Collision Between Freight Train and Charter Motorcoach at

High-Profile Highway–Railroad Grade Crossing

Biloxi, Mississippi

March 7, 2017

Accident Report

NTSB/HAR-18/01 

PB2018-101328 National

Transportation 

Safety Board
NTSB/HAR-18/01

PB2018-101328

Notation 57568

Adopted August 7, 2018

Highway Accident Report

Collision Between Freight Train and Charter Motorcoach at

High-Profile Highway–Railroad Grade Crossing

Biloxi, Mississippi

March 7, 2017

National 

Transportation 

Safety Board

490 L’Enfant Plaza, S.W. 

Washington, D.C. 20594
National Transportation Safety Board. 2018. Collision Between Freight Train and Charter 

Motorcoach at High-Profile Highway–Railroad Grade Crossing, Biloxi, Mississippi, March 7, 

2017. Highway Accident Report NTSB/HAR-18/01. Washington, DC.

Abstract: On March 7, 2017, a 2016 Van Hool motorcoach, operated by ECHO Transportation 

and occupied by a driver and 49 passengers, was traveling northbound on Main Street in Biloxi, 

Mississippi. The motorcoach stopped in advance of a highway–railroad grade crossing on Main 

Street that had a high vertical profile. The crossing warning system was not in active mode when 

the motorcoach approached, stopped, and then moved onto the railroad tracks. As the driver 

attempted to drive over the crossing, the frame of the motorcoach came into contact with the 

pavement, and the vehicle became stuck on the crossing. An eastbound freight train operated by 

CSX Transportation was approaching the crossing. The grade crossing warning system activated 

when the train was about 29 seconds away. As soon as he became aware of the approaching train, 

the motorcoach driver opened the vehicle’s loading door and told the passengers to evacuate. The 

train engineer put the train into emergency about 502 feet west of the crossing. About 14 seconds 

later, the train struck the left side of the motorcoach, pushing it 259 feet down the tracks before 

coming to a stop, with the motorcoach still in contact with the lead locomotive. Four motorcoach 

passengers died, the driver and 37 passengers sustained injuries, and 8 passengers were uninjured. 

The investigation focused on the safety issues of high-profile grade crossings and emergency 

egress and extrication. As a result of this investigation, the National Transportation Safety Board 

(NTSB) makes new safety recommendations to the Federal Highway Administration, Federal 

Railroad Administration, Mississippi Department of Transportation, City of Biloxi, American 

Association of State Highway and Transportation Officials, American Railway Engineering and

Maintenance-of-Way Association, Association of American Railroads, American Short Line and 

Regional Railroad Association, and Class I railroads. The NTSB reiterates and reclassifies one 

recommendation to the Federal Motor Carrier Safety Administration.

The NTSB is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline 

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

investigation reports, safety recommendations, and statistical reviews.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, 

“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are 

not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment 

of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by 

investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits 

the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages 

resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

For more detailed background information on this report, visit the NTSB investigations website and search for NTSB 

accident ID HWY17MH010. Recent publications are available in their entirety on the Internet at the NTSB website. 

Other information about available publications may be obtained from the website or by contacting: National 

Transportation Safety Board, Records Management Division, CIO-40, 490 L’Enfant Plaza SW, Washington, 

DC 20594, (800) 877-6799 or (202) 314-6551.

Copies of NTSB publications may be downloaded at no cost from the National Technical Information Service, at the 

National Technical Reports Library search page, using product number PB2018-101328. For additional assistance, 

contact: National Technical Information Service, 5301 Shawnee Road, Alexandria, VA 22312, (800) 553-6847 or 

(703) 605-6000 (see NTIS website).
NTSB Highway Accident Report

ii

Contents

Figures and Tables....................................................................................................................... iv

Acronyms and Abbreviations.......................................................................................................v

Executive Summary..................................................................................................................... vi

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

1.1 Crash Narrative .........................................................................................................................1

1.2 Injuries ......................................................................................................................................3

1.3 Emergency Response, Evacuation, and Occupant Protection ..................................................6

1.3.1 Initial Response ..............................................................................................................6

1.3.2 Evacuation of Motorcoach Occupants............................................................................6

1.3.3 Occupant Protection........................................................................................................7

1.4 Motorcoach ...............................................................................................................................7

1.4.1 Damage ...........................................................................................................................8

1.4.2 Rear Door........................................................................................................................9

1.4.3 Mechanical Inspection and History ..............................................................................11

1.4.4 Data Recording Systems...............................................................................................12

1.5 Highway Factors and Railroad Grade Crossing......................................................................13

1.5.1 Traffic Characteristics ..................................................................................................13

1.5.2 Main Street Configuration ............................................................................................14

1.5.3 Main Street Grade Crossing Signage and Warning Systems........................................14

1.5.4 Main Street Grade Crossing Vertical Profile................................................................17

1.5.5 Main Street Grade Crossing Maintenance and Incident History..................................19

1.5.6 Other Grade Crossings in Biloxi...................................................................................21

1.5.7 Postcrash Actions..........................................................................................................22

1.5.8 National Grade Crossing Inventory..............................................................................24

1.6 Railroad Operations................................................................................................................25

1.6.1 Train Operation..............................................................................................................25

1.6.2 Rail Operation...............................................................................................................26

1.6.3 Train Crew....................................................................................................................27

1.6.4 Recorders......................................................................................................................28

1.7 Motor Carrier Operations........................................................................................................29

1.7.1 Carrier Training Program .............................................................................................29

1.7.2 State and Federal Oversight..........................................................................................30

1.7.3 Driver Grade Crossing Guidance..................................................................................30

1.8 Motorcoach Driver...................................................................................................................31

1.8.1 Licensing, Experience, and Driving History ................................................................31

1.8.2 Medical Certification, Health, and Toxicology ............................................................32

1.8.3 Precrash Activities........................................................................................................32

1.8.4 Route Selection.............................................................................................................33

1.8.5 Driver’s Actions at Crossing and Postcrash Sight Distance Observations....................34

1.9 Weather and Roadway Conditions..........................................................................................35
NTSB Highway Accident Report

iii

2 Analysis.....................................................................................................................................36

2.1 Introduction.............................................................................................................................36

2.2 Operator Actions.....................................................................................................................37

2.2.1 Motorcoach Driver........................................................................................................37

2.2.2 Train Crew....................................................................................................................38

2.3 High-Profile Grade Crossings.................................................................................................38

2.3.1 Signage and Reconstruction Guidelines.......................................................................38

2.3.2 Coordination of Maintenance and Risk Monitoring.....................................................42

2.4 Emergency Egress and Extrication .........................................................................................45

3 Conclusions...............................................................................................................................49

3.1 Findings...................................................................................................................................49

3.2 Probable Cause........................................................................................................................50

4 Recommendations....................................................................................................................51

4.1 New Recommendations..........................................................................................................51

4.2 Recommendation Reiterated and Reclassified in this Report.................................................53

Appendix A: Investigation ..........................................................................................................54

References.....................................................................................................................................55
NTSB Highway Accident Report

iv

Figures and Tables

Figure 1. Overhead view of crash location and forward view of northbound approach to Main 

Street grade crossing ...................................................................................................... 2

Figure 2. Motorcoach and train final rest positions....................................................................... 3

Figure 3. Motorcoach seating chart................................................................................................ 5

Figure 4. Motorcoach postcrash, showing contact damage to the left side ................................... 8

Figure 5. Motorcoach interior, showing the buckling of the floor and the lateral displacement 

of the seats...................................................................................................................... 9

Figure 6. Interior of the motorcoach, showing the three assemblies necessary to open the 

rear door ....................................................................................................................... 11

Figure 7. Diagram of Main Street, grade crossing, and Esters Boulevard north and south of 

the crossing................................................................................................................... 15

Figure 8. Photograph showing the northbound approach to the grade crossing and 

cross-section diagram of the measured vertical profile of the approach’s slope.......... 18

Figure 9. Photograph showing the southbound approach to the grade crossing and 

cross-section diagram of the measured vertical profile of the approach’s slope.......... 19

Figure 10. Postcrash view of the northbound approach to the Main Street crossing................... 23

Figure 11. Activities of the motorcoach driver, March 4–7, 2017............................................... 33

Figure 12. Three alternative routes proposed for the motorcoach to travel from Hollywood 

Casino in Bay St. Louis to Boomtown Casino in Biloxi ............................................ 34

Table 1. Injury levels for motorcoach occupants and train crew ................................................... 4

Table 2. Roadway signs on the northbound Main Street approach to the grade crossing ........... 16

Table 3. National summary of high-profile grade crossings and crash information.................... 25

Table 4. Sequence of events near Main Street grade crossing on March 7, 2017, concerning 

the train’s movement, the motorcoach’s grounding, and the crash ............................... 29
NTSB Highway Accident Report

v

Acronyms and Abbreviations

AAMVA American Association of Motor Vehicle Administrators

AASHTO American Association of State Highway and Transportation Officials

AREMA American Railway Engineering and Maintenance-of-Way Association

BASICs Behavior Analysis and Safety Improvement Categories

BFD Biloxi Fire Department

BPD Biloxi Police Department

CDL commercial driver’s license

CFR Code of Federal Regulations

CSXT CSX Transportation

DOT [state] department of transportation

FAA Federal Aviation Administration

FHWA Federal Highway Administration

FMCSA Federal Motor Carrier Safety Administration

FRA Federal Railroad Administration

GPS global positioning system

GVWR gross vehicle weight rating

IC incident commander

LGCGC low ground clearance grade crossing

MDOT Mississippi Department of Transportation

MUTCD Manual on Uniform Traffic Control Devices for Streets and Highways

NHTSA National Highway Traffic Safety Administration

NO&M New Orleans & Mobile (CSXT railroad subdivision)

NTSB National Transportation Safety Board

TRB Transportation Research Board

TxDPS Texas Department of Public Safety

US-90 US Route 90

USC United States Code

USDOT US Department of Transportation
NTSB Highway Accident Report

vi

Executive Summary

Investigation Synopsis

On Tuesday, March 7, 2017, about 2:11 p.m. central standard time, a 2016 Van Hool 

motorcoach, operated by ECHO Transportation and occupied by a 60-year-old driver and 

49 passengers, ranging in age from 50 to 88, was traveling northbound on Main Street in Biloxi, 

Mississippi, having departed that afternoon from a casino in Bay St. Louis, Mississippi, to travel 

to a casino in Biloxi. The motorcoach stopped in advance of a highway–railroad grade crossing on 

Main Street that had a high vertical profile. 

The grade crossing was marked with (1) a crossbuck, (2) warning lights that would activate 

at a train’s approach, (3) a gate arm that would lower at a train’s approach, and (4) a low ground 

clearance grade crossing warning sign with a “LOW GROUND CLEARANCE” plaque below it 

on the signpost. The crossing warning system was not in active mode when the motorcoach 

approached, stopped, and then moved onto the railroad tracks. As the driver attempted to drive 

over the crossing, the frame of the motorcoach came into contact with the pavement, and the 

vehicle became stuck on the crossing. The driver moved the motorcoach back and forth in an 

attempt to dislodge it from the crossing but was unsuccessful. 

As the motorcoach became stuck on the crossing, an eastbound freight train operated by 

CSX Transportation was approaching the crossing at a recorded speed of 27 mph while

continuously sounding its warning horn. The grade crossing warning system activated when the 

train was about 29 seconds away; first, the warning lights began to flash, and then the gate arm 

began to descend 3 seconds later. As soon as he became aware of the approaching train, the 

motorcoach driver opened the vehicle’s loading door and told the passengers to evacuate. Due to 

their age and limited mobility, the passengers’ evacuation was slow and the aisleway became 

congested; only six passengers had safely evacuated before the train struck the grounded 

motorcoach. 

The train engineer told investigators that he had noticed the motorcoach on the tracks

ahead, but he expected it to clear the crossing before the train reached it. Once the engineer realized

that the motorcoach might not clear the tracks, he put the train into emergency about 502 feet west 

of the crossing. About 14 seconds later, by which time the train had decelerated to about 19 mph, 

it struck the left side of the motorcoach, pushing it 259 feet down the tracks before coming to a 

stop, with the motorcoach still in contact with the lead locomotive. Four motorcoach passengers 

died, the driver and 37 passengers sustained injuries, and 8 passengers were uninjured. The train 

crewmembers were uninjured.

Probable Cause

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

Mississippi, crash was the failure of CSX Transportation and the City of Biloxi to coordinate and 

take action to improve the safety of the Main Street grade crossing, a high vertical profile crossing 

on which motor vehicles were known to ground frequently; their inaction led to the grounding of 

the motorcoach that was subsequently struck by the CSX Transportation freight train. Contributing 
NTSB Highway Accident Report

vii

to the circumstances of the crash was the inadequate guidance from the Federal Highway 

Administration on how to mitigate the risks posed by grade crossings with high vertical profiles.

Safety Issues

The crash investigation focused on the following safety issues: 

• High-profile grade crossings. No current guidelines for high-profile grade crossings 

(1) describe the conditions under which signage that selectively excludes certain 

vehicle types from using the crossing should be installed or (2) define when a crossing 

should be reconstructed (or otherwise have its safety risk mitigated) due to its unsafe 

vertical profile. Also, railroad companies are not required to coordinate their

maintenance plans with local and state highway transportation agencies, and crossing 

safety risk is not effectively monitored. The report explores approaches to improve 

grade crossing safety by addressing these deficiencies.

• Emergency egress and extrication. The motorcoach was equipped with a secondary 

door in the rear, which was not used for emergency egress or passenger extrication. 

Had the rear door been used, it most likely would have expedited the postcrash 

extrication of the passengers. The report discusses pretrip safety briefings that might 

be used to enhance passengers’ awareness of the secondary door as an emergency 

egress point and extrication route.

Recommendations

As a result of this investigation, the National Transportation Safety Board (NTSB) makes 

new safety recommendations to the Federal Highway Administration, Federal Railroad 

Administration, Mississippi Department of Transportation, City of Biloxi, American Association 

of State Highway and Transportation Officials, American Railway Engineering and 

Maintenance-of-Way Association, Association of American Railroads, American Short Line and 

Regional Railroad Association, and Class I railroads. The NTSB reiterates and reclassifies one 

recommendation to the Federal Motor Carrier Safety Administration.
NTSB Highway Accident Report

1

1 Factual Information

1.1 Crash Narrative

On Tuesday, March 7, 2017, about 2:11 p.m. central standard time, a 2016 Van Hool 

motorcoach, operated by ECHO Transportation and occupied by a 60-year-old driver and 

49 passengers, ranging in age from 50 to 88, was traveling northbound on Main Street in Biloxi, 

Mississippi.

1 The motorcoach’s trip was part of a charter tour for senior citizens organized by 

Diamond Tours. This segment of the tour was taking the passengers from Hollywood Casino in 

Bay St. Louis, Mississippi, to Boomtown Casino in Biloxi.2 The motorcoach stopped in advance 

of a highway‒railroad grade crossing that had a high vertical profile.

3

This active grade crossing was marked with (1) a crossbuck, (2) warning lights that would 

activate at a train’s approach, (3) a gate arm that would lower at a train’s approach, and (4) a low 

ground clearance grade crossing (LGCGC) warning sign with a “LOW GROUND CLEARANCE”

plaque below it on the signpost (see figure 1).

4 The crossing warning system was not in its active 

mode when the motorcoach approached the crossing, stopped, and then moved onto the railroad 

tracks. As the driver attempted to drive across the grade crossing, the vehicle’s frame came into

contact with the pavement north of the railroad tracks, and the motorcoach became grounded on 

the crossing.

5 The driver moved the motorcoach back and forth to try to dislodge it, but he was 

unsuccessful. 

 1 Unless otherwise indicated, all times cited in the report are central standard time.

2 The trip and the route selection are discussed in section 1.8.4.

3 Such grade crossings are known as “high-profile,” “hump,” or “humped” crossings.

4 According to the Federal Railroad Administration (FRA), an active grade crossing consists of active warning 

and control devices such as bells, flashing lights, and gate arms that lower and rise, in addition to passive warning 

devices such as crossbucks. 

5 In this report, “grounding” refers to a significant contact between a vehicle frame and the surface of a grade 

crossing such that it prevents vehicle movement. Other terms describing such contact are “stuck” and “lodged.”
NTSB Highway Accident Report 

2 

Figure 1. Overhead view of crash location (top) and forward view of northbound approach to Main 

Street grade crossing (bottom). 

While the motorcoach was stuck on the crossing, an eastbound freight train operated by 

CSX Transportation (CSXT)—comprising 3 locomotives, 27 loaded cars, and 25 empty cars—

was approaching the crossing at a recorded speed of 27 mph with its horn continuously sounding, 

its headlights on, and its auxiliary lights flashing.6 The grade crossing warning devices activated

when the train was about 29 seconds away; first, the crossing warning lights began flashing, and 

then the crossing gate arms began to descend 3 seconds later. As soon as he became aware of the 

approaching train, the motorcoach driver opened the loading door and told the passengers to 

evacuate. Because of the passengers’ age and limited mobility, the evacuation was slow and the 

aisleway became congested; only six passengers had safely evacuated before the train struck the 

grounded motorcoach. 

6 The train had left New Orleans, Louisiana, that morning, and its final destination was Waycross, Georgia.
NTSB Highway Accident Report 

3 

The train engineer later said that he had noticed the motorcoach on the tracks, but he 

expected it to clear the crossing before the train arrived there. As soon as the engineer realized that 

the motorcoach was not clearing the tracks, when the train was about 502 feet west of the crossing, 

he put the train into emergency braking. About 14 seconds later, by which time it had decelerated 

to about 19 mph, the train struck the left side of the motorcoach, pushing it 259 feet down the 

tracks before coming to a stop, with the motorcoach still in contact with the lead locomotive (see 

figure 2).7

Figure 2. Motorcoach and train final rest positions. (Source: Biloxi Police Department)

1.2 Injuries

As a result of this crash, 4 motorcoach passengers died, the driver and 21 passengers 

sustained serious injuries, 16 passengers received minor injuries, and 8 passengers were uninjured. 

The train engineer and the conductor were also uninjured. Table 1 summarizes the distribution of 

injury severity.

7 For additional information about the train’s movement and the engineer’s actions, see section 1.6. 
NTSB Highway Accident Report

4

Table 1. Injury levels for motorcoach occupants and train crew.

a

Fatal Serious Minor None TOTAL

Train crew -- -- -- 2 2

Motorcoach driver -- 1 -- -- 1

Motorcoach passengers 4 21 16 8 49

TOTAL 4 22 16 10 52

a Although 49 Code of Federal Regulations (CFR) Part 830 pertains to the reporting of aircraft accidents and 

incidents to the National Transportation Safety Board (NTSB), section 830.2 defines fatal injury as any injury 

that results in death within 30 days of the accident, and serious injury as any injury that (1) requires 

hospitalization for more than 48 hours, commencing within 7 days from the date of injury; (2) results in a 

fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, 

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

any burn affecting more than 5 percent of the body surface.

Video from an interior-facing camera on the motorcoach showed that three of the 

passengers who died were attempting to exit the motorcoach when the train struck it.

8 One of those 

passengers had just stepped down from the loading door, while the other two were in the loading 

area and were ejected at impact; all three passengers were subsequently struck by the motorcoach 

and the locomotive. The fourth passenger who died was standing in the rear of the motorcoach, in 

the aisleway by row 14. He died as a result of cervical vertebrae fractures sustained at impact. 

The 22 seriously injured motorcoach occupants sustained multiple blunt force injuries,

including fractures, head injuries, and internal organ lacerations. The 16 passengers with minor 

injuries generally sustained contusions and abrasions. Of the eight motorcoach passengers who 

were uninjured, six had evacuated before the crash. 

Based on interviews with the surviving passengers and video from the interior-facing 

onboard camera, at the time of impact, 42 passengers were on the motorcoach; 23 were standing 

and 19 were seated. One passenger had stepped off the motorcoach just before the train struck it.

As indicated in figure 3, the distribution of nonfatal injuries was similar among the seated and 

standing passengers, but their location within the motorcoach had a much greater effect on the 

extent of their injuries. The distribution of injury severity shows that most of the passengers—18 

of 21—who sustained serious injuries were located in the front half of the motorcoach (row 7 and 

forward). Of the 20 passengers who were in the rear half of the motorcoach, 1 died, 3 received 

serious injuries, 14 received minor injuries, and 2 were uninjured.

 8 The motorcoach was equipped with Lytx DriveCam, an event-based driver-monitoring video system. For more 

details, see section 1.4.4.
NTSB Highway Accident Report 

5 

Figure 3. Motorcoach seating chart, showing the injury classifications and positions of the 

motorcoach driver and 43 passengers who were on or just outside the vehicle at the time of 

impact. 
NTSB Highway Accident Report

6

1.3 Emergency Response, Evacuation, and Occupant Protection

1.3.1 Initial Response

The City of Biloxi emergency communication center received a 911 call about the crash at 

2:12 p.m.; the dispatcher immediately notified Biloxi Police Department (BPD) patrol units, the 

first of which arrived on the scene at 2:13 p.m. The first engine unit from the City of Biloxi Fire 

Department (BFD) was dispatched at 2:13 p.m.; this unit, which included the fire chief, arrived on

the scene at 2:17 p.m. The fire chief assumed the role of incident commander (IC) upon arrival 

and declared a mass casualty incident. The BFD dispatched to the scene a total of eight engine 

units, two truck companies, one rescue truck, and one medivac unit.

Keesler Air Force Base, located minutes from the crash location, sent two ambulances to 

the scene, as well as additional physicians to a local hospital to help with incoming trauma patients. 

American Medical Response and Acadian Ambulance Services, which are the contracted 

emergency service providers for the area surrounding the crash, dispatched eight ambulances.

American Medical Response transported 24 motorcoach occupants to area hospitals, and Acadian 

Ambulance Services transported 16 occupants. Although three medivac helicopters were 

dispatched to the scene, only one transported a passenger. The last motorcoach occupant was 

transported to a local hospital at 3:20 p.m. 

The City of Biloxi has an emergency management plan based on the national incident 

management system and incident command system. As part of the plan, the City of Biloxi conducts

annual disaster drills with neighboring jurisdictions, city agencies, and Keesler Air Force Base. 

The last drill before the crash was held on February 16, 2017.

1.3.2 Evacuation of Motorcoach Occupants

1.3.2.1 Preimpact. During postcrash interviews, several passengers reported having been alerted 

to the train’s approach by the sound of its horn and the activation of the warning bells and lights 

at the crossing, as well as by the sound of the crossing arm striking the side of the motorcoach.

9

Passengers reported that, moments after they informed the motorcoach driver of the approaching 

train, he opened the loading door and told everyone to evacuate. The driver said that he heard the 

crossing warning bells after he had opened the loading door to permit passenger evacuation. The 

driver could not recall how many passengers had exited the motorcoach before the train struck. 

After the crash, NTSB investigators measured the distance of the bottom step of the loading 

bay from the ground, using an exemplar motorcoach positioned as close as possible to the location 

of the crash motorcoach at the time of impact; the height from the ground was 22 inches.10 The

distance from the bottom step to the ground and the passengers’ limited mobility (due to age) 

slowed the evacuation; as a result, many passengers were queued in the aisleway when the crash 

occurred. Several passengers reported that, having been unable to exit due to the congested 

aisleway, they moved to the back of the motorcoach to avoid the immediate impact area; others 

 9 See section 1.6.4 for additional information about the activation times of the grade crossing warning system.

10 In the grounded position, the loading door of the crash-involved motorcoach would have been positioned 

several inches north of the same door on the exemplar motorcoach, which would have made the distance between the 

ground and the crash motorcoach’s bottom loading bay step several inches greater. (On a flat surface, the distance 

from the bottom step of the loading bay to the ground measured 12 inches.)
NTSB Highway Accident Report

7

elected to remain seated and braced for impact. A small group of passengers was standing near the 

rear door as the train approached; they later told investigators that they had been unaware of the 

door’s presence.

1.3.2.2 Postimpact. Several passengers reported that, when the motorcoach came to rest, the 

aisleway was blocked by fallen and injured passengers. First responders initially entered through 

the loading door and evacuated those passengers who were in the front of the motorcoach. Because 

multiple injured passengers were lying in the aisleway, blocking access to the rest of the 

motorcoach, first responders also entered through the rear windows to reach the injured passengers 

in the rear. First responders extricated these rear passengers or assisted them to exit through the 

windows; they helped some to climb down ladders placed against the side of the motorcoach. 

Several passengers had to be placed on backboards before they were evacuated and, due to the 

limited space available inside the motorcoach, their extrications were challenging. 

Although the motorcoach was equipped with a secondary door in the rear, first responders 

were unable to open it. Because of the prolonged extrication process, the IC ordered the removal 

of the rear door to speed passenger evacuation. Two passengers were ultimately extricated through 

the rear door opening. (Section 1.4.2 discusses the rear door in additional detail.)

1.3.3 Occupant Protection

The motorcoach driver seat and all its passenger seats were equipped with lap/shoulder 

belts.11 The driver and seven of the passengers reported having used the available lap/shoulder 

belts during a portion of the crash trip. Only two passengers reported having been belted at the 

time of the crash.12

The motorcoach driver had given a pretrip safety briefing to the primary group of

passengers on the first day of travel—March 5, 2017—when he collected them in Bastrop, Texas. 

The briefing included a description of the emergency exit windows and an explanation of the use 

of lap/shoulder belts. The driver did not mention the rear door. Most of the passengers were 

members of a senior center in Bastrop, but some—friends of senior center members—were from 

Sealy, Texas. After beginning the trip in Bastrop, the motorcoach stopped in Sealy to pick up these 

passengers. When collecting the Sealy passengers, the driver did not provide a second pretrip 

briefing. 

1.4 Motorcoach

The 56-passenger 2016 Van Hool CX 45 motorcoach was equipped with a Detroit Diesel 

DD13 500-horsepower engine and an Allison WTB500 automatic transmission. The motorcoach 

had a gross vehicle weight rating (GVWR) of 54,000 pounds, a wheelbase of 29.5 feet, and an 

overall length of 45.5 feet. It had 15 rows of passenger seats on the left (driver) side and 13 rows 

on the right side. 

 11 Although not a factor in this crash, several seat belt buckles were not functional. Van Hool is working to 

reengineer the buckle or to find a new seat belt supplier. 12 One of the two belted passengers was seated in the window seat on the right side in row 7 and sustained serious 

injuries; the other belted passenger was seated in the aisle seat on the right side in row 9 and received minor injuries.
NTSB Highway Accident Report 

8 

1.4.1 Damage

1.4.1.1 External. The motorcoach sustained significant contact damage on the left side, which 

began about 16.3 feet from the rear and extended forward about 9.3 feet (see figure 4). The 

maximum lateral displacement occurred about 22.7 feet from the rear, where the left sidewall 

intruded 27 inches. This maximum intrusion was in the region of rows 5 through 7. The luggage 

compartment door just forward of the rear axle was displaced and the compartment door to its left 

was folded toward the front of the motorcoach. The location of the impact damage on the left side 

indicated that the front of the motorcoach was about 20.4 feet past the north side of the rail tracks 

when the locomotive struck it. The front end sustained no crash damage. 

Figure 4. Motorcoach postcrash, showing contact damage to the left side.

On the motorcoach’s right side, the sidewall was bowed out in the area corresponding to 

the impact on the left side. The maximum lateral displacement occurred about 25.7 feet from the 

rear of the motorcoach, where the right sidewall bowed outward about 18 inches.

1.4.1.2 Interior. The driver seat was intact, and the steering wheel was undamaged. The front 

interior of the motorcoach, up to about row 4, was largely undamaged, and the aisleway in this 

area retained its original width of 17 inches. Extensive interior damage began at row 5 on the left 

side and extended to slightly beyond row 8 (see figure 5). The area of these four rows showed 

evidence of intrusion that reduced the overall interior width of the motorcoach, sidewall to 

sidewall, by 16 inches. The aisle in this area decreased in width from 17 inches to 8 inches. As a 

result of the impact, the motorcoach floor buckled, starting in the aisleway at row 4. The floor in 

front of the seats in row 5 on the right side had buckled and partially collapsed, creating an opening 

in the floor that extended into the row 6 seats on the right side. As a result of this floor collapse, 

the aisle seat in row 5 on the right side had dropped about 2 inches below the floor level, intruding 

into the luggage compartment. The upward buckling of the floor in row 5 raised the floor level at 

this location by about 12 inches. 
NTSB Highway Accident Report 

9 

Figure 5. Motorcoach interior, showing the buckling of the floor and the lateral displacement of 

the seats.

1.4.1.3 Windows. The motorcoach was equipped with seven windows on each side, four of which 

on each side were configured as emergency exit windows. Four windows on the left side were 

displaced, two were partially pushed out of their frames, and one was removed during the 

extrication process.13 The windshield, which consisted of two panes, had its left pane displaced; 

the right pane was intact. Two of the seven windows on the right side were missing from their 

frames; others were intact.14 The motorcoach was equipped with two roof hatches above the 

aisleway, located above the third and twelfth rows of seats, respectively; the hatches were intact 

and closed. 

1.4.2 Rear Door

The motorcoach was equipped with a secondary door in the rear, between the lavatory and 

the seatback of the last row of seats on the right side. The clearance between the lavatory wall and 

the back of the seatback was 17 inches. Using an exemplar motorcoach positioned as close as 

possible to the location of the crash motorcoach at the time of impact, NTSB investigators 

measured the distance from the motorcoach floor at the rear door to the ground as 4 feet 8 inches.

Van Hool originally designed the rear door on this model motorcoach for two potential 

uses: (1) operation/access for wheelchairs (per the Americans with Disabilities Act) or 

(2) secondary egress (this use is only possible when the wheelchair restraints are not prohibiting 

access to the rear door). Although the rear door can be used for either purpose, the purchasing 

motor carrier determines its configuration. 

13 Two of the displaced windows were emergency exit windows, and both of the windows that were partially 

pushed out of their frames were emergency exit windows.

14 One of the displaced windows was an emergency exit window.
NTSB Highway Accident Report

10

The rear door on the crash motorcoach was not configured for wheelchair access, and 

ECHO Transportation did not use it as a wheelchair access point. ECHO Transportation told 

investigators that it did not intend the door to be used for emergency access, because this was not 

required by US regulations. The door’s design, however, made it a possible secondary egress point. 

Secondary exit doors for motorcoaches are permitted but not required under the Federal 

Motor Vehicle Safety Standards. According to the standards, buses with GVWRs greater than 

10,000 pounds are required to provide side emergency exit windows and to have optional 

configurations for other emergency exits in their midportion or rear.15 The standards permit

motorcoaches with a rear engine to have at least one emergency roof exit hatch instead of a rear 

exit door. The crash motorcoach, with its two roof hatches, met the requirements for emergency 

egress without the rear door.

In the European Union, a bus such as the crash motorcoach would be required to have at 

least two service doors, or one service door and one emergency exit door.16 Van Hool 

motorcoaches with the same configuration of windows and doors as the crash motorcoach are sold 

in Europe and are considered to meet European Union requirements.

On the crash motorcoach, placards above, on the wall next to, and on the rear door indicated 

how to unlock the rear door. The wording on the placards is provided below in italics:

Above the door: EMERGENCY DOOR RELEASE [turning this valve dumps the air 

that holds the door pistons in place]

On the wall beside the door: DOOR HANDLE FOR EMERGENCY USE ONLY

[once removed from this fixture, the door handle can be inserted into the handle 

placement fixture below to open the rear door]

On the door just below the window: REMOVE HANDLE WHEN DOOR IS 

SECURED [putting the door handle onto the fixture at this location allows the 

handle to turn and open the rear door]

Turning the valve to release the emergency door, obtaining the door handle, and putting 

the handle into the release fixture (and turning it) opens the rear door. No driver action is required 

to open the rear door from the inside, but it can be opened only when the motorcoach speed is 

below 5 mph. Figure 6 shows the rear door and the elements required for its release. 

 15 The crash motorcoach met the criteria for a commercial vehicle, per 49 CFR 390.5, and for a bus with a 

designed seating capacity greater than 10 persons, per 49 CFR 571.3.

16 Section 7.6 of Economic Commission for Europe Regulation 107 defines various acceptable exit

configurations, based on vehicle type and passenger capacity.
NTSB Highway Accident Report 

11 

Figure 6. Interior of the motorcoach, showing the three assemblies necessary to open the rear 

door.

According to a passerby who entered the motorcoach after the crash but before the arrival 

of emergency responders, he attempted to open the rear door from inside the vehicle. He reported 

taking the handle that he saw mounted on the wall of the lavatory and placing it on the door in an 

attempt to open it, but he was unsuccessful.17 

If the rear door is locked, it cannot be opened from outside the motorcoach. When the first 

responders attempted to open the rear door from the outside, they found it locked. Once inside the 

motorcoach, they were unable to locate the emergency door handle and could not open the door.

18

1.4.3 Mechanical Inspection and History

NTSB investigators performed functional checks of the motorcoach’s steering, electrical, 

suspension, and braking systems, and they examined its tires and wheels. They found no damage 

to any steering or electrical system components. The suspension system included (1) a “kneeling 

system” that allows a driver to lower the vehicle’s front end to facilitate loading/unloading of 

passengers, and (2) a rear-lift system that enables a driver to increase the height of the rear 

suspension air springs, elevating the rear of the motorcoach by 4 inches. At the time of the crash, 

the kneeling system was not engaged, but the rear-lift system was engaged.

19 Investigators found 

no evidence of damage or defects affecting the suspension system. The motorcoach was equipped 

with pneumatic antilock brakes on all axles. Examination of the brake components, including the 

linings, showed that they were within specifications. The tread depths on the tires were sufficient 

to meet minimum requirements, and no noncollision defects were found on any tires or wheels.20

17 The attempt to open the rear door was most likely unsuccessful because the passerby did not release the 

emergency door valve. 18 First responders later found the handle in debris. 19 Investigators examined whether raising the rear of the motorcoach affected the height of the front of the vehicle 

but found it unchanged.

20 Title 49 CFR 393.75(b) provides requirements for the minimum tread depths for tires on various axles.
NTSB Highway Accident Report

12

The motorcoach had passed its most recent annual inspection on April 7, 2016. The service 

records indicated regular maintenance and repair. The motorcoach was not subject to any safety 

recalls. 

1.4.4 Data Recording Systems

1.4.4.1 Global Positioning System. The motorcoach driver used his personal global positioning 

system (GPS) device—a Garmin DEZL 570MT—for navigation; the device was found in the 

motorcoach postcrash. Although the GPS device was damaged, its data were retrievable. Data from 

the GPS showed that the motorcoach reached the stop line of the Main Street grade crossing at 

2:11:08 p.m. This time corresponds to about 35 seconds before the crash, based on the clock from 

the locomotive’s forward-facing camera (see section 1.6.4 for more details on train recorders).21

The GPS recorded three coordinate points at this location—12 and 31 seconds apart—showing the 

motorcoach arriving at the stop line, being on the tracks, and being about 20 feet north of the 

tracks.

22

The Garmin DEZL 570MT is designed to aid in the navigation of commercial vehicles,

such as a motorcoach. A driver can input the dimensions of a vehicle, which allows the system to 

navigate it away from routes with conflicting limitations, such as height restrictions.23 Although 

the device can display warning signs that are present in the environment, the system does not avoid 

routing vehicles over high-profile grade crossings, unless prohibitory signs are present.

24

Using the same model Garmin GPS, NTSB investigators inputted the dimensions of the 

crash motorcoach and tested the device’s navigation by monitoring and documenting the suggested 

directions while driving from Hollywood Casino in Bay St. Louis to Boomtown Casino in Biloxi.

After reaching US Route 90 (US-90), the GPS device suggested a route that included traversing 

the Main Street grade crossing.25 When approaching the crossing, the device sounded an auditory 

alert and its screen depicted the railroad tracks and showed an LGCGC warning in the upper right 

corner. When the warning was tapped, the device screen displayed a banner across its top that read

“Risk of Grounding.”

NTSB investigators contacted HERE Technologies, which provides Garmin with 

geospatial mapping data. HERE stated that the Main Street grade crossing has been present in its 

database since at least August 2013, when the information about the LGCGC warning sign at this 

 21 Although the GPS clock was not synchronized with the clocks from the locomotive recorders and the recorded 

location represented a midpoint of the accuracy diameter, NTSB investigators determined that the time of the 

motorcoach’s approach to the railroad tracks about 35 seconds before the crash was reasonably consistent with data 

from the train recorders. 22 According to Garmin, its GPS devices are accurate within 10 meters, and possibly within an even narrower 

range, depending on the number of satellites the device is tracking. If the calculated GPS location is outside the 

roadway, the reported location typically corrects the vehicle position to the nearest roadway location.

23 The driver reported that he selected the commercial vehicle operation mode and inputted the motorcoach’s 

dimensions into the GPS device. The device was damaged in the crash, which kept investigators from verifying the 

mode of operation at the time of the crash.

24 The capability of the GPS to display warning signs that are present in the environment or to restrict navigation 

over certain grade crossings depends on whether the device is accessing the latest data, such as information that a 

specific grade crossing has a sign prohibiting transit by certain vehicles. 25 Although the Garmin unit that the NTSB investigators tested was the same model GPS device as the one used 

by the motorcoach driver, it was running a newer software version. NTSB investigators were unable to roll back the 

older version of the software onto the test device or to find an identical unit still using the older software.
NTSB Highway Accident Report

13

location was added. In January 2015, HERE added information about this grade crossing’s 

protected status—the presence of the crossing gates.26

1.4.4.2 Engine Control Module. The motorcoach engine was controlled by a Detroit Diesel 

Electronic Control IV system, which can store vehicle parameters and record trip activity, 

including diagnostic information associated with engine or sensor faults. The module can also store 

last stop events, which are recorded when the vehicle stops and idles for at least 2 minutes or when 

it stops and the engine powers off. The extracted data from the control module showed that the 

motorcoach stopped at 2:11:55 p.m., which corresponds to the approximate time the motorcoach 

came to its final rest. 

1.4.4.3 Lytx DriveCam. The motorcoach was also equipped with Lytx DriveCam, a monitoring 

and recording device that continually tracks driving performance metrics and records pertinent 

information when triggered by critical events, such as stability control or hard braking.27 The 

DriveCam was mounted near the midpoint on the left edge of the right windshield pane (near the 

center of the full windshield); the device included a two-channel image recorder for recording 

video from forward- and interior-facing cameras. The extracted data showed that the DriveCam 

system captured crash-relevant information, including 8 seconds of video data from both cameras.

The video from the motorcoach’s interior-facing camera shows 8 seconds of preimpact and 

4 seconds of postimpact events. The beginning of the video shows the open loading door, and four 

passengers evacuate through the door before the train strikes the motorcoach. Based on postcrash

interviews with motorcoach occupants and autopsy records, three of those passengers evacuated 

to a safe distance, and one died. The video also shows two passengers attempting to evacuate from 

the loading door area and their being ejected through the door at impact; both of these passengers 

died. This video does not show the other three passengers who safely evacuated before the start of 

the recording.

1.5 Highway Factors and Railroad Grade Crossing

1.5.1 Traffic Characteristics

1.5.1.1 Highway. The Gulf Regional Planning Commission collects traffic volume information 

for the Main Street crossing about every 3 years; the last collection was completed in 2016. At the 

request of NTSB investigators, the City of Biloxi conducted a traffic count for the Main Street 

grade crossing on July 15, 2017. The traffic count indicated daily traffic of 2,117 vehicles, 

99 percent of which were cars and similar noncommercial vehicles.28 The speed limit on this 

section of Main Street was 25 mph.

 26 Following the crash, the City of Biloxi installed a sign at the Main Street grade crossing prohibiting certain 

vehicle types from using that crossing (see section 1.5.7). Once information about the prohibitory sign is in the HERE 

database, an up-to-date commercial navigation device would not suggest a route using the Main Street grade crossing 

for the prohibited vehicle types.

27 The threshold for triggering a stability control event is lateral movement of at least 0.4 g (force of gravity); for 

a hard-braking event, the trigger is a 9-mph deceleration in 1 second.

28 This count was conducted after the City of Biloxi took the postcrash action of placing selective exclusion signs 

prohibiting certain vehicle types from transiting the crossing (see section 1.5.7).
NTSB Highway Accident Report

14

1.5.1.2 Railroad. The average daily train volume at the Main Street grade crossing was 12.5 trains

in 2016; it was 11.5 trains in 2017. The speed limit on this section of the railroad tracks, as 

established by CSXT, was 45 mph. 

1.5.2 Main Street Configuration

Main Street is a north–south road that crosses the tracks at railroad milepost 726.6. The 

grade crossing is bordered to the north and south by Esters Boulevard, two streets of the same 

name that run parallel to the tracks on both sides. (This report refers to the parallel streets as Esters 

Boulevard N and Esters Boulevard S, to indicate their positions relative to the tracks.) 

1.5.2.1 South of Esters Boulevard S. South of Esters Boulevard S, each direction of travel on

Main Street consists of a single 11-foot-wide travel lane, a single 5-foot-wide bicycle lane, and an 

8-foot-wide parking lane. The two directions of travel are separated by two 4-inch-wide solid 

yellow pavement stripes; the bicycle lanes in both directions are separated from both the travel 

lane and the parking lane by 4-inch-wide solid white stripes. 

1.5.2.2 Between Esters Boulevard S and N. Between Esters Boulevard south and north of the 

tracks, Main Street consists of a 12-foot-wide northbound and a 16-foot-wide southbound lane of 

travel. The two lanes are delineated by two 4-inch-wide solid yellow pavement stripes.

29

1.5.3 Main Street Grade Crossing Signage and Warning Systems

The northbound approach to the Main Street grade crossing includes multiple signs and 

warning systems notifying roadway users of the upcoming grade crossing. The warning features

include pavement markings, warning signs, and an active grade crossing warning system.

1.5.3.1 Pavement Markings. The northbound approach to the Main Street grade crossing is 

marked with a grade crossing pavement symbol, about 155 feet south of the railroad tracks (see 

figure 7). The southbound approach (north of the tracks) is not marked with a grade crossing 

pavement symbol. Both the northbound and southbound approaches to the crossing have worn, but 

visible, 2-foot-wide white stop lines. The line is located about 22.5 and 23 feet, respectively, from 

the nearest rail track on the northbound and southbound approaches.

 29 The solid yellow markings are faded and partially covered by recently applied asphalt.
NTSB Highway Accident Report 

15 

Figure 7. Diagram of Main Street, grade crossing, and Esters Boulevard north and south of the 

crossing.

1.5.3.2 Signage. Warning and advisory signs are present on both the northbound and southbound 

approaches to the crossing. Along the northbound approach, at the time of the crash, multiple signs 

notified road users of the upcoming grade crossing (see table 2). They included the following:

(1) grade crossing advance warning sign, located 382 feet from the tracks; (2) LGCGC warning

sign, located 25 feet from the tracks; (3) “LOW GROUND CLEARANCE” plaque, located just 

below the LGCGC warning sign on the same signpost; (4) “CONSTRUCTION AHEAD” 

temporary traffic control sign, located 24 feet from the tracks; (5) 15-mph advisory speed limit

plaque, located just below the “CONSTRUCTION AHEAD” sign on the same signpost; and 

(6) grade crossing crossbuck, located 13 feet from the tracks.30 The southbound approach to the 

crossing contained the same crossing-specific signs.

31 

30 The “CONSTRUCTION AHEAD” sign indicated road work that started at Esters Boulevard N. At the time of 

the crash, there was no construction, and all lanes were open to traffic. 

31 The southbound approach to the grade crossing had the same signage as the northbound approach, except for 

the “CONSTRUCTION AHEAD” sign and advisory speed limit plaque. The southbound approach also had a “No 

Turnaround” plaque below an additional LGCGC warning sign, located about 1,500 feet north of the grade crossing.
NTSB Highway Accident Report 

16 

Table 2. Roadway signs on the northbound Main Street approach to the grade crossing.

Name Design Dimensions Distance to 

Crossing

Grade crossing advance 

warning 36-inch diameter 382 feet

LGCGC warning 30-inch x 

30-inch

25 feet

“LOW GROUND CLEARANCE”

plaque

24-inch x 

18-inch

25 feet

“CONSTRUCTION AHEAD” 

temporary traffic control 

warning 

36-inch x 

36-inch

24 feet

15-mph advisory speed limit 

plaque 

18-inch x 

18-inch

24 feet

Grade crossing crossbuck 36-inch x 

36-inch

13 feet

Esters Boulevard south and north of the grade crossing also had warning signs alerting 

drivers to the upcoming Main Street grade crossing. Parallel grade crossing and intersection 

advance warning signs were located at distances 105–170 feet from the grade crossing. 

1.5.3.3 Grade Crossing Warning System. The southbound and northbound approaches to the 

Main Street crossing each have a flashing light signal and an automatic gate assembly. The flashing 

light signals are mounted on a mast and consist of two sets of 12-inch-diameter red LED lights 

mounted back-to-back, such that they are visible to traffic on Main Street approaching the crossing 

from both directions. Two additional sets of 12-inch-diameter red LED lights are mounted 

back-to-back on the mast, such that they are visible to traffic on Esters Boulevard approaching 

Main Street from either direction. 

The automatic gate consists of a drive mechanism, three red lights, and a gate arm marked 

with reflective red and white tape. In the down position, the gate arm extends across the 
NTSB Highway Accident Report

17

approaching traffic lane; the light nearest the arm’s tip is continuously illuminated and the other 

two lights flash alternately, in unison with the mast-mounted flashing light signal. The flashing 

light signal and the gate assemblies are located about 13 feet and 13.5 feet from the nearest rail for 

the northbound and southbound approaches, respectively. An emergency notification sign, 

providing information about the grade crossing location and the phone number for reporting 

emergencies to CSXT dispatch, is also on each side of the track.

1.5.4 Main Street Grade Crossing Vertical Profile

NTSB investigators measured the vertical grade of the Main Street grade crossing in the 

northbound direction of travel. South of the railroad tracks, the average slope is +4.2 percent 

(uphill) with an approximate maximum slope of 7.5 percent, measured about 5.7 feet south of the 

tracks. North of the railroad tracks, the average slope is -13.3 percent (downhill) with an 

approximate maximum slope of -24.4 percent, measured about 10.6 feet north of the tracks.32

NTSB investigators also measured the average vertical grades of travel at 30 feet from the 

nearest rail. At 30 feet from the nearest rail, the road surface is 14.4 inches and 45.4 inches below 

the track level, south and north of the tracks, respectively. These levels correspond to vertical 

grades of 4.2 percent south and -13.3 percent north of the tracks.

The American Association of State Highway and Transportation Officials (AASHTO) and 

the Federal Highway Administration (FHWA) have each developed guidance for grade crossing 

design, including the maximum recommended vertical profile; the guidance is published in 

AASHTO’s A Policy on Geometric Design of Highways and Streets and the FHWA’s 

Railroad-Highway Grade Crossing Handbook (AASHTO 2011 and FHWA 2007). Both sources 

recommend that the crossing surface be level with the top of the rails for at least 2 feet beyond the 

rails.33 Additionally, both recommend that the road surface be no more than 3 inches higher or 

lower than the track level at 30 feet from the nearest rail (see figures 8 and 9). Following this 

guidance would result in a maximum grade of 0.89 percent. The American Railway Engineering 

and Maintenance-of-Way Association (AREMA), a railway industry group, also provides 

guidance on the vertical profiles of grade crossings (AREMA 2011). The AREMA guidance 

matches the AASHTO and FHWA recommendations. Although the Mississippi Department of 

Transportation (MDOT) provides its own guidance on the design of grade crossingsin its Roadway 

Design Manual (MDOT 2001), since 2010, MDOT has relied on the FHWA guidance for approval 

of grade crossing projects.34

 32 Because the grade crossing’s approach and departure slopes are vertical curves, the grade measurements 

constantly change over the length of the crossing. The reported average grade measurements were calculated from the 

difference in vertical total station (a surveying instrument) survey measurements taken at distances of 2 feet and 

30 feet from the nearest rail. The maximum reported slope value for each approach was obtained from the steepest 

total-station survey data segment along the measured profile line. Data points along the profile line were collected at 

intervals of about 1 foot; reported measurements should therefore be considered approximate values. 

33 For the Main Street crossing, at 2 feet south of the railroad tracks, the road surface was 0.1 inch below the track 

level. At 2 feet north of the tracks, the road surface was 0.5 inch below the track level.

34 At the time of the collision, the MDOT manual recommended that, at 10 feet from the nearest rail, a crossing 

surface should be no more than 6 inches below the track level or 3 inches above the track level. An MDOT rail 

engineer told NTSB investigatorsthat the office has relied on FHWA/AASHTO guidance since 2010, when he became 

an MDOT rail engineer. As of July 2018, MDOT was in the process of updating its grade crossing guidance to match 

the guidance of the FHWA and AASHTO.
NTSB Highway Accident Report 

18 

Figure 8. Photograph showing the northbound approach to the grade crossing (top)—what the 

driver would have seen—and cross-section diagram of the measured vertical profile of the 

approach’s slope (bottom). The blue line in the diagram represents the maximum elevation 

difference between the crossing and the approach as recommended by the FHWA and AASHTO, 

and the gray line represents the actual elevation difference at the grade crossing. 
NTSB Highway Accident Report 

19 

Figure 9. Photograph showing the southbound approach to the grade crossing (top) and 

cross-section diagram of the measured vertical profile of the approach’s slope (bottom). The blue 

line in the diagram represents the maximum elevation difference between the crossing and the 

approach as recommended by the FHWA and AASHTO, and the gray line represents the actual 

elevation difference at the grade crossing. 

1.5.5 Main Street Grade Crossing Maintenance and Incident History

1.5.5.1 Maintenance History. Although the exact date of the initial construction of the Main 

Street grade crossing is unavailable, City of Biloxi records indicate that the crossing has existed 

since at least 1870. It was most recently reconstructed in 1977. The reconstruction plans specified 

a 12.3-percent downgrade slope north of the tracks. At the time of this reconstruction, the 

American Railroad Engineering Association offered the only source of guidance on grade crossing

design.

35

35 In 1997, the American Railroad Engineering Association combined with two other engineering associations to 

form AREMA. 
NTSB Highway Accident Report

20

Since the 1977 reconstruction, railroad maintenance has been performed in the area of the 

grade crossing. In February 2014, CSXT replaced wooden railroad ties along the section of track 

that included the Main Street crossing. Tie replacement typically results in raising the track by 

about 1.5 inches.

36 MDOT was not informed of this planned maintenance or of the resulting 

increase in track elevation.

37 It would have been standard practice for CSXT to inform the City of 

Biloxi of the 2014 track maintenance, because it would have affected the grade crossing’s

availability for use by highway traffic. However, investigators found no evidence indicating that 

CSXT informed the city about the nature of the maintenance, specifically, that it would affect the 

crossing’s vertical profile.38

The City of Biloxi was unable to provide records of Main Street grade crossing 

maintenance before 2008 because any records of work done before that date were lost in a 2008 

flood. CSXT told NTSB investigators that it did not have any Main Street grade crossing 

maintenance records before January 2012, when it replaced the steel tracks; this track replacement 

maintenance would not have affected the track elevation. 

The most recent precrash maintenance on Main Street in the vicinity of the grade crossing 

occurred in March 2016. This work included milling the pavement of Esters Boulevard north of 

the rail tracks and the adjacent segment of Main Street, as well as applying a temporary surface on 

the same sections of the roadway; the closest milling to the rail tracks was about 25 feet away.

According to the road repair plans, the resurfacing was not expected to affect the elevation of the 

roadway surface. NTSB investigators examined the milled and resurfaced section of the road and 

determined that the transition between the existing asphalt surface and the milled asphalt was 

smooth; there was no noticeable drop-off between the two road areas.

1.5.5.2 Maintenance Responsibilities. NTSB investigators discussed the responsibilities for 

grade crossing maintenance with CSXT representatives, as well as with City of Biloxi officials. 

The CSXT personnel stated that they believed the City of Biloxi was responsible for maintaining 

the approach to the Main Street grade crossing. Although the City of Biloxi has responsibility for 

maintenance of local roads, including Main Street, city representatives stated that they believed 

that only CSXT could conduct maintenance in the immediate vicinity of the tracks and that the 

city had to seek approval from the railroad before performing any type of work in that area.

Mississippi statutory authority grants MDOT a certain level of authority over public 

roadway/railroad crossings, including the following power:

After having made proper investigation, and after notice and hearing, if requested, 

to abolish any public roadway/railroad crossing heretofore or hereafter established, 

to vacate and close that part of the roadway on such crossing abolished, and to erect 

 36 A CSXT engineer described to NTSB highway investigators the process of replacing wooden ties. He stated 

that tracks are initially elevated by about 2 inches, but that settlement and compaction reduce the elevation by about 

0.5 inch. NTSB railroad investigators confirmed the accuracy of this statement.

37 NTSB investigators obtained this information during a conversation with an MDOT rail engineer.

38 The City of Biloxi reported that, as part of the maintenance conducted in February 2014, CSXT lowered the 

gates at the Main Street grade crossing and other crossings affected by the maintenance. The city publicized the grade 

crossing closure on its traffic notifications website.
NTSB Highway Accident Report

21

barricades across the roadway in such a manner as to prevent the use of such 

crossing as a roadway (Miss. Code. Ann. § 65-1-175 [2013]).

Additionally, MDOT can require the installation of warning and flashing signs at grade crossings 

and prescribe a portion of the cost of the installation and maintenance of such signage to railroad 

carriers and local highway authorities. Further, MDOT’s approval is required for the construction 

of new, or reconstruction of existing, grade crossings.

1.5.5.3 Crashes and Incidents. According to the grade crossing accident reports provided by the 

FRA, 18 collisions involving train impacts took place on the Main Street grade crossing between 

November 1976 and March 2017. Eleven of those collisions involved a train striking a car (or 

similar noncommercial vehicle), six involved a train striking a commercial vehicle, and one

involved a train striking a pedestrian. In addition to the subject (motorcoach) crash, two collisions 

in this period had fatal outcomes; both involved a car (or similar noncommercial vehicle). Since 

the February 2014 track maintenance that raised the track elevation, two more crashes, in addition 

to the subject crash, involved a vehicle—a commercial vehicle in both cases—that was stalled or 

grounded on the Main Street crossing.39 The last crash before this maintenance occurred in 2003.

NTSB investigators examined the CSXT incident tickets, the documented instances of 

vehicle groundings on the Main Street grade crossing, and the records from various City of Biloxi 

departments concerning the crossing. These records showed numerous incidents involving a 

vehicle becoming grounded on the crossing. In addition to the 3 vehicle groundings that resulted 

in a crash, in the 5-year period before the subject crash, 24 other incidents occurred in which a 

vehicle was reported as grounded on the crossing; 20 of these incidents involved a truck-tractor 

combination vehicle.

40 In each of the 24 cases, either the vehicle was dislodged before a train 

approached the crossing or the CSXT train crew was notified early enough to safely decelerate and 

stop the train before reaching the crossing.

Twenty-four of the 27 grounding incidents (including the one resulting in the subject crash)

that took place at the crossing in the 5-year period occurred after February 2014, when the last 

CSXT track maintenance raised the elevation of the railroad tracks. In most of these 27 grounding 

incidents, both the BPD and CSXT were notified.41 CSXT had records for 25 of these incidents;

the City of Biloxi had records for 22.

1.5.6 Other Grade Crossings in Biloxi

Biloxi contains about 8.6 miles of railroad track, and 29 grade crossings are within the city 

limits. Twenty-two of the crossings are in southeastern Biloxi, along 2.6 miles of railroad track.

NTSB investigators measured the slopes of all 29 grade crossings in Biloxi and found that all have

 39 One of the crashes occurred on August 28, 2014; it involved a truck-tractor combination vehicle and resulted 

in injury to one railroad employee. The second crash occurred on January 5, 2017; it involved a single-unit truck and 

resulted in injury to two railroad employees.

40 The other four incidents involved a motorcoach, a truck with an attached horse trailer, an unspecified truck, 

and an unspecified vehicle. 41 The City of Biloxi Engineering Department had records for only a few of the incidents that the BPD recorded.
NTSB Highway Accident Report

22

a vertical slope (on either the northbound or the southbound approach) greater than the maximum 

recommended by the FHWA/AASHTO for new and reconstructed grade crossings.

42

According to FRA grade crossing accident reports, 190 collisions occurred on grade 

crossings in Biloxi between June 1975 and March 2017; of these, 172 occurred on crossings other 

than the Main Street crossing.

43 NTSB investigators also examined CSXT incident tickets that

recorded vehicle groundings on a grade crossing that did not result in a collision with a train. 

Between March 2012 and the March 7, 2017, crash date, 15 incidents of vehicle grounding took 

place on grade crossings in Biloxi other than the Main Street crossing.

When the March 7, 2017, crash occurred, both the BFD and the Biloxi Public School 

District had restrictions on their vehicles’ use of certain grade crossings in the city. One particular 

BFD vehicle was allowed to use only 3 of the 29 grade crossings in Biloxi; it was prohibited from 

using the Main Street grade crossing. Additionally, the district’sschool buses were prohibited from 

using two of the other grade crossings in Biloxi.44

1.5.7 Postcrash Actions

On March 10, 2017, the City of Biloxi placed three selective exclusion signs bearing the 

No Trucks icon, in combination with “NO BUSES TRUCKS RVs” plaques, near the Main Street 

crossing. Two of the exclusion signs were placed on northbound Main Street, 234 feet and 25 feet

from the rail tracks, respectively. The third exclusion sign was placed on southbound Main Street, 

104 feet from the tracks. (See figure 10 for a view of the new No Trucks icon sign and exclusion 

plaque located nearest the tracks on the northbound approach to the crossing.) Also, on March 13, 

the city installed two more LGCGC warning signs, accompanied by “LOW GROUND 

CLEARANCE” plaques, at the crossing. One was put on the southwest corner of the crossing,

25 feet from the tracks and facing northbound traffic; the other sign was put on the northeast 

corner, 12 feet from the tracks and facing southbound traffic.

 42 (a) The measurements were conducted in the same manner as the measurement for the Main Street grade 

crossing, as described earlier in this report. (b) MDOT also measured the slopes of these grade crossings at 30 feet 

from the nearest rail and found them to be outside the FHWA/AASHTO-recommended guidance. Due to differences 

in the accuracy of the surveying equipment (NTSB investigators used an advanced system), there are slight differences 

in the recorded slope measurements between MDOT and NTSB calculations.

43 Five collisions occurred while a vehicle was grounded on a grade crossing. 44 (a) According to a BFD directive from 1999, the department’s aerial apparatus vehicle, Aerial-1, was allowed 

to use only the Oak Street, Caillavet Street, and Reynoir Street grade crossings. (b) Biloxi Public School District 

school buses were prohibited from using the Querens Avenue and Benachi Avenue grade crossings. After the March 

2017 crash, the district added another five grade crossings, including the Main Street crossing, to its list of prohibited 

crossings.
NTSB Highway Accident Report 

23 

Figure 10. Postcrash view of the northbound approach to the Main Street crossing, showing the

new vehicle exclusion sign and plaque (circled in yellow) posted by the City of Biloxi after the 

crash.

As a result of this crash, the MDOT Rails Division initiated a safety program in April 2017. 

As part of this program, MDOT met with local municipalities along the 74 miles of CSXT track 

in Mississippi and identified all grade crossings with vertical profiles exceeding the slope limits 

recommended in the FHWA/AASHTO design guidance. MDOT offered the local municipalities 

free access to LGCGC warning signs and accompanying “LOW GROUND CLEARANCE” 

plaques for installation at those crossings not meeting the design guidelines. As of July 2018, of 

the 12 entities eligible to receive the signs, 6 had requested them.

According to CSXT incident tickets, only one vehicle grounding occurred on the Main 

Street crossing in the year following the March 2017 crash.45 

The City of Biloxi has requested funding from the Gulf Regional Planning Commission to 

conduct a route planning study for commercial vehicle traffic for the city. The study is designed 

to identify the optimal routes for commercial vehicle movement through Biloxi, including 

identifying grade crossings involved in the routing. When the study is complete, the City of Biloxi 

intends to publicize the commercial vehicle route (or routes) through the installation of advisory 

signage throughout the city. The city also intends to work with navigational device makers and 

geospatial mapping developers to electronically disseminate the commercial vehicle routing

information for Biloxi.

45 (a) CSXT dispatch received a call about a vehicle—a car—on the tracks; the car had cleared the crossing by 

the time that CSXT staff arrived. It is unclear whether the vehicle had been grounded or stalled on the tracks. (b) The 

NTSB received incident reports from CSXT for March 8, 2017, to April 6, 2018. 
NTSB Highway Accident Report

24

1.5.8 National Grade Crossing Inventory

In 1975, the FRA, in cooperation with the FHWA, National Highway Traffic Safety 

Administration (NHTSA), Association of American Railroads, and American Short Line and 

Regional Railroad Association, established a national grade crossing inventory. The inventory 

contains current and historical records on grade crossings, including the crash history for each 

listed crossing and whether an LGCGC warning sign is posted at the crossing. The FRA maintains 

the inventory and updates it with information provided by state departments of 

transportation (DOT) and railroad companies when they complete the grade crossing inventory 

form (FRA form 6180.71).

46

States and railroad companies are required to complete different sections of the inventory 

form. State DOTs are responsible for completing information about grade crossing warning 

devices and signage. The Rail Safety Improvement Act of 2008 (49 United States Code [USC]

Section 20160), which had an enforcement date of August 9, 2016, directs that state DOTs shall

report to the Secretary of Transportation “current information, including information about 

warning devices and signage, as specified by the Secretary, concerning each previously unreported 

public crossing located within its borders.” The act further directs that states shall provide this 

information within 6 months of opening for a new crossing and once a year for all grade crossings.

The railroad companies are responsible for providing details of railroad operations, such as types

of trains, speed limits, track characteristics, and types of train detection equipment.

To be considered a high-profile grade crossing in the FRA national inventory, (1) the 

crossing must be posted with an LGCGC warning sign, and (2) the presence of the sign must be

recorded on FRA form 6180.71. NTSB investigators obtained grade crossing inventory 

information for a 5-year period before the Biloxi crash. Table 3 shows the percentages of 

high-profile grade crossings in the nation and the numbers of crashes that have occurred on those 

crossings. There has been a large increase in the number of high-profile crossings reported in the 

national inventory since 2015. The number of reported crossings increased by 113 percent in 2016, 

and by an additional 216 percent in the first 3 months of 2017. This increase most likely is due to 

improved recording of the presence of LGCGC warning signs on the grade crossing inventory 

form—as required by the Rail Safety Improvement Act—rather than from a sudden surge in the 

installation of the signs. According to FRA personnel, the number of reported high-profile 

crossings is expected to rise until August 2019, because all previously reported grade crossings 

are required to update within 3 years of the act’s enforcement date.

 46 For a description of the reporting responsibilities concerning grade crossings for state DOTs and railroad 

companies, see Federal Railroad Administration Guide for Preparing U.S. DOT Crossing Inventory Forms, accessed 

March 16, 2018.
NTSB Highway Accident Report

25

Table 3. National summary of high-profile grade crossings and crash information. (2017 data 

are preliminary)

Year Total 

Crossings

High-Profile

Crossings

Percent of 

High-Profile

Crossings

Crashes at 

All

Crossings

Crashes at 

High-Profile 

Crossings (total 

and percent)

2012 129,661 1,582 1.2% 1,694 35 (2.1%)

2013 130,308 1,618 1.2% 1,756 33 (1.9%)

2014 130,345 1,587 1.2% 1,942 51 (2.6%)

2015 130,971 1,595 1.2% 1,767 44 (2.5%)

2016 131,462 3,400 2.6% 1,724 57 (3.3%)

2017a 131,775 10,740 8.2% 449 45 (10.0%)

a Includes data from January 1 through March 31, 2017.

All of the 31 grade crossings that NTSB investigators examined in the Biloxi and Gulfport 

area exceeded the vertical profile guidance provided by the FHWA and AASHTO, yet, at the time 

of the crash, only 4 of these 31 crossings were marked with LGCGC warning signs.

47 Only one of 

these four grade crossings appeared in the FRA inventory as a high-profile crossing (this crossing 

appeared in the inventory accompanied by a check mark indicating that an LGCGC warning sign 

was present). Neither the Main Street crossing nor the other two crossings posted with LGCGC

signs appeared as high-profile crossings in the FRA inventory database.

According to MDOT, it has been updating its sections of the crossing inventory forms for 

all Mississippi grade crossings. MDOT plans to update the state’s grade crossing inventory yearly, 

during annual railroad track inspections. MDOT is also developing a mobile application to assist 

rail inspectors in gathering and logging the inventory-related information.

1.6 Railroad Operations

1.6.1 Train Operation

The train consisted of 2 locomotives, 27 carsloaded with mixed freight (19 of which carried 

hazardous materials), and 25 empty cars. The train was 3,164 feet long, and it weighed 3,990 tons. 

It was equipped with two-way telemetry and a trip optimizer.

48 The lead locomotive was equipped 

with the required headlight, auxiliary lights, and horn warning device; it was additionally 

instrumented for positive train control, a forward-facing digital video recorder, a locomotive event 

 47 Investigators examined all 29 grade crossings in Biloxi and 2 in Gulfport. All four grade crossings with an 

LGCGC warning sign were in Biloxi.

48 (a) Telemetry is the combination of a head-of-train device on the controlling locomotive and an end-of-train 

device on the train’s rear car that can communicate train-related information to and from the controlling locomotive. 

(b) A trip optimizer is an intelligent, fuel-saving cruise control system for a locomotive that optimizes fuel 

consumption.
NTSB Highway Accident Report

26

data recorder, and an alerter.

49 Postcrash, an FRA inspector tested the devices on the locomotive 

and found them operational. 

1.6.2 Rail Operation

This crash occurred in the CSXT New Orleans & Mobile (NO&M) Subdivision, Atlanta 

Division. Train movements on the NO&M Subdivision are governed by operating rules, timetable 

instructions, and signal indications from the traffic control system. Two control points—signal 

stations that are remotely controlled by a train dispatcher—are near the Main Street grade crossing;

the South End Ocean Springs control point is east of the crossing, and the North End Beauvoir 

control point is west of it.

The track configuration in Biloxi consists of a single main track. The maximum authorized 

train speed on the CSXT NO&M Subdivision is 60 mph for freight trains, with permanent speed 

restrictions between posted timetable mileposts. The maximum authorized train speed over the 

Main Street grade crossing is 45 mph. The segment of track preceding the crash location (west to 

east) is straight for 1 mile before the crossing and for 1,584 feet after the crossing. There is a 

0.26-percent descending grade in the train’s direction of travel. No buildings or vegetation 

obstructed the view for the train crew or the motorcoach driver. NTSB investigators examined the 

CSXT track inspection records for the previous 3 months and determined that the railroad had 

completed the required twice-weekly inspections of the tracks and had found no exceptions to the 

FRA standards.

50

The warning system at the Main Street crossing was controlled by a Safetran Grade 

Crossing Predictor, a monitoring and recording system.

51 Data extracted from the recording unit

showed that the system detected the train and initiated a warning sequence. As part of this 

sequence, the system activated the crossing warning bells and flashing lights when the train, at its 

current speed, was 29 seconds from the crossing; 3 seconds later, the crossing gate arm for the 

roadway began to descend to a horizontal position.

52 Title 49 CFR 234.5 requires a grade crossing 

warning system to activate at least 20 seconds before the arrival of a train. 

After the crash, NTSB investigators, with FRA investigators and CSXT staff, conducted

operational tests of the warning system, and examined documents, photographs, and data. They

found no evidence of problems with the grade crossing warning system. 

 49 (a) According to 49 USC 20157(i)(3), positive train control is a system designed to prevent train-to-train 

collisions, over-speed derailments, incursions into established work zone limits, and movement of a train through a 

switch left in the wrong position. (b) Title 49 CFR Part 229 defines an alerter as a device or system installed in the 

locomotive cab to promote continuous, active locomotive engineer attentiveness by monitoring certain

engineer-induced control activities.

50 The section of the tracks where the crash occurred was considered class 4 track and was maintained to that

standard. Class 4 tracks must be inspected at least twice weekly, with at least 1 calendar day between inspections. 

51 The Safetran Grade Crossing Predictor model 3000ND2 continually monitors the track approach to railroad 

grade crossings, computes the arrival time of a detected train, and activates the crossing-protection equipment at a 

predetermined time before the train’s predicted arrival.

52 Although the time it took for the gate arm to reach the fully horizontal position was not recorded, this movement 

is typically completed in 10–12 seconds. 
NTSB Highway Accident Report

27

1.6.3 Train Crew

1.6.3.1 Experience and History. The train engineer was a 47-year-old male who has been 

employed in this position by CSXT since 2004. He reported that he was in good health, had good 

vision and hearing, and was not regularly taking any medications. No postcrash toxicological 

testing was conducted, because the circumstance of this crash did not meet the requirements of

US Department of Transportation (USDOT) regulations (49 CFR 219.201[b]) concerning such 

testing.

53 Cell phone records indicated that the engineer did not use his cell phone during the train’s

operation. He reported making about three roundtrips each week along the section of the track 

where the crash occurred. Based on the engineer’s postcrash interview statements, his work 

schedule, and his cell phone records, in the 3 nights preceding the crash, he had obtained about 

11.5 hours, 5.0 hours, and 8.5 hours (night before the crash) of sleep, respectively.

The train conductor was a 37-year-old male who had been hired by CSXT in 2008; he was 

certified as both a conductor and an engineer. He told investigators that he was in good health, had 

good vision and hearing, and was not regularly taking any medications. He reported that he usually 

worked with the same engineer and that he regularly operated on the section of the track where the 

crash occurred. Cell phone records indicated that the conductor did not use his cell phone during 

the train’s operation.

1.6.3.2 Crash Trip and Sight Distance Observations. During a postcrash interview, the 

engineer stated that he had clear signals as he approached the Main Street grade crossing, and he 

estimated the train speed as 28 mph.54 He said that he monitored up to three crossings ahead but 

focused his attention on the nearest crossing. He reported that he did not see the motorcoach enter 

the Main Street grade crossing but first saw it on the railroad tracks about 15 seconds before he 

activated the train’s emergency brake.

He said that he did not immediately react to the motorcoach because he frequently 

encounters vehicles on grade crossings, and he expected the motorcoach to clear the tracks. The 

engineer reported putting his hand on the emergency brake moments later. He and the conductor 

both reported discussing the motorcoach’s presence on the crossing and whether it was going to 

move off it in time.

55 The engineer also stated that he did not want to apply the brakes unnecessarily 

because he was concerned about the hazardous materials on the train and the potential for a 

hazardous materials spill in a populated area in case of train derailment. The engineer said that,

although he expected the motorcoach to move off the tracks, he told the conductor that he intended 

to apply the emergency brakes and then did so. Even then, he believed that the motorcoach would 

clear the crossing.

 53 For conditions that require train crews to undergo postcrash toxicological testing, see 49 CFR 219.201. 54 Earlier in the trip, as instructed by a CSXT dispatcher, the engineer had stopped the train due to a report of a 

vehicle being stuck on a grade crossing about 16 miles west of the Main Street crossing. When the engineer began 

moving the train, he decided to maintain the lower speed—the speed limit was 45 mph—due to upcoming speed 

restrictions on a drawbridge about 2 miles east of the Main Street crossing.

55 They told investigators that they saw no indication that the motorcoach was “in distress.”
NTSB Highway Accident Report

28

The engineer reported that, on this section of the railroad, because of the streets that run 

parallel to the tracks, he encounters vehicles on the tracks on a daily basis. He described these 

vehicles as waiting on the tracks for traffic to clear. The engineer also reported that, earlier on this 

same trip, CSXT dispatch had instructed him to stop his train due to a vehicle being stopped on a 

(different) grade crossing about 16 miles ahead. The conductor estimated that about once a week 

they heard about or were involved in a situation in which CSXT dispatch instructed a train crew 

to stop its train due to a possible vehicle on a grade crossing.

NTSB investigators conducted sight distance observations to determine the approximate 

distance at which the train crew could have perceived the motorcoach on the Main Street grade 

crossing. Because an exemplar motorcoach would be at risk of grounding, investigators instead 

placed a truck on the tracks, which, because of its higher ground clearance, could more safely 

represent the crash motorcoach. Then, an exemplar CSXT locomotive, moving about 10–15 mph 

and operated by an experienced engineer, approached the crossing from the west. The engineer 

reported being able to perceive the truck at 3,850 feet from the Main Street grade crossing.

1.6.4 Recorders

NTSB investigators examined data from the locomotive event data recorder, the digital 

video recorded by the forward-facing locomotive camera, and the signal stations to determine the 

actions of the train engineer, the visibility conditions, the timing of the crash, and the timing of the 

grade crossing warning system activation. Table 4 shows the sequence of the crash events 

involving these factors. 
NTSB Highway Accident Report

29

Table 4. Sequence of events near Main Street grade crossing on March 7, 2017, concerning the 

train’s movement, the motorcoach’s grounding, and the crash.

Time (p.m.) Event Source

2:05:45 – 2:11:28 Speed of the train varies between 27 mph and 29 mph Train event data 

recorder

2:09:26 – crash Horn activates nearly continuously (with one 2-second break) Train event data

recorder

~2:11 Motorcoach arrives on the crossing Driver’s GPS

2:11:14 Warning bells and flashing lights at the crossing activate Warning system 

recorder

2:11:15 Object is visible at the Main Street crossing Forward-facing 

locomotive cameraa

2:11:17 Gate arms start to lower Warning system 

recorder

2:11:21 Object at the Main Street crossing is identifiable as a motorcoach Forward-facing 

locomotive camera

2:11:28 – crash Motorcoach at the Main Street grade crossing appears stationary Forward-facing 

locomotive camera

2:11:29 Engineer engages emergency brake (502 feet west of the crossing) Train event data 

recorder

2:11:43

Crash Forward-facing 

locomotive camera

Train speed is 19 mph at impact Train event data 

recorder

2:12:00 Train comes to a complete stop, 259 feet east of the crossing Forward-facing 

locomotive camera

a NTSB investigators and party representatives derived the description of the video from the forward-facing locomotive camera, after 

a frame-by-frame viewing of the recording. See the Onboard Image Recorder (Train) report in the NTSB public docket for this 

investigation (HWY17MH010) for additional descriptive information on the recording from the locomotive camera.

1.7 Motor Carrier Operations 

ECHO Tours and Charters, doing business as ECHO Transportation, is domiciled in Dallas, 

Texas, and began operating as an interstate carrier in 2011. At the time of the crash, the carrier 

operated 109 vehicles and employed 169 drivers.

The carrier’s primary terminal is in Dallas—the motorcoach driver’s home terminal—and 

it has satellite operations in four other Texas locations. For-hire charter operations represent the 

largest part of ECHO Transportation’s business.

1.7.1 Carrier Training Program

ECHO Transportation employs a safety manager who, with other staff, implements and 

oversees the carrier’s safety and training programs. According to carrier documentation, all ECHO

Transportation drivers receive new driver training, new driver onboard training, continual 

performance monitoring, and defensive driving training. The new driver training program consists 

of 9 days of classroom and on-the-road training. Continual performance monitoring is conducted 
NTSB Highway Accident Report

30

using Lytx DriveCam. The safety manager monitors DriveCam events and provides coaching to 

drivers if a recorded event is determined to have presented a safety risk; some recorded events may 

result in disciplinary action. All drivers also complete defensive driving training every 6 months. 

The carrier provided NTSB investigators with several written policies, including those addressing 

seat belt and cell phone use, as well as a policy on proper procedures for transiting railroad 

crossings. The railroad crossing policy included a step-by-step guide outlining the Federal Motor 

Carrier Safety Administration (FMCSA) requirements for speed, safe following distance, and 

operating in adverse weather while traversing grade crossings. The carrier’s policy did not include 

any guidance pertaining to LGCGC warning signs.

1.7.2 State and Federal Oversight

Although the Texas Department of Public Safety (TxDPS) Commercial Vehicle 

Enforcement Service has authority over intrastate motor carriers, it does not inspect interstate 

carriers like ECHO Transportation. As such, TxDPS Commercial Vehicle Enforcement did not 

perform any compliance reviews of ECHO Transportation, but it did conduct regular roadside 

inspections of the carrier’s vehicles, including three inspections of the motorcoach involved in this 

crash. None of the three inspections, the most recent of which occurred on January 24, 2017, 

resulted in violations.

The FMCSA conducted two compliance reviews of ECHO Transportation, in April 2012

and September 2014; both resulted in “satisfactory” ratings. The Motor Carrier Management 

Information System showed that ECHO Transportation had no Behavior Analysis and Safety 

Improvement Categories (BASICs) in alert status at the time of the crash.56 The records indicated

that the carrier had two reportable crashes before the Biloxi grade crossing crash, but neither 

involved the crash driver.57 As a result of the Biloxi crash, the FMCSA initiated a compliance 

review of the motor carrier on April 5, 2017. This review identified two noncritical safety 

violations and resulted in a “satisfactory” rating.58

1.7.3 Driver Grade Crossing Guidance

In the Manual on Uniform Traffic Control Devices for Streets and Highways (MUTCD), 

the FHWA provides guidance on the LGCGC warning sign at grade crossings; however, this 

guidance is intended for traffic engineers and describes the roadway conditions under which 

LGCGC signs should be installed. The MUTCD provides no guidance to drivers on such signage

(FHWA 2009). Neither the Texas nor the Mississippi commercial motor vehicle drivers’

handbook/manual mentions the LGCGC warning sign (TxDPS 2014 and MDOT 2012). No 

guidance from the FMCSA or the American Association of Motor Vehicle Administrators 

(AAMVA) addresses the LGCGC warning sign at grade crossings. These organizations do issue 

warnings about the dangers of becoming grounded on a grade crossing, and they highlight the risk 

 56The FMCSA uses data from roadside inspectionsincluding all safety-based violations, state-reported crashes, 

and the Federal Motor Carrier Censusto quantify a carrier’s performance in seven BASICs. These BASIC categories 

are (1) unsafe driving, (2) hours-of-service compliance, (3) driver fitness, (4) controlled substances and alcohol, 

(5) vehicle maintenance, (6) hazardous materials compliance (if applicable), and (7) crash indicator. A carrier’s rating 

for each BASIC depends on its number of adverse safety events, the severity of its violations or crashes, and when the 

adverse safety events occurred (more recent events are weighted more heavily).

57 Neither of the drivers involved in the other two reportable crashes was issued a citation.

58 The two noncritical safety violations were (1) using a driver who has not completed and furnished an 

employment application and (2) false or inaccurate record-of-duty status report.
NTSB Highway Accident Report

31

of grounding for vehicles with low trailers. For example, AAMVA guidance to commercial drivers 

(AAMVA 2016, 2-28 to 2-30) states that—

Hanging up on a railroad crossing is a dangerous predicament, and is becoming too 

common as more very low trailers are manufactured. Lowboy trailers, car carriers, 

moving vans, and possum-belly livestock trailers are particularly susceptible, as are 

single-axle tractors pulling a long trailer with landing gear which is set to 

accommodate a tandem-axle tractor.

Motorcoaches are not discussed as types of vehicles susceptible to grounding on

high-profile grade crossings in any of the guidance material for commercial drivers examined by 

NTSB investigators.

1.8 Motorcoach Driver

1.8.1 Licensing, Experience, and Driving History

The motorcoach driver was a 60-year-old male who obtained his first commercial driver’s 

license (CDL) in June 2006, when he operated school buses for the Fort Worth Independent School 

District. In February 2013, he was employed by Gotta Go Trailways, which was later purchased 

by ECHO Transportation. At the time of the crash, the driver held a Texas class B CDL with 

passenger and school bus endorsements; the license had no restrictions.

The motorcoach driver completed Gotta Go Trailways new-hire training in March 2013.

He also completed a recertification class in December 2015, took a driver training class in 

January 2017, and attended three company safety meetings.59 Between November 2015 and 

March 2017, the driver had 34 DriveCam events, 27 of which resulted in coaching sessions; none 

of these events incurred suspension.60

NTSB investigators examined multiple sources to obtain the motorcoach driver’s history 

of traffic violations, including CDL information systems, Texas Department of Motor Vehicle 

records, and driver qualification files from previous employers. The records showed that the driver 

had two speeding violations in personal vehiclessince 2015 and a non-USDOT-reportable accident 

in August 2015.61 Additionally, the driver underwent two roadside safety inspections, one in July 

2016 in Peach Springs, Arizona, and the other following the Biloxi crash. Although both 

inspections resulted in safety violations for the driver, none were considered out-of-service 

violations. The driver received no citations in connection with this crash.

 59 (a) The driver completed a recertification class due to an employment termination in January 2015 that resulted 

from a non-driving-related incident. The carrier investigated the circumstances of the incident and offered to rehire 

the driver in September 2015. The recertification class is a shorter version of new-hire training. (b) The topics of 

company safety meetings vary depending on the current need and may include subjects such as winter driving, hours 

of service, or customer service. 

60 Most of the coaching sessions resulted from DriveCam events showing the driver allowing traffic to shorten 

his following distance. This driver’s overall number of coaching sessions was similar to those provided to other drivers 

at the carrier. 

61 This event occurred while the driver was operating a commercial vehicle; he made a sharp turn and slightly 

contacted the fender of a parked vehicle. Because the crash did not result in towing of either vehicle or injuries, it was 

not required to be reported to the USDOT. The driver’s employer provided the record of this crash.
NTSB Highway Accident Report

32

1.8.2 Medical Certification, Health, and Toxicology 

The motorcoach driver obtained his most recent precrash CDL medical certificate in 

January 2017; it was valid for 2 years. On the medical examination report form, the driver 

indicated that he had not taken any medications in the past 5 years, and he did not report any 

injuries or medical conditions that could affect his ability to operate a vehicle safely. The results 

of the examination, which included visual acuity and urinalysis, were within normal limits. NTSB 

investigators also obtained medical records from the motorcoach driver’s primary care physician. 

These records did not indicate any significant chronic medical conditions.

The driver submitted to a USDOT preemployment drug test before beginning work for 

ECHO Transportation; the results of the test were negative. The carrier’s records indicated that the 

driver had not been selected for random drug testing since employment. Postcrash, the carrier 

requested that the hospital where the driver was taken perform toxicology testing as required by 

USDOT regulation. The breath test analysis performed at 4:35 p.m.—about 2 hours 20 minutes 

after the crash—was negative for alcohol. The testing of the driver’s urine, which was collected at 

5:10 p.m.—about 3 hours after the crash—was negative for other drugs.62 At the request of NTSB 

investigators, the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research 

Laboratory performed additional testing on the driver’s blood sample. It was negative for alcohol 

and other drugs, including the prescription medications that NTSB investigators found in the 

motorcoach after the crash.

63

1.8.3 Precrash Activities

NTSB investigators used information obtained from cell phone records, interviews with 

the motorcoach driver and passengers, the charter tour plan, and hotel records to reconstruct the 

driver’s activities in the days before the crash.

The motorcoach driver reported obtaining good quality sleep and not taking any sleeping 

medications. He stated that he typically works during the day and sleeps at night and that he goes 

to sleep before 10:00 p.m. when working the next day. The driver said that for the 3 nights before

the crash, he obtained about 7.5–9.5 hours of sleep each night. On March 5, after having slept for 

about 9.5 hours, he began driving at 6:45 a.m., when he picked up passengers in Bastrop, Texas; 

he arrived in Lafayette, Louisiana, about 4:45 p.m. that day. On the following morning of March 6, 

after obtaining about 7.5 hours of sleep, the driver began driving at 9:00 a.m.; the motorcoach 

arrived at Hollywood Casino in Bay St. Louis, Mississippi, at 1:30 p.m. 

On March 7, the day of the crash, after having had a 9-hour opportunity for sleep, the 

motorcoach driver picked up the passengers from the casino hotel about 1:00 p.m. and began the 

 62 The tests provide evidence of use of the following 11 substances: amphetamine, methamphetamine, MDMA, 

MDA, MDEA, tetrahydrocannabinol (the active compound in marijuana), cocaine, codeine, morphine, heroin, and 

phencyclidine.

63 (a) The laboratory conducted analyses to detect amphetamines, opiates, marijuana, cocaine, PCP, 

benzodiazepines, barbiturates, antidepressants, antihistamines, and commonly used prescription and over-the-counter 

drugs. For a comprehensive list of the drugs tested for, see the FAA WebDrugs website, accessed April 13, 2018. 

(b) NTSB investigators found several prescription medication bottles in the driver’s name in the motorcoach, including 

vitamin D, etodolac, amoxicillin, ibuprofen, cyclobenzaprine, and meloxicam. These medications were prescribed to 

be taken as needed.
NTSB Highway Accident Report 

33 

trip to Boomtown Casino in Biloxi. When the crash occurred, the driver had been on duty and 

driving for less than 2 hours. Figure 11 shows the driver’s activities for the 3 days before the crash.

Figure 11. Activities of the motorcoach driver, March 4–7, 2017. (Driver’s activity on March 4 

before 2:00 p.m. is unknown.) 

1.8.4 Route Selection

When the motorcoach driver left Hollywood Casino in Bay St. Louis on the day of the 

crash, his vehicle was one of three charter motorcoaches—organized by Diamond Tours—each 

operated by a different motor carrier. Although the three motorcoaches left locations at different 

times and traveled separately, because they were all part of the Diamond Tours charter, they all 

followed the same itinerary. For this part of the charter tour, the established itinerary included 

directions from Hollywood Casino to Boomtown Casino in Biloxi, which instructed drivers to take 

Interstate 10, a route that would not have included traversing the grade crossing on Main Street in 

Biloxi.

Before the three motorcoaches departed Bay St. Louis on March 7, the Diamond Tours 

manager sent a text message to the driver and group leader of each motorcoach, suggesting that 

they take an alternative, optional, scenic route along US-90; the message included directions and 

instructions for this optional route.64 The new directions instructed the drivers to exit on Caillavet 

Street in Biloxi, resulting in a route that did not include traversing the grade crossing on Main 

Street.65 The crash motorcoach driver, who was operating the ECHO Transportation motorcoach, 

was not sent these instructions from Diamond Tours; instead, the text message was mistakenly 

sent twice to the group leader for that motorcoach. The group leader for the ECHO Transportation 

motorcoach later told investigators that she did not receive the text message.

On the morning of March 7, during breakfast at the Hollywood Casino hotel, some of the 

passengers and the group leader from the ECHO Transportation motorcoach learned about the 

64 One passenger on each of the three motorcoaches in the tour was designated as the group leader for that 

motorcoach. The group leader served as a contact point with Diamond Tours. 65 Like Main Street, Caillavet Street runs north–south in Biloxi. It is located about 0.4 mile west of Main Street. 

Although Caillavet Street crosses the railroad tracks, the crossing has a considerably lesser slope than the Main Street 

crossing. 
NTSB Highway Accident Report 

34 

scenic route from passengers from the other two tour motorcoaches comprising the Diamond Tours 

charter. At the start of the trip from Bay St. Louis, the ECHO Transportation motorcoach driver 

inputted the address of the Biloxi Boomtown Casino into his GPS device and programmed the 

device for commercial vehicle operation. 

Soon after the ECHO Transportation motorcoach left Bay St. Louis, its group leader asked 

the driver if they could take a scenic route along US-90 to travel to the Boomtown Casino. In 

response, the driver began driving toward US-90. At that time, his GPS device recalculated its 

navigational instructions, which now directed the driver to Main Street in Biloxi and across the 

grade crossing. This GPS-provided scenic route, which the crash driver followed, was different 

both from the route included in the original Diamond Tours itinerary and from the optional scenic 

route with specific directions suggested by the Diamond Tours manager in her text message sent 

on the morning of the crash. (See figure 12 for a map showing the three routes from Bay St. Louis 

to Biloxi discussed above.) 

Figure 12. Three alternative routes proposed for the motorcoach to travel from Hollywood Casino 

in Bay St. Louis to Boomtown Casino in Biloxi. The route in blue is the original planned route from 

the Diamond Tours itinerary; the route in yellow is the optional scenic route proposed by the 

Diamond Tours manager on the morning of the crash trip; and the route in red is the one indicated 

by the motorcoach driver’s personal GPS device. The route in red is the crash route. 

1.8.5 Driver’s Actions at Crossing and Postcrash Sight Distance Observations 

1.8.5.1 Motorcoach Driver’s Actions. During a postcrash interview, the motorcoach driver 

stated that, as he approached the Main Street grade crossing, he noticed the LGCGC warning sign; 

he described it as depicting a truck with a lowboy trailer. The driver said that, as he approached 

the tracks, he stopped at the stop line, turned on his hazard flashers, raised the rear of the 

motorcoach, and looked down the tracks in both directions.

66 He stated that the grade crossing 

66 The driver said that, because of the incline, he decided to raise the rear of the motorcoach to avoid scraping the 

rear bumper when crossing. As was noted earlier, this motorcoach had a rear-lift system that allowed the driver to 

raise the height of the rear suspension air springs, elevating the rear of the motorcoach by 4 inches.
NTSB Highway Accident Report

35

warning lights were not flashing and, because he did not see a train, he began to drive across the 

tracks. 

The driver reported that he became aware of the steepness of the north side of the grade 

crossing only after the vehicle had crested the crossing. By that time, the motorcoach had become 

grounded on the crossing. The driver stated that he attempted to free the motorcoach from the 

crossing by pulling forward and reversing, but he was not successful. He reported that the 

passengers then told him that a train was coming, at which point, he opened the loading door and 

told the group leader that everyone should evacuate the motorcoach.

1.8.5.2 Postcrash Sight Distance Observations. NTSB investigators conducted sight distance

observations to assess the motorcoach driver’s description of his actions at the crossing. Driving

an exemplar motorcoach, an experienced CDL driver approached the Main Street grade crossing 

from the south, replicating the crash motorcoach’s northbound path. Moving his vehicle very 

slowly, the exemplar driver reported his observations about the steepness of the crossing on the 

north side of the tracks. The exemplar driver said that, while stopped at the stop line, he could not

perceive the degree of the slope north of the rail tracks. He reported that, until he had moved the 

exemplar motorcoach beyond the stop line, it appeared to him that the grade crossing was safely 

traversable. The exemplar driver also stated that, while accelerating normally from the stop line, a 

motorcoach driver would find it difficult to perceive the steepness of the north slope in time to 

prevent the vehicle’s grounding on the crossing.

1.9 Weather and Roadway Conditions

Data from the weather station at Keesler Air Force Base in Biloxi, about 2.5 miles from 

the crash site, indicated that, at 1:58 p.m. on March 7, 2017, the temperature was 72°F, and there 

was a south wind of 11.5 mph, no precipitation, and visibility of 10 miles. The crash occurred in 

daylight.
NTSB Highway Accident Report

36

2 Analysis

2.1 Introduction

The crash sequence began when a motorcoach carrying passengers to a casino in Biloxi, 

Mississippi, attempted to travel across a highway‒railroad grade crossing on Main Street in Biloxi 

and became grounded on the tracks. Within the next minute, a CSXT train approaching the grade 

crossing from the west struck the motorcoach and pushed it about 259 feet eastward. Four 

motorcoach passengers died, and the driver and 37 passengers sustained minor-to-serious injuries.

The analysis first examines the motorcoach driver’s decision-making that led him to 

deviate from the originally planned route and attempt to traverse the grade crossing, and then the 

train crew’s response to the grade crossing hazard and activation of the emergency braking system. 

The analysis also discusses the following safety issue areas:

• High-profile grade crossings, specifically—

 Signage and reconstruction guidelines.

 Coordination of maintenance activities and monitoring of crossing safety risk.

• Emergency egress and extrication.

As a result of this investigation, the NTSB established that the following factors did not

cause or contribute to the crash:

• Motorcoach driver and train crew licensing and experience: The motorcoach driver 

held a CDL with appropriate endorsements and had more than 10 years of commercial 

driving experience. The train engineer and conductor each had appropriate

certifications and more than 7 years of experience.

• Cell phone distraction, fatigue, substance impairment, and medical conditions: Cell 

phone records gave no indication that the motorcoach driver or the train crewmembers

were engaged in texting or cell phone conversation at the time of the crash. Based on 

interviews, cell phone records, and witness accounts, the investigation found no 

evidence of fatigue for the motorcoach driver or the train crew. Postcrash toxicology 

test results revealed no evidence that the motorcoach driver had used alcohol or other 

drugs before the crash. (Consistent with federal regulations, no toxicological tests were 

performed on the train crew.) Examination of the motorcoach driver’s available 

medical records showed no evidence of medical conditions that could have affected his

ability to operate the vehicle.

• Vehicle condition, railroad track condition, and rail signal system operation: NTSB 

investigators examined the motorcoach and found no preexisting mechanical 

conditions that would have contributed to the circumstances of the crash. The 

investigators also examined the railroad track and signal system and found them to have 

been functioning as designed at the time of the crash.
NTSB Highway Accident Report

37

• Weather: There was no precipitation at the time of the crash, the road surface was dry, 

and the visibility was adequate.

• Emergency response: First responders provided appropriate and efficient emergency 

medical services, and they followed appropriate IC handover and communication 

protocols. Although responders had to cut the rear door from the motorcoach to 

expedite extrication of the passengers, medical evidence suggests that, in this case, the 

additional time required to remove the door did not affect the survival of any passengers

(see section 2.4 for additional information). 

The NTSB therefore concludes that none of the following were causal or contributory 

factors in the crash: (1) motorcoach driver licensing or experience; (2) train engineer or conductor 

licensing or experience; (3) motorcoach driver cell phone distraction, substance impairment, or 

medical condition; (4) train engineer or conductor cell phone distraction; (5) mechanical condition 

of the motorcoach; (6) railroad track condition or signal system operation; or (7) weather. The 

NTSB further concludes that the emergency response to the crash was timely and effective.

2.2 Operator Actions

2.2.1 Motorcoach Driver

Shortly after departing Bay St. Louis, at the suggestion of the onboard tour group leader

and as a scenic alternative, the motorcoach driver deviated from the tour’s original planned route 

to the Boomtown Casino in Biloxi and instead traveled along US-90. The new route was navigated 

by the driver’s personal GPS, which he had preprogramed for commercial vehicle travel. This 

GPS-provided route included travel on Biloxi’s Main Street and over the grade crossing where the 

crash occurred. The manager of Diamond Tours had proposed a different scenic route for this 

segment of the charter tour, which did not include travel on Main Street or over this grade crossing; 

however, the motorcoach driver did not receive the text from Diamond Tours that provided the 

directions for this alternative route. The NTSB concludes that the motorcoach driver’s decisions 

to take a scenic route and to rely on a portable GPS device programmed for commercial vehicle 

navigation were reasonable.

When interviewed by NTSB investigators, the motorcoach driver stated that he had noticed 

the LGCGC warning sign that preceded the Main Street grade crossing. In anticipation of a high 

slope, he raised the rear of the motorcoach to prevent the rear bumper from scraping the crossing. 

The driver also said that, by the time he could see the steepness of the slope on the north side of 

the railroad tracks, the motorcoach was already grounded. NTSB investigators confirmed the crash 

driver’s statement by conducting a postcrash test drive with an exemplar motorcoach driven by an 

experienced CDL driver. Based on his test drive at the crossing, the exemplar vehicle driver stated 

that, under normal acceleration, it would have been difficult to perceive the steepness of the north 

slope in time to prevent the motorcoach from grounding on the crossing.

The NTSB concludes that, given that (1) the motorcoach driver most likely could not have

perceived the steepness of the northern slope before beginning to traverse the crossing, (2) he took 

the precaution of raising the rear of the motorcoach to prevent scraping the crossing, and (3) no 

signage prohibited transiting the crossing in a commercial vehicle, the driver’s decision to travel 

over the Main Street grade crossing was reasonable.
NTSB Highway Accident Report

38

2.2.2 Train Crew

When interviewed by NTSB investigators, the train engineer stated that he monitored up 

to three grade crossings ahead of his train but focused his attention on the nearest crossing. He

reported not seeing the motorcoach enter the Main Street grade crossing but estimated that he first 

saw it on the tracks about 15 seconds before he applied the train’s emergency brake. At that time, 

the train was traveling 27–29 mph.

After seeing the motorcoach and realizing that it might not move off the tracks before his 

train arrived at the crossing, the engineer placed his hand on the emergency brake, briefly discussed 

with the conductor the likelihood of the motorcoach clearing the crossing, and considered the risk 

of putting the train into emergency, which would include the potential for train derailment and a 

release of hazardous materials cargo in a populated area. He then activated the emergency brake. 

The engineer reported that, even then, he still expected the motorcoach to clear the crossing before 

a collision occurred. The data from the locomotive event data recorder showed that the engineer 

engaged the emergency brake about 14 seconds before the crash (when the train was about 502 feet 

west of the crossing).

Using the clock time from the motorcoach driver’s personal GPS to establish when the 

motorcoach reached the Main Street crossing stop line (about 35 seconds before the crash), the 

NTSB estimated that the train would have been about 1,364 feet from the crossing at that time.

67

The sight distance observations conducted by NTSB investigators showed that a vehicle on the 

Main Street grade crossing could be perceived by a train crew at that distance. However, at that 

location, a train crew could also see three other grade crossings that preceded the Main Street

crossing.

68 Train engineers are trained to monitor up to three grade crossings ahead but to focus 

on the nearest crossing. Engineers and conductors encounter vehicles crossing railroad tracks daily

without collision and, based on that experience, they have a reasonable expectation that a vehicle 

will clear the crossing before their train reaches it.

The NTSB concludes that, given the speed of the train, the brief period that the motorcoach 

spent grounded on the tracks before the crash, the numerous grade crossings in this area, and how 

frequently the train crew encountered vehicles on crossings that ultimately cleared them safely, 

the estimated time that the train engineer took to detect the motorcoach on the tracks was 

reasonable, and his response time before engaging emergency braking was acceptable.

2.3 High-Profile Grade Crossings

2.3.1 Signage and Reconstruction Guidelines

2.3.1.1 LGCGC Warning Signs. AASHTO and the FHWA both provide guidance for the design

of new and reconstructed grade crossings, including providing the maximum recommended 

vertical profile, which is 3 inches above or below track level at 30 feet from the nearest rail. The 

vertical profile of the Main Street grade crossing was well beyond the maximum recommended 

 67 The train traveled 502 feet after the emergency brake was engaged, 14 seconds before the crash. At an average 

speed of 28 mph, the train would travel 862.4 feet in 21 seconds (35 – 14 = 21). Thus, the total distance the train 

traveled in the 35 seconds before the crash would have been about 1,364.4 feet (502 feet + 862.4 feet).

68 The three other grade crossings are on Magnolia Street, Delauney Street, and Lameuse Street, for a train 

traveling from west to east toward Main Street.
NTSB Highway Accident Report

39

guidance; at 30 feet north of the rail tracks, Main Street was 45.4 inches below the track level, 

corresponding to a 13.3-degree slope. The Main Street grade crossing was not unique in this 

respect; in an area spanning 2.6 miles in Biloxi, there were 22 grade crossings, all of which had

vertical profiles beyond the recommended limit.

Although a grade crossing that falls outside the recommended parameters for vertical 

profile can be termed a high-profile crossing, there is no single, comprehensive definition of a 

high-profile grade crossing. The FRA defines a high-profile grade crossing simply as one that is 

posted with an LGCGC warning sign that is also noted on the grade crossing inventory form; 

however, it is highway authorities (state or local) that decide whether to post such a sign, based on

the subjective interpretation of a traffic engineer. Moreover, the guidance concerning 

countermeasures to address the safety risks posed by high-profile grade crossings is limited.

Signage is a frequently used countermeasure, and one that was present at the Main Street 

grade crossing at the time of the crash. Ahead of the crossing, an LGCGC warning sign alerted 

road users of the crossing’s high vertical profile. The MUTCD provides broad guidance describing 

the conditions under which an LGCGC warning sign should be installed, as follows: “...if the 

highway conditions are sufficiently abrupt to create a hang-up situation for long wheelbase 

vehicles or for trailers with low ground clearance...” (FHWA 2009). The term “sufficiently 

abrupt” is vague and open to interpretation, which could result in inconsistent installation of

warning signs. For example, at the time of the crash, the Lee Street grade crossing in Biloxi was 

posted with an LGCGC warning sign; however, three other grade crossings in Biloxi and two in 

the neighboring city of Gulfport with higher vertical profiles than the Lee Street crossing did not 

have LGCGC warning signs.

69

LGCGC warning signs inform road users of a grade crossing’s steeper-than-normal slope. 

They do not specify the steepness of the slope, nor do they adequately inform road users about

exactly what types of vehicles are at risk. At the time of the crash, four grade crossings in the 

Biloxi and Gulfport areas were posted with LGCGC warning signs. NTSB investigators examined 

the approach slopes at those crossings and found that the top grades ranged 

from -11.4 to -21.5 percent.

70 These differences in the approach slopes are drastic, and the degree 

of discrepancy is not effectively conveyed by posting identical LGCGC warning signs at these 

various locations. The LGCGC warning sign at the Main Street crossing was accompanied by a 

“LOW GROUND CLEARANCE” plaque at the time of the crash, and, although the motorcoach 

driver took precautions in response to the warning signage, the vehicle still grounded on the 

crossing.

71 The current design of an LGCGC warning sign does not convey what a driver should 

do in response to it. Even the driver of a truck with a lowboy trailer—as is pictured in the LGCGC 

 69 NTSB investigators measured the approach grades of all grade crossings in Biloxi (29 crossings) and Gulfport 

(2 crossings). In Biloxi, the higher slope on the Lee Street grade crossing measured 11.4 percent; the higher slopes on 

the Holley Street, Nixon Street, and Benachi Avenue crossings measured 13.7 percent, 17.6 percent, and 16.4 percent, 

respectively. The higher slope of two grade crossings in Gulfport—Walston Avenue and Gulf Avenue—measured 

23.5 percent and 16 percent, respectively.

70 For comparison, according to the FHWA/AASHTO guidance, the maximum acceptable height difference of 

3 inches at a distance of 30 feet from the tracks corresponds to a grade of 0.89 percent.

71 At the same time, when approaching the crossing, the GPS device sounded an auditory alert and its screen

depicted the railroad tracks and showed an LGCGC warning in the upper right corner. If the warning were tapped, the

device screen displayed a banner across its top that read “Risk of Grounding.”
NTSB Highway Accident Report

40

sign—would not know from the sign whether to take another route to avoid the crossing, to cross 

it slowly, to accelerate quickly over it, etc.

Additionally, based on pertinent vehicle dimensions, such as length, ground clearance, and 

rear overhang, many types of vehicles are at risk of grounding on a high-profile crossing. For 

instance, motorcoaches, such as the one involved in the Biloxi crash, are at risk for grounding on

high-profile grade crossings due the ratio of their length to ground clearance; yet neither AAMVA

nor FMCSA guidance mentions motorcoaches as low ground clearance vehicles with a strong

potential for grounding. Moreover, the guidance does not specifically discuss the meaning of, and 

appropriate responses to, LGCGC warning signs. NTSB investigators reviewed the available 

literature but had difficulty in finding evidence of the effectiveness of LGCGC warning signs, 

primarily due to their nonspecific purpose and measure of success. 

Between February 2014, when CSXT performed maintenance that raised the level of the 

tracks at the Main Street grade crossing, and the March 7, 2017, crash date, 23 incidents were 

reported of a vehicle grounding at the crossing, 2 of which resulted in collisions. Clearly, the 

LGCGC warning sign and “LOW GROUND CLEARANCE” plaque, which were present 

throughout this period, were not effective in preventing long wheelbase vehicles, vehicles with 

significant rear overhang, and those with low ground clearance from traversing this grade crossing. 

However, we cannot determine whether the grounding incidents might have been still more 

frequent had the LGCGC warning signage been absent. 

The NTSB concludes that, based on the high frequency of grounding incidents at the Main 

Street grade crossing, which was posted with LGCGC warning signage, and the lack of evidence

of the safety benefits provided by LGCGC warning signs, the effectiveness of such signs in 

promoting safety at grade crossings may be negligible.

2.3.1.2 Grade Crossing Exclusion Signs. Following the crash, the City of Biloxi posted a 

selective exclusion sign at the Main Street grade crossing, which specifically prohibited access to

buses, trucks, and recreational vehicles. Unlike LGCGC warning signs, which provide a generic 

warning and rely on the driver to determine the appropriate response, an exclusion sign leaves no 

room for interpretation—drivers can see that the specified vehicle types are prohibited from using

the crossing.

The MUTCD does not provide any guidance for determining when a jurisdiction should 

install exclusion signs at grade crossings, although it does provide guidelines for the installation 

of other types of grade and low clearance warning signs. For example, if a downgrade of a road 

poses a potential hazard to road users, the MUTCD recommends that a “hill grade” sign be 

installed to convey specific information about the severity of the grade. If a road crosses under a 

low overhead structure, the MUTCD recommends that a “low overhead clearance” sign be 

installed to convey information about maximum vehicle height (FHWA 2009). Grade crossings 

pose more complex decision-making problems, because the risk of grounding is dependent not 

only on the approach slope but also on the vehicle’s wheelbase and ground clearance.

Traffic engineers could benefit from guidance specifying the conditions under which they 

should consider the installation of exclusion signs, as well as which vehicle types the signage

should exclude. Guidelines or standards for placing an exclusion sign can be based on various 
NTSB Highway Accident Report

41

criteria, particularly including (1) the grade crossing’s topographical profile (its slope or curvature) 

and (2) the frequency of crashes or vehicle groundings taking place on the crossing. Guidance 

based on a crossing’s topographical profile could be considered proactive, with the possibility of 

preventing future vehicle groundings. However, given the variability in the topographical profiles 

of grade crossings and the possible combinations of vehicle types based on their various pertinent 

dimensions—wheelbase length, ground clearance, rear overhang, etc.—it may be challenging to 

develop solely topographical standards that apply to all grade crossings and vehicle types. In 

contrast to topographical standards, guidance based on the frequency of past grounding incidents

on a grade crossing might be considered reactive, but such a system has the advantage of using

real-world data that are specific to a particular grade crossing. Using both proactive and reactive 

methods to develop signage standards would combine their advantages.

A multipronged approach to developing appropriate standards is used when determining 

the need for other types of highway safety treatments. For example, the criteria for installing

median barriers that prevent or reduce instances of median crossovers and head-on crashes are 

typically based on the location’s high-risk factors, such as median width and average annual daily 

traffic. However, some states add a criterion for making the decision—the frequency of median 

crossovers—regardless of median width or traffic volume. The dual approach of considering both 

the roadway characteristics and the crash rate allows traffic engineers to address sections of a 

highway that have a high incidence of crossovers but that do not meet the conventional roadway 

definition of being at high risk for such events. Similarly, a standard for placing exclusion signs at 

grade crossings that considers the frequency of vehicle groundings would address those grade 

crossings that are at high risk for groundings, even if they do not have the topographical features 

of a typical high-profile crossing.

The FHWA can develop such a standard for grade crossing signage and include it as a 

recommended practice in the MUTCD. However, incorporating new standards into the MUTCD 

can be a lengthy process. As an interim measure, the FHWA has the option of issuing an official

interpretation of a guidance practice that already exists. The interpretations are issued “when 

unique situations arise for device applications that might require interpretation or clarification of 

the Manual (FHWA 2009).”72 As such, the guidance practice for installing LGCGC warning 

signage could include an interpretation specifying other options that traffic engineers might adopt 

for high-profile grade crossings, such as the use of exclusion signs.

The NTSB concludes that traffic engineers would benefit from clear guidance that 

describes when vehicle exclusion signs should be installed at grade crossings. Therefore, the NTSB 

recommends that the FHWA issue an interpretation of the guidance practice for LGCGC warning 

signage in the MUTCD to suggest the use of other signage, such as vehicle exclusion signs, to 

address safety issues at high-profile grade crossings; and inform the state DOTs of the new 

interpretation. Additionally, the NTSB recommends that the FHWA develop and establish a 

guidance practice addressing the circumstances in which vehicle exclusion signs should be 

installed to restrict access to high-profile grade crossings and the types of vehicles to which the 

exclusions should apply; and incorporate the guidance practice into the MUTCD.

 72 The FHWA official interpretations are included in section 1A.10 of the MUTCD. For additional information,

see the FHWA MUTCD website, accessed June 25, 2018.
NTSB Highway Accident Report

42

2.3.1.3 Grade Crossing Reconstruction. AASHTO, the FHWA, and AREMA provide guidance 

on the maximum acceptable vertical profile for a new or newly reconstructed grade crossing.

However, neither highway nor rail guidance documents specify the maximum vertical profile that 

a grade crossing may reach during its service life before it should be reconstructed. 

One common consequence of regular railroad maintenance—specifically, the replacement 

of wooden ties—is to increase the vertical profiles of grade crossings. The effects of such 

maintenance were evident in the dramatic increase in the frequency of vehicle groundings at the 

Main Street grade crossing following the February 2014 replacement of wooden railroad ties. The 

NTSB concludes that, due to the February 2014 track maintenance work, which increased the 

crossing’s vertical profile and resulted in increased frequency of vehicle groundings, the Main 

Street grade crossing had been unsafe for certain types of vehicles for several years before the fatal 

March 2017 crash.

Since the crash, the City of Biloxi has installed a selective vehicle exclusion sign and begun

plans to develop a commercial vehicle route through Biloxi. According to CSXT, there was only 

one vehicle grounding at the crossing in the year following the crash. Postcrash, the City of Biloxi 

considered reconstructing the Main Street grade crossing, but, due to the high cost and the lack of 

funding, it ultimately determined to proceed with other countermeasures. Although the cost of 

reconstructing a grade crossing is a critical decision-making factor for local authorities, the lack 

of guidance or standards for establishing a maximum acceptable vertical profile of an existing 

grade crossing also presents a challenge when determining whether reconstruction is necessary. 

Because neither the FHWA nor the FRA provides guidance indicating what the maximum vertical 

profile of a crossing should be, a jurisdiction’s decision on crossing reconstruction is essentially 

subjective.

The NTSB concludes that traffic engineers would benefit from clear guidance that 

describes the maximum vertical profile a grade crossing may have before comprehensive risk 

mitigation options, including crossing reconstruction, should be considered to improve safety. The 

NTSB recommends that the FHWA, with assistance from the FRA, AASHTO, and AREMA, 

develop specific criteria to establish when an existing grade crossing should be reconstructed, 

closed, or otherwise have the risk posed by its unsafe vertical profile comprehensively mitigated;

and incorporate the guidance into its Railroad-Highway Grade Crossing Handbook.

2.3.2 Coordination of Maintenance and Risk Monitoring

2.3.2.1 Early Coordination on Maintenance. The Main Street grade crossing had last been 

reconstructed in 1977. The reconstruction plans specified a downgrade slope of 12.3 percent north 

of the tracks, which is well beyond the current recommended guidance for maximum slope. Since 

1977, CSXT has performed regular maintenance of the tracks, including replacing wooden railroad 

ties, a procedure that raises the track level by about 1.5 inches each time it is performed. Over the 

years, this accumulation of track level elevations can substantially raise the railroad track above 

its original construction level. Moreover, even a single track elevation can have a substantial 

impact on grade crossing safety. 

At the Main Street crossing, the wooden railroad ties had last been replaced in February 

2014. The 23 vehicle groundings that were reported at the crossing in the 3 years after the February 

2014 track maintenance—compared to only 3 reported groundings for the previous 2 years—
NTSB Highway Accident Report

43

suggest that the last elevation of the tracks substantially increased the risk of vehicle groundings

on the crossing. Railroad maintenance that affects a grade crossing’s vertical profile can have a 

considerable safety impact on all road users, particularly when it increases the crossing’s vertical 

profile beyond recommended parameters, as specified by both highway (AASHTO and the

FHWA) and railroad (AREMA) organizations. 

The FRA does not require railroad companies to coordinate with, or even inform, local and 

state transportation agencies when they conduct maintenance on railroad tracks. MDOT was not 

informed of the track maintenance that CSXT conducted in February 2014. Although CSXT most 

likely informed the City of Biloxi that it planned to carry out some railroad work—given that the 

work required closure of the affected crossings—NTSB investigators uncovered no evidence that 

CSXT gave the city details about the work being done, or specifically, that it would raise the 

crossings’ vertical profiles. 

The Transportation Research Board (TRB) has published research on practices pertaining 

to the review and implementation of projects between highway agencies and railroad companies, 

including work on improving and reconstructing grade crossings (TRB 2010). As part of this 

research, practitioners from more than 50 highway agencies and railroad companies were 

interviewed, and TRB identified 20 commonly desired practices, including (1) early formal 

coordination between a railroad company and state and local highway agencies, and (2) periodic 

and ongoing reviews of the project throughout its development.

Although early coordination on grade crossing maintenance projects can be beneficial, the 

extent to which such coordination about the February 2014 track maintenance might have affected 

the circumstances of this crash cannot be determined. We do not know whether MDOT or the City

of Biloxi might have realized that raising the vertical profile of the Main Street crossing could 

increase the risk of vehicle grounding, or whether either agency would have elected to take 

effective countermeasures based on such knowledge. At a minimum, however, with better 

communication, MDOT and the City of Biloxi would have had the opportunity to consider the 

potential for increased risk of vehicle groundings on the crossing. By not communicating 

effectively with MDOT and the city about the crossing maintenance and its consequences, CSXT 

denied them this opportunity.

The NTSB concludes that, had CSXT communicated and coordinated with the City of 

Biloxi and MDOT about planned railroad projects that might affect the vertical profiles of grade 

crossings in their jurisdictions, it would have provided them the opportunity to assess and monitor 

the risks of vehicle groundings and, if necessary, to take proactive action to reduce those risks.

Therefore, the NTSB recommends that all Class I railroads implement a process to notify and 

coordinate with the local and state transportation agencies responsible for highway maintenance 

at grade crossings as early as possible before conducting any planned maintenance work that has 

the potential to increase track elevation.

2.3.2.2 Risk Monitoring. There is some confusion as to which entity is responsible for safety 

associated with grade crossing maintenance. CSXT and the City of Biloxi each claimed that the 

other party was responsible for maintaining grade crossings. The NTSB examined a 1977 

agreement between CSXT and the City of Biloxi, as well as the relevant case law. Although the

agreement indicates that the city assumed the entire expense of construction, installation, 
NTSB Highway Accident Report

44

maintenance, and operation of any grade crossings in its jurisdiction, including any warning 

devices, some subsequent case law indicates that a railroad may not contract away its duties and 

liabilities concerning the safety of public grade crossings. In addition, Mississippi statutes (Miss. 

Code. Ann. § 65-1-175 [2013]) grant MDOT a certain level of authority over public 

roadway/railroad crossings, including the power to abolish or close a crossing, require new 

safety-related signage, or approve the construction of new or existing crossings.

It is outside the scope of this investigation to make a definitive determination as to which 

entity bears the responsibility for maintenance of the Main Street grade crossing; however, both 

CSXT and the City of Biloxi were aware of the frequency of vehicle groundings in the 3 years

following the February 2014 track maintenance that increased the crossing’s vertical profile.

73 The 

NTSB concludes that, although CSXT and the City of Biloxi knew that numerous vehicle 

groundings had occurred on the Main Street grade crossing after track maintenance was performed 

in early 2014, neither took action to reduce the safety risk posed by the crossing to both railroad 

and highway traffic.

Many state DOTs have negotiated standard legal agreements with railroad companies 

regarding grade crossing maintenance and reconstruction. For example, in 1976, the state of Iowa 

initiated a grade crossing surface repair program with the primary objective of reconstructing all 

grade crossings and providing subsequent regular maintenance (TRB 2010). Under the program, 

grade crossings throughout the state are reviewed, scored as to their need for reconstruction 

(determined by multiple factors, including average annual daily traffic, elevation differential, and 

approach profile), and then selected for improvement. By agreement, these projects are funded by 

contributions from state and local governments, as well as from railroad companies. Some states,

like Iowa and Washington, have centralized coordination of all highway projects related to rail

operations, which allows the state to prioritize projects and ensure consistency in negotiating and 

establishing agreements with railroad companies. 

Although Mississippi does not have centralized coordination of highway–railroad projects, 

MDOT does have limited authority over grade crossings, including the power to close any it deems 

unsafe. MDOT is divided into six districts that communicate with local municipalities and relay 

significant safety issues to MDOT management. However, incidents of vehicle groundings on 

grade crossings are not communicated to MDOT. Given sufficient information, MDOT may be in 

the best position to provide oversight, facilitate communication, and assist in arbitrating situations 

when a railroad company and a local authority disagree on maintenance responsibilities. Local

municipalities are critical sources of information on the safety of individual grade crossings, 

including the incidence of vehicle groundings and secondary measures of risk, such as the 

crossing’s slope and average annual daily traffic of commercial vehicles. However, the local 

highway transportation departments that communicate with MDOT may not have complete 

records of all such incidents within their municipalities. For example, although the BPD was aware 

of nearly all grounding incidents on the Main Street grade crossing, the Biloxi Engineering 

Department had records for only a fraction of these incidents.

 73 As noted earlier, after the February 2014 maintenance, there were 23 incidents of vehicle grounding on the 

Main Street grade crossing, 2 of which ended in collisions. The BPD was aware of 18 of these incidents, and CSXT

had records for 22 of them.
NTSB Highway Accident Report

45

The NTSB concludes that, because MDOT has authority to close grade crossings in the 

state, increasing the department’s awareness of the safety conditions of grade crossings through 

enhanced communication with local municipalities might enable it to prioritize improvements to 

Mississippi grade crossings and assist in improving grade crossing safety. Therefore, the NTSB 

recommends that MDOT establish communication channels with local municipalities, particularly 

the City of Biloxi, to monitor the safety of grade crossings, focusing particularly on incidents of 

vehicle groundings, and, as necessary, assist municipalities in improving the safety of high-risk 

grade crossings. Additionally, the NTSB recommends that the City of Biloxi implement a program 

to document incidents of vehicle groundings at grade crossings and to share this information with 

MDOT.

Although various agencies in the City of Biloxi were aware of the incidents of vehicle 

groundings at the Main Street grade crossing, other, especially smaller, municipalities may not 

maintain such records. If state DOTs rely solely on local municipalities to monitor the safety of 

grade crossings, particularly through the evidence of incidents of vehicle groundings, they may be 

insufficiently informed. CSXT, on the other hand, keeps records of vehicle grounding incidents, a 

practice typical of railroad companies. Railroad companies are highly incentivized to share 

information about high-risk grade crossings with agencies able to effect safety improvements.

Such grade crossings represent a safety risk not only to highway vehicles but also to trains, because

emergency braking, and especially crashes, can cause derailments. Considering that grounding 

data can be critical in determining the safety of a grade crossing and in predicting the likelihood 

of future crashes, such grounding incident information should be shared. Therefore, the NTSB 

concludes that if railroads shared their information on incidents of vehicle groundings on grade 

crossings with state DOTs, it would enable state authorities to continuously monitor and assess the 

safety of the grade crossings in their jurisdictions. Therefore, the NTSB recommends that all

Class I railroads implement a process to make information about incidents of vehicle groundings 

at grade crossings that did not result in a crash on their railroad available to the appropriate state 

departments of transportation.

Moreover, to ensure that the railroad industry as a whole is aware of the important safety 

issues associated with coordinating and communicating with local authorities about both grade 

crossing risk and maintenance work at crossings, the NTSB further recommends that the 

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

Association inform their members of the circumstances of the March 7, 2017, Biloxi, Mississippi, 

grade crossing crash, and emphasize the importance of communication with local and state 

highway transportation agencies regarding railroad maintenance activities and vehicle grounding 

incidents on grade crossings.

2.4 Emergency Egress and Extrication

Emergency evacuation from the motorcoach occurred both before and after the collision.

Based on data from various recorders, the motorcoach was grounded on the crossing for a brief 

period before the grade crossing warning system activated, which occurred about 29 seconds 

before the crash. When the passengers noticed the crossing lights and bells activating, and saw the 

approaching train and heard its horn, they told the driver, who opened the loading door and told 

them to evacuate. It is unclear when the driver opened the loading door but, based on the onboard 

video from the motorcoach’s interior-facing camera—which shows about 7 seconds of preimpact 
NTSB Highway Accident Report

46

events, an already-open loading door, and passengers evacuating—and postcrash interviews with 

the passengers, the door was open for more than 8 seconds before the crash. Six passengers safely 

evacuated before the impact; the evacuation of three of these passengers was captured by the 

camera, and the other three passengers had safely evacuated before the video began. Two of the 

passengers who died were attempting to exit the motorcoach at the time of impact, while a third 

passenger who died had stepped off the vehicle just before the impact.

Preimpact evacuation was a safer option than remaining on the motorcoach, but only for 

those passengers who had sufficient time to reach a safe distance from the crash area before the 

collision. All the passengers were attempting to evacuate via the loading door, which crowded the 

aisleway exit path and limited the time available for safe egress by this route. The passengers were 

mostly members of a senior center, and their limited mobility, as well as the (at least) 22-inch 

distance from the loading door’s bottom step to the ground (while the motorcoach was stuck on 

the track), most likely reduced the speed of evacuation through the loading door.

None of the passengers who remained on the motorcoach attempted to use the rear door or 

the emergency windows as means of precrash egress, and it is difficult to determine whether any 

would have had time to safely evacuate through these alternate egress points before the impact. 

The time between the driver’s order to evacuate and the train’s impact was brief. The NTSB 

concludes that, with respect to preimpact evacuation, because of the brief period during which the 

motorcoach was grounded on the crossing before the train struck it and the limited mobility of 

many of the passengers, it is unlikely that many more passengers could have safely evacuated 

before the collision occurred, regardless of which means of egress was used.

Although the motorcoach was equipped with a secondary door at the rear, no attempts were 

made to use the door during the preimpact evacuation. Even had the passengers’ evacuation 

parameters been optimal—proximity to egress point, good physical condition, sufficient time to 

reach a safe area, etc.—their ability to open the rear door would depend on their being aware of its

existence and their understanding of how to operate it. Some passengers, who were trapped in the 

rear of the motorcoach because of the overcrowded aisle, were standing near the rear door before

the collision, but they told investigators that they had been unaware of its presence.

Although it is debatable whether the rear door could have been safely used for egress before

the train struck the motorcoach, particularly because its bottom edge was about 4 feet 8 inches 

above the ground, the door’s potential postcrash usefulness is clear. The train’s impact reduced the 

aisle width in the middle section of the motorcoach to about 8 inches, and it caused the floor to 

buckle and tear. Also, some injured passengers were on the floor, which—combined with the 

reduced aisle width—caused significant aisle congestion and prevented passengers at the rear of 

the motorcoach from exiting through the loading door. First responders assisted the passengers in 

the rear to evacuate through the windows but, due to the limited mobility of many of the passengers 

and the need to extricate some on backboards, evacuation via the windows was challenging. 

By the time emergency responders were removing occupants from the motorcoach, the rear 

door was inoperative from inside the motorcoach. Although the rear door was undamaged, its

emergency handle had been removed and displaced by a passerby who entered the motorcoach

ahead of emergency responders. Eventually, responders cut away the entire rear door to help speed 

the extrication process. Had the passengers been aware of the presence of the rear door and been 
NTSB Highway Accident Report

47

able to open it immediately after the impact, its use most likely would have reduced the evacuation 

time. Although the rear door’s considerable distance from the ground would have made it 

challenging for passengers to use it to jump from the motorcoach unaided, the door would have 

provided responders with an easy extrication access point. However, based on the evidence of the 

injuries sustained by passengers, it is unlikely that the injury outcomes would have been changed

had the first responders been able to evacuate rear passengers sooner.

As a result of a 2014 motorcoach crash in Orland, California, in which damage and a 

postcrash fire made passengers’ egress difficult, contributing to the severity of their injuries

(NTSB 2015), the NTSB recommended that NHTSA require new motorcoaches to include a 

secondary door for use as an emergency exit (Safety Recommendation H-15-13, which is 

classified “Open—Acceptable Response”). Although the rear door on the Biloxi motorcoach was 

not designated as an emergency exit, it would have been considered one on some differently 

configured motorcoaches. The design of this door would have allowed it to be used as a secondary 

egress point; yet, for the reasons indicated earlier, it was not used for that purpose in this case.

As a result of the Orland investigation, the NTSB also recommended that the FMCSA—

Require all passenger motor carrier operators to (1) provide passengers with pretrip 

safety information that includes, at a minimum, a demonstration of the location of 

all exits, explains how to operate the exits in an emergency, and emphasizes the 

importance of wearing seat belts, if available; and (2) also place printed instructions 

in readily accessible locations for each passenger to help reinforce exit operation 

and seat belt usage. (H-15-14)

This recommendation is classified “Open—Acceptable Response.”

In its most recent correspondence concerning this recommendation, dated March 2018, the 

FMCSA stated that, due to the wide variance in vehicles operated by passenger carriers, it does 

not believe that Safety Recommendation H-15-14 is viable; consequently, it does not plan to 

implement the necessary rulemaking. However, the FMCSA stated that it will continue to 

recommend that carriers voluntarily provide safety-related information to passengers. Although

the NTSB acknowledges the challenges in implementing this recommendation among the various 

types of passenger vehicles and operations to which it applies, we reject the FMCSA’s conclusion 

that the recommendation is not viable. 

The motorcoach driver in this case did provide a pretrip safety briefing to the initial group 

of passengers, which included a description of the emergency exit windows; however, he did not 

mention the rear door as a means of emergency egress.74 ECHO Transportation stated that, because 

federal regulations do not require the use of a secondary door for emergency egress, it did not train 

its drivers on how to operate the rear door or inform passengers about the door’s function.

Secondary exit doors are permitted under the Federal Motor Vehicle Safety Standards, and they 

are considered designated emergency exits on certain buses. Van Hool motorcoach models with 

 74 The driver did not provide any safety briefing to the second group of the passengers that he picked up shortly 

after the Bastrop loading stop. Also, he gave the briefing only on the first day of the trip, March 5, 2017.
NTSB Highway Accident Report

48

the same configuration of windows and doors as the Biloxi motorcoach are sold in Europe; to meet 

the European Union requirements, the rear door is considered a designated emergency exit.

75

The NTSB concludes that, with respect to postimpact evacuation, although use of the rear 

door might not have improved the passengers’ injury outcomes, a pretrip safety briefing that 

included a demonstration of how to operate the rear door might have enabled the passengers to 

open that door after the impact, expediting the postcrash evacuation and extrication process. As a 

result, the NTSB reiterates Safety Recommendation H-15-14 to the FMCSA and reclassifies it 

“Open—Unacceptable Response.”

 75 Section 7.6 of Economic Commission for Europe Regulation 107 defines various configurations of acceptable 

exits according to vehicle type and passenger capacity.
NTSB Highway Accident Report

49

3 Conclusions

3.1 Findings

1. None of the following were causal or contributory factors in the crash: (1) motorcoach 

driver licensing or experience; (2) train engineer or conductor licensing or experience; 

(3) motorcoach driver cell phone distraction, substance impairment, or medical condition; 

(4) train engineer or conductor cell phone distraction; (5) mechanical condition of the 

motorcoach; (6) railroad track condition or signal system operation; or (7) weather. 

2. The emergency response to the crash was timely and effective.

3. The motorcoach driver’s decisions to take a scenic route and to rely on a portable global 

positioning system device programmed for commercial vehicle navigation were

reasonable.

4. Given that (1) the motorcoach driver most likely could not have perceived the steepness of 

the northern slope before beginning to traverse the crossing, (2) he took the precaution of 

raising the rear of the motorcoach to prevent scraping the crossing, and (3) no signage

prohibited transiting the crossing in a commercial vehicle, the driver’s decision to travel 

over the Main Street grade crossing was reasonable.

5. Given the speed of the train, the brief period that the motorcoach spent grounded on the 

tracks before the crash, the numerous grade crossings in this area, and how frequently the 

train crew encountered vehicles on crossings that ultimately cleared them safely, the 

estimated time that the train engineer took to detect the motorcoach on the tracks was 

reasonable, and his response time before engaging emergency braking was acceptable.

6. Based on the high frequency of grounding incidents at the Main Street grade crossing, 

which was posted with low ground clearance grade crossing (LGCGC) warning signage, 

and the lack of evidence of the safety benefits provided by LGCGC warning signs, the 

effectiveness of such signs in promoting safety at grade crossings may be negligible.

7. Traffic engineers would benefit from clear guidance that describes when vehicle exclusion 

signs should be installed at grade crossings.

8. Due to the February 2014 track maintenance work, which increased the crossing’s vertical 

profile and resulted in increased frequency of vehicle groundings, the Main Street grade 

crossing had been unsafe for certain types of vehicles for several years before the fatal 

March 2017 crash.

9. Traffic engineers would benefit from clear guidance that describes the maximum vertical 

profile a grade crossing may have before comprehensive risk mitigation options, including 

crossing reconstruction, should be considered to improve safety.

10. Had CSX Transportation communicated and coordinated with the City of Biloxi and the 

Mississippi Department of Transportation about planned railroad projects that might affect 

the vertical profiles of grade crossings in their jurisdictions, it would have provided them 
NTSB Highway Accident Report

50

the opportunity to assess and monitor the risks of vehicle groundings and, if necessary, to 

take proactive action to reduce those risks. 

11. Although CSX Transportation and the City of Biloxi knew that numerous vehicle 

groundings had occurred on the Main Street grade crossing after track maintenance was 

performed in early 2014, neither took action to reduce the safety risk posed by the crossing

to both railroad and highway traffic.

12. Because the Mississippi Department of Transportation has authority to close grade 

crossings in the state, increasing the department’s awareness of the safety conditions of 

grade crossings through enhanced communication with local municipalities might enable

it to prioritize improvements to Mississippi grade crossings and assist in improving grade 

crossing safety.

13. If railroads shared their information on incidents of vehicle groundings on grade crossings 

with state departments of transportation, it would enable state authorities to continuously 

monitor and assess the safety of the grade crossings in their jurisdictions. 

14. With respect to preimpact evacuation, because of the brief period during which the 

motorcoach was grounded on the crossing before the train struck it and the limited mobility 

of many of the passengers, it is unlikely that many more passengers could have safely 

evacuated before the collision occurred, regardless of which means of egress was used.

15. With respect to postimpact evacuation, although use of the rear door might not have 

improved the passengers’ injury outcomes, a pretrip safety briefing that included a 

demonstration of how to operate the rear door might have enabled the passengers to open 

that door after the impact, expediting the postcrash evacuation and extrication process.

3.2 Probable Cause

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

Mississippi, crash was the failure of CSX Transportation and the City of Biloxi to coordinate and 

take action to improve the safety of the Main Street grade crossing, a high vertical profile crossing 

on which motor vehicles were known to ground frequently; their inaction led to the grounding of 

the motorcoach that was subsequently struck by the CSX Transportation freight train. Contributing 

to the circumstances of the crash was the inadequate guidance from the Federal Highway 

Administration on how to mitigate the risks posed by grade crossings with high vertical profiles.
NTSB Highway Accident Report

51

4 Recommendations

4.1 New Recommendations

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

following new safety recommendations:

To the Federal Highway Administration:

Issue an interpretation of the guidance practice for low ground clearance grade 

crossing warning signage in the Manual on Uniform Traffic Control Devices for 

Streets and Highways to suggest the use of other signage, such as vehicle exclusion 

signs, to address safety issues at high-profile grade crossings. Inform the state 

departments of transportation of the new interpretation. (H-18-23)

Develop and establish a guidance practice addressing the circumstances in which 

vehicle exclusion signs should be installed to restrict access to high-profile grade 

crossings and the types of vehicles to which the exclusions should apply. 

Incorporate the guidance practice into the Manual on Uniform Traffic Control 

Devices for Streets and Highways. (H-18-24)

With assistance from the Federal Railroad Administration, American Association 

of State Highway and Transportation Officials, and American Railway Engineering 

and Maintenance-of-Way Association, develop specific criteria to establish when 

an existing grade crossing should be reconstructed, closed, or otherwise have the 

risk posed by its unsafe vertical profile comprehensively mitigated. Incorporate the 

guidance into your Railroad-Highway Grade Crossing Handbook. (H-18-25)

To the Federal Railroad Administration:

Assist the Federal Highway Administration (FHWA) in developing specific criteria 

to establish when an existing grade crossing should be reconstructed, closed, or 

otherwise have the risk posed by its unsafe vertical profile comprehensively 

mitigated, to be incorporated into the FHWA Railroad-Highway Grade Crossing 

Handbook. (R-18-11)

To the Mississippi Department of Transportation:

Establish communication channels with local municipalities, particularly the City 

of Biloxi, to monitor the safety of grade crossings, focusing particularly on 

incidents of vehicle groundings, and, as necessary, assist municipalities in 

improving the safety of high-risk grade crossings. (H-18-26)
NTSB Highway Accident Report

52

To the City of Biloxi, Mississippi:

Implement a program to document incidents of vehicle groundings at grade 

crossings and to share this information with the Mississippi Department of 

Transportation. (H-18-27)

To the American Association of State Highway and Transportation Officials:

Assist the Federal Highway Administration (FHWA) in developing specific criteria

to establish when an existing grade crossing should be reconstructed, closed, or 

otherwise have the risk posed by its unsafe vertical profile comprehensively 

mitigated, to be incorporated into the FHWA Railroad-Highway Grade Crossing 

Handbook. (H-18-28)

To the American Railway Engineering and Maintenance-of-Way Association:

Assist the Federal Highway Administration (FHWA) in developing specific criteria 

to establish when an existing grade crossing should be reconstructed, closed, or 

otherwise have the risk posed by its unsafe vertical profile comprehensively 

mitigated, to be incorporated into the FHWA Railroad-Highway Grade Crossing 

Handbook. (R-18-12)

To the Association of American Railroads and the American Short Line and Regional 

Railroad Association:

Inform your members of the circumstances of the March 7, 2017, Biloxi, 

Mississippi, grade crossing crash, and emphasize the importance of communication 

with local and state highway transportation agencies regarding railroad 

maintenance activities and vehicle grounding incidents on grade crossings. 

(R-18-13)

To all Class I railroads:

Implement a process to notify and coordinate with the local and state transportation 

agencies responsible for highway maintenance at grade crossings as early as 

possible before conducting any planned maintenance work that has the potential to 

increase track elevation. (R-18-14)

Implement a process to make information about incidents of vehicle groundings at 

grade crossings that did not result in a crash on your railroad available to the 

appropriate state departments of transportation. (R-18-15)
NTSB Highway Accident Report

53

4.2 Recommendation Reiterated and Reclassified in this Report

The National Transportation Safety Board also reiterates and reclassifies the following 

safety recommendation:

To the Federal Motor Carrier Safety Administration:

Require all passenger motor carrier operators to (1) provide passengers with pretrip 

safety information that includes, at a minimum, a demonstration of the location of 

all exits, explains how to operate the exits in an emergency, and emphasizes the 

importance of wearing seat belts, if available; and (2) also place printed instructions 

in readily accessible locations for each passenger to help reinforce exit operation 

and seat belt usage. (H-15-14)

This recommendation is reiterated and reclassified “Open—Unacceptable Response” in 

section 2.4 of this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ROBERT L. SUMWALT, III EARL F. WEENER

Chairman Member

T. BELLA DINH-ZARR

Member

Adopted: August 7, 2018
NTSB Highway Accident Report

54

Appendix A: Investigation

The National Transportation Safety Board (NTSB) received notification of this crash on 

March 7, 2017, and launched an investigative team to address highway, vehicle, human 

performance, and survival factors; motor carrier and railroad operations; and onboard recorders. 

The NTSB team included staff from the Offices of Board Member Robert L. Sumwalt; Highway 

Safety; Railroad, Pipeline, and Hazardous Materials; Research and Engineering; Safety 

Recommendations and Communications; and Chief Information Officer. Board Member (now 

Chairman) Robert L. Sumwalt was the NTSB spokesperson on scene.

The Federal Highway Administration, the Federal Railroad Administration, the Federal 

Motor Carrier Safety Administration, the Mississippi Department of Transportation, the Biloxi 

Police Department, the Biloxi Department of Engineering, CSX Transportation, TBL 

Group–ECHO Tours and Charters, and ABC Companies (c/o Van Hool) were parties to the 

investigation.
NTSB Highway Accident Report

55

References

AASHTO (American Association of State Highway and Transportation Officials). 2011. A Policy 

on Geometric Design of Highways and Streets, 6th edition. Washington, DC: AASHTO.

AAMVA (American Association of Motor Vehicle Administrators). 2016. Commercial Driver’s 

License Manual. Arlington, Virginia: AAMVA.

AREMA (American Railway Engineering and Maintenance-of-Way Association). 2011. AREMA 

Manual for Railway Engineering. Landover, Maryland: AREMA.

FHWA (Federal Highway Administration). 2007. Railroad-Highway Grade Crossing Handbook, 

revised 2nd edition. Washington, DC: FHWA.

–––. 2009. Manual on Uniform Traffic Control Devices for Streets and Highways. Washington, 

DC: FHWA.

MDOT (Mississippi Department of Transportation). 2001. Mississippi Roadway Design Manual. 

Jackson, Mississippi: MDOT.

–––. 2012. Mississippi Professional Driver’s Manual for Class A, B & C Commercial Driver 

License. MDOT. Accessed July 23, 2018, https://driving-tests.org/mississippi/ms-cdlhandbook/.)

NTSB (National Transportation Safety Board). 2015. Truck-Tractor Double Trailer Median 

Crossover Collision With Motorcoach and Postcrash Fire on Interstate 5, Orland, 

California, April 10, 2014. Highway Accident Report NTSB/HAR-15/01. Washington, 

DC: NTSB.

TRB (Transportation Research Board). 2010. Strategies for Improving the Project Agreement 

Process Between Highway Agencies and Railroads (SHRP 2). Report S2-R16-RR-1.

Washington, DC: TRB.

TxDPS (Texas Department of Public Safety). 2014. Texas Commercial Motor Vehicle Drivers 

Handbook. Austin, Texas: TxDPS. [Note: Handbook indicates that its content was created 

for and provided to state driver license agencies by the American Association of Motor 

Vehicle Administrators in 2005.]