F PB99-917004

NTSB/SIR-99/03

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

RAILROAD SPECIAL INVESTIGATION REPORT

NORTHERN INDIANA COMMUTER

TRANSPORTATION DISTRICT

RAILROAD SAFETY ASSESSMENT

7184
National Transportation Safety Board. 1999. Northern Indiana Commuter Transportation District Railroad

Safety Assessment. Railroad Special Investigation Report NTSB/SIR-99/03. Washington, DC.

Abstract: About 4:31 a.m. on June 18, 1998, a westbound Northern Indiana Commuter Transportation District

(NICTD) two-car passenger train struck the second semitrailer of a long combination vehicle that consisted of a

tractor pulling two flatbed semitrailers loaded with steel coils at a highway-rail grade crossing near Portage, Indiana.

Three fatalities and five minor injuries resulted from the accident. In a June 18, 1998, letter to National

Transportation Safety Board Chairman James Hall, U.S. Senator Richard Lugar and U.S. Congressman Peter J.

Visclosky cited three previous accidents that had involved the NICTD system and expressed concern about NICTD’s

long-term safe operation. The Safety Board reviewed the accident history of the NICTD system and determined that,

given the series of incidents experienced on the NICTD line, an evaluation of NICTD’s overall safety should be

conducted. 

The safety issues discussed in this report are the safety of NICTD grade crossings, the implementation of the NICTD

System Safety Program Plan, and the effectiveness of the NICTD corporate safety culture.

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

Indiana Department of Transportation, and the Boards of Commissioners of Indiana’s Lake, LaPorte, Porter, and

St. Joseph Counties.

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 PB99-917004 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

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

Northern Indiana Commuter Transportation District 

Railroad Safety Assessment 

NTSB/SIR-99/03

PB99-917004 National Transportation Safety Board

Notation 7184 490 L’Enfant Plaza, S.W.

Adopted August 10, 1999 Washington, D.C. 20594

E P LUR IBUS UNUM

N AT I O N A L T R A S PO R T A T IO N

B O A R D

SA F E T Y

N

iii Railroad Special Investigation Report

Contents

Introduction....................................................................................................................... v

Investigation ...................................................................................................................... 1

Northern Indiana Commuter Transportation District.......................................................... 1

General......................................................................................................................... 1

Major Accident History ............................................................................................... 5

Safety Record............................................................................................................. 10

NICTD Infrastructure and Operating Practices ................................................................ 11

Operations.................................................................................................................. 11

Track .......................................................................................................................... 12

Structures ................................................................................................................... 13

Signals ....................................................................................................................... 15

Highway-Rail Grade Crossings ................................................................................. 17

NICTD Safety Programs................................................................................................... 22

System Safety Program Plan ..................................................................................... 22

Director of Safety and Training ................................................................................. 24

Emergency Response Programs ................................................................................ 28

NICTD Corporate Safety Culture ..................................................................................... 29

General....................................................................................................................... 29

Safety Documents...................................................................................................... 30

Summary.......................................................................................................................... 32

Conclusions...................................................................................................................... 33

Recommendations........................................................................................................... 35

Appendixes

 A—Letter from Senator Richard Lugar and Congressman Peter J. Visclosky......... 39

 B—Data on Federal Railroad Administration Inspections of NICTD ..................... 41

Acronyms and Abbreviations ........................................................................................ 43

v Railroad Special Investigation Report

Introduction

About 4:31 a.m. central daylight time on June 18, 1998, a westbound Northern

Indiana Commuter Transportation District (NICTD) two-car passenger train struck the

second semitrailer of a long combination vehicle (LCV) that consisted of a tractor pulling

two flatbed semitrailers loaded with steel coils at a grade crossing near Portage, Indiana.

When the vehicles collided, the second semitrailer broke away from the first semitrailer

and was dragged by the front of the NICTD train while the chain securing a steel coil to

the second semitrailer broke. The released steel coil entered the first train car through the

front bulkhead and moved into the passenger compartment. Three fatalities and five minor

injuries resulted from the accident. 

In a June 18, 1998, letter to National Transportation Safety Board Chairman James

Hall, U.S. Senator Richard Lugar and U.S. Congressman Peter J. Visclosky cited three

previous accidents that had involved the NICTD system and expressed concern about

NICTD’s long-term safe operation. (See appendix A.) The Safety Board reviewed the

accident history of the NICTD system and determined that, given the series of incidents

experienced on the NICTD line, an evaluation of NICTD’s overall safety should be

conducted. 

The Safety Board conducted a special investigation that examined the following

safety issues:

• Safety of NICTD grade crossings

• Implementation of the NICTD System Safety Program Plan, and 

• Effectiveness of the NICTD corporate safety culture

The intent of this special investigation was not to determine whether NICTD is a

“safe” or “unsafe” railroad but to examine those elements of its overall operation known

to affect safety and to indicate where improvements could be made in these areas. The

Safety Board recognizes that factors not examined in this investigation may also affect

NICTD safety, either positively or negatively.

As a result of its special investigation, the Safety Board makes safety

recommendations to NICTD, the Indiana Department of Transportation (INDOT), and the

Boards of Commissioners of Indiana’s Lake, LaPorte, Porter, and St. Joseph Counties. 

1 Railroad Special Investigation Report

Investigation

To assess NICTD’s overall safety, the Safety Board examined the rail system’s

accident history and safety record, infrastructure and operating practices, safety programs,

and corporate safety culture. Investigators placed emphasis on NICTD’s internal processes

for ensuring safe operations, such as the organization’s compliance with its own System

Safety Program Plan (SSPP), which “establishes the Safety philosophy of the whole

organization and provides the means of implementation.”1 (SSPPs will be discussed in

detail later in this report.) 

Northern Indiana Commuter Transportation District

General

History—This rail system began in 1903 as the Chicago and Indiana Air Line

Railway, a streetcar service between Indiana Harbor and East Chicago. By 1908, the

developing rail line stretched across northwest Indiana, extending 68.9 miles from

Hammond to South Bend. By 1909, the line operated trains to Pullman, Illinois, where

passengers changed trains to continue their journey to downtown Chicago. The system

later worked out an agreement with the Illinois Central Railroad in which “Lake Shore”

cars were coupled to a steam locomotive at Kensington, Illinois, and hauled into

downtown Chicago. In June 1925, the system was renamed the Chicago SouthShore and

South Bend Railroad (CSS). During World War II, annual ridership on the CSS, which

provided freight as well as passenger service, rose to over 6 million. After that war, the

CSS passenger service began a long period of ridership decline.

In 1976, faced with mounting losses and deteriorating railcars, stations, and

electrical systems, the CSS asked the Interstate Commerce Commission to allow it to

discontinue its passenger service. In 1977, the Indiana General Assembly passed

legislation enabling the four counties served by the CSS to create NICTD to maintain the

passenger service. (The CSS continued as a freight operation.) Indiana’s actions and funds

from the State of Illinois and the Federal Government allowed the commuter operation to

continue as NICTD. 

NICTD ridership is reported to have increased from about 1.6 million people per

year in the late 1970s to about 3.5 million per year in 1997. In 1997, NICTD passengers

traveled a combined 106 million miles on the railroad. NICTD operates 365 days a year

and carries 11,000 to 12,000 commuters each weekday and usually about half that number

on weekends and holidays. 

1

 American Public Transit Association, Manual for the Development of System Safety Program Plans

for Commuter Railroads (Washington, D.C.: American Public Transit Association, 1998), p. 5.
Investigation 2 Railroad Special Investigation Report

Organization—NICTD provides service between the Michiana Regional Airport

in South Bend, Indiana, and the Randolph Street Station in Chicago, Illinois. The line is

about 90 miles long. NICTD owns all mainline rights of way and track between South

Bend and the Indiana-Illinois State line (68.1 miles). NICTD leases 1.1 miles of right of

way within the Michiana Regional Airport in Indiana and 6.2 miles of track between the

Indiana-Illinois State line and the Kensington Interlocking from the CSS. (See figure 1 for

a map of the NICTD track system.) NICTD pays a trackage rights fee to operate on the

Chicago Northeast Illinois Regional Commuter Rail Corporation (Metra) Electric District

for a distance of 14.3 miles. Metra, the commuter railroad division of the Regional

Transportation Authority, subsidizes 21 percent of NICTD’s eligible operating losses

under a purchase-of-service agreement. 

Although NICTD is a commuter railroad, the CSS still operates, as a contracted

Class II freight carrier, over NICTD property. The CSS pays maintenance and annual

rental fees to NICTD. The CSS operates an average of six trains a day, Monday through

Friday, and four trains each weekend day. The freight train movements are commingled

with the NICTD passenger train service. The CSS superintendent told Safety Board

investigators that most of the CSS freight business involves moving unit coal trains to

power generating stations owned by the Northern Indiana Public Service Company and

unit coal trains to Bethlehem Steel facilities. (Indiana is one of the Nation’s leading States

for the production of steel, and northern Indiana has a particularly high level of steel

industry activity.) Additionally, the CSS provides direct service to 23 customers on the

NICTD line. The CSS connects with 6 other railroads and has 23 points of interchange.

NICTD has about 270 employees. Most of the nonmanagement employees work in

one of six department areas—mechanical, transportation, track, line and signal, buildings

and bridges, and accounting. In 1990, a municipal transit police force joined NICTD and

began operating in fully marked, high-profile police cars with Indiana police license

plates. NICTD has five full-time uniformed police officers.

Oversight—NICTD is part of the general railway system and must comply with

the appropriate rules and regulations administered by the Federal Railroad Administration

(FRA). The FRA is responsible for determining the adequacy of NICTD’s compliance

with its published rules and regulations and for taking any enforcement action necessary

to ensure compliance.

The Safety Board reviewed FRA-provided information about the FRA’s

inspections of NICTD from January 1993 to January 1998 concerning motive power and

equipment, operations, signal, and track. The FRA reported having conducted 443

inspections in these areas over the 5-year period. The inspections resulted in FRA’s

finding 391 defects and issuing 5 violations. (See appendix B for greater detail on FRA

inspection results.) These findings are comparable to those for similar rail operations

inspected by the FRA. 

In discussing NICTD with Safety Board investigators, the FRA Chicago deputy

regional administrator expressed no immediate concern about NICTD train operations or
 Figure 1. Map of NICTD track system 
Investigation 4 Railroad Special Investigation Report

the safety of passengers on NICTD because of the FRA’s relatively positive inspection

experience with NICTD. 

The FRA-reportable accident records (contained in published FRA

accident/incident bulletins) for NICTD and CSS train operations from January 1993 to

June 1998 listed the following events:

January 18, 19932 Gary, Indiana Head-on collision

March 3, 1993 Michigan City, Indiana Grade crossing

June 16, 1994 Michigan City, Indiana CSS train derailed one car in shops

September 11, 1994 South Bend, Indiana Abandoned auto at grade crossing

October 30, 1994 Miller, Indiana Grade crossing

May 9, 1995 Dune Park, Indiana Vandalism

June 18, 1998 Portage, Indiana Grade crossing

The FRA is conducting a series of Safety Assurance and Compliance Program

(SACP) meetings with various rail carriers over which it has regulatory authority. FRA

representatives told the Safety Board that the meetings are designed to help carriers better

understand regulatory compliance requirements. A SACP meeting was held between FRA

and NICTD officials in August 1999. 

The Federal Transit Administration (FTA) provides financial and technical

assistance to local transit systems. Since 1994, NICTD has received $40.7 million in

grants from the FTA. The FTA conducts no inspections of NICTD with respect to its

commuter operation, nor does it review what use NICTD makes of the grant money it

provides. The deputy director of the FTA Office of Safety and Security told the Safety

Board that the FTA relies on the FRA to perform any necessary NICTD safety oversight.

NICTD operates within two States—Indiana and Illinois. Neither State exercises

safety oversight of NICTD; each refers to the FRA for safety oversight. The INDOT

Public Transportation Section (PTS) administers funds to public transit systems to help

them offset operating and capital expenses. The systems also use the funds to match

Federal grant funds. The PTS is responsible for financial oversight and requires each

public transit system to submit quarterly and annual reports that include financial and

operating information. Each system must submit an annual audit to the PTS office.

Between 1993 and 1998, NICTD submitted reports to INDOT as required. NICTD

received about $7 million in State funds from INDOT in 1997. 

The Illinois Commerce Commission (ICC) railroad section’s jurisdiction over

railroads is described in the Illinois Compiled Statutes, chapter 625 (Illinois Vehicle Code,

2

 National Transportation Safety Board, Collision Between Northern Indiana Commuter Transportation

District Eastbound Train 7 and Westbound Train 12 Near Gary, Indiana, on January 18, 1993, Railroad

Accident Report NTSB/RAR-93/03 (Washington, D.C.: National Transportation Safety Board, 1993).
Investigation 5 Railroad Special Investigation Report

IVC), act 5, chapter 18c, parts 7101 through 7504. The safety requirements delineated for

track, facilities, and equipment are consistent with those of the FRA and have been

adopted by Illinois. The ICC does not inspect railroad equipment, perform operational

oversight of train movements, or conduct track inspections. The ICC told Safety Board

investigators that NICTD had not had an accident or incident reported in Illinois since

1993. 

Major Accident History

The Safety Board has developed reports on four accidents that occurred on NICTD

property. Since 1985, the Safety Board has made eight safety recommendations to the

CSS, which operates on NICTD tracks. All eight recommendations were “Closed—

Acceptable Action” or “Closed—Acceptable Alternate Action.”

New Carlisle, Indiana, 1984—This accident occurred on May 18, 1984, when a

CSS train derailed at a switch near New Carlisle, Indiana.3

 The probable cause of the

accident was a broken switch crank, which allowed the switch to gap. After the accident,

the Safety Board issued one safety recommendation to the CSS on June 28, 1985:

R-85-75

Install a switch point lock on each hand-operated switch over which

passenger trains make facing point movements. 

The recommendation was “Closed—Acceptable Action” on February 17, 1987.

Gary, Indiana, 1985—This accident occurred on January 21, 1985, near Gary,

Indiana, when two CSS trains collided head-on west of the Gary Station platform.4 The

Safety Board determined that the probable cause of this accident was the failure of the

dispatcher to coordinate the movement of the two trains properly; the lack of a clear

provision in General Notice No. 62 for a meeting of two opposing trains scheduled to

depart Gary Station at the same time; and the mistaken determination by the crew of

eastbound train No. 123 while at Clark Road Station that there was sufficient time for the

train to reach Gary Station and clear the single track before the scheduled departure of

westbound train No. 218.

3

 National Transportation Safety Board, Derailment of Commuter Train No. 20 Chicago SouthShore and

South Bend Railroad, New Carlisle, Indiana, May 18, 1984, Brief of Railroad Accident CHI84FR003

(Washington, D.C.: National Transportation Safety Board, 1985).

4

 National Transportation Safety Board, Head-on Collision of Chicago SouthShore and South Bend

Railroad Train Nos. 123 and 218, Gary, Indiana, January 21, 1985, Railroad Accident Report

NTSB/RAR-85/13 (Washington, D.C.: National Transportation Safety Board, 1985).
Investigation 6 Railroad Special Investigation Report

On November 13, 1985, the Safety Board issued seven safety recommendations to

the CSS:

R-85-106 (Closed—Acceptable Alternate Action; October 7, 1987)

Provide for a 3-minute delay similar to that in rule 83A for all operations

involving single track operating rules at locations where the arrival and

departure times of opposing trains are in conflict.

R-85-107 (Closed—Acceptable Action; February 11, 1986)

Require that ‘Call Orders’ be issued to train crews to call the dispatcher

before a train enters the single track section when single track operating

procedures and rules are established temporarily in double track territory.

R-85-108 (Closed—Acceptable Action; October 7, 1987)

Install a tape-monitoring system to record and preserve a record of

communications to and from the dispatcher on the dispatcher’s telephone

and radio circuits.

R-85-109 (Closed—Acceptable Action; February 11, 1986)

Establish a reliable reporting system to provide the dispatcher more

accurate passing times of trains entering upon the Chicago SouthShore and

South Bend tracks at Kensington Interlocking for use in estimating the

movement of trains.

R-85-110 (Closed—Acceptable Alternate Action; October 7, 1987)

Modify the power-monitoring system so that the time trains pass the

substation can be identified more readily, and require the dispatcher to

record those times promptly on his train sheet.

R-85-111 (Closed—Acceptable Action; February 11, 1986)

Provide written instructions to operating personnel concerning the action

required when a train encounters a stop-and-proceed signal aspect in a

section of track where no propulsion power is available.

R-85-112 (Closed—Acceptable Action; March 15, 1988)

Develop a comprehensive curriculum covering the critical elements and

job skills, including communication skills and manner for each position,

and require that an employee pass a uniform examination before being

advanced to a new position.
Investigation 7 Railroad Special Investigation Report

Gary, Indiana, 1993—At 9:34 a.m. on January 18, 1993, NICTD eastbound

commuter train 7, traveling from Chicago, Illinois, to South Bend, Indiana, and NICTD

westbound commuter train 12, traveling from South Bend to Chicago, collided at milepost

61.1 in Gary, Indiana.5 Seven passengers died and 95 people were injured.6 Damage to the

two trains was estimated at $854,000.

The Safety Board determined that the probable cause of the collision between the

two NICTD trains was the inattentiveness of the engineer on train 7, resulting in his train

passing a stop signal and partially blocking the westbound track. Contributing to the

severity of the accident was the failure of the engineer on train 12 to take timely action to

slow or stop his train before the collision. Contributing to the severity of the injuries was

the breach of the passenger compartment in the lead cars of both trains. 

The Safety Board issued recommendations concerning crashworthiness and rail

personnel fitness to the FRA, the FTA, the American Public Transit Association (APTA),7

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

Association.

Portage, Indiana, 1998—About 4:31 a.m., June 18, 1998, the westbound two-car

NICTD train 102 struck the second semitrailer of an LCV that consisted of a tractor

pulling two flatbed semitrailers loaded with steel coils at the National Steel Corporation’s

Midwest Steel Division grade crossing near Portage, Indiana. The LCV had entered the

crossing and proceeded via the northbound lane toward the entrance to the Midwest Steel

plant. The Midwest Steel grade crossing traversed two sets of railroad tracks, the NICTD

and the Consolidated Rail Corporation (Conrail) main tracks. The LCV proceeded over

the NICTD main tracks and approached the Conrail main tracks. (In June 1999, the

Conrail operation in this area was taken over by the Norfolk Southern Corporation.) As

the LCV was crossing the NICTD tracks, the grade-crossing signals for the Conrail track

activated and the gates lowered in front of the LCV tractor. The driver stopped the LCV

before the Conrail south grade-crossing gate, which caused the LCV’s second semitrailer

to stop on the westbound NICTD track.

Meanwhile, NICTD train 102, traveling westbound about 68 mph, was

approaching the Midwest Steel grade crossing. Seeing the LCV on the track, the engineer

placed the train in emergency braking, but it did not stop in time to avoid collision. As the

collision occurred, the chain that secured a steel coil to the second semitrailer broke. The

released steel coil entered the first train car through the control compartment. The coil

5

 National Transportation Safety Board, Collision Between Northern Indiana Commuter Transportation

District Eastbound Train 7 and Westbound Train 12 near Gary, Indiana, on January 18, 1993, Railroad

Accident Report NTSB/RAR-93/03 (Washington, D.C.: National Transportation Safety Board, 1993).

6

 The FRA database has only 41 injuries associated with this accident because the FRA used criteria

different from those used by the Safety Board in developing its injury totals. 

7

 APTA is a nonprofit international association of over 1,200 member organizations, including transit

systems; planning, design, construction, and finance firms; product and service providers; academic

institutions; and State associations and departments of transportation. More than 90 percent of those people

using public transportation in the United States and Canada are served by APTA members. 
Investigation 8 Railroad Special Investigation Report

moved about 34 feet into the passenger compartment before coming to rest. Three

fatalities and five minor injuries resulted. 

Another incident at the Midwest Steel grade crossing took place on July 16, 1998.

At 6:34 a.m., the engineer of the eastbound Conrail train MAIL8M, traveling at 60 mph on

the No. 2 (inside) track, put the train into emergency braking because he was concerned

that a southbound flatbed trailer was extending onto the No. 2 track. According to the

engineer, he could not tell whether the trailer was on the track or simply close to it. The

engineer said that he was about an “engine length” away when the truck moved forward

and a collision was avoided. 

Because of the safety problems at the crossing, the Safety Board determined that

immediate action was necessary to prevent a recurrence of the June 18, 1998, accident.

The Board issued urgent Safety Recommendations R-98-44 to the FRA, R-98-45 to the

Federal Highway Administration, R-98-46 to INDOT, and R-98-47 to the National Steel

Corporation’s Midwest Steel Division. The recommendations called for the organizations

to work together to

Take immediate steps to provide traffic controllers to supervise and

coordinate the safe movement of highway and railroad traffic at the

Midwest Steel and Wilson Road grade crossings. Ensure that the traffic

controllers are able to communicate directly with highway and railroad

traffic, and keep the controllers assigned to this duty until permanent

engineering changes to these grade crossings can be identified and

implemented. 

Since August 31, 1998, a traffic controller has been posted to coordinate the safe

movement of traffic through the Midwest Steel grade crossing. The FRA, the Federal

Highway Administration, INDOT, and the National Steel Corporation’s Midwest Steel

Division have informed the Safety Board that they are working with the involved railroads

to find ways to continue to improve safety and user awareness at the Midwest Steel

crossing, as well as to provide grade separation. All the recommendations are currently in

“Open—Acceptable Response” status. 

In its final report on the 1998 Portage accident, the Safety Board determined that

the probable cause of the collision between NICTD train 102 and an LCV (truck) at the

National Steel Corporation’s Midwest Steel grade crossing was ineffective action by

Federal, State, and private agencies to permanently resolve safety problems at the

Midwest Steel grade crossing, which they knew to be a hazardous crossing.

The Safety Board issued the following safety recommendations as a result of its

investigation of the Portage accident:

to the U.S. Department of Transportation:

Eliminate any differentiations between private and public highway-rail

grade crossings with regard to providing funding for, or requiring the

implementation of, safety improvements. (I-99-02)
Investigation 9 Railroad Special Investigation Report

to the FRA:

Work together with the Federal Highway Administration, INDOT, the

National Steel Corporation, the Norfolk Southern Corporation, and NICTD

to make, within 2 years, permanent engineering changes to the Midwest

Steel highway-rail grade crossing that will minimize or eliminate safety

hazards at this crossing. (R-99-31) 

Determine the extent of the weld quality assurance inadequacies

demonstrated by Nippon Sharyo Ltd. in its collision post welds, and

implement corrective action as necessary to ensure the strength of the

collision posts. (R-99-32)

Require 100-percent nonvisual inspection of all collision post attachment

welds made on multiple-unit locomotives and passenger cars during

manufacture, and require that inspection records be retained for the life of

the car. (R-99-33)

to the Federal Highway Administration:

Work together with the FRA, INDOT, the National Steel Corporation, the

Norfolk Southern Corporation, and NICTD to make, within 2 years,

permanent engineering changes to the Midwest Steel highway-rail grade

crossing that will minimize or eliminate safety hazards at this crossing.

(H-99-27) 

to INDOT:

Work together with the FRA, the Federal Highway Administration, the

National Steel Corporation, the Norfolk Southern Corporation, and NICTD

to make, within 2 years, permanent engineering changes to the Midwest

Steel highway-rail grade crossing that will minimize or eliminate safety

hazards at this crossing. (H-99-28) 

to the National Steel Corporation, Midwest Steel Division:

Work together with the FRA, the Federal Highway Administration,

INDOT, the Norfolk Southern Corporation, and NICTD to make, within 2

years, permanent engineering changes to the Midwest Steel highway-rail

grade crossing that will minimize or eliminate safety hazards at this

crossing. (H-99-29) 

to the Norfolk Southern Corporation:

Work together with the FRA, the Federal Highway Administration,

INDOT, the National Steel Corporation, and NICTD to make, within 2

years, permanent engineering changes to the Midwest Steel highway-rail

grade crossing that will minimize or eliminate safety hazards at this

crossing. (R-99-34) 
Investigation 10 Railroad Special Investigation Report

to NICTD:

Work together with the FRA, the Federal Highway Administration,

INDOT, the National Steel Corporation, and the Norfolk Southern

Corporation to make, within 2 years, permanent engineering changes to the

Midwest Steel highway-rail grade crossing that will minimize or eliminate

safety hazards at this crossing. (R-99-35) 

Inspect the collision post welds of all Nippon Sharyo Ltd. railcars in your

fleet and repair any welds that are deficient. (R-99-36)

Also as a result of its Portage investigation, the Safety Board reiterated the

following safety recommendation:

to the U.S. Department of Transportation:

Develop a standardized hazard index or a safety prediction formula that

will include all variables proven by research or experience to be useful in

evaluating highway-rail grade crossings, and require the States to use it.

(H-98-33)

Safety Record

Railroads report accidents and incidents to the FRA using two forms:

FRA F6180.54, the Rail Equipment Accident/Incident Report (RAIR), and

FRA F6180.57, the Highway-Rail Grade Crossing Accident/Incident Report (GXIR). The

RAIR is filed for any “safety-related event involving on-track rail equipment (both

standing and moving) causing monetary damage to the rail equipment and track above a

prescribed amount” (the 1998 threshold was $6,600). The GXIR is filed in response to any

“impact between a rail and highway user (both motor vehicles and other users of the

crossing) at a designated crossing site, including walkways, sidewalks, etc., associated

with the crossing.”8

 Grade-crossing accidents that result in damages of, or greater than,

$6,600 are reported on both forms. 

NICTD experienced 12 grade-crossing accidents from 1990 through 1998 that

resulted in damage exceeding the RAIR dollar threshold. NICTD experienced a total of 68

grade-crossing incidents during this period. On average, NICTD experienced 1.63 gradecrossing accidents per million train miles traveled during the 9-year period. 

NICTD reported 22 nongrade-crossing accidents during the 1990 through 1998

period. Before 1998, NICTD’s nongrade-crossing accident rate was 2.31 per million train

miles. NICTD experienced 7 nongrade-crossing accidents in 1998, which raised the

railroad’s cumulative nongrade-crossing accident rate to 3.0 per million train miles for the

period. 

8

 FRA, http://safetydata.fra.dot.gov/officeofsafety, 1999.
Investigation 11 Railroad Special Investigation Report

NICTD Infrastructure and Operating Practices

Operations

The train dispatcher’s office in Michigan City, Indiana, controls NICTD train

operations. Eleven substations supply 1,500 volts DC to an overhead catenary for

propulsion power. The maximum authorized speed on the track is 79 mph.

About 58 NICTD railroad commuter cars currently operate from the overhead

catenary. Nippon Sharyo Seizo Kaisha Ltd. of Toyokowa, Japan, manufactured the cars.9

NICTD put 43 cars, each with 93-passenger seating capacity, in service in 1982 and 1983.

NICTD added 7 powered cars and 10 nonpowered trailers, each with 110-passenger

seating capacity, to its operation in 1992.

Powered cars are self-propelled by four DC traction motors, one on each axle.

Each car is capable of independent two-way operation and is equipped with two

pantographs, one at each end of the car roof. Each car is also equipped with automatic

couplers, which connect the pneumatic and electrical train control systems. If necessary,

the cars can be connected to a diesel locomotive.

The cars are designed so that equipment components requiring inspection and

maintenance are readily accessible. To ensure that components can be removed or

serviced, NICTD cars have identification and access doors and panels to the equipment

spaces. The underfloor equipment has been arranged and identified to allow ready access

from maintenance pits or the side of the car.

NICTD cars receive unscheduled maintenance (for defects that occur during daily

use), scheduled maintenance, and “mid-life” maintenance. Maintenance employees,

consisting of 4 supervisors, 13 car men, 11 electricians, and 5 machinists, perform the

scheduled and unscheduled maintenance. A separate group of seven car men and seven

electricians perform the mid-life maintenance.

Federal regulations10 require daily and periodic inspections. Qualified NICTD

inspectors conduct these inspections. Written records are stored on the units and at the

departmental office in Michigan City. Periodic inspection is required every 92 days;

NICTD routinely performs such inspections every 60 days.

NICTD is working to increase its fleet size. Its entire mechanical department meets

regularly with Klauder and Associates11 and carries out a detailed planning process for

equipment procurement operations. NICTD senior managers, supervisors, mechanical

engineers, and line-level mechanics participate in the discussions and meetings. Topics

9

 Nippon Sharyo Seizo Kaisha Ltd. is now operating under the name Nippon Sharyo Ltd. Sumitomo

Corporation of America handled commercial arrangements for the NICTD car transaction. 

10 Title 49 Code of Federal Regulations (CFR) Part 229, “Railroad Locomotive Safety Standards,”

Subpart B–Inspections and Tests.

11 A firm that provides technical consultation and quality assurance regarding railcars. 
Investigation 12 Railroad Special Investigation Report

routinely discussed include existing equipment performance history as it relates to failure

rates, reliability, parts availability, and the potential transition from electromechanical

propulsion to some form of solid-state technology. 

NICTD train operating rules are in The Chicago SouthShore and South Bend

Railroad and Northern Indiana Commuter Transportation District, Rules and Regulations

for the Government of the Operating Department. The rule book became effective on

September 1, 1986, and was revised in April 1990. NICTD uses a timetabled train order

system with wayside automatic block signals (ABS). The timetable in use became

effective at 4:01 a.m., August 25, 1996. NICTD issues general notices and circulars as

needed.

The N.I.C.T.D. Strategic Plan, dated July 1992, details NICTD’s operational goals.

NICTD’s chief operating officer, through the superintendent of transportation, administers

the operational and test inspection program. The trainmaster and senior trainmaster do

most testing. In a July 16, 1997, letter to the FRA associate administrator for safety, the

NICTD superintendent of transportation described NICTD’s operations testing program as

being in compliance with the FRA’s Notice of Safety Directive published on June 30, 1997. 

Track

The main NICTD track is constructed with 115-pound continuous-welded rail,

secured to 7- by 8-inch by 9-foot crossties (most are made of timber, but some are 9-foot

concrete ties and “Nucore”12 concrete ties). The ties rest in FRA-specification No. 3

crushed limestone ballast, maintained to 12-inch shoulders.

NICTD’s written track maintenance standard plan is the NICTD Maintenance of

Way Quality Assurance Manual. Standards in the manual are more restrictive than those

set forth by the FRA in 49 CFR Part 213, “Track Safety Standards.” The manual satisfies

the track safety requirements detailed in the NICTD SSPP. A consultant drafted the

Maintenance of Way Quality Assurance Manual, with input from the NICTD track

engineer. The manual also contains the NICTD bridge inspection policy and the standards

for signal maintenance and construction. 

The NICTD track engineer is responsible for overseeing the track department; he

is a civil engineer whose experience began in 1969 with the Akron Youngstown Railroad

and included work on the Denver and Rio Grande Western Railroad. His staff consists of

an assistant track engineer, a supervisor of track inspections, and 32 to 35 contract (union)

employees. The assistant track engineer is responsible for the day-to-day operation of the

maintenance crews and various administrative assignments. The supervisor of track

inspections performs track inspections via a Hy-Rail vehicle twice a week. The switches

receive a walking inspection once a month, and the curves receive periodic walking

inspections. The supervisor of track inspection also sets the priorities for the work of the

track maintenance crews. The NICTD track department has crews stationed in Michigan

City, Gary, and Ogden Dunes, Indiana. 

12 These are short 2-foot ties connected by structural I-beams; each rail is supported on a tie. 
Investigation 13 Railroad Special Investigation Report

The NICTD track department has fully implemented the Roadway Workers’

Protection Act,13 which is designed to prevent accidents and maintenance-of-way

workers’ casualties caused by moving railroad cars, locomotives, or roadway maintenance

machines on rail rights of way. NICTD uses “form–B” orders for exclusive track

occupancy. The forms are issued to all trains through their track permits. If a train is to

enter an area covered by a form B, train personnel must call the person in charge of the

track occupancy and request permission to enter and pass through the work limits. Until

permission is received, the train may not enter the work limits.

NICTD inspects the main track rail for internal defects using leased rail detector

cars. According to the track engineer, NICTD has never had a geometry car on the

property. The track inspector determines cross-level compliance during walking

inspections.

Safety Board investigators took a number of trips over NICTD tracks by train and

Hy-Rail vehicles. During the Hy-Rail trips, stops were made to permit more thorough

inspection of the track and structures. No anomalies were found. 

NICTD requires all track employees to qualify on the NICTD Book of Rules

annually. (At this time, most track employees are qualified, and NICTD intends all to be

qualified eventually.) Freight carriers and other commuter properties do not normally

require this annual rules qualification, and the FRA does not mandate it. 

Based on the preceding information concerning NICTD track maintenance

programs and policies, the Safety Board concludes that NICTD does not appear to have

significant deficiencies in its track maintenance program.

Structures

NICTD provided the Safety Board a copy of its bridge inspection policy. The

stated purpose of the policy is to provide an assurance of safety in the use of bridges on or

over the railroad. Inspections are not limited to bridges owned by the railroad. NICTD

owns and maintains 34 bridges. It operates over and maintains another five bridges owned

by the CSS. In addition, six highway bridges cross NICTD tracks.

Bridge inspections covered under this policy are categorized as annual, periodic,

special-detailed, or emergency. Bridge inspection safety is covered by company rules and

49 CFR Part 214. Inspection procedures and techniques reference those of the American

Railway Bridge and Building Association (now part of the American Railway

Engineering and Maintenance of Way Association) and the American Railway

Engineering and Maintenance of Way Association. In addition, NICTD cites the

University of Tennessee Transportation Center and the U.S. Department of Transportation

as procedural sources. 

13 This legislation enacted 49 CFR Part 214, “Railroad Workplace Safety,” Subpart C–Roadway Worker

Protection, as amended on December 16, 1996. 
Investigation 14 Railroad Special Investigation Report

NICTD bridge inspection records show 59 bridge structures inspected by

NICTD.14 NICTD operates over 42 of these bridges; the remaining 17 are highway

overpasses. Thirty-nine bridges are listed as NICTD’s maintenance responsibility. The

other 20 are either owned or maintained by the CSS or the State and/or local governing

highway agency. 

The 1998 NICTD engineering department bridge inspection report, completed

October 1998, stated that all bridges had been inspected and found to be in satisfactory

condition to carry traffic. The report recommended repairs or maintenance for 28 bridges,

as well as future inspections. Only minor repairs were recommended.

The failure of a pin-plate on one bridge (No. 61.07) structure prompted NICTD to

conduct a fatigue analysis to estimate the remaining life of major structural components. A

contracted consulting firm performed the inspection and evaluation, which was completed

during July 1997. Based on estimated traffic volumes, the analysis showed that the fatigue

life of the stringers had been consumed. The consultant made no recommendations.

The consultant completed more inspections and evaluations of bridges (Nos.

54.73, 47.32, 63.37, 61.07, and 50.11) in November 1997. The consultant found that,

based on the inspection and analysis, the age of the structures, and the serious fatigue

damage to hangers of the trusses, rehabilitation of the floor system was not an option. The

consultant recommended a bridge replacement schedule (to which NICTD is adhering).

The bridges ranged in age from 90 to 102 years. Closer monitoring was recommended for

bridge Nos. 54.73 and 47.32 after every 2 to 3 million gross tons of traffic. In addition, the

consultant recommended that special handling and speed reductions be enforced for loads

heavier than 263,000 pounds and newer AC locomotives with axle loads greater than

65,750 pounds. NICTD has implemented or is in the process of implementing the

consultant’s recommendations.

According to the NICTD general manager (GM), the latest NICTD gross tonnage

report shows 10.3 million gross tons of traffic annually, and NICTD has programmed for a

periodic floor system inspection every 3 months. Additionally, NICTD has contracted

with two other consultants to conduct detailed inspections and ultrasonic testing on the

connecting pins. No indications of member cracking or failure have been reported.

The NICTD GM also stated that NICTD is preparing a request for proposals for

load-rating work on all structures and will develop special handling instructions for loads

in excess of 263,000 pounds. The trainmaster will enforce the special instructions and

handling through normal speed restrictions, and the track department will conduct train

weight audits.

Further, the GM reported that NICTD has recognized the need to update its bridge

rating tables based on the structural evaluations and methods previously used for rating.

14 Bridge number totals may not match because inspection reports show double-track bridges supported

independently of each other as two spans (bridges), while there is only one bridge number.
Investigation 15 Railroad Special Investigation Report

NICTD is completing its 5-year plan on bridges, as well as interim repairs to synchronize

with the 5-year plan. 

Therefore, the Safety Board concludes that NICTD has followed standard

engineering practice in contracting structural engineering expertise for evaluating,

inspecting, and load-rating its older bridges and has implemented measures to maintain

the structures for the safe passage of expected train traffic. 

Signals

General—NICTD maintains about 75.5 miles of an ABS system, four

interlockings (three controlled by other railroads), and four signaled sidings for passing

and meeting trains. The NICTD ABS system consists of 58 miles of single main track and

17.5 miles of double main track. NICTD uses 96.4 track miles of ABS system track.15 The

signal system uses 60 Hz AC and electronic track circuits to detect trains and AC singlewire single-break relay-based common return circuits and DC double-wire double-break

line circuits to control signals. 

The signal system consists of fixed-block, three-aspect, colorlight signals that

supplement the timetable and train order system by establishing space intervals between

trains to increase the safety of operations. The block signal system does not convey

authority for trains to operate, except for those block signals that are also interlocked. 

The Safety Board reviewed NICTD’s Maintenance of Way Quality Assurance

Manual, which contains special instructions governing the maintaining, testing, and

inspecting of highway-rail grade crossings and signal systems and apparatus. The manual

contains instructions and test result forms. NICTD updated the manual on March 10,

1995.

FRA communications and signal test records16 were examined in Michigan City,

Indiana. The records were on preprinted or computerized forms, contained the required

information, and were filed in the office of the supervisory official having jurisdiction.

The monthly signal failure reports17 inspected for the years 1993 through 1998

showed that three false proceed indications18 had occurred during the period. NICTD

reported one signal activation failure19 since January 1993. This type of failure suggests to

15 Metra maintains the remaining miles of ABS system that NICTD uses.

16 Test record requirements appear in 49 CFR 234.273 and 236.110. 

17 Signal system failure reporting requirements appear in 49 CFR 233.7. 

18 Failure of an appliance, device, method, or system to function or indicate as required that results in a

more favorable aspect than intended or other condition hazardous to the movement of a train. 

19 Failure of an active highway-rail grade-crossing warning system to indicate the approach of a train at

least 20 seconds before the train’s arrival at the crossing, or to indicate the presence of a train occupying the

crossing, unless the crossing has an alternative means of actively warning highway users about approaching

trains. 
Investigation 16 Railroad Special Investigation Report

the motorist that it is safe to proceed across the railroad tracks when it is not safe to do so.

A shorted insulated joint caused this incident, which occurred on June 19, 1997. 

The Safety Board reviewed NICTD-provided FRA signal and train control

inspection reports for the period between October 2, 1992, and June 2, 1998, to determine

whether trends in noncompliance or safety issues were evident. Seventy-six percent of the

inspection reports provided by NICTD showed no exceptions taken to equipment or

records inspected. This sample also indicated that, in comparison to similar railroad

operations, NICTD’s signal inspection record had a lower-than-average defect ratio.

FRA inspections of 20 highway-rail grade crossings resulted in citations of

defective conditions at 5 crossings. Fifty-five percent of the defective conditions cited

concerned failure to prevent dust or moisture from entering flashing light units and failure

to secure other component housings against unauthorized entry. The FRA inspected 300

signal maintenance records and found no exceptions. In addition, the Board reviewed the

signal system annual reports20 for 1993 through 1998. NICTD’s reports were up to date

and contained the appropriate information. Based on its review of the inspection records

and other FRA data, the Safety Board concludes that NICTD appears to be effectively

implementing and administering its signal inspection program. 

Signal System Control Circuits—In 1990, the FRA performed a systems

assessment of various Chicago commuter rail operations, including NICTD. Following

this assessment, the FRA recommended that NICTD eliminate AC line circuits and

convert to DC line circuits to reduce the potential for grounding. At that time, the NICTD

signal system used 60 Hz 110 volt AC single-wire single-break relay-based common

return line circuits to control signal aspects. 

In an interview with Safety Board staff, the NICTD chief electrical engineer stated

that NICTD has a Federal grant to eliminate pole lines, install electronic track circuits, and

convert from AC single-wire single-break relay-based common return circuits to DC

double-wire double-break line circuits for controlling signals. He also stated that the

double-wire double-break circuits provide a higher level of security and reduce potential

risks, such as grounds. NICTD has installed 10 track miles of electronic track circuits to

eliminate pole lines. The chief electrical engineer stated that he prefers installing

electronic track circuits because they provide a platform on which to add automatic cab

signals and train control. NICTD’s installation of electronic track circuits and conversion

of signal control line circuits is about 75 percent complete.

The Safety Board acknowledges that NICTD has made progress in converting its

signal system since the FRA’s recommendation in 1990. However, in light of the safety

problems (such as false proceed signal indications) that can result from electrical

grounding and the nearly 9 years since the FRA made the recommendation, the Safety

Board is concerned about the pace at which the project is being completed. The Safety

Board concludes that NICTD’s failure to complete the elimination of AC line circuits and

20 Signal system reporting requirements appear in 49 CFR 233.9. 
Investigation 17 Railroad Special Investigation Report

conversion to DC line circuits on its signal system may have reduced the system’s safety.

Because the conversion of signal control circuits would reduce the potential for

grounding, it would result in increased NICTD system safety and should be completed as

soon as possible. The Safety Board believes that NICTD should complete the conversion

or elimination of signal control line circuits within 2 years. 

Highway-Rail Grade Crossings 

General—The average grade-crossing density for the NICTD system is about 1.74

crossings per route mile.

NICTD told the Safety Board that the NICTD system currently contains 151

crossings, of which 103 are public, 37 are private, and 11 are pedestrian railroad crossings

at grade. Forty-two crossings have passive railroad warning devices (crossbuck signs),

and 11 crossings have no warning devices. Thus, 53 crossings, about one-third of all

NICTD grade crossings, currently have passive or no warning devices. Fifteen of the 42

locations with railroad crossbucks are on private crossings, and all 11 crossings with no

warning devices are on private crossings.

On July 21, 1998, the Safety Board adopted a safety study of passive grade

crossings that detailed the dangers inherent in many passive grade-crossing

arrangements.21 The study noted that

In 1996, passive grade crossings accounted for about three-quarters of all

grade crossings in the United States; although there is less highway and

train traffic at passive crossings than at active crossings, passive crossings

accounted for 54 percent of all grade-crossing accidents and 60 percent of

all grade-crossing fatalities in that year.22

The report further found that

A systematic and hierarchic approach to improving passive grade crossing

safety is needed, an approach that does not depend primarily on the ability

of the driver approaching the crossing to see an oncoming train. The

hierarchic approach includes grade separation and closure, installation of

active warning devices, improved signage, and intelligent transportation

systems technology.23

The passive grade-crossing safety problems and possible solutions identified in the

safety study are applicable to a wide range of rail operations, including NICTD. Eleven

passive grade crossings on the NICTD system had no signage or advance warning devices.

All were private crossings. 

21 National Transportation Safety Board, Safety at Passive Grade Crossings, Volume I: Analysis, Safety

Study NTSB/SS-98/02 (Washington, D.C.: National Transportation Safety Board, 1998).

22 Safety at Passive Grade Crossings, Volume I: Analysis, Safety Study NTSB/SS-98/02, p. 61. 

23 Safety at Passive Grade Crossings, Volume I: Analysis, Safety Study NTSB/SS-98/02, p. 64. 
Investigation 18 Railroad Special Investigation Report

The Safety Board understands that NICTD has only limited authority over and

responsibility for private crossings. NICTD’s main purpose, however, is to provide safe

and reliable transportation services to the public. With this charge comes the responsibility

to ensure the safety of NICTD’s customers and vehicular traffic. 

Poor or nonexistent signage provides insufficient information for motorists to

make prudent decisions regarding safe courses of action at grade crossings. When

motorists make uninformed decisions at grade crossings, the safety of both vehicles and

trains is jeopardized. Therefore, the Safety Board concludes that the lack of adequate

signage and advance warning devices at some NICTD passive grade crossings poses a risk

to NICTD’s customers and motorists. 

In its 1998 passive grade-crossing study, the Safety Board studied the use of stop

signs at passive grade crossings in depth.24 The Board found that 

Despite concerns about the use of stop signs at passive crossings, the

Safety Board believes that the benefits of stop signs at passive crossings

outweigh the concerns. Foremost, in the Safety Board’s opinion, is the need

for a system-wide approach that provides consistent information and

instruction to the driver. Specifically, (1) the action required by a stop sign

is well understood by drivers, (2) a driver stopped at a crossing has more

time in which to detect an approaching train, and (3) sight distance along

the tracks when viewed from a stop sign is generally accurate, according to

study accident data.

The safety benefits provided by use of stop signs at passive crossings are

applicable to the passive grade crossings on the NICTD system that lack signage and

advance warning devices. When a stop sign is placed at a passive grade crossing, the

driver knows where the crossing is and what action must be taken. Such clear

communication of critical information would improve safety at passive grade crossings.

Therefore, the Safety Board believes that NICTD should work with INDOT and Indiana’s

Lake, Porter, LaPorte, and St. Joseph Counties to install stop signs at all NICTD passive

grade crossings, unless a traffic engineering analysis determines that installation of stop

signs would reduce the safety of the crossing. Any NICTD crossings at which conditions

are such that the installation of stop signs would reduce the level of safety should be

upgraded with active warning devices or eliminated. 

Highway-Rail Grade-Crossing Safety Efforts—NICTD has indicated to the

Safety Board that since 1991, two NICTD highway-rail grade crossings have been closed.

NICTD is also working to close several other grade crossings on its system. 

24 Safety at Passive Grade Crossings, Volume I: Analysis, Safety Study NTSB/SS-98/02, pp. 68-74. 
Investigation 19 Railroad Special Investigation Report

NICTD participates in Operation Lifesaver25 and makes presentations designed to

educate interested parties about the dangers of grade crossings. The NICTD chief of police

is on the Indiana Operation Lifesaver Committee and participates in Operation Lifesaver

programs. Since the Portage grade-crossing accident in June 1998, NICTD has given two

Operation Lifesaver education programs at the Midwest Steel grade crossing, during

which NICTD representatives provided truckers with Operation Lifesaver materials about

the dangers of highway-rail grade crossings. 

NICTD has had a grade-crossing “near-miss” identification program since the

mid-1980s. In general, it functions as follows:

• A train engineer experiences what he or she considers a near-miss between the

train and a vehicle at a highway-rail grade crossing.

• The engineer notifies the dispatcher of what took place, including the vehicle

license plate number, if possible.

• The dispatcher records the information provided by the engineer and

documents it in a NICTD “trouble report.”

• The engineer fills out a NICTD near-miss report form, blank copies of which

are provided in each locomotive cab. The form captures information such as a

description of the violating vehicle, the vehicle’s license plate number, and

whether the violation resulted in an emergency brake application.

• The near-miss form is forwarded to the NICTD police.

• A NICTD police officer tries to locate the identified vehicle.

• The NICTD police department runs a license plate check on that vehicle and

sends a crossing violation notice form to the vehicle owner. The form includes

a suggestion that the motorist contact the NICTD police and provides the

phone number of the NICTD police.

• The motorist typically contacts the NICTD police. (The NICTD chief of police

told the Safety Board that the department has had a nearly 100-percent

compliance rate, with motorists communicating with the NICTD police after a

violation has been reported and a crossing violation notice form issued.)

25 Operation Lifesaver is a nonprofit, nationwide public education program designed to eliminate

collisions, deaths, and injuries at highway-rail intersections and on railroad rights of way. It is sponsored

cooperatively by a variety of partners, including Federal, State, and local government agencies, highway

safety and transportation organizations, and the Nation’s railroads. The program is designed to increase

public awareness about the danger where roadways cross train tracks and on railroad rights of way.

Operation Lifesaver also seeks to improve driver and pedestrian behavior at highway-rail intersections by

encouraging compliance with traffic laws relating to crossing signs and signals. Operation Lifesaver also

emphasizes the enforcement of existing traffic and trespassing laws, the consolidation and closure of

redundant highway-rail crossings, and the improvement of crossing engineering.
Investigation 20 Railroad Special Investigation Report

• When contacted, the NICTD police inform the motorist about Operation

Lifesaver and the dangers of attempting to maneuver around lowered crossing

gates and across the path of an oncoming train.

• Penalties, such as a traffic ticket, may be issued. 

If a NICTD police officer is in the grade-crossing area at the time of the violation,

the officer immediately tries to respond to the violation and locate the vehicle. Under such

circumstances, the police officer usually issues a traffic citation26 to the violator. 

The Safety Board acknowledges NICTD’s efforts to decrease the number of

violations that motorists commit at highway-rail grade crossings. Nonetheless, NICTD

records show that, between 1995 and 1998, a total of 215 highway-rail grade-crossing

violations were reported on the NICTD system and 109 traffic citations were issued.

NICTD sent 54 highway-rail grade accident or incident reports to the FRA between

January 1, 1993, and July 31, 1998. Five fatalities and five injuries were reported to have

resulted from these accidents or incidents. Also, on October 21, 1998, while riding in a

NICTD cab car en route to Chicago, Illinois, two Safety Board investigators observed four

vehicles violating railroad grade-crossing signals. Therefore, the Safety Board concludes

that, despite the NICTD near-miss program to educate motorists who violate highway-rail

grade crossings, significant numbers of highway-rail grade-crossing violations continue

on the NICTD system.

The NICTD near-miss program could be improved. In particular, the current

program does not provide NICTD employees feedback about the outcomes of their

reports. NICTD employees reporting near-miss incidents and providing identification

information about the motorist causing the incident are not told what use is made of the

information they provide. They do not know, for example, whether the motorist is issued a

traffic citation or other penalty based on their report. In other words, no one tells them the

specific results of their participation in the near-miss reporting program. Some NICTD

employees told Safety Board representatives that if the NICTD employee reporting the

violation were made aware of the result of his or her near-miss report, the employee would

be encouraged to continue to report incidents. Consequently, the Safety Board believes

that NICTD should revise its near-miss program to provide closure with individuals

reporting violations.

Throughout this special investigation, NICTD personnel at both the management

and field levels expressed their concern about grade-crossing safety. The NICTD GM said

that railroad workers repeatedly told him that their primary safety-related concern was

grade crossings. The NICTD chief of police told investigators that every NICTD crossing

is a major concern. He stated that

26 A uniform traffic ticket for the State of Indiana. 
Investigation 21 Railroad Special Investigation Report

It’s just an accident waiting to happen. I mean, ultimately, in any transit or

railroad situation, I would think the goal would be complete grade

separation. We know that’s impossible... but the officers certainly will do

their best. Routinely, if there is a broken gate and it’s a major crossing with

lots of vehicular traffic, the police department will respond with an officer

to that location and he’ll take up a position there... .

In addition to its Operation Lifesaver and near-miss programs, NICTD has

attempted to make its grade crossings safer through engineering. Normally, the State or

municipal government having jurisdiction over the highway involved initiates most

improvements to highway-rail grade-crossing warning systems. In 1994, however,

INDOT allowed railroads under its authority to apply for corridor improvements. NICTD,

through the Northwest Indiana Regional Planning Commission, proposed replacing all its

8-inch crossing signal light units with 12-inch units to make the crossings more visible to

motorists. NICTD offered to pay all labor costs if the State would pay for the material.

INDOT approved the project in August 1995 but did not provide NICTD with funding or

materials to proceed. The Safety Board concludes that making grade-crossing signal lights

more conspicuous would provide more effective warning and additional stopping time for

motorists approaching grade crossings.

During the 4 years since NICTD proposed making its crossing signal lights more

visible, Light Emitting Diode (LED) flashing lights have gained acceptance by the

railroad industry because of the dramatically increased conspicuity and reliability they

provide. NICTD personnel told investigators that when INDOT takes action on the light

upgrading project, NICTD will propose using the newer LED flashing light technology.

The Safety Board believes that INDOT should assist NICTD in upgrading all 8-inch

crossing signal light units on NICTD territory. 

In summary with regard to grade-crossing safety on the NICTD system, the Safety

Board found through its investigation that several factors point to possible problems in

this area. First, NICTD has a relatively high density of grade crossings on its system

(approaching two crossings per mile of track), which provides substantial opportunity for

grade-crossing accidents to occur. Also, about one-third of NICTD grade crossings have

passive or no warning devices, and 11 passive grade crossings on the NICTD system have

no signage or advance warning devices. Further, NICTD has experienced a number of

grade-crossing accidents and incidents in recent years, and, despite steps taken by NICTD

to improve grade-crossing safety, near-miss and other incidents continue to occur at

NICTD grade crossings. In addition, NICTD personnel repeatedly expressed concerns

about the risks posed by grade crossings. The Safety Board considers that all these factors

indicate that a systematic effort on the part of those agencies best equipped to develop

methods to improve NICTD grade-crossing safety is needed. Therefore, the Safety Board

believes that the U.S. Department of Transportation, INDOT, and NICTD should work

together to develop and implement a strategic plan to improve safety at NICTD highwayrail grade crossings. 
Investigation 22 Railroad Special Investigation Report

NICTD Safety Programs

System Safety Program Plan

Following the Safety Board’s investigation of the 1996 collision of a Maryland

Rail Commuter train with an Amtrak train in Silver Spring, Maryland,27 the FRA issued

Emergency Order No. 20, requiring certain inspections and modifications to commuter

train operations and passenger equipment. Among other provisions, Emergency Order No.

20 required each property to submit an emergency preparedness plan and an effective

safety program to the FRA. In the section “Interim system safety plans,” the order stated

that 

The plan shall take into consideration the overall safety of all passengers

and crewmembers and shall, at a minimum, address the following

opportunities for risk reduction: (A) Use of cab car/multiple unit car... (B)

Operating rules... (C) Adverse conditions... (D) Short-term technology

enhancements... (E) Crew management... (F) Highway-rail grade

crossings... (G) Emergency exit notification... . 28

Subsequently, the commuter railroads agreed among themselves to fulfill this

element of Emergency Order No. 20 by developing and implementing SSPPs with the

assistance of the FRA and APTA. The FRA planned to review the interim SSPPs to

“determine whether other mandatory action appears necessary to address hazards

associated with the subject rail passenger service.” With respect to reviewing and

approving SSPPs, the FRA is working in partnership with APTA, because APTA has

personnel trained and knowledgeable in assessing SSPPs.

APTA, working with the FRA, drafted a Manual for the Development of System

Safety Program Plans for Commuter Railroads29 to provide more detailed direction to

commuter railroads developing SSPPs in accordance with Emergency Order No. 20. The

manual lists 29 elements that should be addressed in every SSPP and states that

A commuter railroad has the responsibility of maintaining oversight of its

safety status and program to ensure all responsibilities are being carried out

and coordinated. This process is known as system safety. A commuter

railroad establishes an [SSPP] by formalizing this process in a written

document.

27 National Transportation Safety Board, 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, Railroad Accident Report NTSB/RAR-97/02 (Washington, D.C.: National

Transportation Safety Board, 1997).

28 FRA, Commuter and Intercity Passenger Railroads, Including Public Authorities Providing

Passenger Service, and Affected Freight Railroads—Emergency Order Requiring Enhanced Operating

Rules and Plans for Ensuring the Safety of Passengers Occupying the Leading Car of a Train, Emergency

Order No. 20, Notice No. 1, February 20, 1996 (Washington, D.C.: U.S. Department of Transportation,

1996).

29 APTA, Manual for the Development of System Safety Program Plans for Commuter Railroads

(Washington, D.C.: American Public Transit Association, 1998).
Investigation 23 Railroad Special Investigation Report

The overall goal of a System Safety Program for commuter railroads is to

identify, eliminate, minimize, and/or control safety hazards and their

attendant risks by establishing requirements, lines of authority, levels of

responsibility and accountability, and methods of documentation for the

organization.30

As the primary reasons for implementing an SSPP, the manual cites to

• Establish a safety program on a systemwide basis,

• Provide a medium through which a property can display its commitment to 

safety,

• Provide a framework for the implementation of safety policies and the 

achievement of related goals and objectives,

• Satisfy Federal and State requirements,

• Meet accepted industry standards and compliance assessment provisions, and 

• Satisfy self-insurance provisions. 31

On October 15, 1997, NICTD management submitted an SSPP to APTA. This

draft SSPP largely reflected and formalized those safety practices that NICTD was already

following. APTA did not approve the plan NICTD initially submitted; APTA returned it to

NICTD with a critique that stated that the draft SSPP was not sufficiently thorough. Using

the APTA comments and guidance, NICTD redrafted the SSPP and submitted a revised

document that was broader in scope to APTA on April 8, 1998. NICTD included each of

the 29 elements provided in the Manual for the Development of System Safety Program

Plans for Commuter Railroads in its redrafted SSPP. APTA approved the second

submission. 

The NICTD superintendent of transportation began the drafting of the NICTD

SSPP, and the manager of human resources completed the document and began its

implementation. He told investigators that NICTD managers had met concerning the

SSPP during the implementation process. NICTD accepted comments on the document

format, and meeting participants discussed plans for SSPP implementation. No defined

implementation plan was adopted. The original date for the SSPP implementation was

May 1998. NICTD later postponed the implementation date to September 1998 and then

delayed it further.32 Ultimately, NICTD set no date for full implementation of the SSPP.

The NICTD manager of human resources told investigators that “basically the plan is

implemented [in effect] but not specifically, and now we have to live with it.” He said

NICTD should amend the plan and place it in a three-ring binder to make it more “user

30 Manual for the Development of System Safety Program Plans for Commuter Railroads, pp. 3 and 6.

31Manual for the Development of System Safety Program Plans for Commuter Railroads, p. 5.

32 NICTD told investigators that complications caused by the June 18, 1998, Portage accident were one

source of the implementation delay.
Investigation 24 Railroad Special Investigation Report

friendly,” as well as develop a system for monitoring compliance with the SSPP.

According to the GM, NICTD is implementing the SSPP but has not completed the

process.

The investigative team also interviewed the NICTD chief operating officer, chief

engineer (mechanical department), track engineer, director of safety and training (DST),

and superintendent of transportation about SSPP compliance within NICTD. Those

interviewed said that they knew the SSPP is a relatively new document mandated by the

FRA. NICTD has issued the document to all its managers, and NICTD personnel can

obtain it through their individual department managers. 

Each NICTD department has specific safety responsibilities under the adopted

SSPP. The departments have individual safety plans and documents that constitute the

components of the overall NICTD safety program as detailed in the SSPP. To comply with

the SSPP, NICTD has written a maintenance standard plan for the mechanical department,

a quality assurance manual for the track department, an operating rules manual for

operating trains, a manual for the procurement of vehicles, and an emergency response

program plan. 

Although the SSPP requires such action, NICTD has not developed an accident or

investigation team (or manual) for determining the probable causes of accidents or

incidents or for administering corrective action following accidents or incidents. The

NICTD human resources department conducts all nonderailment accident and incident

investigations, and the transportation department investigates all derailments. Currently,

corrective action is negotiated on-scene. A fully implemented SSPP would include a

means of determining the probable causes of accidents and incidents and of providing

corrective action.

Despite the fact that several NICTD managers have stated that the SSPP has been

implemented, the consensus of those NICTD personnel providing comments to the Safety

Board is that the SSPP has not yet become a well-known and accepted element of the

NICTD safety structure. The Safety Board concludes that, until its SSPP required by the

FRA in Emergency Order No. 20 is fully implemented, some program-related safety

benefits may not be realized by NICTD. Full implementation should include the

familiarization of NICTD personnel at all organization levels with the goals, components,

and expected results of the SSPP. Therefore, the Safety Board believes that NICTD should

immediately and fully implement its SSPP, as required by the FRA under Emergency

Order No. 20. 

Director of Safety and Training 

The NICTD SSPP’s implementation is under the jurisdiction of the DST. The

railroad established the DST position in March 1997 (after the FRA issued Emergency

Order No. 20 in February 1997) to formalize NICTD’s safety and training practices.

NICTD had no safety officer before March 1997. The DST’s office is physically located in

Michigan City, Indiana, about 25 to 30 miles away from the GM’s office in Ogden Dunes,

Indiana.
Investigation 25 Railroad Special Investigation Report

As defined in the SSPP, the DST has specific authority to conduct scheduled and

unscheduled inspections aimed at identifying hazards and unsafe practices, operations,

and conditions. The DST may halt unsafe activities or operations that present an

immediate and serious hazard within the system. The DST reports safety conditions that

require remedial action to the appropriate department head, the chief operating officer, the

manager of human resources, and the GM. The DST also coordinates safety training with

department heads and ensures that safety rules are observed and enforced.

Additional DST responsibilities include:

• Assisting in the investigation of accidents and injuries to passengers and 

employees that may involve safety considerations;

• Working with department heads to develop ongoing safety training programs 

that are directly related to each department;

• Evaluating current safety rules and making recommendations to the chief 

operating officer and/or the GM for changes or additions to safety rules;

• Conducting appropriate reviews, audits, inspections, and analysis involving 

safety, health, and environmental issues;

• Assisting in human resource activities that relate to safety or training issues;

• Keeping current on all new or modified FRA and Occupational Safety and 

Health Administration (OSHA) rules and regulations, and conveying the 

information to appropriate authorities; and

• Ensuring that any new or revised regulations are implemented as they relate to 

safety or training.

The DST told investigators that he had been an assistant superintendent before

assuming the role of DST and that he had received no specialized training on how to

structure and implement a safety program either before or after assuming this post. The

DST further stated that he had never met with NICTD’s board of trustees, nor had he ever

briefed them about the duties and responsibilities of the DST position. 

The Safety Board has long advocated that transportation personnel be adequately

trained to fulfill their job responsibilities. In particular, the person responsible for building,

shaping, and managing the organization’s safety system must be fully qualified to perform

this duty. The DST had no experience in safety assurance before being selected for this

position. He was unfamiliar with SSPPs and their functions. He was largely unaware of

the vital role a DST plays in an organization. The Safety Board concludes that NICTD did

not adequately prepare and train its DST to fulfill the responsibilities of the position. 

Because the SSPP forms the basis of the NICTD safety program, the most efficient

means of preparing the DST to fulfill the responsibilities of his position would be to train

him in the functions and implementation of SSPPs. Therefore, the Safety Board believes

that NICTD should provide any individual holding the office of DST with appropriate
Investigation 26 Railroad Special Investigation Report

training, including instruction on the functions, development, and implementation of

SSPPs. 

As shown in the NICTD organizational chart (see figure 2), the DST reports to the

human resources manager and not the GM. The GM said that this is a “good technique,”

since the human resources department is responsible for safety and the coordination of

personnel activities. The DST said that the fact that his position is not at the departmenthead level has not proven to be an obstacle, and he further stated that if he had a problem,

he would not hesitate to contact the GM. 

For years, the Safety Board has stated that the lead safety officer of any

transportation organization should be situated at the highest managerial level within the

organization. The Safety Board Chairman underscored this position during the April 24,

1997, corporate culture symposium held by the Safety Board, when he stated (in reference

to the organization of an urban transit system):

A new director of safety will be joining [the organization], and he will be

reporting directly to the general manager. This is an organizational

structure we have been recommending for years... and is particularly

evident among the major airlines. [Emphasis added.]

In its report on a derailment that took place in Kelso, California, in 1997, the

Safety Board expressed its belief that the lead safety officer in a rail management structure

should report directly to the primary managerial authority, in part, to avoid possible

conflicts of interest between business operations and safety.33 The Board noted that

making the safety officer subordinate to the operating officer implies that safety may be

secondary to operations. On February 25, 1998, the Safety Board recommended that the

Union Pacific Railroad:

R-98-16

Review the functions and responsibilities of the Union Pacific Railroad

general director of safety and make any organizational changes necessary

to ensure that this official: (1) reports directly to the Union Pacific Railroad

president and chief operating officer; (2) is involved in all Union Pacific

Railroad operational issues that could affect train, railroad, and personnel

safety and; (3) has the authority to take effective safety actions throughout

the Union Pacific Railroad.

The Union Pacific Railroad did not concur with the recommendation. On April 5,

1999, the Safety Board classified the recommendation “Open—Unacceptable Response.”

In the case of NICTD, reorganizing the management structure so that the DST

reports directly to the GM would allow the DST to provide prompt input concerning

management policies and practices that might not sufficiently address safety issues. In

33 National Transportation Safety Board, Derailment of Union Pacific Railroad Freight Train 6205 West

Near Kelso, California, January 12, 1997, Railroad Accident Report NTSB/RAR-98/01 (Washington, D.C.:

National Transportation Safety Board, 1998), p. 30. 
Investigation 27 Railroad Special Investigation Report

 Figure 2. Selected elements of NICTD organizational chart, 

indicating the position of the director of safety and training

GENERAL MANAGER

Chief Financial Officer Chief Operating Officer

Senior Attorney

Marketing

Equipment

EEO Manager

Disadvantaged Business

Enterprise Manager

Human Resources Manager

Director of Safety

and Training

Various offices 

and officers

Various offices 

and officers

Chief of Police

Various 
Investigation 28 Railroad Special Investigation Report

addition, important safety information could be communicated more reliably, avoiding the

potential for miscommunication should the DST’s information be misinterpreted by the

department head in reporting to the GM or, conversely, should the GM’s messages to the

DST be misconstrued by the department head. Finally, placing the DST at the departmenthead level would send an unambiguous message to employees, customers, and the public

that NICTD considers safety a high priority that encompasses and permeates all aspects of

the organization. Therefore, the Safety Board concludes that the efficiency of safety

information communication would be enhanced and the profile of safety would be

heightened within the NICTD organization if the DST reported directly to the GM. The

Safety Board believes that NICTD should elevate the position of DST to the departmenthead level and require that the DST report directly to the GM. 

Emergency Response Programs

The NICTD emergency response plan details potential emergency scenarios, as

well as standard procedures necessary to manage each situation. The document also

stresses the importance of communication during an emergency and provides NICTD

procedural guidelines and a directory listing various phone numbers and addresses of

police, fire, and rescue agencies. The plan lists approved procedures for NICTD

dispatchers and train crews to follow in the event of an emergency and outlines actions for

responding to an emergency, as well as procedures for establishing an emergency response

team. As part of its SSPP, NICTD has submitted its emergency response plan to the FRA. 

Before drafting its FRA-mandated SSPP, NICTD had written an emergency

response manual entitled Passenger Train Emergency Preparedness. The manual was

included in the SSPP to comply with FRA requirements. 

Since 1996, NICTD has conducted four emergency response drills: two drills

simulated a collision between a passenger train and a freight train, one involved a

passenger train traveling through fumes released from a tank car stopped at a siding, and

the fourth simulated a passenger car derailing upright. Various agencies, including local

hospitals, emergency medical services, ambulance services, the American Red Cross,

police departments, fire departments, hazardous materials response units, and freight

services, participated in the mock disaster drills. 

Trains involved in accidents and incidents on Metra tracks are governed by the

Metra Emergency Preparedness Plan. NICTD’s operation from Kensington Avenue to

Randolph Street in Chicago is on the Metra Electric District Line. NICTD trains are

handled by the Metra Randolph Control/Dispatch Center when they are in that territory.

NICTD supervisors are trained by Metra through “Train the Trainer” programs. NICTD

supervisors train NICTD on-board personnel in the Metra plan. Emergency response test

records are kept in the office of the NICTD DST in Michigan City, Indiana. NICTD told

the Safety Board that it plans to conduct an emergency response drill with Metra of

Chicago on their jointly operated tracks.

When interviewed by Safety Board investigators, NICTD managers expressed

concern about conducting emergency responses in areas with limited accessibility, such as
Investigation 29 Railroad Special Investigation Report

regions with large waterways or swampy conditions. The NICTD system includes a

number of bridges over waterways and significant areas of marshy land. The Safety Board

has found in previous investigations34 that when accidents take place in less accessible

areas, emergency rescue procedures become both more difficult and more crucial.

Therefore, the Safety Board concludes that safety would be enhanced if greater efforts

were made to prepare local response agencies to deal with commuter train accidents in

areas that are geographically difficult to access. The Safety Board believes that NICTD

should develop training procedures and drills, in conjunction with local emergency

response agencies, that address conducting emergency responses in all types of

geographical conditions. 

NICTD Corporate Safety Culture

Corporate safety culture is an organization’s set of beliefs, norms, attitudes, roles,

and social and technical practices that are concerned with minimizing the exposure of

employees, customers, and members of the public to conditions considered dangerous or

injurious.35 During this investigation, the Safety Board attempted to determine the nature

of NICTD’s safety culture. To that end, Safety Board personnel interviewed the NICTD

GM and members of his staff, as well as 16 employees from various departments. In

addition, the investigators examined and evaluated NICTD safety documents and the

organization’s safety procedures and processes. 

General

Some NICTD employees said that the organization routinely held safety meetings

by department and that, in general, safety had improved over the past several years. Some

employees also said that work areas were inspected for safety hazards about once a month.

One employee commented that communications within the organization had improved in

recent years, while another stated that the information flow was good. An employee told

investigators that the resolution of safety concerns had improved and that safety had been

enhanced in the last year. 

Several employees interviewed by the Safety Board said that safety could be

improved. Specifically, one employee said that NICTD lacked a formal training program;

another said that the entire safety program was not very effective and required work. Still

another said that the DST needed a staff to be able to address safety adequately. 

The NICTD chief operating officer said that NICTD had experienced the

“realization of fatalities” and that safety was paramount. When asked about NICTD’s

safety culture, the DST said that a strong safety culture was something the organization

34 National Transportation Safety Board, Derailment of Amtrak Train No. 2 on the CSXT Big Bayou

Canot Bridge Near Mobile, Alabama, September 22, 1993, Railroad-Marine Accident Report

NTSB/RAR-94/01 (Washington, D.C.: National Transportation Safety Board, 1994).

35 B.A. Turner, N.F. Pidgeon, D.I. Blockley, and B. Toft, Position Paper for the Second World Bank

Workshop on Safety Control and Risk Management, November 6-9, 1989, “Safety Culture: Its Importance in

Future Risk Management” (World Bank: Karlstad, 1989).
Investigation 30 Railroad Special Investigation Report

endorsed and practiced. Both managers expressed particular concern about grade-crossing

safety.

The NICTD GM told investigators that each department within NICTD was

responsible for convening safety meetings (the frequency of meetings varied by

department) during which employees could raise safety concerns. The NICTD chief

operating officer said that while employees may have been reprimanded for failing to

follow safety rules, no NICTD employee had ever been reprimanded for identifying a

safety concern. The DST stated that NICTD had no safety hotline or other mechanism by

which employees could anonymously bring safety concerns to management attention, but

he said that employees had occasionally requested that he investigate a safety concern and

not identify them as the source of the complaint. 

Concerning the communication of safety information within the organization, the

DST said that NICTD disseminated weekly safety notices and that personnel with

operating, engineering, and mechanical responsibilities were required to read general

(operational) notices. With regard to the means of identifying safety-related information to

be provided to employees, he said that an employee monitored the Federal Register for

information, that the railroad subscribed to several OSHA safety letters, and that he had

contacts within the industry with whom he exchanged safety information. 

The DST also said that every NICTD department had a safety committee and that

NICTD had an organization-wide safety committee composed of seven members—two

from the mechanical department and one each from the transportation, track, line and

signal, buildings and bridges, and accounting departments—representing the main NICTD

operational areas. Each departmental safety committee focused on those safety concerns

specific to that department, while the NICTD safety committee dealt with NICTD-wide

safety issues. 

In response to a questionnaire that investigators asked him to complete, the DST

reported that NICTD sometimes held safety meetings and that meeting attendance was

documented. The DST also noted that since the Portage accident, he has been developing

individual safety and training files for each NICTD employee.

Safety Documents

The Safety Board examined two NICTD safety publications, the NICTD Rules of

Safety and the Chicago SouthShore and South Bend Railroad and Northern Indiana

Commuter Transportation District, Rules and Regulations for the Government of the

Operating Department. 

The NICTD Rules of Safety is a 91-page, pocket-sized handbook that NICTD

provides to each NICTD employee. It covers hundreds of rules that concern safety in

every aspect of NICTD activity, from personal protective equipment to office practices.

The handbook is in loose-leaf format, so that pages can be removed and replaced as

NICTD updates safety procedures. On its first page, the handbook states 
Investigation 31 Railroad Special Investigation Report

Safety is every employee’s primary responsibility. [Emphasis appears in

original.]

Accident prevention is the primary goal and benefit of a successful safety

program. Conditions and procedures must be constantly monitored and

evaluated by all employees to improve safety conditions. 

This revised Safety Rule Book establishes the minimum mandatory

guidelines that must be followed to prevent injury and property damage.

Your vigilance and judgment are vital to accident prevention.

The Chicago SouthShore and South Bend Railroad and Northern Indiana

Commuter Transportation District, Rules and Regulations for the Government of the

Operating Department is a document of about 170 pages, and it covers the operational

procedures necessary to NICTD’s activities. A “General Notice” on the second page of the

book states (in part)

Safety is of the first importance in the discharge of duty. In case of doubt,

adopt the safe course. Speed must always be sacrificed for safety.

Obedience to the rules is essential to safety and is required. [Emphasis

appears in original.]

While some NICTD employees stated that the organization could improve safety,

the Safety Board’s investigation did not reveal any instances of blatant disregard for safety

concerns. The fact that the various departments within NICTD convene safety meetings

during which unsafe conditions and practices are identified and addressed shows that

NICTD has developed a systematic means of publicizing and resolving workplace safety

issues. Furthermore, consistent with the views of many safety professionals, who contend

that management is responsible for the practices, customs, and attitudes that relate to safe

operations, NICTD managers have shown by their testimony and actions that they are

aware they must set the tone for safety by policy and example. In addition, NICTD has

provided its employees exhaustive written guidelines that stress the importance of safety

to the organization. Therefore, the Safety Board concludes that NICTD’s corporate culture

generally encourages safety awareness in rail operations. 
32 Railroad Special Investigation Report

Summary

In its special investigation, the Safety Board examined the safety aspects of

NICTD’s accident history and safety record, infrastructure and operating practices,

internal safety programs, and corporate safety culture. With respect to the particular issues

reviewed, the Safety Board’s investigation found that NICTD’s operating practices

generally adhere to accepted safety principles, NICTD has an established system of

internal safety programs, and NICTD’s corporate culture generally encourages safe

employee behavior. Nevertheless, the investigation indicated that NICTD has problems,

which NICTD recognizes and is attempting to address, regarding the serious issue of

grade-crossing safety. To enhance NICTD’s safety practices, the Safety Board urges

NICTD to adopt the recommendations made in this report regarding grade-crossing safety,

signal upgrading, SSPP implementation, emergency response drills, and the role of the

DST within the organization.

The Safety Board emphasizes that these selected factors do not represent the full

range of conditions that may affect an organization’s safety. The Board also notes that,

until the NICTD SSPP is fully implemented, significant elements will be absent from the

NICTD safety system. Therefore, the Safety Board concludes that, in addition to the

specific areas in which the Safety Board recommends that NICTD take action to improve

safety, other safety-enhancement opportunities may remain for NICTD to pursue. 

In particular, the Safety Board is anxious that NICTD take steps to ensure that the

implementation of its SSPP results in the production and maintenance of a NICTD safety

program that is comprehensive and as effective as possible. The Safety Board therefore

believes that NICTD should engage an independent safety auditing organization to

conduct a comprehensive safety audit of NICTD operations. 
33 Railroad Special Investigation Report

Conclusions

1. The Northern Indiana Commuter Transportation District does not appear to have

significant deficiencies in its track maintenance program. 

2. The Northern Indiana Commuter Transportation District has followed standard

engineering practice in contracting structural engineering expertise for evaluating,

inspecting, and load-rating its older bridges and has implemented measures to

maintain the structures for the safe passage of expected train traffic.

3. The Northern Indiana Commuter Transportation District appears to be effectively

implementing and administering its signal inspection program. 

4. The Northern Indiana Commuter Transportation District’s failure to complete the

elimination of AC line circuits and conversion to DC line circuits on its signal system

may have reduced the system’s safety. 

5. The lack of adequate signage and advance warning devices at some Northern Indiana

Commuter Transportation District passive grade crossings poses a risk to system

customers and motorists. 

6. Despite the Northern Indiana Commuter Transportation District near-miss program to

educate motorists who violate highway-rail grade crossings, significant numbers of

highway-rail grade-crossing violations continue on the Northern Indiana Commuter

Transportation District system.

7. Making grade-crossing signal lights more conspicuous would provide more effective

warning and additional stopping time for motorists approaching grade crossings. 

8. Until the Northern Indiana Commuter Transportation District System Safety Program

Plan, required by the Federal Railroad Administration in Emergency Order No. 20,

dated February 20, 1996, is fully implemented, some program-related safety benefits

may not be realized by the Northern Indiana Commuter Transportation District. 

9. The Northern Indiana Commuter Transportation District did not adequately prepare

and train its director of safety and training to fulfill the responsibilities of the position.

10. The efficiency of safety information communication would be enhanced and the

profile of safety would be heightened within the Northern Indiana Commuter

Transportation District organization if the director of safety and training reported

directly to the general manager.

11. Safety would be enhanced if greater efforts were made to prepare local response

agencies to deal with commuter train accidents in areas that are geographically

difficult to access.
Conclusions 34 Railroad Special Investigation Report

12. The Northern Indiana Commuter Transportation District’s corporate culture generally

encourages safety awareness in rail operations.

13. In addition to the specific areas in which the National Transportation Safety Board

recommends that the Northern Indiana Commuter Transportation District take action

to improve safety, other safety-enhancement opportunities may remain for the

Northern Indiana Commuter Transportation District to pursue. 
35 Railroad Special Investigation Report

Recommendations

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

makes the following safety recommendations:

to the Northern Indiana Commuter Transportation District:

Work with the U.S. Department of Transportation and the Indiana

Department of Transportation to develop and implement a strategic plan to

improve safety at Northern Indiana Commuter Transportation District

highway-rail grade crossings. (R-99-37)

Work with the Indiana Department of Transportation and Indiana’s Lake,

Porter, LaPorte, and St. Joseph Counties to install stop signs at all your

passive grade crossings, unless a traffic engineering analysis determines

that installation of stop signs would reduce the safety of the crossing. Any

Northern Indiana Commuter Transportation District crossings at which

conditions are such that the installation of stop signs would reduce the level

of safety should be upgraded with active warning devices or eliminated.

(R-99-38) 

Immediately and fully implement your System Safety Program Plan, as

required by the Federal Railroad Administration under Emergency Order

No. 20, dated February 20, 1996. (R-99-39)

Provide any individual holding the office of director of safety and training

with appropriate training, including instruction on the functions,

development, and implementation of System Safety Program Plans. 

(R-99-40)

Elevate the position of director of safety and training to the departmenthead level and require that the director of safety and training report directly

to the general manager. (R-99-41) 

Complete the conversion or elimination of signal control line circuits

within 2 years. (R-99-42)

Revise your near-miss program to provide closure with individuals

reporting violations. (R-99-43)

Develop training procedures and drills, in conjunction with local

emergency response agencies, that address conducting emergency

responses in all types of geographical conditions. (R-99-44)

Engage an independent safety auditing organization to conduct a

comprehensive safety audit of Northern Indiana Commuter Transportation

District operations. (R-99-45)
Recommendations 36 Railroad Special Investigation Report

to the Indiana Department of Transportation:

Work with the U.S. Department of Transportation and the Northern Indiana

Commuter Transportation District to develop and implement a strategic

plan to improve safety at Northern Indiana Commuter Transportation

District highway-rail grade crossings. (R-99-46)

Assist the Northern Indiana Commuter Transportation District in

upgrading all 8-inch crossing signal light units on its territory. (R-99-47)

Work with the Northern Indiana Commuter Transportation District and

Indiana’s Lake, Porter, LaPorte, and St. Joseph Counties to install stop

signs at all Northern Indiana Commuter Transportation District passive

grade crossings, unless a traffic engineering analysis determines that

installation of stop signs would reduce the safety of the crossing. Any

Northern Indiana Commuter Transportation District crossings at which

conditions are such that the installation of stop signs would reduce the level

of safety should be upgraded with active warning devices or eliminated.

(R-99-48) 

to the Lake County, Indiana, Board of Commissioners:

Work with the Northern Indiana Commuter Transportation District and the

Indiana Department of Transportation to install stop signs at all Northern

Indiana Commuter Transportation District passive grade crossings in your

county, unless a traffic engineering analysis determines that installation of

stop signs would reduce the safety of the crossing. Any Northern Indiana

Commuter Transportation District crossings at which conditions are such

that the installation of stop signs would reduce the level of safety should be

upgraded with active warning devices or eliminated. (R-99-49) 

to the Porter County, Indiana, Board of Commissioners:

Work with the Northern Indiana Commuter Transportation District and the

Indiana Department of Transportation to install stop signs at all Northern

Indiana Commuter Transportation District passive grade crossings in your

county, unless a traffic engineering analysis determines that installation of

stop signs would reduce the safety of the crossing. Any Northern Indiana

Commuter Transportation District crossings at which conditions are such

that the installation of stop signs would reduce the level of safety should be

upgraded with active warning devices or eliminated. (R-99-50) 

to the LaPorte County, Indiana, Board of Commissioners:

Work with the Northern Indiana Commuter Transportation District and the

Indiana Department of Transportation to install stop signs at all Northern

Indiana Commuter Transportation District passive grade crossings in your

county, unless a traffic engineering analysis determines that installation of

stop signs would reduce the safety of the crossing. Any Northern Indiana

Commuter Transportation District crossings at which conditions are such
Recommendations 37 Railroad Special Investigation Report

that the installation of stop signs would reduce the level of safety should be

upgraded with active warning devices or eliminated. (R-99-51) 

to the St. Joseph County, Indiana, Board of Commissioners:

Work with the Northern Indiana Commuter Transportation District and the

Indiana Department of Transportation to install stop signs at all Northern

Indiana Commuter Transportation District passive grade crossings in your

county, unless a traffic engineering analysis determines that installation of

stop signs would reduce the safety of the crossing. Any Northern Indiana

Commuter Transportation District crossings at which conditions are such

that the installation of stop signs would reduce the level of safety should be

upgraded with active warning devices or eliminated. (R-99-52) 

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

Adopted: August 10, 1999

39 Railroad Special Investigation Report

Appendix A

Letter from Senator Richard Lugar and 

Congressman Peter J. Visclosky
Appendix A 40 Railroad Special Investigation Report
41 Railroad Special Investigation Report

Appendix B

Data on Federal Railroad Administration 

Inspections of NICTD

(Note: The FRA database changed in 1995.)

Table 1. FRA inspections of NICTD

Table 2. FRA violations reported for NICTD

Year

Motive Power and 

Equipment Operations Signal Track TOTAL

1998 5 16 4 10 35

1997 6 90 6 16 118

1996 13 80 7 1 101

1995 13 5 8 9 35

1994 7 32 27 8 74

1993 10 46 10 14 80

Year

Motive Power and 

Equipment Operations Signal Track TOTAL

1998 0 0 000

1997 0 0 000

1996 1 0 023

1995 0 0 000

1994 0 0 000

1993 0 0 202
Appendix B 42 Railroad Special Investigation Report

Table 3. FRA defects found for NICTD

Year

Motive Power 

and Equipment Operations Signal Track TOTAL

1998 0 1 214

1997 1 3 509

1996 10 12 15 2 39

1995 49 3 18 18 88

1994 14 5 11 53 83

1993 17 22 100 29 168
43 Railroad Special Investigation Report

Acronyms and Abbreviations

ABS automatic block signal

APTA American Public Transit Association

CFR Code of Federal Regulations

Conrail Consolidated Rail Corporation

CSS Chicago SouthShore and South Bend Railroad

DST NICTD director of safety and training

FRA Federal Railroad Administration

FTA Federal Transit Administration

GM NICTD general manager

GXIR Highway-Rail Grade Crossing Accident/Incident 

Report

ICC Illinois Commerce Commission

INDOT Indiana Department of Transportation

LCV long combination vehicle

LED Light Emitting Diode

Metra Chicago Northeast Illinois Regional Commuter Rail 

Corporation

NICTD Northern Indiana Commuter Transportation District

OSHA Occupational Safety and Health Administration

PTS INDOT Public Transportation Section

RAIR Rail Equipment Accident/Incident Report

SACP Safety Assurance and Compliance Program

SSPP System Safety Program Plan