Collision of Amtrak Passenger Train 371 and Norfolk

Southern Railway Company Freight Train 23M

Chicago, Illinois

November 30, 2007

Accident Report 

NTSB/RAR-09/01 

PB2009-916301 

National 

Transportation 

Safety Board 

NTSB/RAR-09/01 

PB2009-916301 

Notation 7989A 

Adopted March 31, 2009 

Railroad Accident Report 

Collision of Amtrak Passenger Train 371 and Norfolk Southern 

Railway Company Freight Train 23M 

Chicago, Illinois 

November 30, 2007

National 

Transportation 

Safety Board 

490 L’Enfant Plaza, S.W. 

Washington, D.C. 20594
National Transportation Safety Board. Year. Collision of Amtrak Passenger Train 371 and Norfolk 

Southern Railway Company Freight Train 23M, Chicago, Illinois, November 30, 2007. Railroad 

Accident Report NTSB/RAR-09/01. Washington, DC. 

Abstract: On Friday, November 30, 2007, Amtrak (National Railroad Passenger Corporation) passenger 

train 371, consisting of one locomotive and three passenger cars, struck the rear of a standing Norfolk 

Southern Railway Company freight train near Chicago, Illinois. The forward portion of the Amtrak 

locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and 

five crewmembers were transported to hospitals; two passengers and one crewmember were subsequently 

admitted. The weather was clear, and the temperature was 30o F. Estimated damage was $1,299,000 

As a result of its investigation of this accident, the Safety Board identified the following safety issues: 

wayside signal indication training and proficiency programs, crewmember communication and action in 

response to operating concerns, and inadequate locomotive cab emergency egress and rescue access. 

As a result of its investigation of this accident, the National Transportation Safety Board makes 

recommendations to the Federal Railroad Administration, Amtrak, the Association of American 

Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive 

Engineers and Trainmen, the United Transportation Union, and the American Public Transportation 

Association. 

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. 

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available publications also may be obtained from the website or by contacting: 

National Transportation Safety Board 

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490 L’Enfant Plaza, SW 

Washington, DC 20594 

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

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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. 
Railroad Accident Report 

Contents 

Figures........................................................................................................................................... iii

Acronyms and Abbreviations ..................................................................................................... iv

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

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

Accident Synopsis............................................................................................................................1 

Accident Narrative...........................................................................................................................1 

Injuries .............................................................................................................................................5 

Damage ............................................................................................................................................5 

Amtrak Car 35008 ....................................................................................................................6 

Amtrak Car 34054 ....................................................................................................................7 

Amtrak Car 34002 ....................................................................................................................7 

Personnel Information......................................................................................................................8 

Engineer....................................................................................................................................8 

Relief Engineer .......................................................................................................................10 

Equipment Information..................................................................................................................11 

Preaccident Inspections and Maintenance..............................................................................12 

Postaccident Inspections.........................................................................................................12 

Signal Information .........................................................................................................................12 

Operations Information..................................................................................................................13 

CSX Transportation................................................................................................................13 

Norfolk Southern ....................................................................................................................13 

Amtrak Yard ...........................................................................................................................13 

Management Oversight..................................................................................................................13 

Engineer Training ...................................................................................................................14 

Crew Resource Management Training ...................................................................................15 

Meteorological Information...........................................................................................................17 

Toxicological Information .............................................................................................................17 

Emergency Response.....................................................................................................................17 

Local Emergency Response....................................................................................................17 

Crew Extrication.....................................................................................................................20 

Disaster Preparedness ....................................................................................................................20 

Crew Training.........................................................................................................................20 

Emergency Responder Training .............................................................................................21 

Testing and Examination of Seat Mount Studs..............................................................................21 

Event Recorder Information ..........................................................................................................21 

Analysis .........................................................................................................................................23

Exclusions......................................................................................................................................23 

Train Crew’s Actions.....................................................................................................................23 

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Railroad Accident Report 

Amtrak Crew Training and Qualifications .............................................................................26 

Train Signals ..................................................................................................................................27 

Positive Train Control....................................................................................................................28 

Survival Factors .............................................................................................................................29 

Emergency Response..............................................................................................................29 

Extrication of Locomotive Crew ............................................................................................30 

Appliance Securement............................................................................................................31 

Seat Pedestal Securement .......................................................................................................31 

Conclusions...................................................................................................................................32

Findings..........................................................................................................................................32 

Probable Cause.............................................................................................................................32

Recommendations........................................................................................................................34

Appendix A...................................................................................................................................36

Investigation...................................................................................................................................36 

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Railroad Accident Report 

Figures 

Figure 1. Map of Amtrak Train 371’s route and stops. (“X” indicates location of accident.)........2

Figure 2. Path of accident train. ......................................................................................................4

Figure 3. Amtrak locomotive resting on top of container on rear car of 

Norfolk Southern freight train. ........................................................................................................6

Figure 4. Seat pair 19-20.................................................................................................................8

Figure 5. Emergency response locations.......................................................................................19

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Acronyms and Abbreviations 

AAR Association of American Railroads 

Amtrak National Railroad Passenger Corporation 

CFR Code of Federal Regulations

CRM crew resource management 

CSX CSX Transportation 

EMS Emergency Medical Services 

FRA Federal Railroad Administration 

METRA Northeast Illinois Regional Commuter Rail Corporation 

MP milepost 

NORAC Northeast Operating Rules Advisory Committee 

psi pounds per square inch 

PTC positive train control 

National Transportation Safety Board iv
Railroad Accident Report 

Executive Summary 

On Friday, November 30, 2007, about 11:23 a.m., Amtrak (National Railroad Passenger 

Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck 

the rear of standing Norfolk Southern Railway Company freight train 23M near Chicago, 

Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the 

rear car of the freight train. Sixty-six passengers and five crewmembers were transported to 

hospitals; two passengers and one crewmember were subsequently admitted. The weather was 

clear, and the temperature was 30o F. Estimated damage was $1,299,000. 

The National Transportation Safety Board determines that the probable cause of the 

November 30, 2007, collision of Amtrak train 371 with the rear of Norfolk Southern Railway 

Company train 23M near Chicago, Illinois, was the failure of the Amtrak engineer to correctly 

interpret the signal at Englewood interlocking and Amtrak’s failure to ensure that the engineer 

had the competency to correctly interpret signals across the different territories over which he 

operated. Contributing to the accident was the relief engineer’s failure to immediately 

communicate to the engineer that he had miscalled the signal at Englewood and to stop the train 

when he did not respond to her expressed concern. Also contributing to the accident was an 

absence of effective crew resource management between the relief engineer and the operating 

engineer which led to their failure to resolve the miscalled signal prior to the collision. Further 

contributing to the accident was the absence of a positive train control system that would have 

stopped the Amtrak train when it exceeded restricted speed. 

As a result of its investigation of this accident, the Safety Board identified the following 

safety issues: 

• Wayside signal indication training and proficiency programs. 

• Crewmember communication and action in response to operating concerns. 

• Inadequate locomotive cab emergency egress and rescue access. 

As a result of its investigation of this accident, the National Transportation Safety Board 

makes recommendations to the Federal Railroad Administration, Amtrak, the Association of 

American Railroads, the American Short Line and Regional Railroad Association, the 

Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the 

American Public Transportation Association.

National Transportation Safety Board v
Railroad Accident Report 

Factual Information 

Accident Synopsis 

On Friday, November 30, 2007, about 11:23 a.m.,1 Amtrak (National Railroad Passenger 

Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck 

the rear end of standing Norfolk Southern Railway Company freight train 23M near Chicago, 

Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the 

rear car of the freight train. Sixty-six passengers and five crewmembers were transported to 

hospitals; two passengers and one crewmember were subsequently admitted. The weather was 

clear, and the temperature was 30o F. Estimated damage was $1,299,000. 

Accident Narrative 

The engineer and conductor initially went on duty at Chicago on November 29, 2007, at 

4:35 p.m. They were assigned to operate Amtrak train 370 from Chicago to Grand Rapids, 

Michigan. The crew arrived at Grand Rapids with the train and went off duty at 10:28 p.m. The 

following morning, November 30, the crew reported for duty at 5:50 a.m. and was assigned to 

Amtrak train 371, which was destined for Chicago. On the previous day, the crew had been on 

duty 5 hours 53 minutes; they had a rest period of 7 hours 22 minutes. Although 49 Code of 

Federal Regulations (CFR) Part 228 allows for an interim rest period, a rest period greater than 4 

hours but less than 8 hours requires that the hours of the original trip be counted toward the total 

of 12 hours of limited service. The crew had 6 hours 7 minutes until they would reach their 12-

hour limit at 11:57 a.m. 

Train 371 was scheduled to depart Grand Rapids at 6:35 a.m.; however, it departed 27 

minutes late because the cold weather had hampered the operation of a switch. The train departed 

New Buffalo, Michigan, the last scheduled passenger stop, at 10:37 a.m., and was an hour behind 

schedule due to in-transit delays. Concerned that the original crew of train 371 would not have 

enough duty time to reach Chicago, Amtrak called a relief engineer and a relief conductor to 

report for duty. This relief crew was transported to Hammond, Indiana, where the train made an 

unscheduled stop about 10:45 a.m. to pick up the relief crew. (See figure 1.) The relief conductor 

boarded a passenger car, and the relief engineer rode in the cab of the locomotive. 

The original engineer was permitted to work until 11:57 a.m. and opted to continue 

operating the train after the relief engineer came on board. The relief engineer sat in a seat on the 

left side of the locomotive cab. The relief engineer said that she did not specifically ask whether 

the engineer wanted her to operate the train. However, she did recall that the engineer had said 

he was going to be able to “run all the way into the terminal” and had added, “let’s hurry up and 

get on” and “let’s go.” 

 1

 All times are central standard time unless otherwise noted. 

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Railroad Accident Report 

Figure 1. Map of Amtrak Train 371’s route and stops. (“X” indicates location of accident.) 

As the Amtrak train approached Chicago, it entered an area that had a large number of 

freight trains. Approaching Englewood interlocking, which is milepost (MP) 516 and 7 miles 

from Union Station in Chicago, the Amtrak train was operating on track 1 when it passed another 

westbound train (Norfolk Southern freight train 667) that was stopped on track 2 east of 

Englewood interlocking. 

At Englewood interlocking, there was a red over yellow wayside signal aspect for 

Amtrak train 371, and the crossover switch was lined for the train to cross from track 1 to 

track 2. Beyond the interlocking, the engineer and relief engineer saw that an approaching freight 

train was stopped on track 1.

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Railroad Accident Report 

The track was owned by Norfolk Southern, and according to the Norfolk Southern 

operating rules, the red over yellow aspect was a restricting signal that required the Amtrak train 

to be operated at restricted speed. A Norfolk Southern freight train that was stopped ahead on the 

track was the reason for the restricting signal. Norfolk Southern’s operating rules for restricted 

speed required, in part, that the train not exceed 15 mph and that the train be operated so that it 

could be stopped within one-half the range of vision short of either a stop signal or a train that 

might be encountered on the track beyond the signal. 

The engineer said that when he saw the red over yellow signal, he called out slow 

approach2

 in the cab and announced slow approach on the radio3 to the conductor riding in one 

of the passenger cars. A slow approach signal would have required the engineer to not exceed 

30 mph and to be prepared to stop short of the next signal; a slow approach signal also would 

have conveyed that the section of track beyond the signal was not occupied. 

The relief engineer told investigators that after the engineer had miscalled the signal at 

Englewood, she had thought to herself, “... maybe [the engineer] just called it wrong but he 

knew it was a restricting.” She said that she had “wanted to see what he was going to do.” She 

also said, 

... when the vision came clearer, I could see it was a red over yellow which is a 

restricting, and when the engineer called slow approach, I started questioning 

what I knew of signals, and I started going through my head what all the signals 

are in the NS [Norfolk Southern] and what their aspects are. 

In the postaccident interview, the Amtrak relief engineer also said, “... [the] speed was 

still low while I was going through signals in my head.” The locomotive’s event recorder 

indicated that the engineer had slowed the train to 10 mph while traveling through the crossover 

switches from track 1 to track 2. When the train cleared on track 2, it accelerated to 25 mph until 

it cleared a permanent speed restriction (due to curved track) at MP 516.3. (See figure 2.) 

During the postaccident interviews, the crew noted that when the train was traveling 

through the crossovers, they had started a conversation about the job assignments they had 

received while working the extra board.4

 Once the train cleared the curved track at MP 516.3, the 

engineer accelerated the train to more than 40 mph. The relief engineer said that she had become 

uneasy about the speed of the train and that she had challenged the engineer. She said that she 

had asked the engineer what signal he had called at the Englewood interlocking. She said that he 

responded that it was a slow clear. (A slow clear signal would have allowed the engineer to 

accelerate to a maximum authorized speed of 40 mph after clearing the crossovers and the curve 

restrictions.) During postaccident interviews, the relief engineer said that she told the engineer, 

 2

 Postaccident signal testing determined that this signal had displayed a red over yellow aspect, which was a 

restricting signal, not a slow approach signal. 

3

 During postaccident interviews, the conductor on the train confirmed that he had heard the engineer’s 

announcement but, having not seen the signal, had no reason to doubt its accuracy. 

4

 The extra board is a group of employees, usually with low seniority, that fill open work assignments when 

needed. 

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Railroad Accident Report 

“You called a slow approach at Englewood, right? ... Even if it’s a slow approach, you have to 

be down to 30.”5

 

Figure 2. Path of accident train. 

Based on the event recorder data and the postaccident crew interviews, the rear of the 

standing Norfolk Southern freight train on track 2 came into view about a minute after the train 

was accelerated to 40 mph and while the crew was debating the last signal indication. The 

engineer reacted and started applying the brakes 8 seconds before the collision. The event 

 5

 In the Northeast Operating Rules Advisory Committee’s (NORAC’s) Rules, Terminology, Definitions, and 

Authorized Abbreviations, medium speed means not exceeding 30 mph. 

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Railroad Accident Report 

recorder showed that the brakes were quickly applied at several stages until the emergency 

application, which was made about 1 second before the Amtrak train struck the stopped Norfolk 

Southern train. The Amtrak train had slowed to 36 mph at impact. Almost 2 miles and about 

3 1/2 minutes after crossing from track 1 to track 2, the Amtrak train struck the rear car of the 

stopped Norfolk Southern train at MP 517.34. 

Injuries 

The Chicago Fire Department transported 66 passengers and 5 crewmembers to hospitals; 

111 passengers on the scene declined treatment. Of the 71 people transported, two passengers 

and one crewmember were admitted. The two admitted passengers sustained serious injuries as a 

result of the collision. The day after the accident, the crewmember was released from the 

hospital. According to Emergency Medical Services (EMS) records, 10 hospitals received the 

injured passengers and crewmembers. (See table 1.) 

Table 1. Injuries.

Injury Typea Train Crew Passengers Others Total 

Fatal 0 0 0 0 

Serious 0 2 0 2 

Minor 5 64 0 69 

Total 5 66 0 71 

a

Title 49 CFR 840.2 defines fatality as the death of a person either at the time an accident occurs or within 

24 hours thereafter. Title 49 CFR 830.2 defines serious injury as “an 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.” 

Damage 

When the Amtrak train struck the rear of the Norfolk Southern freight train, the Amtrak 

locomotive lifted off its leading truck and rode up onto the rear car, sliding over and crushing the 

rear corner of a container on the car. The locomotive came to rest on top of the container. (See 

figure 3.) 

The derailment did not damage the signals or track structure, except for two crossties that 

were marked by the wheels during the re-railing process; however, these crossties did not require 

replacement. 

The Amtrak locomotive was the only derailed piece of equipment. The leading truck 

assembly6

 ruptured the left front section of the fuel tank, and about 300 gallons of diesel fuel 

 6

 A locomotive truck assembly includes the wheels, the axles, the side frames, and the traction motors. 

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Railroad Accident Report 

spilled from the tank. Both front windows of the cab were dislodged during the collision. The 

rear window on the right side of the cab was shattered but still in its frame. 

Figure 3. Amtrak locomotive resting on top of container on rear car of Norfolk Southern 

freight train. 

Just inside the rear door to the cab from the engine room, the floor was lifted 7 inches and 

was arched upward in the cab. The engineer’s seatback was about 5 1/2 inches from the roof of 

the cab, the center seatback was about 2 1/2 inches from the roof, and the left seatback was 

touching the roof. Normally, the seatbacks are 23 inches from the roof. 

The three trailing Amtrak passenger cars—35008, 34054, and 34002, in order after the 

locomotive—remained on the rail, and the exteriors and undersides of the coaches were 

undamaged. The batteries, battery boxes, power cables, and side and end doors were intact and 

operable. The emergency lighting remained on in Amtrak car 35008 about 3 1/2 hours after the 

collision. The public address system was tested after the accident and determined to be 

functioning in all of the Amtrak cars. 

Amtrak Car 35008 

On the upper level of the car, two emergency windows on the right side had been 

removed. The snack area of the lower level of Amtrak car 35008 had both a microwave oven and 

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Railroad Accident Report 

an empty coffee pot that were found out of their holders and on the floor. The coffee pot’s 

dimensions matched its bracket; however, the microwave’s did not. The microwave oven was 13 

inches tall. Its bracket was 15 7/8 inches tall, and its holder was 14 1/4 inches tall. 

Amtrak Car 34054 

The upper level of Amtrak car 34054 had two emergency windows on the right side that 

had been removed. A seat pair is attached to the car via a wall mount and a pedestal, which is on 

the aisle side. The pedestal is attached to the floor track with two mount studs. The frame of seat 

pair 7-8 was not secured to the floor track; the two mount studs on the pedestal securing the seat 

frame to the track had been fractured. The seat frame was still secured to the wall mount. The 

frame of seat pair 19-20 was not secured to either the floor track or the wall mount. (See 

figure 4.) One mount stud on the pedestal securing the seat frame to the track had been fractured. 

Fractured mount studs were examined in the Safety Board’s Materials Laboratory as described 

later in this report. The rear connection from the wall mount was sheared. The forward 

connection had been pulled intact from the wall bracket. 

Amtrak Car 34002 

On the upper level of the car, two emergency windows (one on either side of the car) 

were open. The mirror in the dressing room of Amtrak car 34002 had shattered, and pieces were 

lying on the floor. The Americans with Disabilities Act ramp was stored and secured. In the 

seating portion of the lower level, one light cover was on the floor. 

The frame of seat pair 41-42 was not secured to the floor track. The forward mount stud 

stayed intact with the pedestal, but the rear mount stud had been fractured. The wall mount was 

still intact. 

The damage was approximately $1,299,000. (See table 2.) 

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Pedestal

Wall Mount

Figure 4. Seat pair 19-20. 

Table 2. Damage Estimates.

Item Damage 

Amtrak Equipment $1,200,000 

Lading 80,000 

Container 12,000 

Freight Car 7,000 

Total $1,299,000 

Personnel Information 

Engineer 

Training/Experience. The Amtrak engineer began his railroad career with the Norfolk 

Southern as a brakeman in October 2002. He was promoted to conductor on February 28, 2003. 

He left the Norfolk Southern on November 13, 2003, to pursue his own business. He never 

worked as an engineer while with the Norfolk Southern. 

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Railroad Accident Report 

On September 8, 2006, Amtrak hired him. He began an 8-week locomotive engineer 

training program at the Amtrak training facility in Wilmington, Delaware. He completed the 

training with an average score of 91 percent. 

He then took the on-the-job training, which consisted of operating trains under the 

supervision of a certified engineer. This on-the-job training typically lasts about 10 months. His 

supervisors noted on different occasions that he needed to make smoother station stops and that 

“[he] needs to stay focused on blowing the whistle for crossings even when other things are 

going on (radio).” On his final evaluation ride, a supervisor noted that he “exhibits good train 

handling skills.” He became a certified locomotive engineer on September 6, 2007. 

The engineer was qualified to operate between Grand Rapids and Chicago on June 15, 

2007.7 He estimated that during his on-the-job training period he had taken 20 to 30 trips to 

Grand Rapids. From September 25, 2007, through November 30, 2007, he primarily worked 

railroad yard jobs in Chicago. On November 10 and 11, 2007, he made a round trip from 

Chicago to Grand Rapids. Then he returned to work on yard jobs. On November 27 and 28, 

2007, he completed a round trip to Grand Rapids. 

After completing his on-the-job training and prior to receiving his certification as a 

locomotive engineer, the engineer attended Amtrak’s annual refresher training in early 

September 2007. During this training, he was examined several times on railroad rules and 

signals. On September 4, 2007, he passed the rules examinations related to the General Code of 

Operating Rules, the Canadian National Railway, and CSX Transportation (CSX). However, he 

failed his examination on Northeast Operating Rules Advisory Committee (NORAC)8 rules. The 

examination was a 15-question multiple-choice examination on the operating rules. He answered 

correctly 8 of the 15 questions. The next day, he retook the examination and passed with a score 

of 93 percent (that is, 14 out of 15). 

The engineer was also given his annual refresher signal examinations on September 4, 

2007. All operating employees must obtain a perfect score (100 percent) on the annual signal 

examination before operating or continuing to operate on that railroad. He failed both the 

Norfolk Southern and the Amtrak terminal signal tests. 

On the 10-question multiple-choice examination that covered Norfolk Southern signals, 

the engineer failed to correctly identify two signals. He gave the same incorrect response for a 

signal as he did on the day of the accident. In both instances, he misinterpreted a restricting

signal as a slow approach signal. After his examination, the instructor reviewed the questions 

with the engineer and verified that he understood the correct answers. The engineer was not 

allowed to work on the Norfolk Southern until he passed the signal examination. The following 

day, September 5, he retook and passed the Norfolk Southern signal examination. 

 7

 “Certification” and “qualification” have different meanings. Certified locomotive engineers are in compliance 

with 49 CFR Part 240 and have displayed the skills and knowledge necessary to operate a train. “Qualified” is a 

term used to signify that an individual has the skills and knowledge about a specific territory and has the necessary 

knowledge of that specific route to operate without assistance. Engineers even when certified are not allowed to 

operate on specific routes until qualified. 

8

 Norfolk Southern used NORAC for its operating rules in the Chicago area. 

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On the Amtrak signal examination for the Chicago Terminal, the engineer missed 4 of the 

10 questions on his first attempt. He incorrectly identified an approach indication, a stop

indication, a medium approach indication, and a medium approach medium indication. The 

following day, he took the Amtrak signal examination for the second time. On this examination, 

he missed 2 of the 10 questions. He incorrectly identified an approach slow indication and a stop

indication. Later that same day, the engineer retook the signal exam and passed. The Safety 

Board notes that the engineer’s incorrect answers on the examinations typically identified signal 

aspects as less restrictive than what the signal indicated. For example, during the engineer’s 

examinations, he had misinterpreted a stop indication as a stop and proceed. 

Work/Rest. The engineer’s activities during the 72 hours that led to the accident were 

reconstructed through interviews, company records, and information provided by the engineer 

following the on-scene investigation. The engineer had gone on duty the previous Tuesday, 

November 27, 2007, at 4:35 p.m. in Chicago. He had been assigned to operate a train to Grand 

Rapids. He arrived at Grand Rapids on Tuesday evening about 10:29 p.m. and then went off 

duty. He said that he went to bed soon after 11:00 p.m. and awoke the next morning, Wednesday, 

November 28, 2007, around 5:00 a.m. He went on duty at 5:50 a.m., and his train departed Grand 

Rapids for Chicago about 6:00 a.m. The train arrived in Chicago about 11:30 a.m., at which time 

he went off duty. He said that he performed some chores in the afternoon and took a 90-minute 

nap. He went to bed about 11:30 p.m. He awoke on Thursday, November 29, 2007, at 5:00 a.m., 

exercised, and did chores. Between 10:00 a.m. and noon, he took a nap. He said that when he 

awoke, he ate lunch. He left for work at 2:00 p.m. He went on duty in Chicago at 4:35 p.m. and 

was again assigned to a train that was headed for Grand Rapids. He went off duty in Grand 

Rapids at 10:28 p.m., and he went to bed about 11:00 p.m. On the day of the accident, he awoke 

about 5:00 a.m. and went on duty at 5:50 a.m. When he was asked about his alertness level at the 

time of the accident, he said that his alertness had been about 4 1/2 on a scale from 1 to 5.9

 

Health. The 50-year-old engineer told investigators that before the accident he was in 

good health. A review of his medical records indicated that his last medical examination with 

Amtrak had been on September 7, 2007. He was found to be medically fit for duty without 

restriction. However, he had been taking prescription drugs to control his high blood pressure. 

Workload. He told investigators that his trip from Grand Rapids to Chicago had been 

mostly typical. He indicated that his workload had been somewhat more demanding than usual 

because he had about 23 temporary speed restrictions during the trip. He said that he had taken 

his cellular telephone with him but had used it only after the collision. The cellular telephone 

records confirmed his statement. 

Relief Engineer 

Training/Experience. In 1987, Amtrak hired the relief engineer as a clerk. In 

October 2003, she became a yardmaster. In October 2005, she left Amtrak and entered the 

dispatcher training program at CSX. In February 2006, she returned to Amtrak as a yardmaster. 

 9

 The scale was explained to the engineer as follows: 1 is a low level of alertness, and 5 is a high level of 

alertness. 

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In June 2006, she entered Amtrak’s locomotive engineer training program in Wilmington, 

Delaware; she completed the training with an average score of 97 percent. 

During her on-the-job training, she spent about 3 months operating trains out of St. Louis, 

Missouri. The remainder of the time, she worked out of Chicago. She said that as a student she 

had made 12 round trips through the area where the accident occurred. 

On June 12, 2007, she became a certified locomotive engineer. She was qualified to 

operate trains between Chicago and Grand Rapids and between Chicago and Battle Creek, 

Michigan. She also worked in the Amtrak rail yard at Chicago. On October 23, 2007, she passed 

her last operating rules examination. 

In the 2 months before the accident, the majority of her time was spent operating in the 

Amtrak rail yard at Chicago; she also made an occasional trip from Chicago to Butler, Indiana. 

Work/Rest. At 10:00 p.m. on the Tuesday before the accident, the relief engineer had 

gone on duty when she was assigned to a yard job in Chicago. On Wednesday morning at 6:00 

a.m., she went off duty. When she had checked with Amtrak, she was told that it was unlikely 

she would be called for work until at least the next day. She said that she had stayed up on 

Wednesday. During the day, she did routine chores and activities. About 8:00 p.m. on 

Wednesday evening, she went to bed. On Thursday about 7:00 a.m., she awoke and did chores; 

Amtrak did not call. On Thursday evening between 9:00 and 10:00 p.m., she went to bed. On 

Friday about 6:30 a.m., she awoke. During interviews, she said that she had felt “very alert” 

when Amtrak called at 8:30 a.m. and told her to report to work at 10:31 a.m. 

Health. The 43-year-old relief engineer told investigators that her overall health was 

good. On May 10, 2007, she had her last medical examination with Amtrak. At that time, she 

was found to be medically fit for duty without restriction. She said that she wore prescription 

lenses when operating trains. At the time of the accident, she was wearing prescription contact 

lenses. 

Workload. When first boarding the train, she read the applicable operating instructions 

issued for the train on this specific trip. Since the engineer did not leave the engineer’s seat, she 

understood that he would operate the train until either reaching his time limit or reaching Union 

Station, whichever occurred first. During the postaccident interview, she said that she had been a 

working crewmember of the locomotive cab. She said that one of her duties was to call aloud the 

wayside signals together with the engineer; however, at Englewood interlocking, she did not call 

out this signal. She said that she had taken her cellular telephone with her but had used it only 

after the collision. 

Equipment Information 

Amtrak train 371 consisted of one locomotive and three Amtrak Superliner I passenger 

cars (35008, 34054, and 34002). The standing Norfolk Southern freight train 23M consisted of 

two locomotives and 20 multi-platform intermodal cars. The Norfolk Southern train was 5,055 

National Transportation Safety Board 11
Railroad Accident Report 

feet long and, excluding the locomotives, weighed 4,062 tons. The Amtrak train, including the 

locomotive, was 338 feet long and weighed 358 tons. 

Preaccident Inspections and Maintenance 

Amtrak train 371 was mechanically inspected and the air brakes were tested before the 

train’s departure from Grand Rapids. The records on the locomotive indicated that the 

predeparture air brake test and mechanical inspection were completed successfully. No 

exceptions were noted in the records concerning the predeparture condition of the train. All 

periodic inspections were within the prescribed limits for each car and the locomotive. 

Postaccident Inspections 

Because of the damage to the Amtrak locomotive in the accident, the air brake system 

could not be tested. While operating the train, the engineer had not reported a defective 

condition. The air brake system of the three Amtrak cars was tested using a Norfolk Southern 

locomotive. The air brake system was charged, and the brakes were applied and released in both 

service and emergency applications. During the tests, no binding or fouling was observed in the 

foundation rigging; the brakes performed as designed. 

Signal Information 

The Englewood interlocking had interlocking signals and power-operated switches, 

which were controlled by the Consolidated Control Facility in downtown Chicago. The facility 

was owned and operated by Northeast Illinois Regional Commuter Rail Corporation (METRA). 

The Amtrak train was traveling on Norfolk Southern tracks, but the Norfolk Southern tracks 

crossed two METRA main tracks at the Englewood interlocking. Typically, when railroads cross 

each other at an interlocking, one of the two railroads will control the crossing location. In this 

case, a METRA control operator controlled the train movements from track 1 and track 2 on the 

Norfolk Southern track. 

On the day of the accident, a data log was recorded at the METRA facility that captured 

the signal events and train movements at Englewood interlocking. The control operator had 

requested that the power-operated switches line for a movement from track 1 to track 2 at 

11:08:54 a.m. Five seconds later, the data showed, the switch reversed and the signal cleared10

for the approaching Amtrak train 371. At 11:19:09, the interlocking track circuit was occupied. 

At 11:20:32, the interlocking track circuit showed the interlocking was unoccupied. These times 

matched the times of Amtrak train 371’s event recorder, which had recorded the train’s 

westbound movement through Englewood interlocking. 

 10 The dispatching system will not indicate the specific aspect given in the field. It can only display if the signal 

has cleared for a movement or the signal is a stop signal. 

National Transportation Safety Board 12
Railroad Accident Report 

The signal maintenance records were examined. Postaccident testing of the applicable 

signals was performed. No condition was identified that would have prevented the signal system 

from functioning as designed. A test was performed to simulate the movement of Amtrak 

train 371. 

Operations Information 

CSX Transportation 

Between Grand Rapids, Michigan, and Michigan City, Indiana, Amtrak train 371 

operated on the CSX’s Chicago Division, Grand Rapids subdivision. The operations were 

governed by the NORAC rulebook. The signal aspects and indications are described in CSX 

Signal Aspects and Indications Rules. 

Norfolk Southern 

Between Michigan City and 21st Street in Chicago, Amtrak train 371 operated on 

Norfolk Southern track. The operations were governed by the same NORAC rulebook. For 

specific instructions, information was available in the Norfolk Southern’s Dearborn Division, 

Northern Region Timetable No. 4. The red over yellow aspect at Englewood interlocking had a 

restricting indication. According to Norfolk Southern’s signal rules, this signal indication 

required the train to be operated at a restricted speed into the next block. The restricted speed 

meant that the train must not exceed 15 mph and that it must be prepared to stop within one-half 

the range of vision of another train. 

Amtrak Yard 

In Chicago, between 21st Street and Union Station, the Amtrak rules for the Central 

Division, Chicago Terminal, governed Amtrak train 371. The signal aspects and indications were 

in Amtrak’s Timetable No. 3. The Central Division, Chicago Terminal General Order No. 3-S16, 

added a rule governing a red over yellow signal. The red over yellow aspect between 21st Street 

Chicago to the Chicago Terminal Union Station had a slow approach indication, which meant 

the following: the engineer should proceed but be prepared to stop at the next signal and, when 

the entire train clears the interlocking or control point limits, proceed at a speed not exceeding 30 

mph and be prepared to stop at next signal. Unlike the Norfolk Southern red over yellow signal 

aspect, there would be no expectation of a train on the track beyond the signal. 

Management Oversight 

Amtrak has to prepare its employees to operate on many different railroads throughout 

the United States. The railroads use different rulebooks and different signal systems. Because a 

National Transportation Safety Board 13
Railroad Accident Report 

particular Amtrak train can operate on several different railroads, the instructions covering a 

single trip can be scattered among multiple operating rulebooks. An Amtrak official told 

investigators that one of the greatest challenges in engineer training is dealing with the signals of 

two different railroads that have similar aspects but different indications. For example, identical 

signal aspects for different railroads may specify different speeds. Managers are responsible for 

signal training and tests. An employee must obtain a perfect score (100 percent) on the annual 

signal examination before he or she is allowed to operate or continue to operate on that railroad. 

Engineer Training 

All prospective Amtrak engineers begin their formal locomotive engineer training at 

Amtrak’s training center in Wilmington, Delaware. This portion of the training, which is 

primarily classroom instruction, lasts 8 weeks. Student engineers are taught the duties and 

responsibilities of being an engineer. Training includes operating rules (including signals), 

equipment (locomotives and troubleshooting equipment problems), airbrakes, train handling, and 

emergency procedures. The Amtrak system general road foreman said that the railroad uses train 

simulators to expose students to the basics of train handling and the application of the operating 

rules. 

The student engineers take written examinations during this part of their training. Most of 

the tests are multiple choice. In signal examinations, students select the indication that matches a 

corresponding color drawing of the signal aspect. A passing percentage for the operating rules 

examination is 85 percent, but 100 percent is required for the signal section. To achieve a passing 

score during the engineer training, students are allowed to take the tests twice. If they fail on 

their second attempt, they are terminated from the training program.11 

Upon successful completion of the training at the training center, prospective engineers 

are sent to different regions and assigned to local engineer instructors. This on-the-job-training 

phase generally lasts about 10 months, depending on the routes on which the engineer will be 

qualified. The purpose of this training is to provide student engineers with direct supervision as 

they learn the physical characteristics, signals, and operating rules particular to territories and 

railroads. 

The engineer trainees and certified engineers also take annual refresher training, in which 

they spend 2 or 3 days in a classroom reviewing policies, procedures, regulations, operating 

rules, physical characteristics, customer service, and emergency procedures. The training 

includes case studies involving operating rules violations and previous incidents or accidents 

involving Amtrak trains.12 The training ends with a 15-question multiple-choice examination on 

operating rules and a 10-question examination on signals. If the participant fails to answer any of 

the signal questions correctly, the instructor hands the examination back without any notations 

 11 To pass the annual signal examination in the field, an engineer must score 100 percent; however, an unlimited 

number of attempts are allowed. 

12 Amtrak officials said that most of the operating violations committed by its locomotive engineers cited in the 

case studies are not due to confusion over a rule (that is, misinterpretation of a signal aspect) but to other factors, 

including operator distraction and inattention. 

National Transportation Safety Board 14
Railroad Accident Report 

and asks whether the engineer would like to change any answers.13 If the participant cannot 

correct the examination, the instructor marks the incorrect answers, and the employee will not be 

in service until completing the exam with a perfect score. An Amtrak supervisor said that most 

employees who fail the test wait at least 1 day before retaking the test. 

Crew Resource Management Training 

Amtrak based its crew resource management (CRM) program on the CRM principles that 

are applied in the aviation industry, as well as on those principles that are already used in the 

railroad industry. Amtrak’s CRM training, which was developed in 2002, was initially a separate 

program that was given to engineers during their initial classroom training in Wilmington and 

was reinforced during their annual refresher training. A few years after its development, 

Amtrak’s CRM training was integrated with a review of operating rules violations and a 

discussion of how CRM tools could have been used to avoid incidents and operating violations. 

Similar to other CRM programs in the transportation industry, Amtrak’s CRM program 

addressed such principles as situation awareness, workload distribution, and effective 

communication. Crewmembers are instructed to assert themselves when they determine that 

proper procedures or safe practices are not being exercised. 

When questioned on how to intercede when an employee is not following the procedures 

properly, an Amtrak system general road foreman whose duties include CRM training told 

investigators that “appropriate assertiveness” should be exercised. The official said, 

If somebody is not willing to accept your direction or you[r] input sometimes you 

have to take action... if you have to pull the air, you pull the air....[14] Part of the 

thing about speaking up is just questioning. You don’t have to be alarmed and 

say, ‘Hey, shouldn’t we be stopping?’ but you could say, ‘Hey, wasn’t that signal 

this or shouldn’t we be doing 15 [mph] ...’ the action may be simply to speak up. 

If that doesn’t trigger the appropriate reaction or the engineer says, ‘Oh, no, I’m 

pretty sure it was a green’ and then the appropriate assertiveness, you may have 

[to] say, ‘No, listen, I’m directing you to stop and sort this out’ or whatever it 

takes. And, you know, it’s an easy thing to say. It’s hard to put into practice, but 

we encourage appropriate action.... I mean my mantra in class is, if in doubt, use 

the air, slow down. I bring up stories and relate incidents that I’ve been involved 

in and that prove that’s the way to go and that can save the day. 

During the training, the instructors may intentionally communicate a wrong signal to an 

engineer trainee while operating a train to observe whether the trainee uses the appropriate 

assertiveness in responding. 

 13 Amtrak’s senior director, System Operating Practices, said that this “second look” on an examination was 

discontinued in 2008. 

14 Pulling the air means placing the train into emergency braking. A brake handle that is accessible to the 

employee in the locomotive cab is on the fireman’s side. 

National Transportation Safety Board 15
Railroad Accident Report 

At the time of the accident, the employees in the cab of the locomotive were governed by 

four NORAC rules that pertain to observing signals. The first rule is the following: 

94. Responsibilities of Employees: Signals and Restrictions 

a. General Requirements 

Employees qualified on the operating rules and located on the leading engine or 

car must be on the lookout for signal affecting the movement of their train. They 

must communicate to each other in a clear manner the name of each signal as 

soon as it becomes clearly visible. After the name of a signal has been 

communicated, employees must observe it until passed. Any change in the signal 

must be communicated in the required manner. 

If a train is not operated in accordance with the requirements of a signal indication 

or restriction, qualified employees located in the leading engine or car must 

communicate with the Engineer immediately. If necessary, they must stop the 

train. 

The second applicable rule is the following: 

956. Observing Signals; Moving Engine 

Engine Service Employees will be responsible for the observance of all signals 

and for controlling movements accordingly. To prevent injury to persons, to 

prevent damage to property and lading, and to avoid collisions and derailments 

they must: 

1. Regulate the speed of their train, 

AND 

2. Exercise discretion, care and vigilance in moving their train. 

The third applicable rule is the following: 

958. Visibility Compromised: Regulation Speed 

If anything distracts attention from a constant lookout ahead or if weather 

conditions make observation of signals in any way doubtful, Engine Service 

Employees must at once regulate the speed of their train to ensure safety. 

The fourth applicable rule explains how to resolve a situation in which more than one speed is 

authorized. The fourth rule, Rule 40, is the following: 

Train speeds may be authorized by the rules, special instructions, signal 

indications, dispatcher messages or other means. When there is a difference in the 

speeds, the lowest speed will govern. 

National Transportation Safety Board 16
Railroad Accident Report 

Amtrak’s operating crews are required to adhere to the rules that govern the territory on 

which they are operating trains. Amtrak does not have written rules that specifically require an 

engineer to either make an immediate brake application or slow the train when another 

crewmember raises concerns about the train’s operation. 

Meteorological Information 

At 10:51 a.m., at the Midway Airport, which is approximately 6 miles west of the 

accident site, the winds were from the northwest at 17 mph with gusts of up to 25 mph. The 

visibility was 10 miles with partly cloudy skies. The temperature was 30o F, and the dew point 

was near 9o F. 

Toxicological Information 

The Amtrak crewmembers (engineer, relief engineer, conductor, relief conductor, and 

assistant conductor) provided postaccident toxicological specimens that were tested for the 

presence of alcohol and drugs.15 Results for all crewmembers were negative for alcohol and 

drugs. 

Emergency Response 

Local Emergency Response 

A passenger aboard the Amtrak train placed the first 911 call at 11:23 a.m. The passenger 

reported the collision but was unsure of the train’s location. After discussions with the passenger, 

the 911 dispatcher determined the location and assured the passenger that ambulances were 

responding. At 11:27 a.m., the Amtrak conductor called 911. 

The initial dispatch, at 11:32 a.m., included four engine companies, four truck companies, 

one heavy rescue squad, four battalion chiefs, one deputy district chief, one mobile command 

and communications vehicle, seven ambulances, two EMS chief officers, one EMS assistant 

deputy chief paramedic, and an advanced life support engine. The conductor reported that the 

first fire department official arrived at 11:37 a.m. The first of the engine companies arrived at 

11:38 a.m. 

The commissioner of the Chicago Fire Department was the incident commander. The 

operations command post for the fire department was established at 312 West 52nd Street, the 

EMS treatment and triage area was established at 5200 South Princeton Avenue, and the EMS 

transport area was established in the 5200 to 5300 block of South Princeton Avenue. The nearby 

 15 Substances tested for included cannabinoids, cocaine, opiates, amphetamines, methamphetamines, 

phencyclidine, barbiturates, and benzodiazepines. 

National Transportation Safety Board 17
Railroad Accident Report 

Parkman Elementary School was used as a shelter and as an additional treatment and transport 

area for passengers. 

A unified command post was established at 5220 South Shields Avenue. Representatives 

of the Chicago Fire Department, the Office of Emergency Management and Communications, 

Amtrak, the Red Cross, and the Chicago Police Department were at this location. The Chicago 

Police Department assisted with the evacuation of the passengers and provided security at the 

accident site and school. Norfolk Southern police and personnel also responded. (See figure 5.) 

Hose lines were run as a precaution because the locomotive’s fuel tank had been 

breached. However, the leaking diesel never ignited. Triage was started immediately on the train. 

Passengers were evacuated from the train to an area near a fence between the rail yard and a 

street east of the accident site. After firefighters had cut down parts of the fence, passengers were 

led down an embankment to a secondary triage and treatment area. Firefighters placed ladders 

along the embankment to help the passengers walk down the embankment. 

At 11:48 a.m., four additional ambulances, another advanced life support engine, and a 

mass casualty unit16 were dispatched. At 11:50 a.m., a heavy rescue unit and a collapse unit were 

requested. At 11:51 a.m., five advanced life support engines were dispatched to assist with 

triaging the patients. At 11:52 a.m., six ambulances and two additional mass casualty units were 

dispatched. At 11:53 a.m., four additional truck companies were requested. At this time, 182 

firefighters were on scene. At noon, two additional battalion chiefs and one EMS chief officer 

were requested. 

The transportation of patients to hospitals began at 12:05 p.m. At 12:13 p.m., the final 

search of the train was complete, and all passengers were off the train. At 12:19 p.m., two 

additional advanced life support engine companies were dispatched. One of these engines 

responded to Parkman School. Four additional ambulances were sent to Parkman School at 12:28 

p.m. 

 16 A mass casualty unit is capable of treating 50 critical patients. 

National Transportation Safety Board 18
Railroad Accident Report 

Figure 5. Emergency response locations. 

Passengers who were not taken by ambulance to hospitals were taken to Parkman School. 

After additional triage and treatment at this location, 24 passengers were transported by bus, 

accompanied by an advanced life support engine company, to Stroger Hospital at about 1:25 

p.m. They were the last to be transported to hospitals. Additional buses were used to take 

uninjured passengers to the train’s final destination, Chicago’s Union Station. The scene was 

secured and released to the railroad at 1:30 p.m., a little more than 2 hours after the collision. 

At one time during the response, Chicago Fire Department personnel at the scene 

numbered 250. At the scene, the following were present: 23 companies (engines, trucks, and 

squads), 6 battalion chiefs, 4 EMS chief officers, 3 mass casualty units, 2 heavy rescue squads, 2 

National Transportation Safety Board 19
Railroad Accident Report 

collapse rescue units, a command and communication unit, a support logistics division vehicle 

with 100 stairchairs, a helicopter, and additional chief officers. 

Crew Extrication 

Because of the damage to the Amtrak locomotive, the two Amtrak engineers were 

trapped in the cab compartment. The locomotive cab had three doors. Each side of the cab had a 

door with a ladder on the outside. The third door was behind the engineer’s seat and led to the 

engine room toward the rear of the locomotive. The crew was not pinned within the cab but 

could not exit through the doors. Firefighters tried to force open the cab door on the right, but 

they were unsuccessful. Instead, they broke a window on the right rear door for access. There 

were no roof access panels or structural weak point to provide additional quick access for 

emergency personnel; nor were they required.17 Once inside the locomotive, they found that the 

door from the engine compartment leading into the cab was jammed closed by the raised floor. 

This door had to be forced open. To reach the trapped engineers, the firefighters also removed a 

panel of the right-side cab window.18 The relief engineer exited the locomotive through the rightside cab window and climbed down the ladder to the ground. The operating engineer walked 

back through the engine to the rear door, was placed in a rescue basket,19 and was lowered to the 

ground. A review of a rail yard video shows that the relief engineer was extricated about 12:05 

p.m. and the operating engineer was extricated about 12:16 p.m.20

Disaster Preparedness 

Crew Training 

Amtrak has an emergency preparedness training program for its crewmembers. This 

training is required by 49 CFR Part 239. A refresher course is required every 2 years. Amtrak’s 

training program is called PREPARE (Passenger Railroad Emergency Preparedness and 

Response Education). The purpose of the course is to prepare operating and on-board crews for 

managing train emergencies. The course includes topics such as rail equipment familiarization, 

passenger evacuation, and emergency care. All of the crewmembers were current with their 

training. 

 17 For passenger train operations with speeds in excess of 125 mph, 49 CFR 238.441 requires roof access panels 

or a structural weak point to provide quick access for emergency personnel. This accident train operated at less than 

125 mph. 

18 The side cab windows were approximately 45 inches wide with one 22-inch panel and one 23-inch panel. 

19 A rescue basket is a rigid body-sized platform on which a stretcher can be secured for transporting patients. 

20 These times were adjusted from the video time stamp to match the accurate time provided by the 911 call-in 

emergency system. 

National Transportation Safety Board 20
Railroad Accident Report 

Emergency Responder Training 

Title 49 CFR Part 239 also requires passenger railroads to maintain liaison with local 

emergency responders. Amtrak provides a training program for emergency responders called 

Passenger Train Emergency Response. This training includes railroad operations, equipment 

familiarization, and types of train service emergencies. In August 2007, Amtrak had held an 

emergency incident management meeting, which included the emergency response training, with 

the Chicago Fire Department, the Chicago Police Department, and the Office of Emergency 

Management and Communications at Union Station in Chicago. The purpose of the meeting was 

to identify areas that emergency responders could use for command posts, treatment and triage 

areas, and field hospitals. 

Testing and Examination of Seat Mount Studs 

Two different types of mount studs were discovered during the postaccident examination 

of the Superliner cars. All the mount studs that fractured were of the same type; Amtrak searched 

its inventory of replacement mount studs and reported that it could find no evidence of this type 

in its inventory. Amtrak also reported the presence of lead in the type of mount studs that 

fractured; however, no lead was found in the type of mount studs that did not fracture. 

The two fractured mount studs from seats 7-8 and the fractured mount stud from seats 19-

20 from car 34054 were sent to the Safety Board’s Materials Laboratory. The Materials 

Laboratory compared the accident mount studs that failed with an exemplar mount stud of the 

type that did not fail. The head profile of each mount stud was measured and the material was 

tested for hardness. Minor differences in head profiles and average hardness values were noted. 

The fractures on two of the mount studs contained crack arrest marks that are typical of 

fatigue cracking emanating from the relief radius between the shank and head portion of the 

mount stud. The fractures on the head of the third mount stud had fine-grained features that are 

typical of overstress separation with no evidence of fatigue cracking. The exposed fracture faces 

showed metal flow that is consistent with the mount stud pulling up relative to the floormounting track. The upper side portion21 of the heads in areas that corresponded to a fatigue 

crack had fretting22 damage. 

Event Recorder Information 

The event recorder captured data through the trip up to the collision. According to the 

recorder, the train had decelerated to 10 mph near the crossover at the railroad crossing at 

Englewood interlocking, the train started to accelerate to 25 mph while within the curve 

restrictions, and finally the train reached a speed of 43 mph. The data showed several brake 

 21 This was the portion of the head that was in contact with the floor-mounting track. 

22 Fretting is damage that is induced under load and in the presence of repeated relative surface motion. 

National Transportation Safety Board 21
Railroad Accident Report 

applications just before the collision, including an engineer-initiated emergency application. The 

last recorded train speed was 36 mph. 

National Transportation Safety Board 22
Railroad Accident Report 

Analysis 

Exclusions 

Safety Board investigators reviewed the signal system data logs and performed 

postaccident signal testing. The logs and tests indicated that the signals were functioning 

properly at the time of the accident. Investigators examined the Amtrak train equipment and 

recovered the maintenance records. The equipment that was tested, including the braking 

systems, had worked as intended. The track and structures had been maintained within tolerances 

and Federal regulations. Both Amtrak operating crewmembers (engineer and relief engineer) 

indicated that until the Englewood interlocking nothing about the accident trip was abnormal or 

created an unmanageable workload. There is no evidence that their performance was affected by 

the use of prescription or non-prescription medication. Postaccident toxicological testing for all 

the crewmembers was negative for drugs and alcohol. Their work/rest schedules were regular; it 

does not appear that operator fatigue was a factor in this accident. Neither crewmember was 

using a cellular telephone or radio before the accident. Nothing in the environment (that is, rain, 

fog, or direct sunlight) affected the visibility of the signals. Therefore, the Safety Board 

concludes that the following were not factors in this accident: the functioning of the signal 

system, the condition of the equipment and the track, drug and alcohol use, fatigue, cellular 

telephone or radio use, and the visibility of signals. 

Train Crew’s Actions 

As westbound Amtrak train 371 approached Englewood interlocking on track 1, the 

operating crew observed two stopped Norfolk Southern freight trains. Both trains were stopped 

to give the Amtrak train priority on the track. 

Train crews understand that Amtrak trains are often given a higher priority than the host 

railroad's freight traffic. It would have been normal for the train dispatcher to route the Amtrak 

train around the freight trains by changing tracks and threading the passenger train through the 

congestion caused by a large number of freight trains. Because of its delayed departure from 

Grand Rapids, the Amtrak train was running about 1 hour behind schedule when it reached 

Englewood. From Englewood, the Chicago passenger terminal was about 15 minutes away. It 

would have been reasonable for the Amtrak engineer, who had just seen two freight trains yield 

to him, to believe that he would continue to receive priority over other trains ahead of him, 

thereby preventing additional delays. He was interested in not being delayed, which was evident 

when he said, “let’s hurry up and get on” and “let’s go” to the relief engineer when she boarded 

the train. The engineer was likely trying to reach the Chicago Terminal before he ran out of work 

time at 11:57 a.m. 

As the train traveled closer to the first signal at Englewood interlocking, the engineer 

made a significant error when he misinterpreted the meaning of the red over yellow signal 

National Transportation Safety Board 23
Railroad Accident Report 

aspect. The red over yellow aspect was a restricting indication, requiring the crew to operate the 

train at a maximum speed of 15 mph and to be prepared to stop for any trains or obstructions 

ahead. The aspect should have alerted the crew to the possibility of a train on the track ahead of 

them. However, the engineer misinterpreted the signal as a slow approach, which would have 

allowed him to operate through the interlocking at a maximum speed of 30 mph while being 

prepared to stop at the next signal. Of even more importance, a slow approach signal indication 

would have meant that there was no train within the next block. 

As the westbound Amtrak train approached Englewood, the engineer slowed his train and 

then crossed over from track 1 to track 2. This action routed his train around the eastbound 

freight train that was directly ahead of him on track 1. Once the Amtrak train was on track 2, the 

eastbound freight train was neither a concern nor a source of additional delay. From that point, 

based on his misinterpretation of the meaning of the signal, the engineer may have had no 

expectation of operating the train at a reduced speed, at least until the train reached the next 

signal. 

The Amtrak engineer, believing he had just received a slow approach indication, 

operated his train at 25 mph around the curves and at 30 mph on tangent track, which is 

consistent with the timetable speed for this territory. The crew observed nothing in front of them 

at that time to suggest that slowing the train below track speed was necessary. Consequently, the 

engineer likely felt comfortable about increasing the train’s speed to the next timetable speed of 

40 mph. Moments later, when questioned by the relief engineer about the signal they had passed, 

he stated that it was a slow clear indication, which would have permitted him to operate at the 

higher speed (40 mph). This second misinterpretation was different from his first 

misinterpretation and, in fact, was even less restrictive. The engineer and relief engineer 

continued to discuss the signal while the engineer maintained the train speed at 40 mph. When 

the engineer saw the stopped Norfolk Southern freight train on the track in front of him, the 

speed and distance did not allow enough time for him to stop his train short of the Norfolk 

Southern train. 

The relief engineer told investigators that she had immediate concerns about the 

engineer’s misinterpretation of the signal indication at Englewood. However, because of their 

conflicting interpretations of the signal, she began doubting her own knowledge of that signal 

and, she said, she thought that initially the engineer had understood the signal but had 

misspoken. Consequently, she delayed voicing her concerns until she gave it additional thought 

and felt more confident with her position.23 She communicated her concerns about 3/4 mile 

before the collision and as the Amtrak train’s speed reached 40 mph, which exceeded both the 

maximum authorized speed (30 mph) of the signal indication that the engineer had erroneously 

called and the maximum authorized speed (15 mph) that she correctly believed the signal 

indication allowed. The relief engineer said that she asked the engineer, “You called a slow 

approach at Englewood, right? ... Even if it’s a slow approach, you have to be down to 30.” The 

discussion about the previous signal between the engineer and the relief engineer lasted for 

 23 Lack of confidence is one of several barriers to communication identified in CRM research. Other factors, 

some of which might have been present in this accident, include gender differences, lack of credibility, rapport, or 

authority, experience, rank, and fear of reprisal. R. Baron, “Barriers to Effective Communication: Implications for 

the Cockpit,” 2005, <http://www.airlinesafety.com/editorials/BarriersToCommunication.htm>. 

National Transportation Safety Board 24
Railroad Accident Report 

several moments, and the engineer, believing that he was operating the train appropriately, 

maintained the train’s speed. 

Although the relief engineer voiced her concerns in time for the engineer to make a brake 

application and safely stop the train, her actions were not immediate and were not adequate. She 

asserted herself after the engineer accelerated the train to 40 mph rather than asserting herself 

immediately after she first believed that the engineer had miscalled the signal, and she never 

asserted to the engineer that she believed that the Englewood signal was a restricting signal that 

limited their speed to 15 mph. After the relief engineer first voiced her concern, the process by 

which the two crewmembers attempted to resolve their differences was to discuss the indication 

of the previous signal: the engineer did not immediately slow the train, and the relief engineer, 

seeing that the engineer did not immediately slow the train, did not herself apply the brakes to 

stop the train. The engineer applied the brakes only after he saw the stopped Norfolk Southern 

train in front of them. Therefore, the Safety Board concludes that the engineer misinterpreted and 

miscalled the signal at Englewood which resulted in the operation of the Amtrak train at a speed 

greater than authorized, and when challenged by the relief engineer, the engineer failed to slow 

or stop the train while he and the relief engineer discussed their differences in understanding the 

signal displayed at Englewood. The Safety Board also concludes that the relief engineer failed to 

communicate effectively and in a timely manner to the engineer that he had miscalled the 

restricting signal at Englewood interlocking and failed to then take action herself to stop the train 

after the engineer did not slow or stop the train when challenged. 

The process by which train crews should identify and strategically respond to unsafe 

situations is addressed in Amtrak’s Crew Resource Management (CRM) program. 

Modern railroads emphasize both the application of CRM principles and crewmember 

proficiency to establish and maintain safe train operations. The purpose of CRM is to help 

operating crews use all of the available resources (information, personnel, and equipment) at 

their disposal effectively. The role for crewmembers is to perform their assigned tasks 

responsibly, to know about or participate in determining the plans for movement of the vehicle, 

to be alert to departures from plans or from the expected performance of others, and to make 

those departures known in time to avert an operational error. If properly applied, CRM will 

increase the likelihood that human operation errors will be detected in time for action to be taken 

to prevent an accident. Although Amtrak’s CRM program emphasizes the importance of 

crewmembers immediately voicing their concerns after recognizing potentially unsafe situations, 

this accident clearly demonstrates the importance of crewmembers implementing the principles 

of CRM to prevent accidents. Therefore, the Safety Board believes that Amtrak, the Association 

of American Railroads, the American Short Line and Regional Railroad Association, the 

Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the 

American Public Transportation Association should use the circumstances of the November 30, 

2007, accident in Chicago, Illinois, during crew resource management training to reemphasize 

the necessity of any qualified person on the leading locomotive or car to immediately 

communicate any disagreement on a called signal and to immediately take action necessary to 

ensure that the train is operated safely. 

National Transportation Safety Board 25
Railroad Accident Report 

Amtrak Crew Training and Qualifications 

Amtrak operating crews are often assigned to operate over multiple railroads, sometimes 

during a single trip, as was the case in this accident. This type of operation requires the crew to 

be competent in multiple signal systems. Generally, Amtrak has been successful in preparing its 

crewmembers for these challenges. 

However, on the accident trip, the engineer appeared to have misinterpreted the meaning 

of a signal aspect found on different railroad properties. The signal displayed a red over yellow 

aspect, yet it had different meanings on different railroads. At Englewood interlocking on 

Norfolk Southern territory, a red over yellow aspect is a restricting indication. During his on-thejob training, the engineer had operated on this territory several times under the supervision of an 

on-board foreman. It is unknown, however, whether the engineer had been exposed to a 

restricting indication during his training.24 In contrast, a red over yellow aspect in the Amtrak 

yard indicates a slow approach. Since receiving his certification, the engineer had spent most of 

his time working yard jobs. His experience with this Amtrak signal aspect and its associated 

indication would have been more recent and frequent and, as a result, more likely committed to 

his memory. 

In the December 27, 2007, proceedings of Amtrak’s internal investigation of this 

accident, the engineer stated, “I looked at the signal [the Norfolk Southern signal at Englewood], 

and I saw our signal, Amtrak’s signal. And I called that signal a slow approach.” Certain 

fallibilities of human memory may have contributed to his misinterpreting or forgetting the 

meaning of the signal at Englewood. His forgetting may have been related to retroactive

interference,

25 which happens when new information affects the recall of somewhat similar 

material that had been previously learned. In this case, the engineer could have easily confused 

the red over yellow (slow approach indication) signal in the train yard, which was a signal 

indication that currently was more salient to him, with the red over yellow (restricting

indication) signal at Englewood, which had been more relevant to him months earlier. 

Furthermore, his last experience of the red over yellow restricting signal indication may have 

been during his written examination, which occurred a few months before the accident. He had 

operated infrequently over the accident territory since then, and this lack of exposure to and 

rehearsal of the signals in their true context may have made it more difficult for him to 

accurately retrieve from his memory the meaning of signal aspects while he was operating in this 

territory. 

The Safety Board also is concerned about the Amtrak engineer’s proficiency with signal 

identification when he received his engineer certification. Specifically, after completing several 

months of training on the accident territory, he nonetheless misinterpreted the meaning of several 

signals on the examinations just before his certification on the Norfolk Southern territories. 

During his signal examination, he made the same misinterpretation of a restricting signal as he 

 24 His certification was 3 months before the accident, and the engineer had operated only twice on the route 

from Chicago to Grand Rapids. 

25 This type of interference is retroactive in the sense that current tasks are interfering with the retrieval of 

memories of learning that took place earlier in time. 

National Transportation Safety Board 26
Railroad Accident Report 

did on the day of the accident. He took this exam only several days before he received his 

engineer certification. 

On the same testing day, he also missed 4 of the 10 questions related to the signals that 

are found on the Amtrak territories on which he had been qualified to operate. He made a 

significant mistake when he misinterpreted a stop indication for a stop and proceed indication. 

Further, he not only missed this question on his first attempt but also on his second attempt. 

Amtrak reported that engineers with limited operating experience may not be exposed to 

all signal aspects for a significant period, but stated that most of its operating violations are due 

to factors unrelated to the crew’s knowledge of the signal indications.26 Although the Safety 

Board understands this, the Board also recognizes that newly certified engineers, whose 

knowledge and skills related to their craft are still being developed, are most vulnerable to errors 

that might be attributed to a lack of rehearsal or experience. The Amtrak engineer struggled on 

his last signal examinations immediately before he received his engineer certification. While 

engineer trainees occasionally miss some signal exam questions, the accident engineer’s multiple 

mistakes during the latter part of his training demonstrate a lack of mastery of this essential skill. 

His failure to correctly interpret critical signal indications of territories on which he had been 

qualified to operate should have raised concerns about his readiness to operate a locomotive 

independently and may have warranted additional preparation. 

Signal interpretation is a skill that should be overlearned (that is, practiced beyond the 

point of mastery). Information that is overlearned is more resistant to disruption and is retained 

longer in memory. Since his last signal examination, it is unlikely the engineer had engaged in 

this type of learning for those signals that he had difficulty remembering. Because his work 

assignments had been predominantly yard jobs since his certification, his experience with the 

signals that he had mistaken would have been extremely limited and would have provided few 

opportunities to reinforce his signal interpretation memories. The Safety Board concludes that 

the engineer did not show the signal recognition proficiency level necessary to operate on the 

territories where the accident occurred. Consequently, the Safety Board believes that Amtrak 

should identify engineers and engineer trainees who have not consistently demonstrated 

competency in interpreting signals and provide them with enhanced training, supervision, testing, 

and evaluation necessary to determine that signal proficiency has been achieved and maintained. 

Train Signals 

Over the years, privately owned railroads have designed and installed signal systems on 

their properties to control their train movements. As previously noted, in this accident the red 

over yellow signal aspect on Norfolk Southern’s signal system had a different meaning from the 

red over yellow signal aspect on Amtrak’s signal system within the Chicago Terminal. Currently, 

there are various railroad signal system configurations across the United States. Hence, the same 

signal aspect may have different meanings or indications, depending on which railroad a train is 

operating. 

 26 A review of Amtrak employee operating violations over the last few years indicates that unfamiliarity with 

the signal system does not appear to be a common problem. 

National Transportation Safety Board 27
Railroad Accident Report 

The Federal Railroad Administration (FRA) issued regulations in 49 CFR 236.23 that 

provide some standards for signal systems. The FRA regulations allow signal aspects to be 

displayed by the color of lights, the position of lights, and the flashing of lights.27 Signal aspects 

may also be qualified by a marker plate, a number plate, a letter plate, and a marker light. Each 

aspect displayed by a signal must be identified by a name and must indicate the action to be 

taken; however, only one name and one indication can apply to each aspect, and the same aspect 

cannot be used with any other name and indication on the same railroad. 

While these regulations apply to each railroad individually, two adjoining railroads may 

have signals with the same aspects and different indications, as in this accident. A signal with the 

same aspect and two different indications or requirements can be confusing. Although railroads 

may use the same aspect to communicate a different meaning, some fundamental conditions 

must apply across all railroads. These regulations address the use of four colors of lights (that is, 

red, green, yellow, and lunar) and their meanings. A red light or a series of horizontal lights must 

be used to indicate stop; a yellow light or a lunar light must be used to indicate that speed is to be 

restricted and a stop may be required; and a green light or a series of vertical lights must be used 

to indicate proceed. The railroads combine colors in numerous arrangements to create signal 

aspects, such as a red light over a yellow light. 

Even though the FRA requires each railroad to define each signal aspect used on its 

property and to provide a meaning for that aspect, the regulations do not prohibit different 

railroads from having different meanings for the same aspect. As seen in this accident, a red over 

yellow signal aspect on the Norfolk Southern’s signal system was restricting; hence another train 

may be occupying the block of track beyond the signal. A red over yellow signal aspect on 

Amtrak’s signal system within the Chicago Terminal was a slow approach; hence the block of 

track beyond the signal was not occupied. 

While engineers and conductors operated predominately on the same railroad territories 

in the past, today’s train crews may operate over several territories in a single day, and train 

crews must be proficient on more than one signal system. The Safety Board concludes that the 

lack of uniform meanings of signal aspects can lead to misinterpretation, as demonstrated in this 

accident. Therefore, the Safety Board believes that the FRA should establish uniform signal 

aspects that railroads must use to authorize a train to enter an occupied block and prohibit the use 

of these aspects for any other signal indication. The Safety Board also believes that the FRA 

should study the different signal systems for trains, identify ways to communicate more 

uniformly the meaning of signal aspects across all railroad territories, and require the railroads to 

implement as many uniform signal meanings as possible. 

Positive Train Control 

Over the last 4 decades, the Safety Board has investigated many railroad accidents in 

which crewmembers failed to operate their trains effectively and in accordance with operating 

 27 These regulations also allow the signal aspect to be displayed by the position of semaphore blades, which are 

signals equipped with a large mechanical arm that raises and lowers to provide different aspects. The use of 

semaphore blades has been discontinued by most railroads. 

National Transportation Safety Board 28
Railroad Accident Report 

rules for a variety of reasons, including fatigue, sleeping disorders, use of medications, or 

distractions within the operating cab. The Board has advocated the implementation of positive 

train control (PTC) systems that compensate for human error and that incorporate collision 

avoidance to prevent train collisions. The Board believes that PTC is particularly important in 

places where passenger trains and freight trains both operate. Because of the Board’s 

longstanding interest in this issue, PTC remained on the Board’s Most Wanted Transportation 

Safety Improvements list from 1990 to 2008. 

Following a head-on collision between a passenger train and a freight train in 

Chatsworth, California, on September 12, 2008, which resulted in 25 fatalities and more than 130 

injuries, the Rail Safety Improvement Act of 2008 was enacted. In addition to other safety 

improvements, this law mandates the installation of PTC systems by December 31, 2015, on all 

main-line tracks where intercity passenger and commuter railroads operate and where toxic-byinhalation hazardous materials are transported. This includes the territory where this accident 

occurred. After the enactment of the Rail Safety Improvement Act of 2008, the Safety Board’s 

Safety Recommendation R-01-06, which called for PTC to be installed on railroads, was 

classified “Closed—No Longer Applicable”28 and was removed from the Board’s Most Wanted 

list in October 2008. 

Had a PTC system been in place at Chicago, it would have intervened by stopping the 

Amtrak train when the engineer failed to comply with the restricted speed. The Safety Board 

concludes that had a PTC system been in place at the time of this accident, the collision would 

not have occurred.

Survival Factors 

Emergency Response 

The first call to 911 was placed by a passenger at 11:23 a.m. The 911 communications 

center spoke with this passenger until 11:35 a.m. During this time, the 911 communications 

center identified a street location for the accident using the computer-aided dispatch system. The 

Chicago Fire Department was dispatched at 11:32 a.m. Fire department units began arriving on 

scene at 11:37 a.m., which was 14 minutes after the first 911 call was initiated. 

The commissioner of the fire department assumed incident command. A command post 

was established. Representatives from the railroads, the Red Cross, the Office of Emergency 

Management, and the Chicago Police Department assisted at the command post. Staging, triage 

and treatment, and transportation operations were established. Specialty equipment, including 

three mass casualty units, two heavy rescue squads, and two collapse rescue units responded. In 

total, 250 members of the Chicago Fire Department operated at the scene of the derailment. 

 28 Closed—No Longer Applicable means the Safety Board’s recommended action has been overtaken by events. 

National Transportation Safety Board 29
Railroad Accident Report 

Firefighters began triage on the train. Passengers were then led from the rail yard to the 

treatment area. Transportation of people to hospitals began 28 minutes after the fire department’s 

arrival. All passengers were off the train 35 minutes after the fire departments arrived. 

The emergency response was rapid and included enough resources to address the size of 

the emergency. Once on scene, the responders evacuated the injured individuals from the train 

and appropriately selected those needing immediate attention and transport. Therefore, the Safety 

Board concludes that the emergency response was timely and effective. 

Extrication of Locomotive Crew 

The Amtrak locomotive’s fuel tank was breached during the accident, and although no 

postaccident fire occurred, about 300 gallons of diesel fuel spilled from the tank. Due to the 

collision forces and structural damage, the cab compartment doors were inoperative. 

Additionally, because the windows were not designed to be removed by the crewmembers, the 

two engineers in the cab could not exit the locomotive without assistance. 

The relief engineer exited the cab through a window that was removed by firefighters, 

about 28 minutes after the fire department’s arrival. The delay occurred because the windows 

also were not designed to be rapidly removed by the emergency responders.29 The engineer was 

extricated from the cab about 39 minutes after the fire department’s arrival. This extended delay 

occurred because the firefighters had to force open a door into the structurally damaged cab. The 

Safety Board concludes that because all cab compartment doors were inoperable and the 

windows were not designed to be easily removable from either the inside or the outside, the 

engineers could not exit the locomotive nor could the emergency responders enter the 

locomotive in a timely manner. 

In 49 CFR 229.206, the FRA’s locomotive design requirements state, 

Each locomotive used in occupied service must meet the minimum ... emergency 

egress ... design requirements set forth in AAR [Association of American 

Railroads] S-580” for locomotives manufactured or remanufactured after January 

1, 2009. The AAR sets forth in its S-580 Locomotive Crashworthiness 

Requirements, subsection 6.3, Emergency Egress that the locomotive cab “must 

allow for exit through at least one opening (for example, the engineer’s side door, 

nose door, windows) in any locomotive orientation. 

After an accident, a train crew may need to quickly exit a locomotive cab, particularly in 

the event of a fire or a hazardous materials release, and a train crew may require assistance from 

emergency responders when injured or incapacitated. The need for passengers to quickly exit 

passenger cars and for emergency responders to be able to enter passenger cars has been 

previously addressed in 49 CFR Part 238. The FRA’s regulations for emergency windows in 

passenger cars have an “ease of operability” requirement. Title 49 CFR 238.113 states that 

emergency window exits in passenger cars “shall be designed to permit rapid and easy removal 

 29 This engineer was smaller, had minor injuries, and was more agile than the other engineer. 

National Transportation Safety Board 30
Railroad Accident Report 

from the inside of the car during an emergency situation without requiring the use of a tool or 

other implement.” Title 49 CFR 238.114 states that rescue access windows in passenger cars 

“must be capable of being removed without unreasonable delay by an emergency responder.” 

While the regulations for emergency egress and access in passenger cars clearly address the need 

for the rapid evacuation of the cars, the requirements for the emergency evacuation of 

locomotives do not incorporate similar “rapid and easy removal” systems. Therefore, the Safety 

Board believes that the FRA should require that emergency exits on new and remanufactured 

locomotive cabs provide for rapid egress by cab occupants and rapid entry by emergency 

responders. 

Appliance Securement 

The microwave oven and the coffee pot in the café car were thrown to the floor during 

the collision. No injuries were attributed to the microwave or the empty coffee pot in this 

accident. The restraining bracket was larger than the microwave and could not have secured the 

microwave to the counter. Since the accident, Amtrak has changed to a new style of microwave 

on Superliner café cars. The new microwaves match their mounting brackets and are properly 

secured. 

Seat Pedestal Securement 

As a result of the collision, three seat pairs were detached from the guides on the floor of 

the car. The Safety Board’s Materials Laboratory examined the mount studs that attached the 

seat pedestals to the mounting guides on the floor. The head portions of two mount studs 

contained preexisting fatigue cracks that contributed to the detachment of each seat pedestal 

during the accident. The fatigue cracks were a stress riser that reduced the impact resistance of 

the mount studs. 

The Safety Board concludes that some of the seat mount studs experienced fatigue 

cracking that resulted in seat pedestals detaching from the floor. Amtrak reviewed its existing 

inventory and found no seat mount studs of the type that fractured in this accident. All mount 

studs on the seats involved in this accident were replaced before the passenger cars were returned 

to service. During Amtrak’s ongoing overhaul program, replacement mount studs of the type that 

did not fracture are being installed in all seat pedestals on Superliner passenger cars. This 

replacement program will be completed within 4 years. 

National Transportation Safety Board 31
Railroad Accident Report 

Conclusions 

Findings 

1. The following were not factors in this accident: the functioning of the signal system, the 

condition of the equipment and the track, drug and alcohol use, fatigue, cellular telephone or 

radio use, and the visibility of signals. 

2. The engineer misinterpreted and miscalled the signal at Englewood which resulted in the 

operation of the Amtrak train at a speed greater than authorized, and when challenged by the 

relief engineer, the engineer failed to slow or stop the train while he and the relief engineer 

discussed their differences in understanding the signal displayed at Englewood. 

3. The relief engineer failed to communicate effectively and in a timely manner to the engineer 

that he had miscalled the restricting signal at Englewood interlocking and failed to then take 

action herself to stop the train after the engineer did not slow or stop the train when 

challenged. 

4. The engineer did not show the signal recognition proficiency level necessary to operate on 

the territories where the accident occurred. 

5. The lack of uniform meanings of signal aspects can lead to misinterpretation, as 

demonstrated in this accident. 

6. Had a positive train control system been in place at the time of this accident, the collision 

would not have occurred. 

7. Because all cab compartment doors were inoperable and the windows were not designed to 

be easily removable from either the inside or the outside, the engineers could not exit the 

locomotive nor could the emergency responders enter the locomotive in a timely manner. 

8. The emergency response was timely and effective. 

9. Some of the seat mount studs experienced fatigue cracking that resulted in seat pedestals 

detaching from the floor. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of the 

November 30, 2007, collision of Amtrak train 371 with the rear of Norfolk Southern Railway 

Company train 23M near Chicago, Illinois, was the failure of the Amtrak engineer to correctly 

interpret the signal at Englewood interlocking and Amtrak’s failure to ensure that the engineer 

had the competency to correctly interpret signals across the different territories over which he 

operated. Contributing to the accident was the relief engineer’s failure to immediately 

National Transportation Safety Board 32
Railroad Accident Report 

communicate to the engineer that he had miscalled the signal at Englewood and to stop the train 

when he did not respond to her expressed concern. Also contributing to the accident was an 

absence of effective crew resource management between the relief engineer and the operating 

engineer which led to their failure to resolve the miscalled signal prior to the collision. Further 

contributing to the accident was the absence of a positive train control system that would have 

stopped the Amtrak train when it exceeded restricted speed. 

National Transportation Safety Board 33
Railroad Accident Report 

Recommendations 

As a result of its investigation of the November 30, 2007, collision of Amtrak train 371 

with the rear of standing Norfolk Southern Railway Company train 23M near Chicago, Illinois, 

the National Transportation Safety Board makes the following recommendations: 

To the Federal Railroad Administration: 

Establish uniform signal aspects that railroads must use to authorize a train to 

enter an occupied block, and prohibit the use of these aspects for any other signal 

indication. (R-09-1) 

Study the different signal systems for trains, identify ways to communicate more 

uniformly the meaning of signal aspects across all railroad territories, and require 

the railroads to implement as many uniform signal meanings as possible. (R-09-2) 

Require that emergency exits on new and remanufactured locomotive cabs 

provide for rapid egress by cab occupants and rapid entry by emergency 

responders. (R-09-3) 

To Amtrak: 

Identify engineers and engineer trainees who have not consistently demonstrated 

competency in interpreting signals, and provide them with enhanced training, 

supervision, testing, and evaluation necessary to determine that signal proficiency 

has been achieved and maintained. (R-09-4) 

Use the circumstances of the November 30, 2007, accident in Chicago, Illinois, 

during crew resource management training to reemphasize the necessity of any 

qualified person on the leading locomotive or car to immediately communicate 

any disagreement on a called signal and to immediately take action necessary to 

ensure that the train is operated safely. (R-09-5) 

To the Association of American Railroads, the American Short Line and Regional Railroad 

Association, the Brotherhood of Locomotive Engineers and Trainmen, the United 

Transportation Union, and the American Public Transportation Association: 

Use the circumstances of the November 30, 2007, accident in Chicago, Illinois, 

during crew resource management training to reemphasize the necessity of any 

qualified person on the leading locomotive or car to immediately communicate 

any disagreement on a called signal and to immediately take action necessary to 

ensure that the train is operated safely. (R-09-5) 

National Transportation Safety Board 34
Railroad Accident Report 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

MARK V. ROSENKER KATHRYN O’LEARY HIGGINS 

Acting Chairman Member 

DEBORAH A. P. HERSMAN ROBERT L. SUMWALT 

Member Member 

Adopted: March 31, 2009 

National Transportation Safety Board 35
Railroad Accident Report 

Appendix A 

Investigation 

The National Transportation Safety Board was notified of Amtrak passenger train 371’s 

collision with Norfolk Southern freight train 23M, near Chicago, Illinois, about 1:30 p.m., on 

November 30, 2007. The investigator-in-charge and the mechanical group chairman were 

launched from the Safety Board’s Los Angeles Regional Office. The track group chairman was 

launched from the Safety Board’s Chicago Regional Office. The operations, human factors, 

survival factors, and signal/event recorder group chairmen were launched from Safety Board 

Headquarters in Washington, D.C. Then-Vice Chairman Robert L. Sumwalt accompanied the 

team to the accident site. 

Parties to the investigation included Amtrak, the Norfolk Southern Railway Company, 

the Federal Railroad Administration, the Illinois Commerce Commission, the Brotherhood of 

Locomotive Engineers and Trainmen, and the United Transportation Union. 

National Transportation Safety Board 36