F PB99-916302

NTSB/RAR-99/02

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

RAILROAD ACCIDENT REPORT

COLLISION OF 

NORFOLK SOUTHERN CORPORATION TRAIN 255L5 WITH 

CONSOLIDATED RAIL CORPORATION TRAIN TV 220

BUTLER, INDIANA

MARCH 25, 1998

7177
National Transportation Safety Board. 1999. Collision of Norfolk Southern Corporation Train 255L5 With

Consolidated Rail Corporation Train TV 220 in Butler, Indiana, on March 25, 1998. Railroad Accident Report

NTSB/RAR-99/02. Washington, DC.

Abstract: On March 25, 1998, about 4:48 a.m. eastern standard time, southbound Norfolk Southern Corporation

(Norfolk Southern) train 255L5, which was en route to Fort Wayne, Indiana, struck eastbound Consolidated Rail

Corporation (Conrail) train TV 220, which was en route to Columbus, Ohio. The Norfolk Southern conductor was

killed; the engineer and student engineer sustained minor injuries. The two Conrail crewmembers were not injured.

The safety issues discussed in this report are the adequacy of Norfolk Southern’s methods for ensuring compliance

with the operating rules, the adequacy of Norfolk Southern’s locomotive engineer training program, and the

importance of train crew resource management to safe and efficient train operations. 

As a result of its investigation, the National Transportation Safety Board issued recommendations to the Federal

Railroad Administration, Norfolk Southern Corporation, the Class I railroads and Amtrak, the American Short Line

and Regional Railroad Association, the Brotherhood of Locomotive Engineers, the United Transportation Union,

Harmon Industries, and the DeKalb County Emergency Management Agency.

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

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

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

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

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, S.W.

Washington, D.C. 20594

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

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

Information Service. To purchase this publication, order report number PB99-916302 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
Railroad Accident Report

Collision of 

Norfolk Southern Corporation Train 255L5 With 

Consolidated Rail Corporation Train TV 220 

Butler, Indiana

March 25, 1998

NTSB/RAR-99/02

PB99-916302 National Transportation Safety Board

Notation 7177 490 L’Enfant Plaza, S.W.

Adopted: July 13, 1999 Washington, D.C. 20594

E P LUR IB USUNUM 

N AT I O N A L T R A S P O R TA T IO N 



 B O A R D

S A F E T Y

N

iii Railroad Accident Report

Contents

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

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

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

Preaccident Events—Conrail....................................................................................... 1

Preaccident Events—Norfolk Southern....................................................................... 5

The Accident................................................................................................................ 9

Damage...................................................................................................................... 10

Postaccident Events ................................................................................................... 11

Train Crew Information .................................................................................................... 12

Conrail Crewmembers............................................................................................... 12

Norfolk Southern Crewmembers............................................................................... 12

Track and Site Information ............................................................................................... 14

Norfolk Southern Operating Rules ................................................................................... 15

Postaccident Tests ............................................................................................................. 17

Visibility and Sight Distance ..................................................................................... 17

Signals ....................................................................................................................... 18

Norfolk Southern Signal Malfunction Reporting ............................................................. 20

Locomotive Engineer Training Program .......................................................................... 21

Crew Communication ....................................................................................................... 23

Analysis............................................................................................................................ 24

Exclusions......................................................................................................................... 24

Accident Discussion ......................................................................................................... 25

Adequacy of Methods for Ensuring Compliance With Operating Rules.......................... 27

Adequacy of the Locomotive Engineer Training Program............................................... 29

Importance of Train Crew Resource Management........................................................... 32

Adequacy of Signal Malfunction Reporting Procedures .................................................. 33

Continued Need for In-Cab Audible Recording Devices on Trains ................................. 35

Importance of Emergency Response Management in Hazardous Materials Accidents ... 36

Conclusions...................................................................................................................... 38

Findings ............................................................................................................................ 38

Probable Cause ................................................................................................................. 40

Recommendations........................................................................................................... 41

Appendixes ...................................................................................................................... 49

A: Harmon Industries Bulletin on Electro Code 4 Units ........................................... 49

B: Norfolk Southern Lake Division Student Engineer Form .................................... 51

C: UP signal Recording Form ................................................................................... 52

Acronyms and Abbreviations ........................................................................................ 53

v Railroad Accident Report

Executive Summary

On March 25, 1998, about 4:48 a.m. eastern standard time, southbound Norfolk

Southern Corporation (Norfolk Southern) train 255L5, which was en route to Fort Wayne,

Indiana, struck eastbound Consolidated Rail Corporation (Conrail) train TV 220, which

was en route to Columbus, Ohio. The collision occurred where the Norfolk Southern

Huntington District and the Conrail Chicago main lines cross at grade at the east end of

the town of Butler, Indiana. Both locomotives and five cars from the Norfolk Southern

train derailed, and three cars from the Conrail train, two with multiple stacked platforms,

derailed. The Norfolk Southern conductor was killed; the engineer and student engineer

sustained minor injuries. The two Conrail crewmembers were not injured. 

No hazardous materials were released, but both Norfolk Southern locomotive fuel

tanks ruptured and released approximately 7,000 gallons of fuel oil. Norfolk Southern

estimated total damages of $264,000 ($187,000 to equipment, $18,000 to track and

signals, and $59,000 to cargo). Conrail estimated total damages of $352,200 ($314,000 to

equipment, $33,500 to track and signals, and $4,700 to cargo). 

The National Transportation Safety Board determines that the probable cause of

this accident was the failure of the engineer and conductor of train 255L5 to comply with

operating rules (specifically, their failure to observe and confirm signal aspects and their

failure to continuously and directly supervise the student engineer) and the failure of

Norfolk Southern Corporation to ensure employees’ compliance with operating rules.

Contributing to the accident was Norfolk Southern Corporation’s failure to ensure that its

locomotive engineer training program provided effective, timely training; oversight; and

feedback to ensure that students were adequately prepared for operational situations. Also

contributing to the probability of this accident occurring was the failure of Norfolk

Southern Corporation’s signal maintenance program to respond to a reported signal

deficiency. 

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

following major safety issues:

• Adequacy of Norfolk Southern’s methods for ensuring compliance with the

operating rules,

• Adequacy of Norfolk Southern’s locomotive engineer training program, and

• Importance of train crew resource management to safe and efficient train

operations.

The analysis also addresses additional safety concerns identified during the

investigation: the adequacy of Norfolk Southern’s signal malfunction reporting

procedures and of Harmon Industries’ signal component repair and replacement program,

the continued need for in-cab audible recording devices on trains to provide essential
Executive Summary vi Railroad Accident Report

details for accident investigations, and the importance of emergency response

management in railroad accidents involving hazardous materials.

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

recommendations to the Federal Railroad Administration, Norfolk Southern Corporation,

the Class I railroads and Amtrak, the American Short Line and Regional Railroad

Association, the Brotherhood of Locomotive Engineers, the United Transportation Union,

Harmon Industries, and the DeKalb County Emergency Management Agency.
1 Railroad Accident Report

Factual Information

Accident Narrative 

On March 25, 1998, about 4:48 a.m.,1 southbound Norfolk Southern Corporation

(Norfolk Southern)2 train 255L5, which was en route to Fort Wayne, Indiana, struck

eastbound Consolidated Rail Corporation (Conrail)3 train TV 220, which was en route to

Columbus, Ohio. The collision occurred where the Norfolk Southern Huntington District

and the Conrail Chicago main lines cross at grade at the east end of the town of Butler,

Indiana. (See figures 1 through 3.) Both locomotives and five cars from the Norfolk

Southern train derailed, and three cars from the Conrail train, two with multiple, stacked

platforms, derailed. The Norfolk Southern conductor was killed; the engineer and student

engineer sustained minor injuries. The two Conrail crewmembers were not injured. 

The National Weather Service’s closest official station to the accident, Fort Wayne,

which is 28 miles southwest of Butler, reported the following conditions at the time of the

accident: no precipitation, unrestricted visibility at 10 statute miles, a temperature of 36o F,

and winds out of the northwest at 7 knots.

Preaccident Events—Conrail

The Conrail crewmembers, an engineer and a conductor, boarded their train at

Elkhart, Indiana, on March 25, 1998, at 1:45 a.m. and departed Elkhart at approximately

2:30 a.m., after the locomotive units were fueled and the required air brake tests were

performed.

The Conrail train, which was 2,101 feet long and consisted of 2 locomotive units

and 14 intermodal cars,4

 was destined for Columbus. The crewmembers stated they were

following an eastbound Conrail train and operating mainly on approach5 signals, with an

occasional clear6 signal.

1 Times given in this report are eastern standard time.

2 See last page of this document for a list of all acronyms and abbreviations used in this report. 

3 Effective June 1, 1999, Norfolk Southern and CSX Corporation became Conrail’s owners. 

4 A single car can consist of several connected, stacked platforms carrying intermodal shipping

containers.

5 Conrail and Norfolk Southern operating rules require that a train operating on an approach signal be

prepared to stop at the next signal and begin reduction to medium speed as soon as the engine passes the

approach signal. 

6 Indicates that a train may proceed at the authorized speed.
Factual Information 2 Railroad Accident Report

 Figure 1. Conrail Chicago Line and Norfolk Southern 

Huntington and Detroit Districts

Chicago E lkhart

Butler

Fort Wayne

Peru

Colum bus

Dearborn

D etroit

Indianapolis

ILLINO IS

INDIANA

OH IO

MICHIGAN

Toledo

Conrail

Norfolk Southern
 Figure 2. Southbound Norfolk Southern (NS) train approaching eastbound Conrail train at Butler 

Conrail train TV 220 NS train 255L5 Conrail connection track Conrail westward to Chicago, IL Con

to T

26 13' N Scale: 1 inch = 132 feet Butler crossing NS home signal State Route 6 Norfolk Southern to Fort Wayne, IN Norfolk Sout

to Detroit
Factual Information 4 Railroad Accident Report

N orfolk

S

o

uth

ern

Conrail Train TV-220

Conrail Train TV-220

Nort

h

West

West

S

o

uth

South

East

East

N

orf

o

kl S

o

uthern

Train

2

5

5

L

5

Tr

ain

2

5

5

L

5

N

ort

h

 Figure 3. Conrail and Norfolk Southern (NS) trains viewed 

facing north (top) and south (bottom)
Factual Information 5 Railroad Accident Report

Several minutes before the collision, the Conrail intermediate signal7 just before

the Butler interlocking,8

 signal 360.2E, displayed an approach aspect, and the home

signal9 at the Butler interlocking was at stop. (See figure 4.) The crewmembers stated that

they complied with the stop signal. After about 3 minutes, the signal upgraded to an

approach aspect, and the train continued east.

While proceeding through the interlocking, both crewmembers stated that they

observed an approaching headlight from the north, which they said was not unusual at that

location. They could not determine the train’s speed. Shortly afterward, the crew heard the

Conrail train’s air brakes apply in emergency. 

Preaccident Events—Norfolk Southern

On March 24, 1998, at 11:35 p.m., the Norfolk Southern crewmembers, an

engineer, a student engineer, and a conductor, reported for duty at the Detroit Terminal.

After reading their orders and clearing them with the train dispatcher, the crewmembers

boarded the two-unit locomotive consist at the round house and proceeded to their train in

the Triple Crown facility. The train, consisting of 85 loaded road-railer10 type cars,

departed the facility about 2:30 a.m., after crewmembers had performed the required air

brake tests.

Once the train left the terminal area, about 2:35 a.m., the engineer turned over the

train’s operation to the student engineer. At that point, the train was passing Oakwood

Junction interlocking in east Dearborn, Michigan, about 114 miles northeast of Butler. The

train continued southwest toward Fort Wayne. The student engineer reported nothing

unusual about the train’s handling before the accident. 

The locomotive was being operated with the long hood forward,11 with the student

engineer seated at the controls on the right side of the lead locomotive; the conductor and

engineer were seated on left side, with the engineer in the forward seat and the conductor

directly behind him in the rear seat. Visibility to the left side of the locomotive is limited

7 Signals between interlocking signals that convey the condition of the block ahead and provide the train

crew with information needed to properly control train speed.

8 An arrangement of signals and control apparatus so interconnected that functions must succeed each

other in a predetermined sequence, thus permitting train movements along routes only if safe conditions

exist.

9 A fixed signal at the entrance of a route or block that governs trains or engines entering or using that

route or block.

10 Truck trailers equipped with wheels for rail operation.

11 Modern diesel-electric locomotives have the controlling cab at one end of the locomotive

superstructure. The remaining portion of the locomotive, which encloses the diesel engine and electrical

generating plant, is referred to as the “long hood.” Typically, locomotives are operated with the cab end or

“short hood” leading for maximum visibility and generally have their controls on the right side. However,

some railroads designate the long hood as the front end to provide added distance and material to protect the

crew in a collision. A stenciled “F” designates the front end of a locomotive. The lead locomotive on

Norfolk Southern train 255L5 was specially configured to have the long hood forward and the control stand

on the right side.
 Figure 4. Conrail (CR) and Norfolk Southern (NS) signals in area of Butler interlocking

112

111

113

110

109

360

355

356

Conrail

Norfolk

Southern

To Fort Wayne

357

Indiana

Ohio

The student engineer was seated at the controls on the side opposite signal 111. The locomotive'slong-hood-forward configuration and the location of the curve reduced the signal's visiblity. 

signal 1

CR (left) and NS (right) home signals controlling theButler interlocking 

N

NS intermediatesignal 111

359

To

Chicago

CR intermediate signal 360.1E

CR intermediate signal 360.2E

ToDetroit

CR train

Not to Scale

NS inte

To To
Factual Information 7 Railroad Accident Report

when it is being operated in this mode, as shown in figure 5. The student told Safety Board

investigators that he had never been formally trained in long-hood-forward operation and

had operated in this mode only once before, on a trip with the same crew from Peru,

Indiana, to Detroit, Michigan, that concluded the day before the accident.

The student engineer said that the conductor and engineer did not call clear

signals.12 At the Norfolk Southern hearing,13 the surviving crewmembers stated the

conductor had told the student upon going on duty at Peru that it was the practice of the

crew not to call clear signals. Norfolk Southern operating rule 34 requires that

crewmembers “call,” or orally communicate, all signals encountered.

12 The student radioed every signal encountered on the accident trip up to signal 111. For a transcript of

the tape-recorded communications, see docket CHI-98-FR-009.

13 Norfolk Southern conducted its hearing on the Butler accident on October 7, 1998, in Fort Wayne.

 Figure 5. Signal 111 at last viewing point from left and right sides of cab

 on a locomotive configured with the long hood forward

Engineer’s View Student Engineer’s View

Signal

111

Signal

111
Factual Information 8 Railroad Accident Report

In postaccident interviews with the Safety Board, the student engineer said that the

engineer and conductor both started reading what he thought were paperback books

shortly after 3:00 a.m., about 30 minutes after departing Detroit. Two paperback books14

were found on the floor of the lead locomotive after the accident. (See figure 6.) The

student engineer also said that about 30 minutes to an hour before the collision, the

conductor or the engineer turned off the overhead light on the left side of the control

compartment. The student said that he left the light on above his position to better observe

the controls. The student was unsure how long the light was out on the other side of the

cab, stating “It could have been a half hour, it could have been an hour. I don’t know.” He

said that during the time the light was off, he did not talk to the engineer or the conductor

or hear them talking to each other. He was unable to state with certainty whether the

engineer or the conductor was asleep while the light was out, only that no communication

occurred between crewmembers during that time.15

In postaccident interviews with the Safety Board, the engineer admitted to reading,

stating, “I had a paperback book that I was looking at back and forth.” The engineer was

unable to explain how or why he missed signal 111 but, while he was at the hospital

undergoing treatment, told the Norfolk Southern division superintendent that he recalled

14 Chickenhawk by Robert Mason and Zen and the Art of Motorcycle Maintenance by Robert M. Pirsig.

 Figure 6. Books on floor of lead locomotive

15 The accident trip occurred at a time of day known for decreased alertness. For further information see:

Rosekind, M., Gander, P., Connell, L., and Co, E., Crew Factors in Flight Operations X: Alertness

Management in Flight Operations. NASA/FAA Technical Memorandum DOT/FAA/RD-93/18, 1994.
Factual Information 9 Railroad Accident Report

the conductor stating that the signal displayed an approach aspect. When asked by Safety

Board investigators whether he was asleep before the accident, the engineer refused to

answer on the grounds of self-incrimination. When questioned by Norfolk Southern

officials about whether he or the conductor was asleep before the accident, the engineer

responded, “Do I gotta say that?”

The student engineer said that as he approached Butler, intermediate signal 108.4

was displaying a clear indication, which he radioed over the road channel.16 He did not see

signal 111, the next intermediate signal on the left side17 of the track and the last

intermediate signal before the home signal at milepost (MP) 113.9, Butler interlocking. 

Locomotive event recorder data indicated that the train was traveling

approximately 60 mph (the maximum speed) as it passed signal 111. According to the

student engineer, when it seemed the train had gone too far without encountering signal

111, he asked the conductor and engineer about the signal location. He said that he began

slowing the train as the stop signal at Butler interlocking became visible and that

“...Howard [the conductor] was coming across, and we saw it together; actually, and he

said it [the home signal] was all red.” The student engineer said he was already in dynamic

braking18 and was applying more air brake when he heard the air brakes go into

emergency. He said that he thought the engineer had applied the emergency brake using

the valve on the left side of the cab. The student then placed the automatic brake valve

handle in the emergency position. 

The Accident

As the Norfolk Southern train approached Butler interlocking, the student engineer

stated that he realized a collision was imminent when he saw the other train going across

the crossing. He said he shouted, “We’ve got to get out of here” twice and turned to leave

by the door behind his position. The conductor was the first to exit, followed by the

student. The engineer stated that he saw both the conductor and student exit before he

exited behind them. 

The student stated that as he went down the locomotive stairwell and saw the

proximity of the oncoming train, he jumped, landing in some water. The student could not

recall whether the conductor jumped but did recall him being on the platform. The

engineer stated the conductor was out of sight when he exited the cab and jumped from the

locomotive. 

16 This is an open channel over which Norfolk Southern train crews orally communicate signals to

radios tuned to that channel.

17 Intermediate signals in the Norfolk Southern Huntington district are predominantly on the left side of

the track for westbound trains.

18 An electrical means of converting some of the energy of a moving locomotive into an effective

retarding force.
Factual Information 10 Railroad Accident Report

Damage

About 4:48 a.m., the Norfolk Southern train, traveling at a recorded speed of 30

mph, struck the Conrail train. The lead Norfolk Southern locomotive derailed, remaining

upright but facing east, while the trailing locomotive rolled over on its right side. Both

Norfolk Southern locomotive cabs remained intact with only minor damage to the left side

window of the lead unit, resulting in survivable space in both cabs. Both locomotive fuel

tanks ruptured,19 releasing about 7,000 gallons of fuel oil. The first through the fifth cars

of the Norfolk Southern train derailed; the first four cars were completely destroyed.

Norfolk Southern estimated total damages of $264,000 ($187,000 to equipment, $18,000

to track and signals, and $59,000 to cargo). 

The Norfolk Southern locomotives passed completely through the sixth car of the

Conrail train. Three of the cars from the Conrail train derailed, one of which was a fiveunit articulated car. (See figure 7.) Conrail estimated total damages of $352,200 ($314,000

to equipment, $33,500 to track and signals, and $4,700 to cargo).

19 These fuel tanks were conventional, frame-suspended tanks, a type that has been vulnerable to

catastrophic puncture and fire in past derailments. The Safety Board will continue to monitor the Federal

Railroad Administration’s progress in improving locomotive fuel tank crashworthiness.

 Figure 7. Point of impact
Factual Information 11 Railroad Accident Report

Postaccident Events

The Conrail engineer stated that after his train went into emergency, he

immediately radioed “Emergency” three times over the road channel and contacted the

train dispatcher in Dearborn. The Conrail conductor said that he then walked back to the

interlocking, where he found the derailed equipment. The conductor said that a white

powder covered the area and that he tried to avoid contact with the substance as he

searched for injured persons. 

The Butler fire department found the fatally injured Norfolk Southern conductor

near the point of impact. The injuries sustained and the final resting point of the body

suggested that the conductor was outside of the lead or trailing locomotive cab at the time

of impact. 

A Butler police officer who was in the vicinity of the accident responded

immediately upon hearing the collision and notified DeKalb County dispatch. The officer

encountered the student and the engineer from the Norfolk Southern train walking along

the track. Both crewmembers were taken by ambulance to DeKalb Memorial Hospital for

treatment of minor injuries. In addition, as directed by Norfolk Southern, they underwent

drug testing in accordance with Federal Railroad Administration (FRA) regulations. 

The Butler fire department responded within minutes and established a field

command post, securing the scene and helping with search and rescue. Because the white

powder spilled by the Norfolk Southern train was potentially hazardous, the DeKalb

County Hazardous Materials Response Plan was initially activated for a level 3 response,20

resulting in two schools being closed. When the two surviving Norfolk Southern

crewmembers were unable to furnish the Butler fire department with a train consist listing

the materials transported on the Norfolk Southern train, emergency responders donned

self-contained breathing apparatus to collect information from one of the broken bags of

white powder. The fire chief then attempted to contact the manufacturer. Because the

accident occurred during nonbusiness hours, a cleaning person answered the telephone

and provided the name of the only chemical manufactured by the company, nepheline

syenite. (The cleaning person’s information was later confirmed by company personnel

during business hours.) The fire chief contacted CHEMTREC (Chemical Transportation

Emergency Center), which confirmed that nepheline syenite is not a hazardous material.

After about an hour, when the white powder had been identified as a nonhazardous

material, the incident was downgraded to a level 2 response because of the diesel fuel on

the ground. According to the Norfolk Southern Lake Division Supervisor, DeKalb County

was not on the list of communities the company had coordinated with on emergency

response planning.

20 A level 3 response addresses a severe hazard or threat to life and the likelihood of a large-scale

evacuation. The DeKalb County Hazardous Materials Response Plan automatically classifies any incident

involving chemicals as level 1, a potential emergency condition, and classifies life-threatening incidents

possibly requiring evacuation of the surrounding area as level 2. 
Factual Information 12 Railroad Accident Report

Train Crew Information

Conrail Crewmembers

The Conrail dispatcher and crewmembers had undergone and passed the required

physical examinations. The two Conrail crewmembers had attended operating and safety

rules classes in the past year. In accordance with the Hours of Service Act, the train

crewmembers had been off duty for at least 8 hours before reporting to work the night of

March 25. Based upon the circumstances of the accident and the criteria contained in 49

Code of Federal Regulations (CFR) 219.201(c), Conrail exempted its dispatcher and

crewmembers from postaccident toxicological testing. 

Norfolk Southern Crewmembers

Engineer—The 45-year-old engineer was hired by Norfolk Southern as a

switchman in January 1987 and, because of his previous experience as an engineer with

another railroad, was promoted to locomotive engineer in July 1987. Disciplinary records

show that the engineer was given a 15-day deferred suspension in July 1990 for failing to

properly protect a movement. He received a letter of reprimand in November 1990 for

failing to directly supervise a student engineer (he had left the locomotive cab while a

student engineer was at the controls) and a 30-day suspension in July 1991 for operating a

train over the maximum permissible speed. This engineer was assigned a student during

the Peru and Butler trips because the student engineer’s regularly assigned engineer was

on leave.

The engineer had attended operating and safety rules classes within the past year.

In August 1997, he passed the physical examination required by the railroad every 3 years

for recertification as an engineer. Company records indicate that he was in compliance

with the Hours of Service Act and had been off duty for approximately 16 hours before

reporting to work the night of the accident. In postaccident interviews, the engineer said

that he had slept for approximately 8 hours during this time (4 to 5 hours of sleep and a

3.5-hour nap). Postaccident toxicological tests conducted in accordance with FRA

regulations were negative for the presence of alcohol and specified drugs.21

Student Engineer—The 38-year-old student engineer was originally hired by

Norfolk Southern as a trainman in January 1995. He was promoted to conductor in August

1995. In February 1998, he successfully passed the classroom phase of locomotive

engineer training. 

Disciplinary records show that the student engineer was given a 10-day deferred

suspension in April 1996 in connection with damage to a locomotive. In August 1997, he

received a letter of reprimand for failure to properly protect an assignment.22

21 Marijuana, cocaine, opiates, amphetamines, and phencyclidines (PCPs) in accordance with 49 CFR

Part 219, Subpart C.

22 Leaving an assignment early without permission or failing to report or reporting late to an assignment. 
Factual Information 13 Railroad Accident Report

Company records indicate that he had attended operating and safety rules classes

within the past year and had passed the railroad’s required physical examination in

January 1998. He was in compliance with the Hours of Service Act and had been off duty

for approximately 16 hours before reporting to work the night of the accident. In

postaccident interviews, the student engineer said that he had slept for approximately

8 hours during this time (7 hours of sleep combined and a 1-hour nap). Postaccident

toxicological tests conducted in accordance with FRA regulations were negative for the

presence of alcohol and specified drugs. 

Conductor—The 59-year-old conductor was first employed by Norfolk Southern

in June 1963 as a fireman and was promoted to conductor in July 1968. 

Norfolk and Western Railway Company (N&W) disciplinary records reveal that

the conductor was dismissed from service in March 1974 for violating rule G, which

concerns the use and possession of alcoholic beverages. He was reinstated in March 1975.

He received a 20-day deferred suspension in September 1988 for an air brake testing

violation.23 He was dismissed from the N&W in September 1988 for conduct unbecoming

an employee and was reinstated in December 1989. In August 1993, he received a 10-day

deferred suspension for not responding to a call for a conductor. In October 1993, he

received a 30-day deferred suspension for missing a call, which activated the 10 days that

had been deferred in August 1993. In March 1996, he received a 10-day deferred

suspension for failing to properly secure cars left standing on a main track. On March 26,

1997, the conductor was issued a letter of reprimand for violating operating rule 34, the

communicating of signals. In January 1998, he was cited for improperly performing his

duties and exposing himself to possible injury when he mounted a moving car. Records

did not indicate whether he was assessed a penalty for that action.

Company records indicate that the Norfolk Southern conductor had attended

operating and safety rules classes within the past year. The conductor’s most recent

physical examination, in November 1997, was conducted for “return to work” purposes

because he had been off work due to a cardiac condition. Medical records indicate that he

was taking aspirin and the following brand name prescription medications: Cardizem CD,

Dyazide, Tenormin, and Zocor.24 The conductor was in compliance with the Hours of

Service Act and had been off duty for approximately 16 hours before reporting to work the

night of the accident. No information was available on the conductor’s rest during this

period. Kidney, brain, and liver specimens obtained from the deceased conductor and

tested in accordance with FRA regulations were negative for the presence of alcohol and

specified drugs.

Dispatcher—The 36-year-old train dispatcher was first employed by Norfolk

Southern in November 1985 as a clerk and was promoted to dispatcher in October 1996.

23 N&W disciplinary records do not specify whether the conductor performed the test improperly or not

at all.

24 Cardizem CD and Tenormin are commonly used to treat angina, irregular heartbeat, and high blood

pressure. Dyazide is commonly used to reduce fluid retention and control high blood pressure. Zocor is

commonly used to lower blood cholesterol.
Factual Information 14 Railroad Accident Report

Disciplinary records disclosed no actions pertaining to the dispatcher. Based on the

circumstances of the accident and on 49 CFR 219.201(c), Norfolk Southern exempted the

dispatcher from postaccident toxicological testing.

Track and Site Information

 Butler, a rural town with a population of 2,800, is in the northeast corner of

Indiana, approximately 31⁄2 miles from the Ohio State line. The Norfolk Southern

Huntington District and the Conrail Chicago main lines cross at grade on the east side of

the town. The Conrail tracks pass through Butler from east to west, while the Norfolk

Southern track runs from northeast to southwest. (See figure 2.) The railroad crossing at

Butler was initially installed in 1881 by predecessor railroads of both carriers.

Conrail refers to the crossing as “CP [control point] 358,” and locates it at

MP 358.5 on its timetable. Norfolk Southern refers to the crossing as “Butler,” and locates

it at MP 113.9 on its timetable. The Butler interlocking consists of two track crossings, or

diamonds, at the points where the single-track Norfolk Southern main line crosses the

Nos. 1 and 2 main lines of the double-track Conrail Chicago Line. (See figure 2.)

The Huntington District of the Norfolk Southern Lake Division is a predominantly

single-track main line with sections of double track and numerous controlled passing

tracks. The Huntington District, in combination with the Detroit District, forms the

Norfolk Southern route between Detroit, Michigan, and Peru, Indiana. This route handles

approximately 20 trains per day and is used for the movement of automobile parts,

finished automobiles, chemicals, and merchandise. Grades are moderate, and trains

normally operate at a timetable speed of 60 mph. The speed limit is 60 miles per hour,

with several areas of speed restrictions for curves. Due to curvature and the diamond,

Butler has a permanent speed restriction of 50 miles per hour for all trains. At the exact

location of the diamond, the grade is 0.21 percent ascending for a westbound train.

The Chicago Line supports over 110 million gross tons annually and is the busiest

segment of the Conrail Dearborn Division. The corridor handles virtually every type of

rail traffic, including six daily Amtrak (National Railroad Passenger Corporation) trains.

East of Butler, approaching the crossing, the track is tangent (straight) for 68 miles.

Tangent track extends west of the diamond for about 0.3 miles. At the diamond, the track

is nearly level, with a recorded grade of 0.08 percent, descending to the east. Both tracks

have a timetable speed of 60 miles per hour for freight trains and 79 miles per hour for

passenger trains. 

On the day of the accident, timetable speeds were in effect for both carriers, with

no temporary speed restrictions. Both Conrail and Norfolk Southern inspected their track

and diamonds 2 days before the accident (March 23) and noted no defects. In addition,

crewmembers did not mention track concerns to Safety Board investigators.
Factual Information 15 Railroad Accident Report

Norfolk Southern Operating Rules

Norfolk Southern general regulation GR-3 states, “All employees must follow

instructions from proper authority, and must perform all duties efficiently and safely.” The

Norfolk Southern operating rules, effective July 2, 1995, and the Norfolk Southern Lake

Division Timetable No. 3 instructions govern trains operating on the Lake Division. 

The operating rules define overall areas of responsibility for both conductors and

engineers. Rule 581 states: 

Conductors have charge of the trains to which they are assigned and all

employees thereon. They are responsible for safe and proper management

of their trains, for protection and care of passengers and property, for

performance of duty by train employees, and for observance and

enforcement of all rules and instructions.

Rule 601 states:

Engineers are responsible for the proper performance and handling of

engines, for care of equipment and economical use of fuel and supplies....”

In addition, the operating rules specifically define responsibilities for all train

crewmembers pertaining to signal indications and signal calling. With regard to signal

indications, Norfolk Southern operating rule 240 requires that trains encountering a stop

signal come to a stop. Rule 285 requires that trains encountering a signal displaying an

approach aspect do the following: “Proceed preparing to stop at next signal. Train or

engine exceeding Medium Speed [not exceeding 30 mph] must at once reduce to that

speed.”

Rule 27 states, in part, that trains approaching a dark signal should regard that

signal as the most restrictive indication possible and promptly report the condition:

A signal imperfectly displayed, a signal functioning erratically, the absence

of a light, a white light displayed where a colored light should be, or in the

absence of a signal at a place where a signal is usually shown, must be

regarded as the most restrictive indication that can be given by that signal

and must be promptly reported to the train dispatcher, control station, or

yard master.

Norfolk Southern further discusses crewmember responsibilities for observing and

reporting improper signal indications in rule 244:

Should an improper signal indication permitting a train to proceed be

observed, employees must report the fact to the proper authority by the

quickest means of communication. In addition, all employees must take

such action as possible to provide protection for the movement of trains
Factual Information 16 Railroad Accident Report

and engines. Crew members who are in a position to do so must observe

whether signals passed by their train or engine assume proper indication. 

Operating rule 34 requires that crewmembers “call,” or orally communicate, all

signals encountered but does not require that crewmembers permanently record them. The

rule further states:

The engineer must comply with the indication of each block, interlocking

and other signal that affects the movement.

Crew members located in the operating compartment must occupy a

window seat when available, and must maintain a vigilant lookout for

signals and conditions along the track that affect the movement. Crew

members located in the operating compartment who cannot avail

themselves of a window seat must maintain a vigilant lookout for signals

and conditions along the track within their view, that affect the movement.

Employees located in the operating compartment of an engine must

communicate to each other in an audible and clear manner by its name the

indication of each signal affecting movement of their train or engine as

soon as the signal is clearly visible or audible. Each signal must be called

(1) as soon as it is clearly visible or audible and (2) again, if other than a

stop signal, just before the signal is passed. It is the responsibility of the

engineer to have each employee comply with these requirements.

When crew members ride in the trailing units their first duty is to observe

signals affecting the movement. If other crew members are present, they

must communicate to each other by its name the indication of each signal.

A crew member on the controlling locomotive will communicate by radio

the name and location of each signal affecting his movement as soon as the

signal becomes visible.

If there are crew members on trailing units and/or caboose they will

acknowledge the transmission, repeating the information to crew

member(s) on the controlling locomotive.

Example of correct procedure to initiate the radio transmission when all

crew members are on the controlling unit:

“NS Train 187 has an Approach signal on No. 1 main at MP 179.3 for

Cumberland Falls, out.”

Examples of correct procedures to initiate and acknowledge the radio

transmission when there are crew members on trailing units and/or

caboose: 

“Engineer Scott, NS train 194 has a Diverging Approach signal at the north

end of Philpott, over.”
Factual Information 17 Railroad Accident Report

“Brakeman Hodges, NS train 194, acknowledging the Diverging Approach

signal at the north end of Philpott, out.” 

If the engineer fails to control movement in accordance with signals or

other conditions, crew members must communicate with him at once. If he

then fails to immediately control the speed properly they must take

necessary action to stop the train.

Title 49 CFR 217.9 requires that each railroad conduct operational tests to

determine the extent of compliance with the operating rules. Norfolk Southern Lake

Division testing records indicate that the following occurred from March 1997 through

February 1998:

Of these tests, 17,278 were conducted specifically on rule 34 compliance, resulting

in 283 reported failures, or a 1.64-percent failure rate. Records also indicate that the

Norfolk Southern engineer was tested 11 times for Norfolk Southern operating rule 34

compliance from January 1, 1997, to March 25, 1998, with no reported failures. In

addition, the Norfolk Southern conductor was tested 15 times for Norfolk Southern

operating rule 34 compliance for the same period. On March 26, 1997, at Butler, the

conductor was found in violation of rule 34 and issued a letter of reprimand. According to

the surviving crewmembers, the conductor had instructed the student engineer that it was

the practice of the crew not to call clear signals. According to Norfolk Southern officials,

this instruction was in violation of Norfolk Southern operating rule 34.

Postaccident Tests

Visibility and Sight Distance

To replicate the conditions on the day of the collision, investigators conducted

sight distance tests in the predawn hours of March 26, the day after the accident. Engine

6507, a unit identical to engine 6508 (the lead Norfolk Southern locomotive in the

collision), was used for the tests. The locomotive traveled in the same direction and at the

speed recorded by the accident train’s event recorder (60 mph). In addition, the

locomotive was configured identically to engine 6508 (long hood forward and the control

stand on the right side).25 Sight distances were taken from both the left and right sides of

the locomotive cab. 

Tests Observations*

* Generally recorded by Norfolk Southern supervisors during the course of normal operations, as opposed to

during a period specifically designated for rules testing.

Total Failures Failure rate

385,987 243,279 629,266 4,378 0.70%

25 Some railroads designate the long hood as the front end to provide added distance and material to

protect the crew in a collision. The lead locomotive on Norfolk Southern train 255L5 was specially

configured to have the long hood forward and the control stand on the right side.
Factual Information 18 Railroad Accident Report

The tests showed that a crewmember at the control stand (right side), where the

student engineer was seated, could see intermediate signal 111 from a distance of 1,397

feet. The signal would no longer be visible from the control stand at 678 feet because

visibility is limited by the long hood of the locomotive (see figure 5).26 The Safety Board

further determined that a crewmember seated at the control stand could see signal 111 for

719 feet, which at 60 mph translates to approximately 8 seconds. From the left side of the

cab, where the conductor and engineer were seated, this signal was visible for 1,698 feet.

A crewmember positioned on the left side of the cab could therefore see the signal for

approximately 19 seconds before advancing past it. 

The sight distance from the right side of the locomotive for the home signal at

Butler interlocking was 5,232 feet, meaning at 60 mph, the signal could be viewed from

the control stand for approximately 60 seconds. From the left side of the cab, the signal

was visible at 5,254 feet, or for approximately 60 seconds.

Signals

Conrail trains receive authorization to move from the signal indications of a traffic

control signal (TCS) system controlled by the Toledo West train dispatcher in Dearborn.

Norfolk Southern trains receive authorization to move from the signal indications of a

TCS system controlled by the Norfolk Southern Huntington train dispatcher in Fort

Wayne. Both Conrail and Norfolk Southern train movements through the Butler railroad

crossing at grade are authorized by the signal indications of an interlocking signal system

controlled by the Conrail Toledo West train dispatcher in Dearborn. The TCS and

interlocking signal systems are interconnected and operate seamlessly.

Conrail—A postaccident signal examination indicated that the TCS system signals

were displaying the proper signal sequence for Conrail train movements on both tracks.

The signal inspection records and the signal event logs did not indicate deficiencies that

would have prevented the TCS system from operating properly. The Conrail

crewmembers stated they had a good view of the home signal at the Butler interlocking

and reported that the weather at the time of the accident was clear, with no visibility

problems. 

The signal event logs from the equipment at Conrail CP 358 (Butler crossing) and

the diagnostic log from the Computer Aided Train Dispatching Facility in Dearborn

indicated that the dispatcher was lining signals for Conrail train movements while home

signal 113.9, governing the movement of Norfolk Southern southbound trains through the

Butler crossing, displayed a correct stop aspect. The signal event logs recorded the aspect

of signal 113.9 as unchanged for approximately 2 hours before the accident. The logs also

recorded a Conrail train occupying the interlocking track circuit past signal 113.9 just

before the collision. 

26 Norfolk Southern has 1,190 of its 2,242 locomotives configured with the control stand on the right

side when operating with the long hood forward.
Factual Information 19 Railroad Accident Report

Norfolk Southern—Postaccident signal testing was conducted to determine the

aspects for the intermediate signals preceding Norfolk Southern home signal 113.9 as the

Norfolk Southern train approached the Butler crossing. (See figure 4.) The tests, which

included signals 108.4 and 111, found that the proper codes were being transmitted to

signal 111 from the electronic track circuit unit at Butler interlocking (Conrail CP 358).

When tested, the signal system transmitted codes in a logical progression and displayed

signal aspects that were not in conflict with each other. Further, tests indicated that the

proper codes were being transmitted to signal 108.4 from the electronic track circuit unit

at signal 111 under all conditions. When signal 111 displayed a yellow, or approach,

aspect, signal 108.4 displayed a green, or proceed, aspect. When signal 111 was dark,

signal 108.4 downgraded to a yellow, approach, aspect. Crew interviews and recorded

radio conversations between the student and dispatcher indicated that signal 108.4

displayed a green, proceed, aspect when the Norfolk Southern train went past it on the day

of the accident.

Signal 111 was observed going dark at random intervals during the postaccident

investigation; consequently, the Electro Code 4 unit containing the lighting module was

removed and bench tested. Bench tests identified failed internal aluminum electrolytic

capacitors27 that caused the signal to go dark for 10 to 24 seconds. (See figure 8.) This

failure did not cause the signal to show any other inappropriate aspect, such as a less

restrictive signal aspect. Norfolk Southern operating rules require that engineers treat a

dark signal as the most restrictive aspect possible for that signal, which in the case of

signal 111 is a restricted signal, meaning that the train could proceed at a restricted speed. 

The investigation further revealed that the signal data recorder28 at MP 111 was

affected by the failed capacitors. The device recorded events despite no physical changes

occurring in the operational status of the signal location, thus rapidly filling the memory

buffer and overwriting older recorded events, including events that occurred at the time of

the accident.

Field inspections of other Harmon Electro-Code 4 units in the Lake Division found

evidence of capacitor failures on the 212A modules manufactured from 1987 to 1988. On

May 15, 1998, Harmon Industries issued product improvement announcement PIA 98-101

detailing the failure of the capacitor and explaining how to exchange the 212A module for

a replacement. (See appendix A.) By the time Harmon issued this announcement as a

result of the failures at signal 111, the faulty unit at signal 111 had been replaced. The

company also offered components and modification instructions to railroads preferring to

and capable of making their own modifications. 

Harmon Industries provided field technicians to aid Norfolk Southern in a

systemwide program to identify and replace all modules manufactured from 1987 to 1988.

27 Electronic device capable of storing an electric charge by means of two electrodes separated by

electrolytic fluid (wet capacitor). Loss of the electrolytic fluid renders the device open and ineffective in

circuit operations. 

28 Records track codes, signal aspects, signal-light-out conditions, track occupancy, and other critical

functions.
Factual Information 20 Railroad Accident Report

During Safety Board depositions held in October 1998, Norfolk Southern Signal

Department officials stated this program was complete for all Norfolk Southern divisions. 

Norfolk Southern Signal Malfunction Reporting

The investigation revealed that the failed capacitors were on an electronic unit not

accessed during required maintenance tests and inspections. Thus, a signal maintainer

would either have to observe the signal failure or receive a report of one to be aware of a

problem.

Norfolk Southern train crews reporting a malfunctioning signal must report the

event to the dispatcher. The dispatcher then completes a signal report form and notifies

the signal maintainer responsible for the territory where the report occurred, who

subsequently investigates the malfunction. After repairing the malfunction or determining

its cause, the maintainer notifies the dispatcher of the result of the investigation. The

dispatcher logs the maintainer’s report on the form, records any train delays caused by the

signal failure, and files a copy of the form. 

A copy of all signal report forms completed by dispatchers is provided daily to the

reporting division’s chief dispatcher and Signal General Supervisor. These individuals

review the reports to determine whether further followup is required or to coordinate train

movements if the problem will cause further delays. The General Supervisor also reviews

 Figure 8. Failed capacitor (at arrow) from MP 111 Electro Code unit
Factual Information 21 Railroad Accident Report

the reports with division supervisors to determine the final outcome of reported

malfunctions. 

Signal malfunction reports indicated that signal 111 had been reported on two

different occasions as downgrading from a yellow, approach, aspect to a dark aspect as

trains approached it. Following the first reported dark signal on February 19, 1998, the

Norfolk Southern signal maintainer responsible for the territory responded to the call and

reported that signal 111 was working properly. Because the cause for the malfunction

could not be determined, the signal maintainer installed a signal event recorder card so

that the signal log could be downloaded later and checked for abnormalities in the signal’s

operation. However, Norfolk Southern personnel did not download the log.

After signal 111 was again reported going dark in March, the Lake Division Signal

General Supervisor requested a download from the division supervisor. The Lake

Division Signal General Supervisor said that he was unaware of the previous dark signal

report. On March 22, 1998, 3 days before the accident, while responding to the second

report of signal 111 going dark, the Norfolk Southern signal maintainer who had

responded to the February call observed a train operating past the reported signal. He

again reported the signal to be working properly. The signal maintainer stated that he was

dispatched to attend to a malfunction at a different location before he could test or

download the signal event recorder log. The download occurred following the accident.

Locomotive Engineer Training Program

After meeting eligibility requirements, candidate student engineers must attend

training in McDonough, Georgia, for 1 month before returning to their divisions for onthe-job training. The training at McDonough, Georgia, consists of classroom training and

20 hours of training in a locomotive simulator. According to Norfolk Southern Training

Center personnel, none of the school’s locomotive simulators are configured in the manner

of the accident train, with the long hood forward, but students may have the opportunity to

operate a train in that configuration on the school’s training track during their month in

McDonough. Training Center personnel also stated that the school considers training

student engineers for conditions that may be unique to a division, such as long-hoodforward operation, to be the division’s responsibility. The section governing student

engineer training in the company’s locomotive engineer certification program29 submitted

to the FRA on June 13, 1995, does not cite knowledge of or practice in long-hood-forward

operation as training objectives. 

The student engineer completed the classroom phase of the locomotive engineer

training program in McDonough in early February 1998 and had successfully completed

all training requirements and tests by the end of the month. The student engineer then

followed the typical route of Norfolk Southern student engineers in reporting back to his

29 Section 5, “Training, Testing, and Evaluating Persons Not Previously Certified,” from Norfolk

Southern’s 49 CFR Part 240 submission Certification of Locomotive Engineers (October 1991, revised June

1995).
Factual Information 22 Railroad Accident Report

division for on-the-job training. This training focuses on gaining experience in operating a

locomotive and on qualifying on the physical characteristics of the territory,30 that is,

becoming familiar with the physical characteristics of the track over which the trainee will

eventually operate. In this case, the student engineer was not assigned to the territory in

which he had worked as a conductor.

According to the Norfolk Southern Division Road Foreman of Engines (DRFE),

student engineers, upon returning to their divisions for on-the-job training, meet with a

road foreman. The road foreman instructs the student engineer on what is expected of

trainees during the on-the-job phase of training, to include presenting the student engineer

with a list of operating requirements. (See appendix B.) The DRFE said that the student

engineer then either chooses, or is assigned, a coach engineer.

The investigation revealed that on March 3, 1998, the student signed a form listing

the operating requirements for student engineers, including the stipulation that he can

operate trains only with his regularly assigned engineer or with another coach-trained

engineer who has been working for at least 1 year.31 The train 255L5 engineer was not the

student’s regular engineer and was not coach trained. (See appendix B for the student’s

copy of the form.) According to the DRFE, for a student engineer to operate a train:

• The student engineer must determine that the engineer is coach trained.

• The coach-trained engineer must confirm that the crewmember is a student

engineer and is knowledgeable of the applicable rules and regulations.

The student stated after the accident that he was aware that engineers must have at

least 1 year of operating experience but that he had forgotten or did not realize they are

also supposed to be coach trained.

The DRFE said that Norfolk Southern had compiled a list of coach-trained

engineers, although he was unable to confirm whether that list had been published before

the accident. The student engineer stated that he received this list several months after the

accident. The DRFE also stated that it is up to the student to inform the engineer that he

can operate the train only with a coach-trained engineer and that Norfolk Southern does

30 Locomotive engineers qualify on the physical characteristics of a territory by making several trips to

become familiar with track grades and curvature, signal locations, interaction with the train dispatcher, and

other operational factors unique to a particular area. Student engineers who have previously worked in a

territory as a conductor and are therefore somewhat familiar with the territory must still learn the territory’s

grades and train control requirements. The road foreman determines when a student engineer has qualified

on the physical characteristics of a particular territory.

31 Regularly assigned engineers are always coach trained. Coach-trained engineers are selected to

supervise on-the-job training of student engineers based upon their ability to effectively communicate with

and be a mentor to others. A candidate coach engineer must have been an operating engineer for at least

1 year and have viewed the company’s coach training video and read the accompanying participant’s guide.

The DRFE testified to Safety Board investigators in November 1998 that the Lake Division had between 50

and 60 student engineers and 400 coach-trained engineers participating in its locomotive engineer training

program.
Factual Information 23 Railroad Accident Report

not provide information on the student engineer program to engineers who are not coach

trained. The engineer of train 255L5 was not coach trained.

Student engineer evaluations are completed on a monthly basis by a district road

foreman (DRF). Because the student engineer had been assigned to the Lake Division for

less than 1 month at the time of the accident, he had not yet been observed and evaluated

by a DRF. He was uncertain about the feedback process related to his performance and

added that he had never received written feedback from a Norfolk Southern employee or

been observed by a road foreman.

The engineer stated that when students accompanied him during trips, he did not

complete written evaluations of their performance and was not required to because he was

not a coach-trained engineer. He also indicated that Norfolk Southern did not provide him

with training on how to evaluate student engineers. He believed that training provided by

Norfolk Southern on instructing student engineers was inadequate and that there was

“complete confusion with [the] engineer process from the beginning.” 

Crew Communication

The engineer and the student engineer both stated that they had previously known

or worked with each other until almost 2 days before the accident, during the trip from

Peru to Detroit that began late March 23. The student also said that he had operated a

locomotive once or twice in other areas and had been on trains traveling through the

accident area about six times before the Peru trip. During the company’s October 7, 1998,

hearing, the engineer testified that the student engineer and conductor “had been working

together” and that the student engineer was “more his boy than mine.” The engineer added

that the conductor “convinced me to let him [the student engineer] run the engine in the

first place.”

The engineer stated that he preferred not to have student engineers with him while

operating trains and that he was unaware that a student would be with him until the student

engineer arrived late March 23 for the trip from Peru to Detroit. The engineer stated that

he quizzed the student engineer during that trip and was impressed with his knowledge of

signal locations, speed restrictions, and interlockings. He indicated that he and the student

engineer also discussed the student’s ability to operate a locomotive. The engineer said

that he allowed the student engineer to operate the train during the accident trip because of

the conductor’s opinion of the student’s abilities and his own observation of the student’s

performance during the previous trip from Peru to Detroit.
24 Railroad Accident Report

Analysis

This analysis consists of three general sections. The first identifies factors that can

be eliminated as causal or contributory to the accident. The second reviews the accident

itself, highlighting the actions and events that resulted in problem conditions. The balance

of the analysis discusses the major safety issues identified in this investigation:

• Adequacy of Norfolk Southern’s methods for ensuring compliance with the

operating rules,

• Adequacy of Norfolk Southern’s locomotive engineer training program, and

• Importance of train crew resource management to safe and efficient train

operations.

The analysis also addresses additional safety concerns identified during the

investigation: the adequacy of Norfolk Southern’s signal malfunction reporting

procedures and of Harmon Industries’ signal component repair and replacement program,

the continued need for in-cab audible recording devices on trains to provide essential

details for accident investigations, and the importance of emergency response

management in railroad accidents involving hazardous materials.

Exclusions

Both train crews had satisfactorily performed the required pretrip tests of their

trains and reported no deficiencies. In addition, postaccident testing revealed no track

defects in the accident area, and crewmembers did not mention track condition as a

concern. Therefore, the Safety Board concludes that the mechanical condition of the trains

and track did not contribute to this accident.

The National Weather Service in Fort Wayne, Indiana, reported unrestricted

visibility at 10 statute miles and no precipitation at the time of the accident. Therefore, the

Safety Board concludes that neither weather nor visibility had a role in this accident. 

A postaccident signal evaluation revealed that the Conrail traffic control system

displayed the proper aspect sequences for Conrail train movements. In addition, the

interlocking signal system did not display conflicting signals; the Norfolk Southern home

signal was at stop in response to the Conrail train’s proceeding through the crossing on an

approach signal. Therefore, the Safety Board concludes that the operation of the Conrail

signal system and the interlocking signal system did not contribute to this accident. 

The carriers determined that the Conrail train crewmembers and the Conrail and

Norfolk Southern dispatchers did not contribute to the accident and thus exempted them

from toxicological testing. Postaccident testing for alcohol and specified drugs conducted

on the Norfolk Southern crewmembers was negative. Members of both train crews had

taken the required operating and safety rules classes in the past year. In addition, the
Analysis 25 Railroad Accident Report

Norfolk Southern student engineer had successfully completed all training requirements

and tests for the classroom phase of the locomotive engineer training almost a month

before the accident. Consequently, the Safety Board concludes that neither alcohol and

drug use nor train crew qualifications were factors in this accident.

Accident Discussion

The Safety Board’s analysis of the signal event logs from the equipment at the

Butler interlocking and of the diagnostic log from the Computer Aided Train Dispatching

Facility in Dearborn indicates that home signal 113.9, governing Norfolk Southern

southbound trains, had correctly displayed a stop aspect at the time of the accident. This

was also confirmed by the crew’s testimony. Signal event logs recorded the aspect of

home signal 113.9 as unchanged for approximately 2 hours before the accident and also

recorded a Conrail train occupying the interlocking track circuit past signal 113.9 just

before the collision. Furthermore, sight distance tests performed the day after the accident

demonstrate that Norfolk Southern’s crewmembers could have seen signals 111 and 113.9.

The student engineer radioed to the dispatcher every signal that he encountered up

to signal 111, including the clear indication at the immediately preceding signal, 108.4,

indicating that he was attentive and vigilant during the accident trip. In addition, the

engineer had been impressed with the student’s knowledge of signal locations based on a

conversation with the student during the Peru trip. However, the student engineer told

investigators that he missed signal 111. Several factors could explain the oversight. First,

the student was not yet qualified on the physical characteristics of the territory. In fact, the

territory to which he was assigned was not the same territory in which he had worked as a

conductor, thus limiting his familiarity with it to the six trips he had made through the area

before working with the Butler train crew. In addition, he had never operated a locomotive

in the accident area before the Peru and Butler trips. Further, although investigators could

not determine whether the intermittent dark signal discovered during the postaccident

investigation at MP 111 was dark when the Norfolk Southern train passed it (see “signal

malfunction reporting” later in analysis), had the signal been dark, it may have contributed

to the student engineer’s confusion about the train’s location. Finally, the operation of the

train with the lead locomotive in the long-hood-forward configuration limited the student

engineer’s visibility from the left side of the locomotive, where MP 111 was located. The

Safety Board concludes that the reduced visibility on the student’s side of the cab as the

train approached MP 111, compounded by a possible dark signal and by the student

engineer’s lack of experience, may have caused the student to miss the signal and the

reflectorized milepost marker. None of these factors, however, applied to the engineer and

conductor. Had the conductor and engineer called the clear signal at MP 108.4 in

compliance with Norfolk Southern operating rule 34, their attention would have been

engaged before the accident. Calling the signal, in turn, would have set the stage for the

train either to prepare to stop in response to an approach signal in accordance with rule

285 or to stop in response to a dark signal in accordance with rule 27, which requires that

a dark signal be treated as the most restrictive indication possible. The Safety Board

concludes that because of the engineer’s and conductor’s lack of vigilance and decision
Analysis 26 Railroad Accident Report

not to call clear signals, the crew of Norfolk Southern train 255L5 failed to react to either

an approach or a possible dark signal at MP 111.

This collision is yet another accident that could have been prevented had a positive

train separation (PTS) system been in place and operational. PTS systems monitor and

control train operations, slowing or stopping trains when the braking distance between

trains is insufficient for safety. 

PTS can be implemented through on-board computers with communication links

to a control center. The trains’ on-board computer systems are automatically and

continuously updated with information including speed limits, work in progress on the

right-of-way, the location of the preceding and following trains, track integrity, and train

makeup conditions (length and weight of trains). If necessary, a PTS system can apply

train brakes automatically to keep trains apart, enforce speed restrictions and signal

indications, or stop trains short of an improperly lined switch or other known obstruction.

Depending upon the railroad’s current signal and train control system, PTS systems can be

used to provide various levels of operation, enhancing a railroad’s current signal and train

control system or providing protection to trains on railroads without signal and control

systems.

When the student engineer failed to slow his train for signal 111, a PTS system

would have intervened by applying the train brakes and stopping the train short of the

Butler interlocking. The Safety Board concludes that a fully implemented PTS system

would have prevented this accident. The Safety Board strongly advocates the development

of PTS systems for U.S. railroads and has included PTS on its list of “Most Wanted

Transportation Safety Improvements.”

Although the investigation revealed no evidence of fatigue on the part of any

crewmember involved in the accident, statements made by the Norfolk Southern engineer

and the student engineer after the accident suggest that the engineer and the conductor

were probably asleep before the train was placed into emergency braking. The engineer,

when questioned by Safety Board investigators about whether he was asleep before the

accident, refused to answer on grounds of self-incrimination. When asked by Norfolk

Southern officials whether he or the conductor was asleep before the accident, the

engineer responded, “Do I gotta say that?” The student engineer said that before the

accident, the side of the locomotive cab occupied by the engineer and conductor was dark.

He was unsure how long the light was out, noting “it could have been a half hour, it could

have been an hour. I don’t know.” He was unable to state with certainty whether the

engineer or conductor was asleep while the light was out, only that no communication

occurred between crewmembers during that time.

The Safety Board believes that both the conductor and engineer were probably

asleep before the conductor rose from his seat to answer the student engineer’s question

regarding their location. The fact that the engineer and conductor had not interacted with

each other or with the student while in a dark environment, for perhaps up to an hour, at a

time of day known for reduced alertness, suggests that both individuals were disengaged

from their environment and were probably asleep. Furthermore, after the accident, the
Analysis 27 Railroad Accident Report

engineer stated that he was comfortable with the student engineer’s performance during

the trip, a belief that may have caused him to relax direct observation of the student

engineer after departing Detroit. The possibility that one or both of these crewmembers

were asleep is particularly compelling given that the engineer was unable to explain how

or why he did not observe signal 111. The engineer’s statement that the conductor called

the approach signal at MP 111 is inconsistent with the student engineer’s testimony that

the engineer and conductor did not call the signal at that location and that no

communication occurred between crewmembers during that time. Even if the signal lights

were out when the Norfolk Southern train approached MP 111, an alert and vigilant

crewmember would have known the physical location of that signal and informed the

student engineer of its status.

The Safety Board finds that the engineer’s inability to explain missing the signal at

MP 111, in the context of his equivocal responses about whether he was asleep before the

accident and his sitting still in a darkened environment, raises valid questions about his

state of alertness before the accident. The Safety Board therefore concludes that the

engineer and conductor failed to observe and call signal 111 because they were distracted,

inattentive, or possibly asleep.

Adequacy of Methods for Ensuring Compliance With 

Operating Rules

During the previous trip from Peru to Detroit, company policies were not

followed, and as a result, the student engineer was operating a train with an engineer who

was not coach trained. However, the Safety Board considers this lapse to be less

significant than what happened after the crew departed Detroit for the accident trip. No

unusual events occurred from the time the train departed Detroit until several minutes

before the accident, which may have led the engineer and conductor to be overly confident

about the student engineer’s abilities and may have caused them to relax their vigilance

even though they knew the student engineer was not qualified on the physical

characteristics of the territory. The possibility that the crewmembers may have relied too

heavily on the student engineer’s abilities is compelling, given that both the engineer and

conductor were reading books during the trip and were probably asleep at the time the

student engineer realized his predicament. 

In addition, no one individual was responsible for supervising the student engineer.

Although the engineer testified that the student engineer was “more his [the conductor’s]

boy than mine” and that the conductor “convinced me to let him [the student engineer] run

the engine in the first place,” he also reported that he had been sufficiently impressed with

the student engineer’s abilities during the preceding trip from Peru to allow the student to

run the train. The statements point to confusion concerning who was responsible for the

student engineer.

According to Norfolk Southern operating rule 601, engineers are responsible for

train handling and care of the equipment and, by extension, for a student’s operation of the

train. According to operating rule 581, conductors are in charge of all train crewmembers
Analysis 28 Railroad Accident Report

and are responsible for enforcing rules and instructions. The Safety Board therefore

concludes that the engineer, as the individual responsible for train handling and care, and

the conductor, as the individual responsible for ensuring that rules and instructions are

followed, disregarded their responsibilities during the accident trip. The Safety Board

further concludes that this accident could have been avoided had the conductor and

engineer complied with Norfolk Southern rules and instructions to include: observing and

confirming all signal aspects; actively supervising the student engineer, particularly one

who was unfamiliar with the territory; and not reading or engaging in other distracting

activities. Therefore, the Safety Board believes that Norfolk Southern should develop and

implement methods to improve employee compliance with company rules and

instructions.

One compliance issue that was pivotal to this accident and that Norfolk Southern

could address promptly concerns operating rule 34. According to testimony by both the

engineer and the student engineer, the conductor stated it was crew practice not to call

clear signals, an instruction that Norfolk Southern officials stated is in violation of the rule

34 requirement to call all signals. The Norfolk Southern Lake Division had a sufficient

record for conducting tests and observations for operating rule compliance, including rule

34 compliance, and reported a low failure rate during testing. But such data may be

misleading because a supervisor must be on board the train and witness noncompliance

for a failure to result. That the train crew could routinely ignore this operating rule, despite

the Lake Division’s conscientious testing and observation program and even after the

conductor had received a letter of reprimand within a year of the accident for violating that

operating rule, strongly argues that an operating rule alone will not guarantee that signals

are called.

Norfolk Southern does not maintain a record of in-cab communication of signals.

Two other railroads, the Burlington Northern Santa Fe Railway Company (BNSF) and the

Union Pacific Railroad (UP), require that signal aspects, time, and speed be noted on a

form. (See appendix C for the UP form.) The BNSF requires that these forms be submitted

at the end of each trip as directed by the applicable division superintendent. The UP

requires that conductors maintain the forms for five trips and keep them in their

possession while on duty. 

The railroad industry already has requirements for recording crewmember actions

or events during a trip, such as those for drug and alcohol testing under 49 CFR 219 and

the use of event recorders under 49 CFR 229.135. These measures provide an after-thefact record, reinforcing desired behavior by ensuring crewmember accountability. In

addition, tasking crewmembers to keep a record of signals observed would enhance train

crew coordination by ensuring that crewmembers communicate during a trip.

The Safety Board concludes that having procedures to actively engage

crewmembers in observing and confirming all signal aspects, such as recording the

aspects, would make it more likely that train crews call signals in compliance with the

operating rules. Therefore, the Safety Board believes that Norfolk Southern should

develop and implement procedures that actively engage crewmembers in observing and

confirming all signal aspects.
Analysis 29 Railroad Accident Report

Adequacy of the Locomotive Engineer Training Program

The Safety Board evaluated the effectiveness of the on-the-job portion of Norfolk

Southern’s locomotive engineer training program principally in the context of the

relationship between the student engineer and the engineer. During the accident trip and

during the preceding trip from Peru to Detroit, the student engineer did not follow

company policy by failing to ascertain whether the engineer was coach trained. That a

student engineer was ultimately paired with an engineer who was not coach trained clearly

illustrates that despite the company’s assertion to the contrary, Norfolk Southern

procedures designed to prevent such situations have not worked.

The student engineer said after the accident that he did not realize or had forgotten

that he could not operate a train without a coach-trained engineer. However, even if the

student had been aware of the restriction, he could not have verified the engineer’s status

until reporting for duty because he did not receive the company’s list of coach-trained

engineers until several months after the accident.

The Safety Board determined that the form (appendix B) noting the restrictions on

student engineers and signed by the student engineer on March 3, 1998, while developed

and deemed appropriate for student engineers assigned to the Lake Division, was not

being used systemwide. The System Road Foreman of Engines (SRFE) stated that the

form was unique to the Lake Division and that other divisions used similar forms or

dispensed similar information orally. The Safety Board concludes that allowing local

variations in training requirements promotes operational inconsistencies and hinders

uniform compliance with the student engineer training program. 

Because Norfolk Southern provided information on the student engineer program

to coach-trained engineers only and, in the Lake Division at the time of the accident, relied

on student engineers to inform engineers of operating restrictions, it is unlikely that the

engineer would have known that the student should not operate the train. According to the

DRFE, a Superintendent’s Notice was issued after the accident informing all Lake

Division personnel of operating restrictions for student engineers. The Safety Board

concludes that unless all Norfolk Southern operating personnel are informed of

restrictions on the operation of trains by student engineers, a situation in which a student

engineer operates a train without proper supervision could occur again. Therefore, the

Safety Board believes that Norfolk Southern should inform all operating personnel of their

responsibilities regarding student engineers.

Furthermore, the Safety Board is concerned that when the student engineer

returned to the Lake Division, he received no feedback on his performance. The fact that

the student received no oral or written feedback during this phase of his training is

additional evidence that the locomotive engineer training program at the time of this

accident was inadequate. The Safety Board regards timely feedback as an essential

element in any training program for achieving and maintaining desired behavior

consistent with stated policy; inadequate or no feedback degrades the training experience.

Performance feedback, whether from a qualified engineer or a road foreman, should occur
Analysis 30 Railroad Accident Report

throughout the training process. The Safety Board concludes that not providing feedback

because the student engineer had not yet reached the point at which he was scheduled to

be formally evaluated by a road foreman (that is, he had not worked in the Lake Division

for 1 month) is inconsistent with the goals of effective training. The Safety Board further

concludes that Norfolk Southern’s oversight of student engineers during the on-the-job

portion of training is inadequate. The Safety Board therefore believes that Norfolk

Southern should assign supervisors dedicated exclusively to student engineers who will, at

a minimum:

• meet with student engineers at the start of the on-the-job training phase to

ensure that student engineers are aware of the conditions under which they can

operate a train and that they know what to do if these conditions are not met;

• track the student engineer’s daily train assignments, daily crew assignments,

and performance evaluations; and

• provide timely feedback and advice to student engineers on a continuing basis.

The Safety Board evaluated the effectiveness of the classroom portion of Norfolk

Southern’s locomotive engineer training program principally in the context of whether the

training adequately prepared the student for operational situations encountered during the

accident trip. The investigation revealed that the student engineer had not been trained to

operate a locomotive in the long-hood-forward configuration; in fact, the first time he had

ever operated a locomotive in this configuration was the day before the accident. 

Norfolk Southern Training Center personnel indicated that locomotive engineer

training includes the fundamental concepts of locomotive and train operations. Classroom

and laboratory activities are combined with daily hands-on simulated train operations

using one full-motion and two stationary locomotive simulators. All three simulators are

configured with the “short nose forward”; consequently, the view from the simulator is

significantly less restricted than the view the student engineer had during the accident trip.

Training Center personnel said that while students in training at McDonough may have the

opportunity to operate a locomotive in the long-hood-forward configuration on the

school’s training track, the division is responsible for training student engineers on

operational variations and conditions unique to the division, including operating

locomotives in the long-hood-forward configuration. 

The Safety Board disagrees with this approach to engineer training. An adequate

training program should address all known or anticipated operational requirements

systemwide. The idea that training should address operational requirements systemwide is

particularly relevant considering the local variations in student engineer training

requirements that were discussed earlier in this section. By delegating selected aspects of

operational training to the divisions, the locomotive engineer training program does not

equally prepare student engineers for situations encountered on the job. The Safety Board

concludes that Norfolk Southern’s engineer training program was not adequate to prepare

student engineers to cope with all known or anticipated operational requirements

systemwide, such as operating trains with the long hood forward. The Safety Board

believes that Norfolk Southern should provide student engineers with formal training in
Analysis 31 Railroad Accident Report

all known or anticipated operational requirements systemwide, including operating trains

with the long hood forward.

The Safety Board considers aggressive oversight to be essential to any program,

but particularly to a training program, because such oversight promotes compliance with

company policy. Since the company’s merger with Conrail in June, the number of

engineers employed by the company has increased from the approximately 3,600

employed at the time of the accident to 5,003, according to Norfolk Southern’s SRFE.

The nearly 40-percent increase in the number of Norfolk Southern engineers since the

company’s acquisition of Conrail makes oversight of the training program even more

critical.

The lack of oversight in this accident is particularly relevant considering the

training improvements that Norfolk Southern stated it had implemented after a strikingly

similar accident near Knox, Indiana, in 1991.32 As was the case in this accident, the Knox

investigation found deficiencies in crew coordination, communication, and cab discipline,

prompting the Safety Board to make the following recommendation to Norfolk Southern:

R-92-09

Review and revise your programs for traincrew supervision, locomotive

cab discipline, and training of student engineers in light of the

circumstances of this accident, and make necessary improvements.

In February 1993, the Safety Board classified this recommendation “Closed—

Acceptable Action,” based on the company’s response that it had revised its training to

emphasize the understanding of and compliance with operating rules and to emphasize the

engineer’s responsibility for safe and effective train handling. However, the circumstances

of the Butler accident show that Norfolk Southern must explore additional ways to

improve engineer training, both in the classroom and the field. In light of the deficiencies

found in both the field and classroom portions of the locomotive engineer training, the

Safety Board believes that Norfolk Southern should conduct a comprehensive assessment

of the locomotive engineer training program and revise it, as necessary, to ensure that

student engineers consistently operate with and are mentored by coach-trained engineers

and that engineer training reflects actual operating conditions. In addition, the Safety

Board believes that the FRA should review Norfolk Southern Corporation’s 49 CFR 240

submission, Certification of Locomotive Engineers, specifically “Section 5: Training,

Testing, and Evaluating Persons Not Previously Certified,” to determine whether the

company’s training program is adequate for training new engineers and require that any

deficiencies found be corrected. 

32 Railroad Accident/Incident Summary Report—Knox, Indiana, September 17, 1991

(NTSB/RAR-92/02/SUM).
Analysis 32 Railroad Accident Report

Importance of Train Crew Resource Management

The events leading up to this accident illustrate that effective crew coordination is

imperative, especially when a crewmember is receiving on-the-job training. Throughout

the accident trip, the engineer and conductor did not call clear signals. Had all signals been

communicated in accordance with Norfolk Southern’s operating rules, the student would

have had a better sense of the train’s location in unfamiliar territory. Based on the

statements of the engineer and the student engineer, all crewmember communication

ceased well before the train approached the interlocking at Butler. In fact, for at least 30

minutes before the accident, the student engineer operated the train independently of the

engineer and conductor. Moreover, he could not utilize their experience to help determine

his location until just before the train was placed into emergency braking because he had

not been provided strategies for dealing with crewmembers who knowingly disregard

carrier rules and procedures. The Safety Board therefore concludes that Norfolk Southern

crew coordination, communication, and cab discipline were inadequate in the events

leading up to this accident.

During the accident trip, the crewmembers’ actions neither promoted compliance

with the operating rules nor provided a positive model for the student to emulate. Norfolk

Southern stated that student engineers could contact the dispatcher or road foreman to

report problems such as the ones that occurred during the accident trip. However, an

employee, particularly a trainee eager to gain operational experience, may be reluctant to

challenge or report fellow crewmembers. The Safety Board concludes that Norfolk

Southern lacks adequate safeguards to prevent student engineers from being placed in

untenable situations in which rules and procedures are disregarded. The Safety Board

believes that Norfolk Southern should provide employees, especially trainees, with

effective strategies for dealing with crewmembers who knowingly disregard the operating

rules.

One method of improving crew coordination and communication is through

training. The Safety Board has long been a proponent of crew resource management

(CRM) training in the aviation community and bridge resource management (BRM)

training in the marine community. The goals of CRM and BRM are similar in that they

promote safe operations by emphasizing the efficient use of all resources to achieve and

maintain better coordination of activities. CRM and BRM training addresses critical areas,

including: 

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning authority. 

The principles of CRM and BRM could be used to develop train crew resource

management (TCRM) training for the railroad industry. The Safety Board has investigated
Analysis 33 Railroad Accident Report

several railroad accidents33 that occurred because of inadequate communication, lack of

discipline, and crewmembers’ failure to function collectively as a team. In 1996, the

Safety Board became aware of training developed by and for railroad employees of the

former Southern Pacific Railroad (now the UP) and modeled after the training provided to

crewmembers at American Airlines. The UP continues to provide this training to its

employees and, since late 1998, has required all newly hired employees to receive it.

Contact with several other Class I railroads revealed that they are not providing TCRM

training. The Safety Board is not aware that the FRA has demonstrated an interest in

exploring and developing TCRM principles and training for the industry. 

The Safety Board concludes that this and other accidents investigated by the

Safety Board demonstrate that railroad safety would be enhanced if crewmembers

received TCRM training. Therefore, the Safety Board believes that Norfolk Southern, the

Class I railroads and Amtrak, the American Short Line and Regional Railroad

Association, the Brotherhood of Locomotive Engineers, and the United Transportation

Union should develop, for all train crewmembers, TCRM training that addresses, at a

minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning authority. 

The Safety Board also believes that the FRA in cooperation with Norfolk

Southern, the Class I railroads and Amtrak, the American Short Line and Regional

Railroad Association, the Brotherhood of Locomotive Engineers, and the United

Transportation Union should develop and require, for all train crewmembers, TCRM

training that addresses these principles. The Safety Board is encouraged by the example of

the UP and is optimistic that the pursuit of TCRM principles by Government, industry,

and labor will facilitate safe and efficient railroad operations.

Adequacy of Signal Malfunction Reporting Procedures

The Norfolk Southern dispatching center in Fort Wayne receives and records

signal malfunctions reported by train crews. After investigating the February and March

1998 reports of dark signal occurrences, the Norfolk Southern signal maintainer reported

to the Norfolk Southern dispatching center that intermediate signal 111 was working

properly. The signal maintainer also informed the dispatching center that the signal would

33 Railroad Accident/Incident Summary Report—Knox, Indiana, September 17, 1991

(NTSB/RAR-92/02/SUM); Railroad Accident/Incident Summary Report—Derailment of Amtrak Train 87,

Silver Meteor, in Palatka, Florida, on December 17, 1991 (NTSB/RAR-93/02/SUM); and Railroad

Accident Report—Collision and Derailment of Maryland Rail Commuter MARC Train 286 and National

Railroad Passenger Corporation Amtrak Train 29, near Silver Spring, Maryland, on February 16, 1996

(NTSB/RAR-97/02).
Analysis 34 Railroad Accident Report

be monitored again. During interviews, the signal maintainer explained that monitoring

consisted of acquiring downloads from the signal data recorder and examining the logs.

However, no followup downloads were performed after either dark signal report. The

Safety Board concludes that the Norfolk Southern Lake Division dispatching center

lacked an effective procedure for identifying reported signal malfunctions of

undetermined causes for further monitoring.

The majority of Class I railroad dispatching centers have full-time signal personnel

working in their dispatching centers to handle all signal and grade crossing malfunction

reports. The dispatchers forward such reports to these representatives, who record and

track the status of the malfunctions and notify the necessary signal maintenance personnel

to investigate and repair them. Having personnel technically knowledgeable in signal

systems aids in prioritizing the investigation and repair of malfunctions that require

immediate attention. Designated personnel not tasked with dispatching trains can also

better and more thoroughly identify and track locations that have repeated malfunction

reports and ensure that all available tools are used to repair the malfunctions and maintain

the proper level of safety. The Safety Board believes Norfolk Southern should designate

dedicated personnel to record and track all signal malfunctions and repairs in order to

identify recurring, unresolved failures.

Adequate followup was crucial in the case of signal 111 because routine

troubleshooting by a signal maintainer would not have identified the failed capacitors;

they are on an electronic unit that the signal maintainer does not normally access. Further,

during the investigation, even a complete field operational test of the electronic track

circuit unit at signal 111 did not identify abnormalities. Only when the signal was

observed going dark during the course of the investigation was the Electro Code 4 unit

containing the lighting module removed and bench tested and the failed components

subsequently identified. 

Postaccident testing revealed that the failed capacitors also affected the signal data

recorder at MP 111, causing it to record events even though no physical changes were

occurring in the operational status at the signal location, thus rapidly filling the memory

buffer and overwriting older recorded events. If a download of the log had been acquired

before the accident, the number of events recorded in a relatively short time should have

prompted the signal maintainer to find a cause for the abnormal readings. In addition, if

the events occurred in the time span examined, close examination of the signal data logs

may have revealed the random dark signal occurrences. Because of the absence of data

relevant to the accident time frame and the randomness of the dark signal occurrences, the

Safety Board concludes that the aspect displayed by intermediate signal 111 to the Norfolk

Southern train just before the accident cannot be determined.

Electro Code 4 units, such as the one at signal 111, determine which aspects to

display from the codes received from the tracks. These units supply energy to illuminate

the signal lamps directly and cause all lamps to go dark if internal self-tests and

microprocessor operations detect a loss or perceived loss of control over the lamp output.

The voltage to the lamps ceases until the failure condition is corrected. 
Analysis 35 Railroad Accident Report

At signal 111, the failed capacitors allowed random noise (variations in voltage)

into the signal lamp output used by the microprocessors to monitor operations, causing the

lamp converters to shut down while the microprocessors performed an internal self-test to

ensure the unit was operational before energizing any signal lamps. The Safety Board

concludes that had Norfolk Southern’s maintenance program responded to and corrected

the twice-reported signal deficiencies at signal 111, the signal would not have continued to

go dark intermittently.

Harmon Industries estimates that of the Electro Code 4 units manufactured from

1987 to 1988, approximately 25,000 are currently installed on the nation’s railroads. The

Safety Board concludes that although the product improvement announcement issued by

Harmon Industries addresses the capacitor problem, replacement of the capacitors is not

just an improvement but needs to be made a requirement for the safe operation of Electro

Code 4 units. Therefore, the Safety Board believes that Harmon Industries should identify

and contact all customers who purchased Electro Code 4 units manufactured from 1987 to

1988, and institute a systematic corrective program for the repair or replacement of faulty

electrolytic capacitors. The Safety Board also believes that the FRA should direct

Harmon Industries and the railroad carriers to identify and replace all faulty Electro Code

4 capacitors and that the FRA should ensure, through followup inspections, that corrective

actions have been taken.

Continued Need for In-Cab Audible Recording Devices on Trains

As noted in the previous section, the absence of signal recorder data relevant to the

accident time frame and the randomness of dark signal occurrences make it impossible to

determine exactly what happened as the Norfolk Southern train approached intermediate

signal 111. The Safety Board concludes that had the train been equipped with an in-cab

voice recorder, recorded crew communications would have been available that could have

provided valuable clues in reconstructing the accident.

The Safety Board, in its investigation of the 1996 Silver Spring accident involving

Amtrak train 29 and Maryland Rail Commuter train 286, concluded that had

crewmembers’ voice communications been recorded, essential details about the

circumstances of that accident could have been captured. Consequently, the Safety Board

recommended that the FRA:

R-97-9

Amend 49 Code of Federal Regulations Part 229 to require the recording of

train crewmembers’ voice communications for exclusive use in accident

investigations and with appropriate limitations on the public release of

such recordings.

The FRA has acknowledged the Safety Board’s recommendation but taken no

action to date. On January 17, 1999, two Conrail trains collided in Bryan, Ohio, resulting

in the deaths of all crewmembers on one of the trains. Because train crew communications

were not recorded, reconstructing that accident will be extremely difficult. Accidents such

as those in Butler, Silver Spring, and Bryan highlight the need for data beyond what can be
Analysis 36 Railroad Accident Report

provided by a locomotive event recorder. Although event recorders have great utility in

providing mechanical response data, such data cannot always answer the inevitable

questions that arise in an investigation regarding the train crew’s actions. The Safety

Board plans to explore this issue further in its investigation of the Bryan collision.

Importance of Emergency Response Management in Hazardous 

Materials Accidents

The Safety Board has long been concerned about the emergency response

management of railroad accidents involving hazardous materials. The Board, in its 1991

safety study34 on transporting hazardous materials by rail, discussed how the lack of

coordination between the railroads and communities on emergency response planning had

presented major safety problems in nine accidents and incidents investigated between

1977 and 1987. The Safety Board subsequently issued the following recommendation to

the Class I railroads:

R-91-15

Develop, implement, and keep current, in coordination with communities

adjacent to your railroad yards and along your hazardous materials routes,

written emergency response plans and procedures for handling releases of

hazardous materials. The procedures should address, at a minimum, key

railroad personnel and means of contact, procedures to identify the

hazardous materials being transported, identification of resources for

technical assistance that may be needed during the response effort,

procedures for coordination of activities between railroad and emergency

response personnel, and the conduct of disaster drills or other appropriate

methods to test emergency response plans.

In July 1991, Norfolk Southern, replying on behalf of its affiliates, responded:

Norfolk Southern Railway Company and its affiliated lines (NSR),

including Norfolk and Western Railway, have developed and maintain an

emergency action plan for hazardous materials incidents, which is

available at all of our yard facilities and is on file in the offices of each

master mechanic, division engineer, and freight agent. We maintain

separate hazardous materials response plans at all of our substantial yard

facilities which contain special information for those locations....

In December 1991, the Safety Board classified Safety Recommendation R-91-15

“Closed—Acceptable Action,” based upon Norfolk Southern’s subsequent letter

elaborating on how emergency response procedures were being implemented. The

November 1, 1991, letter noted that Norfolk Southern directs its emergency response

coordination efforts toward all of the communities along its service routes, not just those

with rail yards, to include sharing hazardous material response plans with localities,

34 Safety Study—Transport of Hazardous Materials by Rail (NTSB/SS-91/01).
Analysis 37 Railroad Accident Report

providing training for the smaller cities and towns along its routes, and providing

personnel to serve on local emergency planning committees.

According to the Norfolk Southern Lake Division Supervisor, DeKalb County was

not on the list of communities trained recently by Norfolk Southern in emergency

response coordination. In this accident, local officials did not attempt to contact the

railroad for assistance beyond asking the surviving Norfolk Southern crewmembers what

substance the Norfolk Southern train carried. The company’s lack of coordination with the

community resulted in emergency response personnel taking an hour to identify a

potentially hazardous substance and in two schools being closed unnecessarily. The Safety

Board concludes that better coordination by Norfolk Southern with DeKalb County may

have prevented the delay in identifying the possibly hazardous material transported on the

Norfolk Southern train. In the Safety Board’s opinion, such a situation is unacceptable,

considering that more than 7 years have passed since Norfolk Southern stated it would

coordinate emergency response plans with the communities along its service routes. The

Safety Board is concerned that other communities may be exposed to similar risks from

hazardous material releases and other rail emergencies because Norfolk Southern has not

followed through on emergency response coordination. Therefore, the Safety Board

believes that Norfolk Southern should conduct an audit to identify all communities

through which it transports hazardous materials and, in coordination with those

communities, develop, implement, and keep current written emergency response plans

and procedures for handling hazardous material releases. The procedures should address,

at a minimum, key railroad personnel and means of contact, procedures to identify the

hazardous materials being transported, identification of resources for technical assistance

that may be needed during the response effort, procedures for the coordination of activities

between railroad and emergency response personnel, and the conduct of disaster drills or

other methods to test emergency response plans. The Safety Board also believes that the

DeKalb County Emergency Management Agency should contact Norfolk Southern Lake

Division officials to provide and keep current, points of contact for emergency response

coordination.
38 Railroad Accident Report

Conclusions

Findings

1. The following factors did not contribute to this accident: mechanical condition of the

trains and track, weather, the operation of the Conrail signal system and the

interlocking signal system, and alcohol or drug use by and qualifications of the train

crew.

2. Norfolk Southern lacks adequate safeguards to prevent student engineers from being

placed in untenable situations in which rules and procedures are disregarded.

3. Allowing local variations in training requirements promotes operational

inconsistencies and hinders uniform compliance with the student engineer training

program. 

4. Unless all Norfolk Southern operating personnel are informed of restrictions on the

operation of trains by student engineers, a situation in which a student engineer

operates a train without proper supervision could occur again. 

5. Norfolk Southern’s engineer training program was not adequate to prepare student

engineers to cope with all known or anticipated operational requirements systemwide,

such as operating trains with the long hood forward. 

6. Not providing feedback because the student engineer had not yet reached the point at

which he was scheduled to be formally evaluated by a road foreman (that is, he had

not worked in the Lake Division for 1 month) is inconsistent with the goals of

effective training.

7. Norfolk Southern’s oversight of student engineers during the on-the-job portion of

training is inadequate.

8. Norfolk Southern crew coordination, communication, and cab discipline were

inadequate in the events leading up to this accident. 

9. The engineer, as the individual responsible for train handling and care, and the

conductor, as the individual responsible for ensuring that rules and instructions are

followed, disregarded their responsibilities during the accident trip. 

10. This accident could have been avoided had the conductor and engineer complied with

Norfolk Southern rules and instructions to include: observing and confirming all

signal aspects; actively supervising the student engineer, particularly one who was

unfamiliar with the territory; and not reading or engaging in other distracting

activities. 
Conclusions 39 Railroad Accident Report

11. Because of the engineer’s and conductor’s lack of vigilance and decision not to call

clear signals, the crew of Norfolk Southern train 255L5 failed to react to either an

approach or a possible dark signal at milepost 111.

12. Having procedures to actively engage crewmembers in observing and confirming all

signal aspects, such as recording the aspects, would make it more likely that train

crews call signals in compliance with the operating rules. 

13. The engineer and conductor failed to observe and call signal 111 because they were

distracted, inattentive, or possibly asleep.

14. A fully implemented positive train separation system would have prevented this

accident.

15. This and other accidents investigated by the National Transportation Safety Board

demonstrate that railroad safety would be enhanced if crewmembers received train

crew resource management training. 

16. The Norfolk Southern Lake Division dispatching center lacked an effective procedure

for identifying reported signal malfunctions of undetermined causes for further

monitoring. 

17. Had Norfolk Southern’s maintenance program responded to and corrected the twicereported signal deficiencies at signal 111, the signal would not have continued to go

dark intermittently.

18. Had the train been equipped with an in-cab voice recorder, recorded crew

communications would have been available that could have provided valuable clues

in reconstructing the accident.

19. Because of the absence of data relevant to the accident time frame and the

randomness of the dark signal occurrences, the aspect displayed by intermediate

signal 111 to the Norfolk Southern train just before the accident cannot be

determined.

20. Although the product improvement announcement issued by Harmon Industries

addresses the capacitor problem, replacement of the capacitors is not just an

improvement but needs to be made a requirement for the safe operation of Electro

Code 4 units. 

21. The reduced visibility on the student’s side of the cab as the train approached milepost

111, compounded by a possible dark signal and by the student engineer’s lack of

experience, may have caused the student to miss the signal and the reflectorized

milepost marker. 

22. Better coordination by Norfolk Southern with DeKalb County may have prevented

the delay in identifying the possibly hazardous material transported on the Norfolk

Southern train.
Conclusions 40 Railroad Accident Report

Probable Cause 

The National Transportation Safety Board determines that the probable cause of

this accident was the failure of the engineer and conductor of train 255L5 to comply with

operating rules (specifically, their failure to observe and confirm signal aspects and their

failure to continuously and directly supervise the student engineer) and the failure of

Norfolk Southern Corporation to ensure employees’ compliance with operating rules.

Contributing to the accident was Norfolk Southern Corporation’s failure to ensure that its

locomotive engineer training program provided effective, timely training; oversight; and

feedback to ensure that students were adequately prepared for operational situations. Also

contributing to the probability of this accident occurring was the failure of Norfolk

Southern Corporation’s signal maintenance program to respond to a reported signal

deficiency. 
41 Railroad Accident Report

Recommendations

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

following safety recommendations:

—to the Federal Railroad Administration:

Review Norfolk Southern Corporation’s 49 Code of Federal Regulations

240 submission, Certification of Locomotive Engineers, specifically

“Section 5: Training, Testing, and Evaluating Persons Not Previously

Certified,” to determine whether the company’s training program is

adequate for training new engineers and require that any deficiencies found

be corrected. (R-99-12)

In cooperation with Class I railroads, the American Short Line and

Regional Railroad Association, the Brotherhood of Locomotive Engineers,

and the United Transportation Union, develop and require, for all train

crewmembers, crew resource management training that addresses, at a

minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-13)

Direct Harmon Industries and the railroad carriers to identify and replace

all faulty Electro Code 4 capacitors. Ensure, through followup inspections,

that corrective actions have been taken. (R-99-14)

—to Norfolk Southern Corporation:

Develop and implement methods to improve employee compliance with

company rules and instructions. (R-99-15)

Develop and implement procedures that actively engage crewmembers in

observing and confirming all signal aspects. (R-99-16)

Inform all operating personnel of their responsibilities regarding student

engineers. (R-99-17)
Recommendations 42 Railroad Accident Report

Assign supervisors dedicated exclusively to student engineers who will, at

a minimum:

• meet with student engineers at the start of the on-the-job

training phase to ensure that student engineers are aware of

the conditions under which they can operate a train and that

they know what to do if these conditions are not met;

• track the student engineer’s daily train assignments, daily

crew assignments, and performance evaluations; and

• provide timely feedback and advice to student engineers on

a continuing basis. (R-99-18)

Provide student engineers with formal training in all known or anticipated

operational requirements systemwide, including operating trains with the

long hood forward. (R-99-19)

Conduct a comprehensive assessment of the locomotive engineer training

program and revise it, as necessary, to ensure that student engineers

consistently operate with and are mentored by coach-trained engineers and

that engineer training reflects actual operating conditions. (R-99-20)

Provide employees, especially trainees, with effective strategies for dealing

with crewmembers who knowingly disregard the operating rules.

(R-99-21)

In cooperation with the Federal Railroad Administration, the American

Short Line and Regional Railroad Association, the Brotherhood of

Locomotive Engineers, and the United Transportation Union, develop, for

all train crewmembers, crew resource management training that addresses,

at a minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-22)

Designate dedicated personnel to record and track all signal malfunctions

and repairs in order to identify recurring, unresolved failures. (R-99-23)

Conduct an audit to identify all communities through which you transport

hazardous materials and, in coordination with those communities, develop,

implement, and keep current written emergency response plans and

procedures for handling hazardous material releases. The procedures
Recommendations 43 Railroad Accident Report

should address, at a minimum, key railroad personnel and means of

contact, procedures to identify the hazardous materials being transported,

identification of resources for technical assistance that may be needed

during the response effort, procedures for the coordination of activities

between railroad and emergency response personnel, and the conduct of

disaster drills or other methods to test emergency response plans.

(R-99-24)

—to the Class I Railroads and Amtrak:

In cooperation with the Federal Railroad Administration, the American

Short Line and Regional Railroad Association, the Brotherhood of

Locomotive Engineers, and the United Transportation Union, develop, for

all train crewmembers, train crew resource management training that

addresses, at a minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-25)

—to the American Short Line and Regional Railroad Association:

In cooperation with the Federal Railroad Administration, the Class I

railroads, the Brotherhood of Locomotive Engineers, and the United

Transportation Union, develop, for all train crewmembers, train crew

resource management training that addresses, at a minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-26)

—to the Brotherhood of Locomotive Engineers:

In cooperation with the Federal Railroad Administration, the Class I

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

the United Transportation Union, develop, for all train crewmembers, train

crew resource management training that addresses, at a minimum:
Recommendations 44 Railroad Accident Report

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-27)

—to the United Transportation Union: 

In cooperation with the Federal Railroad Administration, the Class I

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

the Brotherhood of Locomotive Engineers, develop, for all train

crewmembers, train crew resource management training that addresses, at a

minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-28)

—to Harmon Industries: 

Identify and contact all customers who purchased Electro Code 4 units

manufactured from 1987 to 1988, and institute a systematic corrective

program for the repair or replacement of faulty electrolytic capacitors.

(R-99-29)

—to the DeKalb County Emergency Management Agency:

Contact Norfolk Southern Lake Division officials to provide and keep

current, points of contact for emergency response coordination. (R-99-30)
Recommendations 45 Railroad Accident Report

Adopted: July 13, 1999

John A. Hammerschmidt, Member, filed the following concurring and dissenting opinion

on July 22, 1999:

Notation 7177

Member HAMMERSCHMIDT, concurring and dissenting:

I concur with most of the report, yet there are some parts of the analysis,

conclusions, probable cause, and safety recommendations that do not appear to be

substantiated by the prevailing evidence. My specific concerns and preferred language,

which also apply to the analysis, are as follows:

Conclusions

7. Norfolk Southern’s oversight of the student engineers involved in this accident

during the on-the-job portion of his training was is inadequate.

8. The coordination, communication, and cab discipline of the Norfolk Southern

train crew in this accident were inadequate. crew coordination, communication, and

cab discipline were inadequate in the events leading up to the accident.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

JOHN A. HAMMERSCHMIDT

Member

ROBERT T. FRANCIS II

Vice Chairman

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member
Recommendations 46 Railroad Accident Report

11. This conclusion is not entirely correct. A decision not to call CLEAR (green)

signals is not applicable to this accident since the signal in question, signal 111,

should have been displaying an APPROACH (yellow) signal or have been DARK

(inoperative).

12. This conclusion could be deleted. NS has a rule (rule 34) requiring train crews to

call all signals encountered over the radio, by both the name and indication of

each signal, to inform other trains within the range of the radio transmission and

operating in the same area of the train’s location and the governing signal.

Conclusion 18 covers the use of in-cab voice recorders, which can be used to

monitor compliance with the rule as well as enhance all accident/incident

investigations.

13. The engineer and conductor failed to observe and call signal 111 because they were

either distracted, deliberately or involuntarily inattentive, possibly asleep, or

because the signal was inoperative.

15. This conclusion is speculative; if included, it should state:

This and other accidents investigated by the National Transportation Safety Board

demonstrate that Railroad safety may would be enhanced if crewmembers received

train crew resource management training. railroads developed and implemented crew

resource management programs similar to those used by other transportation modes.

Probable Cause

The accident investigation does not support the statement that the Norfolk Southern

failed to ensure compliance with the operating rules. [The engineer’s statement after

the accident, and the engineer’s and conductor’s disciplinary records, indicate that these

employees made deliberate decisions not to comply with the rule of calling signals as

required (rule 34). However, in the past, when the engineer and conductor had been

observed not calling signals by NS officials, action was taken. The NS program did not

have the ability to detect deliberate noncompliance with rule 34. Compliance could be

monitored if an in-cab voice recorder were in use.]

The accident offers no support that the failure of NS’s training program to have an

effective feedback system was contributory to this accident.

Recommendations

—to the Federal Railroad Administration:

In cooperation with Class I railroads, the Association of American Railroads, the

American Short Line and Regional Railroad Association, the Brotherhood of

Locomotive Engineers, and the United Transportation Union, develop and require,

evaluate the effectiveness of crew resource management training programs,

or similar programs, used by other transportation modes and, as appropriate,
Recommendations 47 Railroad Accident Report

encourage the railroads to develop similar programs to enhance railroad

safety. for all train crewmembers. The programs developed should address, at a

minimum:

• crewmember proficiency, 

• situational awareness, 

• effective communication and teamwork, and 

• strategies for appropriately challenging and questioning 

authority. (R-99-13)

[Change the corresponding recommendations accordingly—R-99-25 through -28.

Recommendation R-99-25 should be to the Association of American Railroads, which will

include all Class I carriers, including Amtrak.]

[The accident investigation does not adequately define “crew resource management”

or the effectiveness the training programs have had in other transportation modes.

In addition, some railroads may have similar programs (UP and NS may have one of

a different name), but the report does not acknowledge if any exist and if they do,

how they work or their effectiveness.]

—to Norfolk Southern Corporation:

Develop and implement Evaluate the effectiveness of your current rules

violation disciplinary methods and then implement the necessary

changes to improve employee compliance with company rules and

instructions. (R-99-15)

Develop and implement procedures, such as an in-cab voice recorder,

that will actively engage motivate crewmembers in observing and

confirming to observe and confirm all signal aspects. (R-99-16)

49 Railroad Accident Report

Appendix A

Harmon Industries Bulletin 

on Electro Code 4 Units
Appendix A 50 Railroad Accident Report
51 Railroad Accident Report

Appendix B

Norfolk Southern Lake Division

Student Engineer Form
52 Railroad Accident Report

Appendix C

UP Signal Recording Form
Acronyms and Abbreviations 53 Railroad Accident Report

Acronyms and Abbreviations

Amtrak National Railroad Passenger Corporation

BNSF Burlington Northern Santa Fe Railway Company

BRM bridge resource management

CFR Code of Federal Regulations

CHEMTREC Chemical Transportation Emergency Center

Conrail Consolidated Rail Corporation

CP control point

CRM crew resource management

DRF district road foreman

DRFE Division Road Foreman of Engines

FRA Federal Railroad Administration

MP milepost

N&W Norfolk and Western Railway Company

Norfolk Southern Norfolk Southern Corporation

PCP phencyclidine

PTS positive train separation

SRFE System Road Foreman of Engines

TCRM train crew resource management

TCS traffic control signal (system)

UP Union Pacific Railroad