquadrant sight distance,î or ìsight

triangle,î can be established. Two sides of this quadrant sight distance, or sight triangle,

are formed by imaginary lines drawn from the highway vehicle to the crossing and from

the crossing to the train. The third side is formed by a line drawn from the train back to the

highway vehicle. The interior of this quadrant or triangle should remain clear of any visual

obstructions.

For a vehicle stopped at the crossing, the driver must be able to see the train far

enough along the tracks to have time to accelerate the vehicle and clear the crossing before

the trainís arrival. The quadrant sight distance needed varies according to the speed and

stopping distances of the train and the highway vehicle. It is also affected by the angle at

which the highway intersects the tracks and the slope of the roadway. Train-activated

Figure 8. West (approach) crossing gate.
Factual Information 29 Railroad Accident Report

crossing traffic control devices, such as those at the McKnight Road crossing, are often

used where permanent visual obstructions exist within the sight distance triangle.

At the McKnight Road crossing, investigators noted several sight obstructions

within the sight distance triangle. The sight line across the northwest quadrant, where an

eastbound motorist would look for a southbound train, was limited in part by a high berm

running along the north side of the highway. From the end of the berm to the tracks, a

building and trees limited visibility. At the time of the accident, about 20 freight cars were

standing on the Lambert Grain Company side track closest to the main track. The freight

car closest to McKnight Road was 376.5 feet north of the centerline of the grade crossing.

An approaching southbound train could not be seen until it had cleared this point.

In an ideally designed crossing, the approaching motorist will have adequate

quadrant sight distance, allowing a clear view of approaching trains. Of equal importance,

however, is the sight distance available for the motorist to see the upcoming crossing,

sometimes known as the approach sight distance. Approach sight distance is the distance

measured along the highway between the motor vehicle and the crossing, and it must be

long enough to enable an approaching motorist to see the crossing (or its warning

devices), react to its presence, and stop the highway vehicle safely before reaching the

crossing. Where highway conditions such as curves in the roadway or intruding vegetation

limit the approach sight distance, additonal measures, such as additional traffic control

devices or brush trimming, may be considered.

The Safety Board examined the crossing area to determine whether an eastbound

motorist had adequate approach sight distance for the grade crossing on McKnight Road.

According to formulae provided by AASHTO, a vehicle traveling about 30 mph along the

highway would require about 207 feet to stop safely before encroaching on the crossing.

Using an exemplar vehicle, the Safety Board determined the point along McKnight Road

at which a truckdriver might first be able to see the crossing or its signals. As mentioned

above, the roadway approach was straight. The flashing light signals were visible to the

truck occupants at the point where the truck turned onto McKnight Road, a distance of

about 650 feet.

Wreckage

Train. The impact caused both locomotives and 11 of the 14 cars in the consist to

derail. The lead locomotive came to rest at a point about 560 feet south of the grade

crossing. Adjacent to this was the second locomotive, the baggage car, a transition sleeper

car, a sleeping car #32035, diner car #38020, and coach car #34089, which came to rest on

its side, all of which were involved in a general pileup of wreckage. (See figure 9.) The

remaining cars in the consist either derailed and remained upright or did not derail at all.

None was involved in the general pileup of wreckage. These cars did not display any

evidence of serious carbody breach, and damage was mostly limited to the carbody endstructures. 
Factual Information 30 Railroad Accident Report

When the Amtrak train derailed, it struck 2 of 10 freight cars that were on an

adjacent siding west of the main track. The northernmost freight car, which was

apparently the first to be struck, was a gondola loaded with bars of steel. This car, struck

by Amtrakís second locomotive, was crushed, spilling its contents. The second car struck

was a covered hopper car containing about 185,000 pounds of dust that was generated by

the steel plantís electrical arc furnace and that was considered a hazardous waste. Both

cars showed evidence of cargo loss. The remaining freight cars on the siding apparently

separated from the first two and were propelled southward on the siding, coming to rest

about 1,300 feet from their original location.

Truck. The train struck the left side of the semitrailer at the last (No. 5) axle, which

separated from the trailer and came to rest about 80 feet south and 60 feet east of the point

of impact. The truck semitrailer combination came to rest in the eastbound lane of

McKnight Road with the front of the tractor about 35 feet from the east crossing gate. The

tractorís left wheels came to rest just on the edge of the pavement. The trailer remained

attached to the tractor, but rotated about 100 degrees counterclockwise around the fifth

wheel coupling. (Refer to figure 5.)

Figure 9. Wreckage diagram (not to scale). Car numbers reflect position in consist.

1

2

4 8

6

11

13 14 15 16

9 10

12

3

ACFX

5

Crew Dormitory

Lead Locomotive

Not In Revenue Service

Sleeping Car

Position in Consist Equip. Description Amtrak No.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

807

829

1166

39004

32035

38020

34089

31034

31540

33009

35001

31016

32031

32046

38032

32058

locomotive

locomotive*

bagage car*

transition sleeper

sleeping car

dining car

coach

coach

coach

lounge car

coach*

coach*

sleeping car

sleeping car*

dining car*

sleeping car*

*Car unoccupied at the time of the accident

Cars from Siding Track

IC

Second Locomotive

7
Factual Information 31 Railroad Accident Report

Safety Board investigators examined the truck tractor and found no indication of

surface abrasion or impact. No marks of any kind were observed on the tractor except for

an indentation on the outer edge of the driverís side view mirror; the source for this

indentation is unknown.

The bed of the semitrailer, beginning at the fifth wheel coupling and continuing to

a point just forward of axle No. 4, was intact but had a clockwise longitudinal spiral twist.

The section of the bed rearward of axle No. 4 was dislodged and scattered along the

railroad bed for about 100 feet; an exception to this was the left frame rail, which was bent

90 degrees to the left and twisted clockwise about 90 degrees. The semitrailerís load of

rebar was scattered along the rail bed for several hundred feet, and many of the bars were

bent.

The left wheel rim and drum assembly of the semitrailerís No. 5 axle had heavy

impact damage that matched the Amtrak locomotiveís coupler in size and conformation.

The hub was destroyed, and the brake shoes and air chamber were dislodged. This was the

only wheel assembly on the semitrailer that showed evidence of impact damage. The left

side dual tires on axle No. 4 showed surface abrasions in one section of the tread area,

with striations perpendicular to the tread.

Tests and Research

Tractor and Semitrailer

The mechanical subsystems on the semitrailer could not be tested. The individual

components were tested or examined, however, to determine their condition and to

determine compliance with the applicable Federal regulations. No discrepancies in the

brake system, the suspension system, or the tires were noted. The truck tractor did not

receive any collision damage, and postaccident inspection and testing revealed no

discrepancies with the steering, suspension, chassis, powertrain, drivetrain, tires, or brake

systems on the tractor.

Train Air Brakes

The Safety Board tested the trainís air brakes and reviewed equipment

maintenance records for the 60 days before the accident. A successful application and

release of the train brakes was made with the following cars, 35140, 33009, 35001, 31016,

32031, 32046, 38032, and 32058. Car 31034 was present but required additional work and

so was not tested at the time. After repairs were made to car 31034, it was successfully airbrake tested and moved with the rest of the cars. These cars were later joined by car

39004, and the brake system was successfully tested for movement. No defects were

found that would have indicated that the equipment was impaired at the time of collision.
Factual Information 32 Railroad Accident Report

Grade Crossing Warning System

Beginning with their arrival at the accident scene, and at intervals during the

following 2 years, Safety Board investigators conducted numerous tests and inspections

on the grade crossing signaling system. Results of the testing of relays, lamp and gate

control devices, cables, and the signal system event recorder indicated that all components

were operating within manufacturersí specifications.

After the accident, the damaged crossing gate arms were replaced with fiberglass

gates. The damaged gate mechanism on the west gate was also replaced. The accident

crossing was placed back in service at 9:00 p.m. on March 17, 1999. Safety Board

investigators observed the crossing and noted the warning times provided as several trains

traversed the crossing. The warning times ranged from 30 to 39 seconds. These warning

times were longer than those for which the system was programmed because track repairs

caused the railroads to issue slow orders, reducing the authorized train speed near the

crossing.

On March 19, 1999, Safety Board investigators conducted tests on both the west

and the east crossing gates to measure the warning times provided by the grade crossing

signal system. Investigators measured the elapsed time from initial signal light activation

to the beginning of the descent of the gates, elapsed time from the beginning of the descent

of the gates until the gates were fully horizontal, and the length of time the gates were

down (fully horizontal) before the train arrived at the crossing. The time the gates

remained horizontal before the arrival of a train was estimated by assuming that the

system would provide 25 seconds as a nominal warning time.

For each gate, an average of 4 to 5 seconds elapsed from the time the signal lights

were initially activated until the gates began to drop. Another 8 or 9 seconds elapsed

before the gates were fully horizontal. The gates were down between 11 and 12 seconds

before the trainís arrival. Again, the time until a trainís arrival was estimated using 25

seconds as a nominal warning time. FRA rules require that crossing gates be in the

horizontal position at least 5 seconds before the arrival of the train at the crossing.

Also on March 19, 1999, the Illinois State Police accident reconstruction team

conducted tests on the west crossing gate. In those tests, the average elapsed time between

the activation of the lights and the initial descent of the gate was also between 4 and 5

seconds. The team recorded an average elapsed time of between 6 and 7 seconds from the

time the gate began to descend until it was fully horizontal.23

Using wooden replacement gate arms, Safety Board investigators, in conjunction

with the Illinois State Police, conducted tests to determine the extent of damage the gates

might sustain by being lowered onto a standing load of rebar. The accident truck tractor,

23 The police reconstruction team used a standard slightly different from that of the Safety Board team

when it measured the time required for the gate to reach the fully horizontal position. While both groups

measured from the same starting point (initiation of descent), the police team measured the time to the

moment the gate reached the horizontal position, whereas Safety Board investigators waited until the gate

had completed a small ìbounceî when it reached horizontal.
Factual Information 33 Railroad Accident Report

with a semitrailer and cargo similar to those involved in the accident, was positioned so

that a lowered gate arm rested on the rebar about 7 feet from the aft end of the rebar

bundles. Investigators noted and photographed several marks made on the underside of the

gate arm where it struck the rebar, and Illinois State Police took custody of the wooden

gate arm. No similar marks were found on the gate arm that was in service at the time of

the accident.

On April 15, 1999, Safetran, the manufacturer of the GCP-3000, field tested the

predictor system under Safety Board observation. On May 21, 1999, the manufacturer, in

the presence of a Safety Board investigator, factory tested the GCP-3000. All testing was

performed in accordance with Safetran bench and pre-shipping test procedures for a newly

manufactured product. The measured values for the accident-involved GCP-3000 system

and modules were within the manufacturerís specifications.

On March 19, 1999, investigators conducted tests to determine whether a similar

truck could maneuver around lowered gates at the McKnight Road crossing. The driver

provided by the State Police was able to drive the truck-tractor semitrailer around the

lowered gates at a low speed. Several timing tests conducted at this time showed that, on

average, the exemplar vehicle required about 34.6 seconds to drive from the steel plant

parking lot to the approximate point of impact; the vehicle averaged 23 mph on these tests.

Also on this date, investigators conducted tests to determine how much time was required

by the nearby crane operator to perform his task, in order to develop an estimate of the

time elapsed between his first noticing the flashing lights and his witnessing the collision.

The average time he required to perform his task was from 24 to 26 seconds.

Grade Crossing Signal Malfunction History

Safety Board investigators examined incident reports filed in 1998 and 1999 for

the warning signal system installed at McKnight Road. These reports documented

incidents involving both false activation and activation failure. A false activation occurs

when the system indicates to a motorist that it is not safe to cross the railroad tracks when,

in fact, it is safe to do so. Based on a review of the records, the Safety Board identified

reports of four false activations, all of which occurred before March 15, 1999.

An activation failure occurs when the signal system fails to warn of the approach

of a train at least 20 seconds before the train arrives at the crossing, or when it fails to

indicate the presence of a train occupying the crossing. According to FRA records, a total

of 596 activation failures were recorded nationwide during 2000. For each of these

activation failures, a cause was discovered. According to the FRAís Grade Crossing

Inventory System database, there are 63,243 grade crossings equipped with train-activated

warning devices; an average of 15.06 trains use these crossings each day.

Two activation failures at the McKnight Road crossing have been reported since

the March 15, 1999, collision. On March 29, 1999, about 12:32 a.m., the signal system

provided only 6 seconds of warning time before the arrival at the crossing of a northbound

IC freight train. Investigation revealed a broken bond wire in a switch south of the

crossing that temporarily shortened the length of the approach circuit and delayed
Factual Information 34 Railroad Accident Report

detection of the train by the signal warning system. About 11:29 p.m. on April 9, 1999, the

gates began to cycle up and down while a southbound IC freight train occupied the

crossing. In this instance, soybean meal had leaked from a car in the train and had built up

between the train wheels and the rail. The material effectively acted as an intermittent

insulator that prevented the signal circuit from detecting the presence of the train. In both

instances, the event recorders indicated that the signal system failed to provide the

intended warning time.

Laboratory Examination

The west crossing gate 24 arm mechanism, the gateís counterweight, the gate mast

base, and the light bulbs from the gate arm were all examined or tested, or both, by the

Safety Boardís Materials Laboratory. The wooden crossing gate arm was examined by the

Materials Laboratory, and by the U.S. Department of Agriculture Forest Products

Laboratory.

Crossing Gate Mechanism. The crossing gate mechanism is that part of the

crossing signal system that contains the motor controlling the motion of the gate arm.

Normally, the gate is held in the ìupî (hold clear) position by an energized relay. When the

train enters the signal circuit, the GCP-3000 determines the appropriate train location to

activate the lights and gates to provide the warning time. When the train reaches the

calculated distance from the crossing, the GCP-3000 de-energizes the crossing control

relay inside the signal bungalow, which in turn de-energizes the relay inside the gate

mechanism, and a motor begins to drive the gate down.25 When the gate reaches about 50

degrees from the horizontal, the motor shuts off, and the gate continues to fall by gravity

alone. As the gate nears the horizontal, the motor acts as a generator, and slows the gateís

descent. The motor again disengages when the gate reaches fully horizontal.

The gate operating mechanism consists of the motor itself, two intermediate gear

and pinion sets, and associated roller bearings and pins. The Safety Boardís Materials

Laboratory marked, removed, cleaned, and examined the gears, roller bearings, and pins

of the west gate assembly. All the gear and pinion teeth showed varying degrees of wear

but were intact.

Examination of the motor revealed that all the wires were firmly attached, and the

commutators and brushes were in good condition. Manual operation of the hold-clear

mechanism confirmed that when the gate was in the up position, the motor shaft was

locked, as designed.

The Safety Board then reassembled the intermediate gear assemblies using the

marks that had been made to ensure that the gears engaged exactly as they had before

24 From the perspective of the accident truckdriver, the west gate was on the approach side of the

McKnight Road grade crossing. This is the gate mechanism that was damaged by the collision and replaced

immediately after the accident.

25 The gate and counterweight assembly are balanced so that the gate will fall by gravity alone;

however, a motor is used in case additional force is needed to counteract the effects of strong winds or to

overcome other resistance.
Factual Information 35 Railroad Accident Report

disassembly. After assembly, and with the gate in the ìdownî position, power was

supplied to the motor, and the gate mechanism was operated. Safety Board, FRA, and

Canadian National/Illinois Central Railroad (CNIC) representatives present at the

disassembly and testing demonstration agreed that the gate mechanism operated as

designed.

The Safety Board conducted several additional examinations of the

electromechanical components of the gate mechanism. On March 29, 2000, investigators

reexamined the gate arm mechanism. On May 30, 2000, Safety Board representatives

participated in tests of the gate mechanism motor control relay performed at the laboratory

of the mechanismís manufacturer. On July 13, 2000, the Safety Board conducted a

teardown of this same relay in its laboratory.

March 29, 2000, Examination. Examinations of the mechanism and its circuits

were conducted by Safety Board Railroad Division staff to identify the failure modes that

might be expected to affect either the gate mechanism or the overall grade crossing signal

system. Specifically, investigators attempted to determine what conditions might cause

one or both of the gates to fail to lower, or that might cause a delay in the lowering of one

or both gates. Representatives of the CNIC and Alstom Signaling, Inc., (Alstom)

participated.

The internal works of the gate mechanism were determined to have been

assembled by General Railway Signals Company (GRS), now Alstom. According to

records maintained by the CNIC, this particular mechanism was manufactured in 1968. A

review of records dating back to 1993, the earliest date for which such records are kept by

the manufacturer, found no failures of GRS gate mechanisms, and no safety notices or

safety reminders relating to gate mechanisms manufactured in 1968 had been issued by

the manufacturer.

The hold-clear mechanism showed no evidence of contamination or material

transfer that could have served to physically hold the gate in place after the activation

relay was de-energized. After an examination of both the gate mechanism and the circuit

diagrams for the mechanism, the examination participants could identify no failure mode

within the mechanism that would cause the simultaneous delayed lowering of both gates

at a crossing. Participants determined that the most likely cause of a failure of a single gate

to lower would be a failure of the motor control relay to open when de-energized. Were

this to happen, the hold-clear mechanism would remain energized, and the gate would not

be released.

The motor control relay was removed from the gate mechanism case at this time.

Simple testing in the laboratory established that the relay still functioned. Participants

decided to conduct more rigorous testing of the relay at the manufacturerís laboratory.

This testing was conducted on May 30, 2000.

May 30, 2000, Testing. Safety Board Railroad Division representatives conducted

tests at Alstomís laboratory in Rochester, New York, to determine the exact current levels

required for the accident gate mechanismís motor control relay to function. Present were
Factual Information 36 Railroad Accident Report

representatives of Alstom and the CNIC. The measured current levels met manufacturerís

specifications.

July 13, 2000, Teardown. The Safety Board disassembled the gate mechanismís

motor control relay and examined the relayís contact surfaces to determine whether either

foreign material or a transfer of matter from one surface to another could have caused the

relay to stick in the closed (energized) position. The contact surfaces did not show

evidence of any transferred or foreign material.

Counterweight Assembly and Gate Mast Base. The gate armís counterweight

was broken off during the collision. The Safety Board examined the fracture face, which

revealed features consistent with an overstress separation propagating from the inside of

the arm (the side closest to the mast) toward the outside.

The base of the crossing gate mast consisted of two castings fastened together

around the mast. Four fasteners screwed the two base castings onto anchor bolts

embedded in a concrete foundation.

A series of indentations was noted on the front edge (facing the roadway) of a

flange on the side of the base. The indentations were spaced about 3/4 inch apart. A

second series of larger indentations, spaced about 1 inch apart, were found on the front

edge of the inner half of the base. A portion of the front edge of the inner half of the base

was cracked and was moved outward to close the gap between the two halves.

Gate Arm Shaft Bearings. The wooden gate arms attach to the gate arm

mechanism by way of a metal shaft, the rotation of which causes the gate to lower and

raise. The shaft enters the gate arm mechanism and attaches to it with press-fit ball

bearings. The inner bearing race rotates with the shaft, while the outer bearing race

remains stationary in relation to the mechanism case. The bearing race locations, relative

to the gate up and gate down positions, were vibro-peened on the outer edges of the races,

and the bearings were removed from the mechanism case for examination.

The bearings were found to have numerous indentations, described as Brinell

marks or brinelling,26 on the active bearing surfaces. (See figure 10.) The presence of

brinelling suggests that, at some time, the bearing received a severe blow, causing the

bearing surfaces to impact one another. According to bearing manufacturers, typical

examples of causes of brinelling include ìusing a hammer to install a bearing, dropping a

bearing, or pressing a bearing onto a shaft by applying force to the non-rotating ring.î27

Other marks were observed and noted, but they did not show the indentations typical of

Brinell marks. 

26 Brinell marks are indentations at ball/roller frequency caused by any static overload or severe impact.

27 <http://www.emersonbearing.com/failures/true.html> as of 10/15/2001.
Factual Information 37 Railroad Accident Report

To determine whether the Brinell marks on the bearing surfaces might have

resulted from normal operations, investigators examined a set of bearings from another,

similar gate arm mechanism. The ball grooves of the inner and outer races of the

comparison bearings bore signs of the ballsí rotation in the grooves and of minor surface

corrosion. The comparison bearings did not show evidence of Brinell marks on any

surface. The rotational signs in the grooves of the inner and outer race aligned to indicate

the range of the gateís movement; these were more prominent on the bearing that

supported the counterweight arm.

Gate Arm Light Bulb Filaments. The Safety Board also examined the light bulbs

from the signal gate arm. If the filaments inside incandescent light bulbs are hot when they

receive a blow, instead of breaking, they may simply deform; this was in fact what

happened with the two light bulbs the Safety Board was able to recover from the accident

gate arm. Because of the way the light bulbs were set in their sockets on the gate arm, the

deformation is principally in the direction parallel to the road.

It was hoped that the shape and direction of the filament deformation might

provide evidence indicating the orientation of the light bulb when it was struck. To test

this hypothesis, the Safety Board tested numerous similar light bulbs at the CNIC signal

shop in Homewood, Illinois. Light bulbs were inserted in a block attached to a wooden

gate arm. Each light bulb was inserted with the filament oriented in a different direction,

and power was supplied to make the light bulbs flash for about 30 seconds before force

was applied to the free end of the gate arm. The light bulbs were then removed, labeled,

and replaced with fresh bulbs to repeat the experiment. The bulb filaments were examined

at the Safety Boardís Materials Laboratory under an optical microscope, and the

Figure 10. West crossing gate arm mechanism main shaft bearings. Numbered markings on inner and outer races indicate location of Brinell marks.
Factual Information 38 Railroad Accident Report

deformations were noted. The examination showed that filament deformations in a

specific direction could result from motion in various directions.

Fire Investigation

Following the accident, sleeper car No. 32035 was removed from the accident site

and taken to the Amtrak facility in Beech Grove, Indiana. On April 27, 1999, investigators

reexamined the car at this facility.

During the course of the derailment, the sleeper carís midsection struck and bent

around the end of the trainís second locomotive. Spilled fuel from the locomotiveís

breached fuel tank ignited, resulting in a large fuel-fed pool fire that severely damaged the

middle one-third of the sleeper car.

Because of the fire and victim recovery efforts, Safety Board investigators could

conduct only a preliminary examination of the sleeper car before Amtrak removed it from

the accident scene. To prepare the car for shipment, workers cut it in half, and the forward

half of the car was compressed to permit it to fit into a railcar. The remaining sleeper car

half was placed on another railcar. Where the car was still accessible to investigators, (on

the top deck, room Nos. 5-10), little fire damage was noted, though some discoloration of

the interior windows and slight sooting of interior materials was evident. Areas closer to

the point of impact showed evidence of burned interior materials.

In 1984, the FRA published guidelines recommending test methods and

performance criteria for the flammability, smoke generation, and fire endurance

characteristics of the interior materials used in the construction of new or rebuilt rail

passenger equipment. The guidelines were originally developed by the Volpe

Transportation Research (Volpe) Center in the late 1970s and were intended for

application to rail transit vehicles. The intent of these guidelines was to prevent fire

ignition and to maximize time available for the evacuation of passengers. The test

methods cited in the guidelines include recommended test methods from the American

Society for Testing and Materials and the Federal Aviation Administration. These

guidelines were codified into full regulations in May 1999.

The flammability of the interior materials (floor and wall covering, seat upholstery,

and cushioning) in sleeper car No. 32035 was reviewed. According to testing records

provided by Amtrak, the materials met the standards. Testing of materials directed by the

Volpe Center produced similar findings.28

Two materials, both samples of foam found in the headrests on the sleeper car,

were not among the materials tested before the accident. These materials were tested,

however, as part of the Safety Boardís investigation. The blue headrest foam is a

28 The National Institute of Standards and Technology (NIST), under the direction of the FRA and the

Volpe Center, is currently conducting research involving the fire safety of rail passenger vehicles. The NIST

project is investigating the use of alternative fire testing methods and computer hazard analysis models to

identify and evaluate approaches to passenger train fire safety. Amtrak provided the materials used in this

testing.
Factual Information 39 Railroad Accident Report

polyurethane foam manufactured by Chestnut Ridge. Kevlar cloth is bonded to the foam

before installation in order to make it fire retardant. The blue foam, with the bonded

Kevlar cloth, was tested by Amtrak. The white headrest foam, tested by the Safety Board,

is known as IMPAK SR-10 LS. It is a rebonded foam that is manufactured by STX, Inc.

The foam is bonded with fire-retardant cotton muslin to protect it from wear and dust. The

white headrest foam used in the testing came from the accident car. 

The FRA requires that the flame spread index, which is the measure of surface

flammability, fall below 25. The index was 162.6 for the white headrest foam, which is not

in widespread use and is being phased out. Since the accident, Amtrak has provided test

records indicating that the flame spread index for the blue foam (with cover) was 21.86.

To meet FRA standards for smoke generation, the smoke generation rating must

fall below 100 after 1.5 minutes of exposure to a heat source, and below 175 after 4

minutes of exposure. After 1.5 minutes of exposure to a flame source, both types of foam

fell within the standard of 100. At 4 minutes of exposure to a flame, the measure rose to

249.5 for the white headrest foam.

Smoke generation tests were also conducted using exposure to a nonflame heat

source. During these tests, after 1.5 minutes exposure, the white headrest foam measured

slightly over the limit at 105.9, while the blue foam sample measured below the limit.

After 4 minutes, the white headrest foam was again above the limit at 292.2, while the

blue foam sample measured below the required limit.

Locomotive Event Recorders

The recorders installed in both locomotives involved in the accident were Pulse

Electronics solid-state permanent core memory (PCM) modules. The locomotive

manufacturer integrates the PCM module into a locomotive data bus that provides data to

the recorder system. The PCM records data onto non-volatile solid-state memory. Each

parameter is recorded at a rate of 1 Hz (once per second), with the exception of the horn

parameter, which is recorded at a rate of 10 Hz (10 times per second).

A PCM module was removed from the lead locomotive, Amtrak unit 807, on

March 16, 1999. Damage sustained by the locomotive prevented power from being

applied to the PCM system within the locomotive, which made it impossible to extract

data from the module while still in place. The module was removed and placed in another

Amtrak P-40 locomotive for readout. A representative of Amtrak used locomotive power,

recorder manufacturerís software, and a laptop computer to download the recorded

information onto a computer diskette.

Software developed by Pulse Electronics was used to transcribe the data and to

produce tabular data and data plots. Approximately 27 hours of locomotive data were

present on the recording, and the accident sequence was recorded without any data loss.

The tabular data indicate that the train was traveling about 79 miles per hour as it

approached the accident crossing and that the train horn was sounded when the train was
Factual Information 40 Railroad Accident Report

more than 3,000 feet from the accident crossing and again when it had approached to

within about 1,600 feet of the crossing. The timing of these horn soundings is in

accordance with the placement of the 3-crossing whistle post located north of the St.

George Road crossing.

A Pulse Electronics PCM module was also removed from the second locomotive,

Amtrak unit 829. Unit 829 was exposed to post-impact fire for just over 90 minutes, and

the group determined, after observation of the PCM, that readout of the unit was not

possible at the scene. Amtrak shipped the unit to the Safety Boardís laboratory in

Washington, D.C., for further examination and possible readout. Further examination,

however, determined that the fire had destroyed the solid-state memory, and that

extraction of the data was not possible.

Accelerometers are not fitted on locomotives, and accelerations are not recorded

on locomotive event recorders. Without the benefit of acceleration data, all event recorder

data were examined to estimate a time of impact. At 9:47:12 p.m., the locomotive current

dropped from 368 amps to zero, and, at 9:47:13 p.m., the recorded throttle position

changed from 8 to idle. Train speed decreased 79 mph to 78 mph during this time. In

addition, the locomotive engineer testified that upon seeing the tractor-trailer on the track

and determining that impact was imminent, he reduced the throttle to idle and braced

himself for the collision. Based on these data, the earliest the collision could have

occurred was 9:47:12 p.m. Between 9:47:13 and 9:47:14 p.m., train speed decreased from

80 mph to 69 mph. Such a deceleration cannot be accomplished with typical locomotive

performance and likely occurred when the train struck the tractor-semitrailer. Thus, based

on all available information, the time of impact was most likely between 9:47:12 and

9:47:14 p.m.

Accident Reconstruction and Computer Simulations

The Illinois State Police Accident Reconstruction Team conducted acceleration

tests using an exemplar vehicle driven in what was described as a normal manner,

traveling from the point where most vehicles leave after securing the loads, and continuing

through the crossing. The test vehicle, starting from a full stop, reached an average speed

of 23 mph at the crossing gate in an average of 34.6 seconds. Using these data, the

calculated average acceleration over that distance was .977 feet/sec2

.

The accident truck measured about 77 feet in length, and the distance from the

west crossing gate to a clear point beyond the accident track was about 18 feet. Thus, if the

truck were at the west gate, it would need to travel about 95 feet in order to reach a point

where no part of it or its cargo intruded on the space required by the train. Tests indicated

that, at a steady speed of 7 mph, the truck could have cleared the crossing in about 8.6

seconds. The Illinois State Police Accident Reconstruction Team attempted to determine

the average minimum time for the accident vehicle to clear the accident crossing from a

stopped position at the west crossing gate. In these tests, the exemplar truck accelerated

across the entire crossing. Timing began when the truck started to move and stopped when

the end of the overhanging steel rods passed the east crossing gate, a distance of about 118

feet. The exemplar truck took an average of 5.54 seconds to clear the crossing.
Factual Information 41 Railroad Accident Report

The Safety Board also conducted a computer simulation study to determine the

estimated speed of the truck at impact, the relative position of the truck as it crossed the

tracks, the amount of time it took the truck to traverse the crossing, and the timing of the

signal activation. The simulation was also used to help determine whether the truck-tractor

semitrailer could have safely stopped short of the crossing. A Human-VehicleEnvironment (HVE) system was used to conduct the computer simulation study. The HVE

System is a software package that includes several programs used by the Safety Board to

simulate certain aspects of the accident. The EDSMAC4 software program, for example,

was used to simulate the accident dynamics between the train and the truck and the

resulting trajectories at various initial speeds. The EDVDS software program was used to

determine the truckís maneuverability as it approached the crossing. Several other

programs were used to generate 3-dimensional computer models of various vehicles for

the simulations.

The HVE system was used to conduct hundreds of simulation scenarios and to

evaluate the effects of several variables. The simulations included the truck approaching at

speeds of 7 mph to 19.6 mph in the right lane, straddling the centerline, and maneuvering

into the left lane. The train was modeled as two locomotives, two locomotives and two

cars, and as two locomotives and two cars with the entire weight of the rest of the train on

the second car. The semitrailer was modeled to the end of the semitrailer and to the end of

the steel rebar. The gates were modeled with the signals and gates working properly, with

the signals and gates deploying late but clearing the tractor, and with the signals and gates

working properly except for the nearside gate, which remains in the upright position until

after the impact. Values such as the various surface frictions for the road, the crossing

timbers, the tracks, and the grass, as well as the inter-vehicle friction during contact, were

varied slightly.

The factors used to evaluate the relative merits of the individual simulations

included how close to the actual values were the beginning of the simulated tire marks, the

track of the tire marks, and the final rest positions of the truck tractor and the semitrailer.

The simulation that best matched the physical evidence had the truck approaching at 15

mph, then slowing to 7 mph and maneuvering into the left lane before turning right across

the crossing and heading for the right shoulder.

The EDSMAC4 simulations highlighted that the truck tractorís right front tire had

to be off the right side of the pavement, beyond the crossing, at impact; that the truckís

semitrailer and the train were at an 87.1-degree angle at impact; that the truckís left tire on

the fourth axle had to be about 1 foot to the left of the centerline at impact; and that the

tractor spun counterclockwise after impact. This was all validated with physical evidence.

The Illinois State Police traffic crash reconstruction report stated:

The furthest east point that the truck tractor reached was indicated by a tire print

made in the dirt of the shoulder by the right steer axle. The furthest east point of

the tire print was approximately four feet east of the actual tire at final position.
Factual Information 42 Railroad Accident Report

The report also stated:

Viewing the tractor from the rear, a scrub mark was visible under the vehicle. The

mark began at the south edge of McKnight Road and continued onto the shoulder

through the dirt and gravel. The mark was not at a right angle to the roadway. Dirt

and grade crossing stone was piled up on the side of and at the base of right tires

on axle 2 and 3Ö. This scuff mark started as a ëVí just west of the west rail of the

passing track, approximately one foot north of the centerline of the roadwayÖ.the

trailer would have been at or near perpendicular to the IC crossing at the time of

impact.

Since the road was at about an 8-degree angle relative to the tracks, the truck was

at an angle on the road at impact as if turning right to avoid the descending far side gate or

the train.

Results similar to the EDSMAC4 were obtained by another analyst using m-smac,

another software program developed by a different software company. Both EDSMAC4

and m-smac were based on the Simulation Model for Automobile Collisions (SMAC),

which was developed by the National Highway Traffic Safety Administration in the

1970s.

The approach of the truck to the crossing was simulated using the EDVDS

software. EDVDS is used to model the vehicle dynamics of a commercial vehicle. Due to

off-tracking (the tracking of the rear wheels inside the front wheels at low speeds), the

truck had to be maneuvered into the left-hand lane and onto the left apron for the truckís

fourth axle left tire to be a foot north of the centerline of the roadway while the right front

tractor wheel was off the right side of the pavement. When the truck straddled the

centerline, the truckís fourth axle left tire was about 2 feet to the right (south) of where the

tire mark was found.

Some of the other highlights of the simulations were as follows:

ï At higher speeds, such as 15.6 mph, the EDSMAC4 simulations did not

replicate the arch of the tire mark left on the crossing. The m-smac simulations

could match the marks with changes in the weight of the train, vehicle interfriction, and stiffness of the semi-trailer.

ï If the truck straddled the centerline, the gates would have to be delayed for at

least 9.9 seconds to clear the tractorís exhaust stack but not more than 14

seconds for the east gate to be down at impact and broken inward by the

spinning rebar.

ï In the most likely simulation, where the truck goes around the gate, the gates

had no effect on the simulation, so the west gate could have been up or down. 
Factual Information 43 Railroad Accident Report

Other Information

Emergency Preparedness

Local Agencies. The emergency management agency for the county in which this

accident occurred was the Kankakee County Emergency Services and Disaster Agency

(ESDA). According to ESDA officials, when a relatively minor emergency occurs, the

local responding agencies, such as the Bourbonnais Fire Protection District, may control

the incident scene with minimal or no assistance from the ESDA. When a larger

emergency occurs that requires assistance from additional, nearby municipalities, the

ESDA may provide increased assistance, including the coordination of communications

and logistics. The ESDA provided such services to the emergency responders on the night

of the accident.

The ESDA has developed several formal response plans to manage numerous

aspects of response to various sorts of disasters (for example, chemical spills, hazardous

materials accidents, etc.). The ESDA plan includes immediate response, incident

command system (ICS) implementation, condition assessment, triage, delivery of

emergency services, communications, and transportation of the injured.

The fire/rescue emergency service responsible for the location in which the

accident occurred was the Bourbonnais Fire Protection District. According to the district

officials, the agency is able, through mutual aid requests, to call on additional support

from neighboring communities; it is also available to provide mutual aid assistance to

other communities. A part of the Kankakee Valley Firefighterís Association (KVFA), the

Bourbonnais Fire Protection District uses the formal documented fire/rescue emergency

response plan organized and adopted by the KVFA. When implementing this emergency

response plan, the Bourbonnais Fire Protection District employs a standard ICS to manage

the on-scene response. Under the ICS, the chief of the department or a designated alternate

serves as the incident commander, who has the overall authority and responsibility for all

resources used in the incident response. The Bourbonnais Fire Protection District

implemented the ICS in response to the accident, and the district chief was designated as

the incident commander.

Before the accident, the ESDA organized and executed emergency response

exercises simulating various event scenarios; the Bourbonnais Fire Protection District

participated in these drills. The exercise scenarios in previous years had included one

involving a railroad accident but not one in which passenger train equipment was

involved. Critiques conducted following several of these drills identified significant

problems with on-scene operational communications. Because these problems were not

resolved before the accident, according to the Bourbonnais Fire Protection District chief,

communications difficulties hampered the emergency response efforts at the grade

crossing accident scene.

Amtrak. According to the requirements of 49 CFR 239.101(a)(5), every passenger

railroad and every railroad hosting passenger train service must jointly adopt a single

emergency preparedness plan describing the procedures to be followed in an emergency.
Factual Information 44 Railroad Accident Report

The regulation requires that each railroad organize a liaison with emergency responders in

order to familiarize these emergency responders with the passenger railroad equipment,

facilities, and communications interfaces.

In order to implement the emergency response liaison element of its emergency

preparedness plan, Amtrak provides, upon request, an instructional information/training

program for those local agencies most likely to respond to an Amtrak emergency. This

training program includes training materials such as manuals and an instructional

videotape. In addition, Amtrak offers on-site instruction sessions during which a

representative of the railroad gives a training course directly to the local emergency

response agencies. This training course is provided whenever possible. Amtrak, however,

notes that it operates through regions that encompass about 15,000 emergency response

agencies and that, because of limited resources, on-site training is not provided for all

agencies that may be called upon to respond to an Amtrak emergency. For example, before

the accident, Amtrak had not provided any on-site instruction or training to the

Bourbonnais Fire Protection District or to other Kankakee County emergency responders.

Amtrak did conduct passenger train emergency response training in Kankakee County,

Illinois, after the accident, on November 12 and 13, 1999.

Current Status of McKnight Road Crossing

The Illinois Commerce Commission, in conjunction with the Village of

Bourbonnais, has considered making improvements to the grade crossings at McKnight

Road and at St. George Road, immediately to the north of McKnight Road. In

October 2000, temporary highway signals were put in place at St. George Road and were

interconnected with the railroad grade crossing signaling system. In addition, pre-signals,

designed to stop highway traffic before reaching the crossing, were installed for eastbound

traffic on St. George Road. Further improvements to St. George Road are planned,

including relocating the crossing 500 feet east of the existing crossing to eliminate the

need for traffic signal interconnection, widening the crossing, upgrading the crossing

warning devices, and installing a barrier median at the crossing. Before agreeing to these

changes, the Illinois Commerce Commission had an engineering diagnostic team evaluate

the crossing. Costs for the relocation and reconfiguration of the St George Road crossing

will be borne by the Illinois Department of Transportation. For the widening of the

crossing and the upgrade of crossing warning devices, about $215,700 will be paid from

the grade crossing protection fund, monies provided to the States by the Federal Highway

Administration. Any additional costs, including the cost of future maintenance, will fall to

the CNIC railroad.

According to the Illinois Commerce Commission, the Village of Bourbonnais is

considering closing the McKnight Road crossing and running an access road to a nearby

crossing, possibly St. George Road. According to the Township of Bourbonnais road

commissioner, the closing of the crossing is a long-term objective. In the meantime, the

township has installed temporary median barriers at the McKnight Road crossing. 
45 Railroad Accident Report

Analysis

General

The Safety Board found no indication that the engineer at the controls of train 59

was acutely or chronically fatigued. Further, he successfully passed a physical

examination 5 months before the accident. There were no problems with his vision or

hearing based on a hearing and vision examination in September 1996. He stated that he

had not used alcohol or drugs, including over-the-counter and prescription medication,

before the accident. The engineer said that he was not overtasked/overworked on the

evening of and before the accident, nor was he distracted or preoccupied before the

accident. The event recorder recorded activities performed by the engineer showing the

whistle being sounded, the throttle being manipulated, and the air brakes being applied on

the train. These activities occurred continuously up to the point of collision.

The train crew satisfactorily performed the required pretrip tests of the train and

reported no deficiencies, nor did they report any problems during the operation of the

train. In addition, postaccident testing revealed no track defects in the accident vicinity,

and crewmembers did not mention track conditions as a concern. The Safety Board tested

the trainís air brakes and reviewed equipment maintenance records for the 60 days before

the accident. No defects were found that would have indicated that the equipment was

impaired at the time of collision.

The mechanical subsystems on the semitrailer could not be tested. The individual

components were tested or examined, however, to determine their condition and to

determine compliance with the applicable Federal regulations. No discrepancies in the

brake system, the suspension system, or the tires were noted. The truck tractor did not

receive any collision damage, and postaccident inspection and testing revealed no

discrepancies with the steering, suspension, chassis, powertrain, drivetrain, tires, or brake

systems on the tractor.

The National Weather Service in Chicago, Illinois, reported unrestricted visibility

at 10 statute miles and no precipitation at the time of the accident. The temperature was

reported to be 33° F. The train engineer and other witnesses indicated that visibility was

good, other than the darkness of the night. The cool temperatures were not mentioned as

having an effect on the accident.

Postaccident drug and alcohol testing of the truckdriver was conducted by the

motor carrier in accordance with Federal requirements. The results of these tests were

negative for illicit drugs and alcohol. Further analysis of the driverís blood and urine

revealed the presence of prescription medications and nonprescription medications. These

drugs either have not been shown to have adverse effects on performance or were taken

more than 24 hours before testing.
Analysis 46 Railroad Accident Report

Although no speed studies were available for McKnight Road, the postaccident

testing established that a truck could reasonably be expected to reach about 23 mph when

approaching the crossing after leaving the parking lot. For a crossing with an estimated

85th percentile approach speed of 25 mph, the MUTCD recommends that the highway/rail

grade crossing circular advance warning sign (W10-1) be placed a distance of 250 feet

before the crossing. For stop or deceleration conditions, the distances are even less. The

circular advance warning sign for eastbound traffic at McKnight Road was 512 feet away.

The 320-foot distance of the railroad crossing sign on the westbound approach from the

most easterly rail is also excessive when the MUTCD criteria are applied. Also, in that

location, the sign was only 70 feet from the westerly curb line of the nearest intersection,

Route 50, a ìTî intersection. At this distance, the driver of a turning vehicle hardly has

sufficient time to recognize the sign. A sign placed closer to the crossing should be more

effective in alerting a driver to the crossing. However, most drivers using this highway are

probably aware of the crossing and the sign primarily serves as a reminder to them.

The Safety Board therefore concludes that the following factors did not cause or

contribute to the accident: the physical condition or actions of the engineer of Amtrak

train 59; the mechanical condition of the train and the condition of the tracks; railroad

operating procedures and policies; the mechanical condition of the truck-tractor

semitrailer; the equipment making up Amtrak train 59; weather; alcohol, drugs, or

prescription medications; and the location of traffic control signs on the approach to the

grade crossing.

Truckdriver Performance

The truckdriver stated that as he approached the grade crossing on the night of the

accident, he saw the crossing signal lights illuminate. He said that because of his

proximity to the crossing when the lights activated, he had to quickly choose a course of

action from several options available to him: (1) he could brake hard and stop short of the

crossing but risk a dangerous load shift, (2) he could brake moderately and prevent the

load from shifting but risk advancing too far and fouling the tracks, or (3) he could

accelerate in an attempt to clear the tracks before the train arrived. In the truckdriverís

estimation, the best course of action was the last, to accelerate across the tracks before the

train arrived.

The truckdriver, therefore, maintained that the amount of time between activation

of the signal lights and the arrival of the train was insufficient to permit him to clear the

crossing. Staff reviewed the driverís testimony, and all of the postaccident tests and

analyses, to determine if the preponderance of evidence supports the driverís contention,

or if an alternative scenario could explain the actual events leading up to the accident.

Specifically, staff examined some of the key facts reported by the truckdriver, including:

the truckís speed before the collision; the truckís distance from the tracks when the red

crossing lights first came on; the operation of the crossing lights and crossing gate; and the

time that the driver first observed the crossing lights.
Analysis 47 Railroad Accident Report

Truck Speed

According to the truckdriver, his vehicle was in sixth gear and traveling about

20 mph at the time of the collision. The Illinois State Police Accident Reconstruction

Team conducted acceleration tests using an exemplar vehicle driven in what was described

as a normal manner, traveling from the point where most vehicles leave after securing the

loads and continuing through the crossing. The test vehicle, starting from a full stop,

reached an average speed of 23 mph at the crossing gate in an average of 34.6 seconds.

Using these data, the calculated average acceleration over that distance was .977 feet/sec2.

If the accident vehicle was operated in the same manner as the test vehicle, then the speed

cited by the truckdriver is consistent with the test results. In testing conducted by the

Illinois State Police, it was not possible to negotiate a similar truck around the gates at

speeds in excess of 15 mph.

Statements by two eyewitnesses, however, suggest that the accident truckdriver

applied his brakes while on the approach to the crossing. The truckdriver who was putting

a tarpaulin on his load in the parking lot stated that he heard the accident truckís jake brake

as it rolled by him on the roadway and that he saw the truckís brake lights come on. In

addition, the motorist who pulled out onto the roadway following the truck stated that he

saw the brake lights on the truck illuminate as the truck approached the crossing. In his

statement at the Safety Boardís public hearing, this witness also estimated that the truckís

speed before reaching the crossing was about 7 mph.

Pivoting around its fifth wheel connection upon impact, the semitrailer left tire

marks on the pavement and rail. The Safety Board used data about the location, angle, and

length of these tire marks to provide a benchmark for the validity of its computer

simulations. When the simulated truck was run at various speeds, the simulated tire marks

created were compared with the locations of the real ones, and the final rest position of the

simulated truck was compared with the truck tractorís actual final rest position. Two

analysts used differing software to generate the simulations; both came up with similar

results. Based on these simulations, it was determined that the existing tire marks were

more likely to have been left by a vehicle traveling between 7 and 14 mph, not 20 mph.

Based on both the eyewitness testimony and the simulation analyses, the Safety

Board concludes, therefore, that the accident-involved truck-tractor semitrailer was

probably traveling between 7 and 14 mph at the time of the collision.

The crossing warning signal system was programmed to activate about 26 seconds

before the arrival of a train at the crossing. If the truck had been approaching the crossing

at an average speed of 7 to 8 mph, it would have been about 284.5 feet from the crossing

26 seconds before impact. At 14 mph, the truck could have traversed more than 500 feet in

26 seconds; this would place the truck near the driveway from which it entered McKnight

Road. The speed of the accident truck undoubtedly varied as it accelerated, then braked on

its course down McKnight Road, and, therefore, the truck was likely to be somewhere

between 285 and 500 feet from the crossing when the lights were programmed to begin

flashing.
Analysis 48 Railroad Accident Report

Warning Signal System Activation

The only scenario under which the time from activation of the warning signals

until the arrival of the train would not have allowed the truckdriver to either stop his truck

short of the crossing or accelerate safely across would involve some malfunction of the

signal warning system. A malfunctioning system that first activated when both the train

and truck were close to the crossing, for example, could conceivably place a driver in a

situation in which, regardless of the speed he was traveling, he would not be able to take

measures to prevent the accident. However, as discussed previously, postaccident testing

of the lights found no evidence that they were not operating as designed.

Statements made by eyewitnesses to the accident, however, raised the question of

whether the grade crossing signal worked as designed. According to the accident-involved

truckdriver, the lights began flashing just as he reached the crossing. He also indicated that

he did not believe he could safely stop the truck before reaching the tracks, and therefore

he accelerated in an attempt to get the truck across the tracks. The motorist who followed

the accident truck stated that he also thought that the lights began flashing just as the truck

reached the crossing, and added that the crossing gate came down on the back of the truck.

The truckdriver in the parking lot indicated that he did not see the lights flash or the gates

deploy. The security guard in the steel plantís scale house said he saw the lights flash

about 5 seconds before the trainís arrival at the crossing, and his wife, who was visiting

him, stated that when she first noticed the lights flash, she thought the truckís cab was on

the crossing.

In an attempt to determine the relative accuracy of these eyewitness accounts, the

Safety Board reexamined the function of the grade crossing signaling system and studied

the vehicle dynamics to determine whether the collision could have occurred as they

indicated.

Based on accident reconstruction scenarios, a truck of the kind involved in this

accident, traveling at a steady speed of 7 mph, could have cleared the crossing in about 8.6

seconds. Tests in which an exemplar truck was stopped at the west gate and then

accelerated across the crossing showed that the truck could have completely cleared the

crossing in an average of 5.54 seconds. If, then, the warning signals at the crossing

provided the designed 26 seconds of warning time before the arrival of the train and if the

truck had been at the approach to the crossing when the signals activated, the truck would

have had more than ample time to successfully traverse and clear the crossing.

Although recollections of some witnesses seemed to indicate that the signal

activation may not have occurred sufficiently in advance of the arrival of the train, several

factors suggest that those recollections may not accurately reflect the timing of the event.

First, the crane operator said he saw the signal lights flashing before he turned to complete

a task that was verified to require about 15 to 20 seconds. He said that when he finished

the task and looked back at the crossing, he saw the collision. These statements suggest

that the flashing lights provided more warning time than the truckdriver and other

witnesses said they remembered.
Analysis 49 Railroad Accident Report

Secondly, the on-scene testing of the signal system found no evidence of a failure

in the electronic components of the system. And, finally, the event recorder for the signal

system indicated that the signals did indeed provide about 26 seconds of warning time.

The recorder was tested on-scene, then removed and tested at the manufacturerís facility.

The laboratory testing showed that the recorder was operating within the parameters

specified for a newly manufactured product; this suggests that the events were recorded

accurately and that the GCP 3000, the computer governing the timing of the signal

activation, functioned as designed. The Safety Board concludes, therefore, that the grade

crossing signal lights began flashing at least 26 seconds before the trainís arrival at the

McKnight Road grade crossing.

Crossing Gate Operation

Crossing gates typically begin to lower within 4 to 5 seconds after the warning

lights activate. Although data downloaded from the signal system event recorder for the

accident crossing showed that a lowering of the gates was initiated, the information

captured by the event recorder does not include the actual position of the gates.

Investigators therefore conducted a number of tests to determine whether, in this accident,

a failure or delay occurred in the lowering of one or both gates.

Investigators examined the circuit diagrams for the gates to determine what could

cause both gates to be delayed or prevented from lowering while the lights are flashing.

Two possibilities were considered: (1) failure within the gate control circuit, or (2)

simultaneous failure of the motor control relay in each gate arm mechanism. Maintenance

and inspection records for this crossingís signals show no indications of a history of

failure within the gate control circuit. In addition, the on-scene field testing conducted

following the accident revealed no problems with the gate control circuit, and the XRPR

relay on that circuit functioned normally in cutting power to the motor control relays that

hold the gates in the upright position. Any failure of both gates, therefore, would have

required the simultaneous failure of two separate motor control relays that did not have a

history of failure and that functioned normally in postaccident tests. Finally, the pattern of

breakage evident on the tip of the east (far side) gate is consistent with that gate having

been fully down at the time of impact.

With a simultaneous failure of both gates to lower properly thus ruled out,

investigators examined a failure mode in which the lights activate at the appropriate time

but one gate (in this case, the west, or approach side, gate) fails to deploy. According to

the circuit diagram, in order for this to happen, a failure within only one of the gate arm

mechanisms would be required.

According to downloaded signal event recorder data, the GCP 3000 warning signal

system computer detected the presence of train 59 at 9:46:59 p.m. Four seconds later, the

XRPR crossing control relay de-energized, which in turn de-energized and opened both

gate motor control relays. When these relays open, power is removed from the gate holdclear mechanisms and the gates are released. At that point, if the gates are operating

normally, the gate motor activates to control the gravity-assisted descent of the gates.
Analysis 50 Railroad Accident Report

Laboratory testing of the west (approach side) gate arm mechanism revealed no

sign of improper operation; nevertheless, investigators recognized that some latent or

intermittent defect could still exist within the mechanism. The Safety Board therefore

conducted laboratory examinations of the mechanical and electromechanical components

of the west gate arm mechanism to determine whether such a failure could be detected.

Motor Control Relay. If, for any reason, the motor control relay within the gate

arm mechanism was not de-energized or if once de-energized, it failed to open, the gate

motor would not receive power, nor would the hold-clear mechanism release the gate. The

data downloaded from the signal event recorder indicated that the gate motor for both

gates did energize. If for any reason the energized motor had then failed to operate, the

gates would still have descended by gravity once the hold-clear mechanism released. The

fact that the gate motors did energize indicates that the motor control relays functioned as

designed. Also, operational tests showed that the motor control relay for the west gate

functioned as designed. The electrical test showed that the operating parameters of the

damaged relay were still within limits specified for new equipment, and the mechanical

teardown found no evidence of foreign material transfer that might have caused the relay

to stick when de-energized.

Bearings. The main shaft bearings bore Brinell marks or indentations indicating

that at some time the bearing components struck one another with considerable force.

When the marks on the inner race, which is affixed to the shaft, were lined up with the

marks on the outer race, which is affixed to the outer casing, they indicated that the gate

was in a fully upright position (in regard to the relative positions of the gate and the shaft)

when the marks were made. Thus, if it could be determined conclusively that the Brinell

marks occurred as a result of this accident, the orientation of the marks could serve as

evidence of the gate position at the time of the collision.

The indentations found on the signal mast base clearly show that, during the course

of the collision between the train and the truck-tractor semitrailer, a bundle of rebar struck

the signal mast. This secondary impact was severe enough to move the entire mast, as well

as the concrete foundation to which it was bolted. Additionally, the impact fractured the

cast metal base of the pole. Much of the impact energy to the base was most likely

absorbed by the impact-induced fracture of the base and pole mounting. Laboratory

analysis of both the wooden gate arm and the cast metal counterweight arm fracture

surfaces suggest that they may have broken as a result of a vibratory flexural motion that

could have been induced by the impact to the base. While such motion could also have

loaded the bearing, no clear evidence exists to indicate it could cause the Brinell marks

observed on the bearing. The bearing races are fabricated from hardened steel. The pole is

fabricated from a ductile alloy of significantly lower strength and hardness than the

bearing races. Since the pole material at the bearing shaft interface showed no signs of

permanent deformation or damage, it is not possible to conclude that any mechanism

existed for transmitting enough impact energy from the pole to the bearing to cause the

Brinell marks.

Several additional facts also make it impossible to declare positively that the

Brinell marks were caused during the accident. First, Brinell marks can be inflicted on a
Analysis 51 Railroad Accident Report

bearing during installation if the bearing is dropped or stuck by a hammer or other object,

or they may occur while the bearing is being pressed onto the shaft. Second, although the

accident crossing had been equipped with crossing gates since 1968, records do not exist

that would indicate whether the mechanism had been replaced one or more times before

the accident or whether the mechanism that was in place on the day of the accident had

received a blow from a previous accident or from another cause at any time before this

accident. Third, because the mechanism was lifted, transported, and placed in an outside

storage area where it lay for several months after the accident, the possibility that the

damage occurred after the accident cannot be entirely discounted. Finally, although the

impact to the base was sufficient to cause fracture of the counterweight arm, it is not

known if the impact generated sufficient force in the proper direction to cause the

brinelling damage to the bearings.

Gate Arm Light Bulb Filaments. The filaments of the accident-involved gate arm

light bulbs were distorted in a direction parallel with the roadway. Investigators conducted

tests on similar bulbs to determine whether the direction of this distortion could offer clues

about the position of the gate at the time the filaments were distorted. These test results

proved inconclusive as they showed that filament deformation in a given direction could

come as a result of the filamentsí being acted upon by forces from several different

directions.

Driverís Actions. The Safety Board also considered the driverís actions as a

possible clue to the functioning of the crossing gates. The driver stated that he did not

notice the movement of the gates at the crossing (whether they were in the process of

moving, or whether they were in an upright or down position) as he approached the tracks.

According to the truckdriver, when he first saw the crossing lights flashing, he quickly

decided to accelerate, and he focused his attention primarily on moving the truck straight

ahead and across the tracks.

Computer simulations conducted by the Safety Board as part of this accident

investigation provided evidence that disputes the truckdriverís account. As mentioned

earlier in the discussion of the truck speed, two different analysts used different software

programs to simulate the accident, generating hundreds of simulations. The simulations

were not only used to estimate the truck speed, they were also used in an attempt to

determine whether the physical evidence, particularly the tire marks, were more likely

created by a truck driving more or less straight through the crossing with a delayed gate or

by a truck driving around lowered gates. The analyses indicated that in order for the truck

to have made the tire marks found at the scene, it must have been at an angle such that, at

the time of impact, the right front tire of the tractor was near its final position and the left

front axle of the trailer was to the left of the highway centerline.

Every highway vehicle experiences, to some degree, a phenomenon called

offtracking, in which the rear wheels follow a shorter radius path than the front wheels

when the vehicle is turning at low speeds. As noted earlier, the accident truck was likely

moving at a relatively low speed (7 to 14 mph). Offtracking is of particular concern with

longer vehicles, because the rear portion of the vehicle can strike roadside objects such as

signs unless the driver compensates by swinging the front of the vehicle along a wider
Analysis 52 Railroad Accident Report

turning path. The simulations conducted by the Safety Board indicate that, when the

offtracking characteristics of the accident truck are considered, the best fit of the observed

data (most significantly, the tire marks) occurs when the truck tractor is moving toward the

right-hand side of the road to recover from having been fully in the left lane. In other

words, the simulations indicate that the data are best matched when the truck is driven as

though to avoid lowered or lowering crossing gate arms.

To summarize, no repeatable malfunction of any of the gate arm mechanismís

components, whether individually or in combination, was found during testing. Thus, the

Safety Board was unable to reproduce any fault that would have caused a failure or a delay

in the lowering of either crossing gate. The Safety Board therefore concludes that, based

on the signal system tests and physical evidence, including evidence of the truckís position

at the time of impact, both crossing gates likely lowered as designed as the accident truck

approached the crossing.

Where highway/railroad grade crossing signal systems are equipped with event

recorders, it is often possible to put in place a method to detect whether the gate has

descended fully. The method of detection is sometimes as simple as an electrical contact

made when the gate reaches the horizontal. Such a system may aid signal maintainers and

inspectors, enabling them to see clear recorded evidence of signal malfunctions before

accidents occur. However, the accident crossing in Bourbonnais was not equipped with a

gate position detection system.

The Safety Board notes that all modern electronic warning signal systems may be

equipped easily with signal event recorders and that almost all the warning systems

installed as new or as upgrades by class I railroads are equipped with such devices. These

recorders may or may not, however, capture the actual deployed gate position for those

systems that are equipped with gates. For example, while all the warning systems installed

or upgraded by the CNIC Railroad since 1995 have been equipped with signal event

recorders, only after the Bourbonnais accident did the company specify that its newly

purchased systems be required to capture gate position (horizontal or other than

horizontal). According to CNIC officials, about 60 to 75 of the companyís crossing signal

event recorders now record this data. Some other class I railroads, notably the Burlington

Northern/Santa Fe, also use event recorders that capture gate position information.299

In the view of the Safety Board, determination of actual crossing gate position is

important not only because it facilitates accident reconstruction but also because it can

help railroads detect and correct warning system defects or anomalies before they become

a hazard to the public. While, as noted above, some railroads already recognize the

benefits of gate position information and are installing event recorders that capture such

data, other railroads are less aggressive in pursuing this option as they install new or

upgraded systems. The FRA, while not requiring that grade crossing warning systems be

equipped with signal event recorders, can nonetheless play a role in ensuring that those

systems that are in place provide gate position information. The Safety Board believes,

29 The Burlington Northern/Santa Fe Railroad event recorders that capture gate position indicate

whether the gate is vertical (between 83 and 90 degrees) or horizontal (between 0 and 5 degrees).
Analysis 53 Railroad Accident Report

therefore, that the FRA should, for all railroads that install new or upgraded grade crossing

warning systems that include crossing gates and that are equipped with event recorders,

require that the information captured by those event recorders include the position of the

deployed gates.

In the interim, nothing prevents railroads that have not done so from following the

lead of other carriers in regard to obtaining gate position information for those crossings

equipped with new or upgraded warning systems that have both gates and event recorders.

The Safety Board therefore believes that all class I and regional railroads should, for all

their new and upgraded grade crossing warning systems that include crossing gates and

that are equipped with event recorders, ensure that the information captured by those event

recorders includes the position of the deployed gates.

Fatigue

The truckdriver customarily worked a 5-day work-week, Monday through Friday,

delivering two loads of steel daily from the plant at Bourbonnais to Dayton, Ohio. These

deliveries were accomplished within the Federal duty-rest requirements in effect at the

time of the accident.

The driver reported that he was off duty for approximately 52 hours on Friday,

Saturday, and Sunday, the weekend before the accident occurred on Monday evening. He

reported receiving 2 full nights of sleep at home on both Friday and Saturday night, and

about 2 hours, 30 minutes of sleep at home on Sunday evening. He awoke at midnight and

reported for duty at 2:00 a.m. on Monday, the day of the accident, and delivered one load

of steel to Dayton during the morning.

According to the reconstruction of the truckdriverís 72-hour history, following

delivery of his steel shipment to Dayton, he loaded a shipment of forklifts in Canal

Winchester, Ohio. He transported the forklifts to Peotone, Illinois, arriving at about 7:00

p.m. At this point, the truckdriver was not in conformity with Federal duty-rest

requirements (discussed below). After unloading, the driver returned home.

In a revised statement, the truckdriver changed his initial account of the amount of

sleep he had received on the day of the accident, reporting that he had slept for a total of 4

hours, 45 minutes, most in the sleeper berth but with a small amount of sleep at home

immediately before the accident trip. Therefore, combining the 2 hours, 30 minutes, of

rest the driver reported he received on Sunday night before reporting to work with the 4

hours, 45 minutes, he reported receiving on Monday would suggest that he accumulated

7 hours, 15 minutes, of fragmented sleep before the accident. A close examination of the

various trip segments on Monday, however, suggests he had even less sleep. Based on

Safety Board calculations of trip times and lengths, it is unlikely that the driver could have

completed the majority of his trip in the amount of time he reported. The calculations

indicate the trip would have taken about 1 hour and 45 minutes longer than the driver

reported, thus allowing that much less time to sleep.
Analysis 54 Railroad Accident Report

In addition, according to the accounts of the shippers and receivers of his trip

loads, it appears that the truckdriver participated in the loading and offloading of his

cargo, thus further reducing the time available for sleep. The amount of time needed to

complete loading and offloading activities is not known, which prevents an exact

determination of the amount of time the driver had for sleep on Monday. But based on all

available evidence, the truckdriver accrued only 3 to 5 hours of fragmented sleep in the 38

hours (Sunday and Monday) before the accident.

Fragmented sleep, such as that experienced by the driver in this accident, has been

associated with driver fatigue and a resulting decrease in performance. Research has

shown that sleep accumulated in short time blocks is less refreshing than sleep

accumulated in one long time period.30 Safety Board research indicates that the duration of

the most recent sleep period, the amount of sleep during the previous 24 hours, and split or

fragmented sleep patterns are among the most critical factors leading to fatigue-related

accidents.31 As indicated above, the truckdriverís cumulative sleep total for the 24 hours

before the accident was about 3 to 5 hours, well below the average of 6.9 hours slept by

truckdrivers involved in fatigue-related accidents examined by the Safety Board.

Truckdrivers involved in non-fatigue-related accidents averaged 9.3 hours of sleep within

the previous 24 hours. The Bourbonnais accident-involved truckdriverís most recent sleep

period lasted about 1 to 2 hours. In the Safety Boardís study, the fatigue-related-accident

truckdrivers had slept an average of 5.5 hours, and the non-fatigue-related-accident

truckdrivers had slept an average of 8.0 hours in their most recent sleep periods before

their accidents.

Research32 has demonstrated how sleep loss is associated with decrements in

decision-making, vigilance, reaction time, memory, psychomotor coordination, and

information processing (for example, fixation on certain material to the neglect of other

information). An operator may react slowly to information, may incorrectly process the

importance of the information, may find decision-making difficult, or may make poor

decisions. This performance degradation can be a direct result of sleep loss and the

associated sleepiness and can play an insidious role in the occurrence of an operational

incident or accident.

It is likely that the small amount of sleep the truckdriver had obtained resulted in

decrements in one or more of the following: his decision-making, vigilance, reaction time,

memory, psychomotor coordination, or information processing. These decrements may

have caused the truckdriver to miss the onset of the grade crossing signal indication and to

preclude his braking in time to avoid stopping on the tracks. Such an event is consistent

30 Dinges, D.F., 1989, ìThe Nature of Sleepiness: Causes, Contexts, and Consequences,î In: Stunkard,

A.J.; Baum, A., Perspectives in Behavioral Medicine: Eating, Sleeping, and Sex, Hillsdale, NJ: Lawrence

Erblaum Associates: 147-79, Chapter 9 (p. 147).

31 National Transportation Safety Board, Factors That Affect Fatigue in Heavy Truck Accidents,

Highway Safety Study NTSB/SS-95/01 (Washington, D.C.: NTSB, 1995).

32 Rosekind, M., Gregory, K., Miller, D., Co, E., Lebacqz, V. Analysis of Crew Fatigue in AIA

Guantanamo Bay Aviation Accident. Fatigue Countermeasures Program, Flight Human Factors Branch,

NASA Ames Research Center.
Analysis 55 Railroad Accident Report

with the driverís contention that the grade crossing warning lights did not activate until he

was very close to the crossing and may have lead to the truckdriverís risky actions well

after the warning system had actually been activated.

Despite the fact that the truckdriver was suffering from fatigue at the time of the

accident, investigators could not determine the extent to which fatigue accounted for his

performance. Investigators could, however, determine that at least some of the

truckdriverís statements lacked credibility and that the accident did not happen exactly as

the truckdriver described it.

As noted above, recorded evidence and the statements of the crane operator

indicated that the signal lights began flashing more than 20 seconds before the arrival of

the train at the crossing. If the signal lights had thus begun to activate just as the truck

reached the crossing, as the truckdriver stated, he would have had more than enough time

to clear the crossing, even if he had had to go around lowered or lowering gates to do so.

The truckdriver said he did not notice the position of the crossing gates. But

eyewitnesses stated that the truck crossed the centerline of the roadway as it attempted to

navigate the crossing. Also, computer simulations indicated that the truck, when struck,

was moving from the left lane back into the right lane. This movement suggests either that

one or both gates were down when the truck began to move over the crossing or that the

truckdriver was anticipating the lowering of the gates and was maneuvering to avoid them

when the collision occurred.

Based on all available evidence, the most likely scenario is that the signal lights

began flashing as the truck was some distance from the crossing. The possibility exists

that the truckdriver may not have noticed the flashing signal lights when they first

activated. But the fact that those lights were seen by a crane operator who was as much as

600 yards away from, and at an angle to, the crossing makes it unlikely that they would

have not been seen by the truckdriver only a few hundred feet away unless the driver was

either sleep-deprived or distracted in some way. But according to witnesses, the

truckdriver reduced throttle, which applied the jake brake, and he may have applied the

brakes and further slowed, which suggests that he did, indeed, see the lights. At some

point, as he continued to approach the crossing, the truckdriver made a judgment that he

could clear the crossing before the train arrived. Perhaps he was misled by the normal

delay in the lowering of the gates, or he may have assumed that the train was a slowmoving freight train rather than a passenger train.33 Whatever the basis of the truckdriverís

judgment and whether or not it was affected by fatigue, by the time the truck reached the

crossing, most of the warning time had elapsed, and the arrival of the train was imminent.

Considering the speed he was traveling and the length of his truck, the truckdriver had no

chance to avoid a collision once he committed to attempting to cross in front of the train.

33 The truckdriver was probably not aware that the signal system was designed to provide a fixed

warning time regardless of the speed of an approaching train.
Analysis 56 Railroad Accident Report

The Safety Board therefore concludes that the truckdriver had ample time to safely

stop his truck and avoid an accident, but likely as a result of fatigue, he failed to respond

appropriately to the signals and instead decided to attempt to cross ahead of the train.

Motor Carrier Performance

On the day of the accident, the truckdriver exceeded the work hours specified in

the Federal Motor Carrier hours-of-service rules.34 Since the truckdriverís last consecutive

8-hour off-duty period, he had been driving for more than 13 hours (10 hours are allowed)

and had been on-duty for almost 20 hours (15 hours are allowed). Furthermore, at the time

of the accident, the truckdriver was beginning another trip that would have put his

duty/rest cycle even more out of balance and would have aggravated his already fatigued

condition.

Originally, the Safety Board was led to believe that on the day of the accident, the

truckdriver had transported the first load of steel and had returned home empty. According

to this scenario, he was off duty at home and returned to work shortly before the accident

to pick up his second load of steel of the day. Had this scenario been accurate, the driver

would have been just within the hours-of-service rules, having driven for about 10 hours,

then having about 8 hours of off-duty time before driving again. However, during the

investigation, a back-haul was discovered. This back-haul load resulted in the driverís

exceeding the hours-of-service limitation and led to his fatigued condition. Melco

indicated that although it had scheduled the two loads of steel, the company was unaware

of the back-haul. However, investigators found that the company (Country Supply) that

arranged the load was closely associated with Melco, and loads similar to the accident

back-haul load were frequently transported by Melco drivers, including the accident

driver. Furthermore, Melco routinely billed Country Supply for the transportation services

associated with those loads. Although Melco denied knowledge of the back-haul load, it

appears that Melco probably knew about the load and may even have assigned it to the

driver.

Unfortunately, investigators were unable to determine how the loads on the day of

the accident were scheduled. Melco used assorted assignment and scheduling practices

that are not uncommon among motor carriers that primarily employ owner-operators.

Therefore, although Melco may have assigned all of the loads on the day of the accident,

the Safety Board could not determine if the company was involved in scheduling the backhaul load for movement on the morning of March 15.

If the accident truckdriver self-scheduled the back-haul load without the

knowledge of Melco, he could have done so with some confidence that its effect on his

duty/rest schedule would not be noted by Melco, since weaknesses in Melcoís driver

oversight program made it unlikely that Melco would scrutinize the driverís duty status to

monitor conformance with hours-of-service rules. Two days after the accident, a DOT

34 Federal Motor Carrier Safety regulations, Part 395.3 Maximum Driving Time.
Analysis 57 Railroad Accident Report

compliance review discovered that Melco had not kept duty status records for about half

of its drivers, and this lapse was sufficient to result in an unsatisfactory rating for that

category. Therefore the Safety Board concludes that Melco failed to provide driver

oversight sufficient to detect or prevent driver fatigue as a result of excessive driving or

on-duty periods.

Flammability of Interior Materials

The flammability of the interior materials of the sleeper car, including the floor and

wall covering, seat upholstery, and cushion materials, was reviewed. The Safety Board

evaluated two types of foam present in the seat headrests for flame spread and smoke

generation. The white headrest foam, which is not in widespread use and is being phased

out, met the requirements for smoke generation following 1 minute of testing but did not

meet them after 4 minutes. The white headrest foam also did not meet the requirements for

flame spread. The blue headrest foam, when tested with the Kevlar cloth cover normally

attached in order to act as a fire barrier, met the standards for flame spread. The blue foam

passed the smoke generation requirements at 1 and 4 minutes, even without the Kevlar

cloth cover.

During the accident, the front half of the sleeper car was severely damaged by fire.

The extensive fire damage was consistent with long exposure to high temperatures.

Examination of the wreckage indicated that, following the collision, the front half of the

car was in close contact with a fully developed pool fire that occurred when fuel spilled

from the second locomotive ignited.

The remaining sleeper car half, where it was not collapsed too much to be

assessed, showed little fire damage. There was some discoloration of the interior window

surfaces, and slight sooting of the interior materials in the areas closer to the impact site in

the middle of the car. Close to the impact area, there was evidence of burned interior

materials. Because the evidence of fire damage was concentrated around the sections of

the car exposed to the external fuel fire and was not spread generally throughout the car,

the Safety Board concludes that the flammability and smoke generation properties of the

trainís interior materials did not contribute significantly to the spread of fire.

Emergency Response

The effectiveness of emergency response is affected by the preparations made by

local jurisdiction responders and by the railroads involved. Because Amtrak is not able to

provide on-site training to every emergency response agency within the territories through

which it operates, these agencies often face the prospect of responding to a passenger train

emergency without any real knowledge about the particular hazards passenger trains may

present. In other words, local emergency responders may not know how to gain access to

an overturned locomotive or passenger car, may not know where in cars to search for
Analysis 58 Railroad Accident Report

trapped occupants, and may not be aware of the quantities of diesel fuel available to fuel a

fire. Before this accident, neither the Bourbonnais Fire Protection District nor other

Kankakee County emergency responders had been provided on-site instruction or training

in responding to such emergencies.

The Braidwood Fire Department officer, who arrived about 50 minutes after the

first emergency responder, was familiar with petrochemical fires and recognized almost

immediately that a large amount of foam was necessary to combat the blaze. Upon

receiving concurrence from the incident commander, he called for heavy foam tanker

trucks to come from a local chemical plant. The foam tanker arrived and was set up about

1 hour later, and within a few minutes of this equipment beginning to apply foam, the fire

was extinguished. Before the arrival of the Braidwood officer, on the other hand, the

incident commander had directed firefighting operations that had proved ineffective at

either extinguishing the flames or at keeping the fire away from the sleeper car in which

occupants were entrapped. The Safety Board concludes that because of insufficient

training in responding to railroad emergencies or inadequate/inappropriate resources, or

both, the Bourbonnais Fire Protection District was not prepared to respond effectively to a

train accident involving a significant diesel fuel fire.

Even though modern locomotives, such as the ones involved in this accident, are

designed with improved protection for fuel tanks, the possibility of a fuel leak and fire is

present anywhere a major railroad accident occurs. The Safety Board believes that

Amtrak, in fulfilling its Federal mandate to help prepare emergency responders to respond

to an accident involving Amtrak equipment, should emphasize to those responders the

possibility that such an accident could result in large quantities of burning diesel fuel and

urge them to be prepared to respond to this specific hazard. The Safety Board further

believes that the International Association of Fire Fighters and the International

Association of Fire Chiefs should inform their memberships of the circumstances

surrounding this accident and of the need for responders to prepare for train accidents that

may result in significant diesel fuel fires.

Train Evacuation Effort

When the first Bourbonnais Fire Protection District personnel arrived at the

accident scene, they saw that some 30 to 35 employees of Birmingham Steel had

responded to the scene had begun the rescue effort. These steel plant employees had cut a

hole in the chain-link fence separating the wreckage site from the steel plantís property

and had brought a number of hand-held fire extinguishers and ladders from the plant to

combat the flames. While some of the steel plant employees applied the fire extinguishers

to the flames, others entered some of the damaged passenger cars to extricate entrapped

passengers. These efforts were continued for an hour or more, when the steel plant

employees were relieved by Bourbonnais Fire Protection District personnel, who

continued the extrication efforts.
Analysis 59 Railroad Accident Report

The Amtrak National Operations Center told emergency responders that the train

could be carrying as many as 400 passengers. When Amtrak management arrived on

scene, this number was lowered to 196. Several days after the accident, Amtrak identified

the number of ìconfirmedî passengers to be 198. However, it was several more days

before a complete list of passenger names was developed by Amtrak, and its accuracy

remained in question. It was only later, when investigators were able to compare that list

with a list provided by the Illinois State Police, that the correct passenger count of 207

could be determined.

The difficulty in determining the number of passengers involved may have put

emergency responders at unnecessary risk. As the fire progressed, entry into some of the

overturned cars became more hazardous, but rescuers repeatedly risked their own safety,

returning to the cars in order to help the trapped occupants. They stopped only when the

fire made it impossible for them to help any further. In some cases, rescue workers were

able to identify locations where people were trapped. In other cases, however, because of

the confusion over the number of passengers actually aboard the train, they may have been

searching for unaccounted-for passengers who did not really exist.

Amtrakís passenger train emergency preparedness plan contained no elements

addressing the need to provide an accurate count of train occupants to local emergency

responders in the event of a passenger train emergency. Nor do the Federal regulations

require such a section. As the confusion following this accident shows, however, the lack

of a reasonably accurate count can lead to rescue personnel risking their lives needlessly.

In September 1994, the Safety Board published a report on its investigation into an

Amtrak accident in Mobile, Alabama.35 In this report, the Safety Board highlighted the

value of providing emergency responders with an accurate count of train occupants,

recommending that Amtrak:

R-94-7

Develop and implement procedures to provide adequate passenger and crew lists

to local authorities with minimum delay in emergencies.

Amtrak responded with a plan to develop a satellite and long-distance messaging

system between long-distance trains and corporate offices. One benefit of this proposed

new communications system would be improved passenger manifests. Following a 1997

Amtrak accident in Kingman, Arizona,36 Amtrak indicated to the Safety Board that such

manifests were unlikely to become possible on unreserved trains, because of the many

stops these trains make. The railroad did state, however, that computer systems exist that

35 National Transportation Safety Board, Derailment of Amtrak Train No. 2 on the CSXT Big Bayou

Canot Bridge Near Mobile, Alabama, September 22, 1993, Railroad Accident Report NTSB/RAR-94/01

(Washington, D.C.: NTSB, 1994).

36 National Transportation Safety Board, Derailment of Amtrak Train 4, Southwest Chief, on the

Burlington Northern Santa Fe Railway near Kingman, Arizona August 9, 1997, Railroad Accident Report

NTSB/RAR-98/03 (Washington, D.C.: NTSB, 1998).
Analysis 60 Railroad Accident Report

would enable them to provide such a list for reserved trains. As a result of these

communications, the Safety Board closed the 1994 recommendation and issued a new

recommendation urging Amtrak to:

R-98-58

Expedite the development and implementation of a passenger and crew

accountability system on reserved trains.

Based on Amtrak responses in 2000, in which the railroad stated that it had

implemented a system to account for all train occupants, the Safety Board classified this

recommendation ìClosedAcceptable Actionî in December 2000.

 Roadway Geometry/Highway Condition

The wearing surface of the pavement was in good condition. The 5/8-inch to

1-inch depressed north shoulder indicates that there has been some use of the shoulder by

vehicular traffic. This depression may have been caused by either railroad maintenance

vehicles parking on the shoulder to service the signal bungalow in the northwest quadrant

of the crossing or by large vehicles driving around lowered gates. According to tests

conducted by the Safety Board and the Illinois State Police, an exemplar truck, loaded as

the accident vehicle, would likely infringe on the shoulder area in the process of

maneuvering around lowered gates. After the accident, the Illinois State Police took a tire

print from this area; it did not match any tire pattern on any of the accident truckís tires.

Railroad pavement markings, consisting of an X, the letters ìRR,î certain

transverse lines, and ìno passingî double solid yellow centerlines, were required by the

MUTCD; none of these were in place. One intent of pavement markings is to inform the

motorist that he is approaching a railroad crossing. But the truckdriver, because of his

experience on this route, was familiar with the crossing and did not need to rely on

pavement markings. Therefore, the Safety Board concludes that the lack of railroad

pavement markings probably had no effect on the truckdriverís driving behavior.

As a result of its investigation of a March 14, 1982, accident in Mineola, New

York,37 in which an impaired driver crossed the centerline to go around lowered gates and

was struck by a Long Island Railroad commuter train, the Safety Board recommended that

the Federal Highway Administration (FHWA):

37 National Transportation Safety Board, Long Island Railroad, Commuter Train/ Ford Van Collision,

Mineola, New York, March 14, 1982, Railroad/Highway Accident Report NTSB/RHR-82/02 (Washington,

D.C.: NTSB, 1982).
Analysis 61 Railroad Accident Report

H-82-052

Review the effectiveness of guidelines in the Manual on Uniform Traffic Control

Devices (MUTCD) on the use of traffic divisional islands to deter motorists from

driving around lowered railroad crossing gates.38

The FHWA responded that the subject would be covered in the Railroad-Highway

Grade Crossing Handbook in 1984 (actually published in 1986). The handbook (a new

edition is being prepared) states that ìtraffic divisional islands may be used at crossings on

multi-lane roadways to prevent motorists from driving around a lowered gate.î The

recommendation was classified ìClosedAcceptable Actionî in 1987.

The Swift Rail Development Act, passed in 1991, required that regulations be

established to require that a trainís horn be sounded on the approach to public highway/rail

grade crossings except when supplemental safety measures fully compensate for the

absence of audible warning, when there is no significant risk to persons, or when it is not

practical (as is the case during certain backing movements). In response to the Swift Act,

on January 13, 2000, the FRA published a notice of proposed rulemaking (NPRM)

entitled ìUse of Locomotive Horns at Highway-Rail Grade Crossings.î In this NPRM, the

FRA indicates that the supplemental safety measures that would be considered adequate

would include (1) four-quadrant gates, (2) medians or channelization devices at gated

crossings, (3) paired one-way streets, (4) temporary crossing closure (for example,

crossing closed at night), or (5) the use of photo-enforcement technology. The NPRM also

indicated that in addition to the supplemental safety devices, all crossings within a quiet

zone had to be equipped with train-activated lights and gates. The period for comments on

the NPRM closed May 26, 2000; the FRA has received more than 2,300 comments. To

give the public an opportunity to provide oral comments, the FRA also conducted a series

of public hearings on the matter in California, the District of Columbia, Florida, Illinois,

Indiana, Massachusetts, Ohio, and Oregon. According to the FRAís Office of Safety, the

rule is expected to be completed by spring 2002.

Given the reasons detailed above, the Safety Board is pleased to note that the

Village of Bourbonnais has installed temporary median barriers in McKnight Road in the

vicinity of the grade crossing until such time as the crossing can be closed.

Reducing Traffic Violations at Grade Crossings

The Safety Board is pleased to note the steps that have been taken in Illinois and

nationwide to improve grade crossing safety through better enforcement of traffic laws at

grade crossings. For example, not only do new Federal regulations promulgated in 1999

prevent States from granting a provisional, probationary, or other temporary license to a

CDL holder whose CDL has been suspended, the new regulations require CDL suspension

for a driver convicted of a grade crossing violation. Further, current Illinois State law

38 The 2000 edition of the MUTCD states that channelization may be used between opposing lanes on

all approaches when four quadrant gates are used.
Analysis 62 Railroad Accident Report

provides that motorists convicted of grade crossing violations may be fined up to $500. In

the case of CDL holders, both the fine and the potential loss of income (by CDL

suspension) should provide an incentive for CDL holders to exercise greater caution at

grade crossings.

But while greater penalties for grade crossing violations are welcomed, their

deterrent effect can be undermined if motorists perceive that they face little threat of

detection or apprehension. To address this problem, some States, localities, and other

entities have developed innovative ways of approaching grade crossing enforcement. For

example, Operation Lifesaver 39 organizations in several States have conducted programs

to place law officers on trains and at stationary locations along the trainsí routes. The

officers at the stationary locations stop and ticket those motorists identified by on-board

officers as having violated traffic control devices at crossings. While programs such as this

can increase law enforcement awareness of grade crossing violations, in some States they

are conducted only sporadically. As noted above, motorists who encounter what is, at best,

limited and intermittent enforcement of traffic laws at grade crossings may conclude that it

is possible to violate those traffic laws with some impunity.

To increase the likelihood that grade crossing violations will not go undetected,

some States, municipalities, and railroads have turned to the use of photo enforcement at

grade crossings. In use throughout the world for more than 40 years,40 photo enforcement

technology such as that used for identifying and citing those who run red lights has

recently been adapted for use at grade crossings. In 1995, for example, the Los Angeles

Metropolitan Transportation Authority (MTA) began a photo enforcement program that

has been credited with reducing by almost 50 percent the number of grade crossing

violations detected at 17 gated crossings along the Metro Blue Line route.41 Encouraged by

the programís success, the MTA is planning to expand its use of photo enforcement by

installing six more crossing video systems during the first half of 2002.

A grade crossing photo enforcement pilot program has also recently been

established in Illinois. The Illinois General Assembly in 1996 required the Illinois

Commerce Commission to conduct a study of the effectiveness of photo enforcement at

grade crossings. According to the commission, it selected three grade crossings in DuPage

County, Illinois, for the test. Because of difficulties in establishing contracts, as well as

construction problems, the three sites were completed at different times. Fully functional

in January 2000, photo enforcement at the grade crossing in the city of Wood Dale

achieved a 47-percent decrease in the number of violations between January and

September 2000. This crossing, which had formerly experienced three to four collisions

per year had only one collision in the pilot programís first 13 months of operation. Photo

39 Operation Lifesaver is a not-for-profit organization that provides information about grade crossing

safety to motor vehicle operators, as well as to law enforcement agencies, through safety education

programs.

40 <http://www.photocop.com> is a non-commercial web site providing research and technical

information about photo enforcement.

41 Metropolitan Transportation Authority, New Signs, Cameras Reducing Accidents, Illegal Crossings on

Metro Blue Line, MTA News <http://www.mta.net/press/stakeholders/scoop_stories/leftturn_trains.htm>.
Analysis 63 Railroad Accident Report

enforcement at the grade crossing in the city of Naperville was functional in July 2000,

and the crossing has seen a 51-percent reduction in the number of violations.

According to the FRA, the State of North Carolina has established, with Federal

assistance, a program to eliminate grade crossing hazards as part of an attempt to develop

a high-speed rail corridor within its borders.42 Known as the Sealed Corridor Initiative, the

program calls for the improvement or closure of every crossing along the proposed

corridor. The plans include installation of four-quadrant gates, longer gate arms, and

median barriers as well as video enforcement of grade crossing traffic laws. The testing of

the video enforcement project has recently begun.

In the Safety Boardís 1998 grade crossing safety study,43 the Safety Board noted

the sporadic nature of traffic law enforcement at passive crossings (those without trainactivated warning devices). In order to promote better law enforcement at passive

crossings, the Safety Board issued the following safety recommendation to the Secretary

of Transportation:

H-98-29

Provide Federal highway safety incentive grants to States to advance innovative

pilot programs designed to increase enforcement of passive grade crossing traffic

laws.

After the DOT indicated that it had made inquiries to State and local law

enforcement for suggestions regarding enforcement programs, the Safety Board classified

Safety Recommendation H-98-29 ìOpenAcceptable Response.î

Whereas this recommendation was directed to enforcement at passive grade

crossings, this accident, as well as subsequent violations recorded at the McKnight Road

and St. George Road grade crossings, indicates that grade crossings equipped with trainactivated warning devices could also benefit from innovative enforcement programs such

as the photo enforcement programs employed in several locations. The Safety Board

therefore believes that the DOT should provide Federal highway safety incentive grants to

States to advance innovative pilot programs designed to increase enforcement of grade

crossing traffic laws at both active and passive crossings. This recommendation replaces

Safety Recommendation H-98-29, which has been reclassified ìClosedSuperseded.î

42 <http://www.fra.dot.gov/o/hsgt/states/NC2.htm> on January 16, 2002.

43 National Transportation Safety Board, Safety at Passive Grade Crossings, Volumes I and II, NTSB

Safety Study Nos. NTSB/SS-98/02 (Vol. I: Analysis) and NTSB/SS-98/03 (Vol. II: Case Summaries)

(Washington, D.C.: NTSB, 1998).
64 Railroad Accident Report

Conclusions

Findings

1. The following factors did not cause or contribute to the accident: the physical

condition or actions of the engineer of Amtrak train 59; the mechanical condition of

the train and the condition of the tracks; railroad operating procedures and policies;

the mechanical condition of the truck-tractor semitrailer; the equipment making up

Amtrak train 59; weather; alcohol, drugs, or prescription medications; and the

location of traffic control signs on the approach to the grade crossing.

2. The accident-involved truck-tractor semitrailer was probably traveling between 7 and

14 mph at the time of the collision. 

3. The grade crossing signal lights began flashing at least 26 seconds before the trainís

arrival at the McKnight Road grade crossing. 

4. Based on the signal system tests and physical evidence, including evidence of the

truckís position at the time of impact, both crossing gates likely lowered as designed

as the accident truck approached the crossing.

5. The truckdriver had ample time to safely stop his truck and avoid an accident, but

likely as a result of fatigue, he failed to respond appropriately to the signals and

instead decided to attempt to cross ahead of the train. 

6. Melco Transfer, Inc., failed to provide driver oversight sufficient to detect or prevent

driver fatigue as a result of excessive driving or on-duty periods.

7. The flammability and smoke generation properties of the trainís interior materials did

not contribute significantly to the spread of fire. 

8. Because of insufficient training in responding to railroad emergencies or

inadequate/inappropriate resources, or both, the Bourbonnais Fire Protection District

was not prepared to respond effectively to a passenger train accident involving a

significant diesel fuel fire. 

9. The lack of railroad pavement markings probably had no effect on the truckdriverís

driving behavior. 
Conclusions 65 Railroad Accident Report

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the collision between Amtrak train 59 and a truck tractor-semitrailer combination vehicle

at the McKnight Road grade crossing in Bourbonnais, Illinois, was the truckdriverís

inappropriate response to the grade crossing warning devices and his judgment, likely

impaired by fatigue, that he could cross the tracks before the arrival of the train.

Contributing to the accident was Melco Tranfer, Inc.ís failure to provide driver oversight

sufficient to detect or prevent driver fatigue as a result of excessive driving or on-duty

periods.
66 Railroad Accident Report

Recommendations

As a result of its investigation of the March 15, 1999, grade crossing accident in

Bourbonnais, Illinois, the National Transportation Safety Board makes the following

safety recommendations:

New Recommendations

To the U.S. Department of Transportation:

Provide Federal highway safety incentive grants to States to advance

innovative pilot programs designed to increase enforcement of grade

crossing traffic laws at both active and passive crossings. (H-02-1)

To the Federal Railroad Administration:

For all railroads that install new or upgraded grade crossing warning

systems that include crossing gates and that are equipped with event

recorders, require that the information captured by those event recorders

include the position of the deployed gates. (R-02-1) 

To All Class I Railroads:

To All Regional Railroads:

For all your new and upgraded grade crossing warning systems that include

crossing gates and that are equipped with event recorders, ensure that the

information captured by those event recorders includes the position of the

deployed gates. (R-02-2)

To the National Railroad Passenger Corporation:

In fulfilling your Federal mandate to help prepare emergency responders to

respond to an accident involving Amtrak equipment, emphasize to those

responders the possibility that such an accident could result in large

quantities of burning diesel fuel and urge them to be prepared to respond to

this specific hazard. (R-02-3)
Recommendations 67 Railroad Accident Report

To the International Association of Fire Fighters:

To the International Association of Fire Chiefs:

Inform your membership of the circumstances surrounding the emergency

response to the March 15, 1999, grade crossing accident in Bourbonnais,

Illinois, and of the need for responders to prepare for train accidents that

may result in significant diesel fuel fires. (R-02-4)

Recommendations Reclassified in This Report

To the U.S. Department of Transportation:

H-98-29

Provide Federal highway safety incentive grants to States to advance innovative

pilot programs designed to increase enforcement of passive grade crossing traffic

laws.

Safety Recommendation H-98-29, previously classified ìOpenAcceptable Responseî is 

reclassified ìClosedSupersededî in the ìReducing Traffic Violations at Grade 

Crossingsî section of this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARION C. BLAKEY

Chairman

CAROL J. CARMODY

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: February 5, 2002

69 Railroad Accident Report

Appendix A

Investigation

The National Transportation Safety Board was notified at 11:52 p.m., eastern

standard time, on March 15, 1999, of a collision and derailment involving an Amtrak

passenger train and a truck tractor-semitrailer combination vehicle in Bourbonnais,

Illinois. The investigator-in-charge, Board Member John Goglia, and other members of

the Safety Board investigative team were dispatched from Washington, D.C.,

headquarters, and from the Chicago, Illinois; Atlanta, Georgia; and Los Angeles,

California, field offices. Upon arriving at the scene, investigative groups were established

to study railroad operations, motor carrier operations, track, highway, signals, railroad

mechanical, highway vehicle, survival factors, railroad human performance, highway

human performance, locomotive event recorders, and hazardous materials issues. A

separate group was established to coordinate the many witness interviews. 

The Safety Board was assisted in the investigation by the Federal Railroad

Administration, the Illinois Commerce Commission, the National Passenger Railroad

Corporation, the Canadian National/Illinois Central Railroad, the Brotherhood of

Locomotive Engineers, the United Transportation Union, the Bourbonnais Fire Protection

District, the Illinois State Police, the Village of Bourbonnais Police Department, Melco

Transfer, Inc., and Alstom Signaling, Inc.

Hearings

The Safety Board held a public hearing, chaired by Member George Black, in

Chicago, Illinois, on September 13-15, 1999. Parties to the hearing included the Federal

Railroad Administration, the Federal Highway Administration, the National Railroad

Passenger Corporation, the Canadian National/Illinois Central Railroad, the Illinois

Commerce Commission, the Brotherhood of Locomotive Engineers, the United

Transportation Union, and Melco Transfer, Inc.