Derailment of Amtrak Auto Train

P052-18 on the CSXT Railroad Near

Crescent City, Florida

April 18, 2002

Railroad Accident Report

NTSB/RAR-03/02

PB2003-916302

Notation 7487A

National 

Transportation

Safety Board

Washington, D.C.

Railroad Accident Report

Derailment of Amtrak Auto Train P052-18 on the 

CSXT Railroad Near Crescent City, Florida 

April 18, 2002

NTSB/RAR-03/02

PB2003-916302 National Transportation Safety Board

Notation 7487A 490 LíEnfant Plaza, S.W.

Adopted August 5, 2003 Washington, D.C. 20594
National Transportation Safety Board. 2003. Derailment of Amtrak Auto Train P052-18 on the CSXT

Railroad Near Crescent City, Florida, April 18, 2002. Railroad Accident Report NTSB/RAR-03/02.

Washington, DC.

Abstract: About 5:08 p.m. eastern daylight time on April 18, 2002, northbound National Railroad

Passenger Corporation (Amtrak) train P052-18, the Auto Train, derailed 21 of 40 cars on CSX

Transportation track near Crescent City, Florida. The train derailed in a left-hand curve while traveling

about 56 mph. The train was carrying 413 passengers and 33 Amtrak employees. The derailment resulted

in 4 fatalities, 36 serious injuries, and 106 minor injuries. The equipment and track costs associated with

the accident totaled about $8.3 million.

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

continuous welded rail temperature control; continuous welded rail restraint, including ballast and rail

anchors; continuous welded rail maintenance procedures and standards; means of end-of-train device

activation; Amtrak passenger accountability procedures; and securement of folding armchairs on Amtrak

Superliner sleeper cars.

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

recommendations to CSX Transportation, Inc., Amtrak, the Federal Railroad Administration, and the

Transportation Security Administration.

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

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

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

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

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

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

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

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

purchase this publication, order report number PB2003-916302 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

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

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

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

Contents

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

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

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

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

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

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Amtrak Train-Operating Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

CSXT Track Maintenance Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Signal Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Track Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Preaccident CSXT Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Track Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

FRA Track Safety Program and CWR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Rail Anchors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Roadbed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Ballast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Track Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Postaccident FRA and State Track Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

CWR Temperature Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Area Emergency Response Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Amtrak Personnel Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Auto Train Event Recorder Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Superliner Passenger Car Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Superliner Sleeper Car Folding Armchairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Testing and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Track Forces Induced by CSXT Coal Train N16815 . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

CWR-SAFE Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Postaccident Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Track Buckle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Track Condition and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Contents iv Railroad Accident Report

Roadbed, Ballast, and Rail Anchor Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Track Alignment After Surfacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

CWR Temperature Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Derailment Dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Auto Train Consist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Two-Way End-Of-Train Device Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Passenger Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Railcar Crashworthiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Superliner Passenger Car Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Superliner Sleeper Car Folding Armchairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

B: Passenger On-Board Record Procedures from Amtrak Service Standards Manual 

 for Management Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

C: Passenger Train Two-Way End-Of-Train Device Regulations . . . . . . . . . . . . . . . . . . . . 68

D: Chronological List of Track Maintenance Operations on Accident Curve 

 Following Shoulder Ballast Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

E: Summary of Key Event Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
v Railroad Accident Report

Executive Summary

About 5:08 p.m. eastern daylight time on April 18, 2002, northbound National

Railroad Passenger Corporation (Amtrak) train P052-18, the Auto Train, derailed 21 of 40

cars on CSX Transportation (CSXT) track near Crescent City, Florida. The train derailed

in a left-hand curve while traveling about 56 mph. The train was carrying 413 passengers

and 33 Amtrak employees. The derailment resulted in 4 fatalities, 36 serious injuries, and

106 minor injuries. The equipment and track costs associated with the accident totaled

about $8.3 million.

The National Transportation Safety Board determines that the probable cause of

the April 18, 2002, derailment of Amtrak Auto Train P052-18 near Crescent City, Florida,

was a heat-induced track buckle that developed because of inadequate CSX

Transportation track-surfacing operations, including misalignment of the curve,

insufficient track restraint, and failure to reestablish an appropriate neutral rail

temperature.

The safety issues addressed in the report are:

ï Continuous welded rail temperature control,

ï Continuous welded rail restraint, including ballast and rail anchors,

ï Continuous welded rail maintenance procedures and standards,

ï Means of end-of-train device activation,

ï Amtrak passenger accountability procedures, and

ï Securement of folding armchairs on Amtrak Superliner sleeper cars.

Other items discussed in the report include:

ï Suitability of the Auto Train consist and

ï Crashworthiness of Superliner passenger car windows.

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

recommendations to CSXT, Amtrak, the Federal Railroad Administration, and the

Transportation Security Administration.

1 Railroad Accident Report

Factual Information

Accident Synopsis

About 5:08 p.m. eastern daylight time1 on April 18, 2002, northbound National

Railroad Passenger Corporation (Amtrak) train P052-18,2

 the Auto Train, derailed 21 of

40 cars on CSX Transportation (CSXT) track near Crescent City, Florida. (See figure 1 for

a map showing the accident location.) The train derailed in a 3-degree, 11-minute lefthand curve while traveling about 56 mph. The train was carrying 413 passengers and 33

Amtrak employees.3 The derailment resulted in 4 fatalities, 36 serious injuries, and 106

minor injuries. The equipment and track costs associated with the accident totaled about

$8.3 million. (See figures 2 through 4 showing the accident aftermath.)

1 Unless otherwise indicated, all times are eastern daylight time.

2 ìP052-18î stands for Passenger Train number 52 of the 18th (of April).

3 Of the 33 Amtrak employees on the train, 24 were service personnel, 5 were service managers, and 4

were train-operating crewmembers.

Figure 1. Map showing accident location on CSXT Sanford subdivision. 

(Insert shows CSXT rail line running north from Sanford. Star marks 

approximate accident site.)

0 20

Miles

40 60 80

Gulf of Mexico

ATLANTIC

OCEAN FLORIDA

GEORGIA ALABAMA

Orlando

Jacksonville

Miami

Tampa

Crescent City

De Land

Palatka

Sanford 0 20

Miles

40
Factual Information 2 Railroad Accident Report

Figure 2. Aerial view of accident site.

Figure 3. View of two cars after the accident.
Factual Information 3 Railroad Accident Report

Accident Narrative

Northbound Amtrak Auto Train P052-18 originated at Sanford, Florida, on

April 18, 2002, bound for Lorton, Virginia. The train consisted of a 2-unit diesel-electric

locomotive and 16 Amtrak Superliner passenger cars, followed by 24 loaded Amtrak

automobile-carrying ìautorackî cars.

According to the Auto Train crewmembers, the train had been assembled before

they boarded. Before departure, carmen4 successfully performed the required Federal

Railroad Administration (FRA) initial terminal equipment inspection, a Class I air brake

test,5 and a two-way end-of-train (EOT) device test. The Auto Train operating crew held a

job briefing before departure.

The CSXT train dispatcher granted the Auto Train permission to come out of the

loading facility and occupy the main track after southbound Amtrak train 97 had cleared

the Sanford Station. The Auto Train departed Sanford at 4:08 p.m., 8 minutes behind

schedule. The engineer performed a mandatory running air brake test6

 after the train

departed the station and noted that the brakes worked as expected. The train-operating

crew said that the trip from Sanford until the accident was uneventful and that all

equipment functioned normally.

Figure 4. Figure 4. Panoramic/composite image view of derailed cars. (Photo source: 

Putnam County Sheriffís Department. Panoramic/composite view developed by the 

Safety Board.)

4 Carmen represent a union (Brotherhood of Railway Carmen) craft of Amtrak mechanical department

employees who service and maintain the rolling equipment, principally the cars.

5 See 49 Code of Federal Regulations 238.313.

6 See 49 Code of Federal Regulations 238.319.
Factual Information 4 Railroad Accident Report

CSXT dispatcher records showed that the Auto Train had an ìout timeî7 at

Sanford8

 of 4:17 p.m. The train passed the Benson Junction, De Land, and Barberville

Stations at 4:23, 4:35, and 4:44 p.m., respectively. As the train moved northwards, it

passed automated hotbox/dragging equipment detectors at Orange City and Barberville,

Florida, which detected no defects. The Auto Train arrived at Seville, Florida, at 4:53 p.m.

and waited on the mainline for a CSXT southbound coal train (train N16815) to pass. The

Auto Train then departed at 5:00 p.m.

Upon leaving Seville, the engineer applied power to accelerate the train to 60 mph,

the maximum speed allowed for the curve 3 miles ahead, between mileposts (MPs) 723.0

and 722.2. The train was operating under a clearsignal indication9

 from the wayside traffic

control signal system. Event recorder data showed that the train was traveling at 56 mph

as it approached MP 722.

The engineer said that he was monitoring the progress of the trainís acceleration,

not wanting to exceed the 60-mph speed restriction. He said that the speed indicator was

showing 57 mph. As he looked at the track ahead, he noticed an irregularity in the track

alignment just before the locomotive passed over it. He saw that both rails were out of

alignment. He described the rails as being parallel to one another and out of line to the

right (to the east, or outside, of the curve) by about 10 inches. The engineer said that as he

raised his hand toward the controls, he was jarred violently as the engine passed over the

misalignment. He said that despite being jolted, he quickly managed to bump the air brake

handle and initiate a service application of the train air brakes. According to event

recorder information, he initiated an emergency brake application a few seconds later. He

activated the two-way EOT device about 15 seconds after initiating the emergency brake

application.10 The 3rd through 23rd (21 total) cars derailed. According to the event

recorder, the lead locomotive unit came to a stop about 700 feet from the point at which

the engineer made the emergency brake application.

The engineer said that during the derailment, the assistant engineer shouted for

him to place the brake handle in emergency. The engineer also heard a radio call from the

conductor requesting an emergency brake application.

The assistant engineer said that he was reviewing a train bulletin when the engine

passed over the track anomaly. He said that he yelled to the engineer and then activated his

7 Out time is not the departure time; it is the time that the train clears the station and interlocking.

8 Sanford is at milepost (MP) 766.3, as measured from a point midway across the CSXT bridge that

spans the James River at Richmond, Virginia, which is MP 0. Technically, all the MPs on this track have an

ìAî as a prefix, in reference to the predecessor railroad Atlantic Coast Line. For simplicity, in this report, the

prefix is omitted in all cases.

9 A clear or green wayside signal indicates that the train may travel up to the maximum authorized

speed.

10 The two-way EOT device is a telemetry tool attached to the end coupler of the train. The EOT device

transmits the brake pipe pressure at the rear of the train to the lead unit (head-end locomotive). The brake

pipe pressure can also be seen on a digital readout on the flashing rear-end device itself. A two-way EOT

device is also capable of receiving a transmission from the lead unit to open the brake pipe and put the train

into emergency.
Factual Information 5 Railroad Accident Report

emergency brake valve. After the train came to a stop, the assistant engineer programmed

the radio to the emergency channel for the dispatcher. The engineer told the train

dispatcher of the derailment and requested emergency assistance. They had the following

exchange:

Engineer: AA --- Emergency radio, over. We have a wreck, milepost 722,

P052. We have cars on their side.11

AA Dispatcher: Okay. P052, we have a wreck at 722 milepost, cars near

the right-of-way or on the right-of-way, over?

Engineer: We were coming around ----, we had a bad kink in the rail.12

AA Dispatcher: Okay. P052, I understand those are your cars on the side, over.

Engineer: We have cars on the side. We will need emergency assistance.

AA Dispatcher: Okay, sir. I will get everybody coming.

The engineer and assistant engineer assessed the situation and decided that the

engineer would remain on the locomotive to relay radio communications. The assistant

engineer went to help the passengers and Amtrak personnel in the derailed cars.

The dispatcher contacted CSXT police and told them of the derailment and the

location. After this conversation, the dispatcher called the Auto Train engineer and they

had the following exchange:

AA Dispatcher: Okay. I have all the emergency people notified now. Can

you give me more information ---- to access it? Over.

Engineer: We were coming around a curve at, the Silver Lake

Curve; milepost 722.2, there was a bad kink in the rail.

The engine made it over, and about the first four cars

made it over and then we got cars piled one on top of the

other behind it.

11 ìAAî is the CSXT letter designation for the dispatcher who controlled the accident area.

12 In the railroad industry, the term ìkinkî (sometimes called a ìsun kinkî) refers to a track buckle. A

track buckle is an irregularity in track alignment. Track buckles may be caused by a number of conditions;

among the causes are rail alignment deviation and the railís expansive forces exceeding the ballast/track

structureís capability to restrain them.
Factual Information 6 Railroad Accident Report

The conductor was riding in the second car at the time of the derailment. He was

thrown about the car as it passed over the misaligned track. After the train came to rest, the

conductor exited the coach and radioed the engineer to shut down the head-end power.13

The assistant conductor was riding in the first dining car, which was the seventh

car from the locomotive. The dining cars were open for the evening meal, and patrons

were being seated at the time of the derailment. The assistant conductor said that he had

just gone downstairs into the lower level of the dining car when the derailment occurred.

As the car derailed, it rolled onto its side. The assistant conductor helped passengers and

crew climb upward out of the ìtopî of the overturned dining car through what had been a

side door.

Auto Train on-board service employees told passengers what had happened and

that emergency services had been called. Some Amtrak employees provided on-scene first

aid to passengers. Amtrak employees continued to assist passengers, and emergency

service personnel upon their arrival on-scene, until all the passengers had been evacuated

and the site secured. Sometime after dark, the train-operating crew was taken to a local

hospital for required FRA alcohol and drug tests.14

Emergency Response

At 5:09 p.m., the Putnam County 911 operator (Putnam County Dispatch) received

a call from the CSXT police dispatcher requesting immediate emergency medical services

for an Amtrak train that had overturned in Crescent City. The dispatcher said that no

information could be provided on the number of passengers involved. Putnam County

dispatched Rescue Unit #6 from Crescent City Fire Station 3 and Putnam County Sheriff

Unit A397 to the derailment at 5:10 p.m. Rescue Unit #6 departed for the accident at

5:12 p.m. A minute later, Engine 3 from Crescent City Fire Station 3 was en route to the

accident. About the same time, the Volusia County 911 dispatcher transferred a call from

an Auto Train passenger to the Putnam County Dispatch. The passenger said that nine

passenger cars were on their sides and that some passengers were trapped.

At 5:15 p.m., a Crescent City police officer arrived on-scene at Jaffa Road and

State Highway 17. Putnam County Sheriff Unit A397 arrived on-scene at 5:17 p.m. and

reported that the accident location was at Old Highway 17 and State Highway 17. About

this time, another passenger called the Putnam County Dispatch and reported that the

entire train was derailed and overturned. The passenger also said that more than 400

people were on the train and that there were injuries.

The first fire department unit, Engine 3 from Crescent City Fire Station 3, arrived

on-scene at 5:18 p.m. At 5:19 p.m., the Volusia County 911 dispatcher transferred another

13 Head-end power comes from the electrical generator(s) in the locomotive units that provide all

electrical power to the passenger cars for heat, light, and air conditioning.

14 See 49 Code of Federal Regulations Part 219.
Factual Information 7 Railroad Accident Report

call from a passenger on the train to the Putnam County Dispatch. This passenger stated

that he could hear sirens, and he told the dispatcher that the emergency responders needed

to come through a farm. At 5:20 p.m., the chief of the Crescent City Fire Department

arrived on-scene (without his radio, which he had left at the station), assumed incident

command, and established a command post on Jaffa Road. The fire chief immediately

began to assign the arriving emergency responders various duties and to set up triage and

staging areas. The fire chief had never before responded to an emergency of this

magnitude, and he walked around the accident scene to evaluate the situation.

At 5:23 p.m., the first arriving paramedic from Rescue Unit #6 reported to Putnam

County Dispatch that 468 people were on the train, several of whom were trapped and

others who were ìwalking wounded.î Shortly thereafter, the deputy chief of Operations

for Putnam County Emergency Services initiated the Putnam County Comprehensive

Emergency Management Plan by cellular phone while he was en route to the derailment.

(The purpose of the plan is to prepare and respond to a variety of disasters and

emergencies that affect the public.) In addition, he notified the State Warning Point,15

which alerted Florida State agencies to respond to a mass casualty disaster.

From about 5:33 p.m. until his arrival on-scene, the training coordinator for

Putnam County Emergency Services attempted to contact the chief of the Crescent City

Fire Department but was unsuccessful (because the chief had no radio with him). At

5:40 p.m., the training coordinator arrived on-scene and established a staging area at

Clifton Road and Old Highway 17. Having been unable to contact the fire chief, the

training coordinator assumed incident command and established a command post at Old

Highway 17, south of Clifton Road, at 5:46 p.m. By 7:08 p.m., the training coordinator

(incident commander) reported that all passengers had been evacuated except for one

entrapped fatality. At 7:19 p.m., the incident commander moved the command post to

State Highway 17 and Clifton Road. The incident commander departed the scene at

8:08 a.m. on April 19, which officially ended the emergency response.

A total of 441 emergency responders from 31 agencies took part in the response.

Ambulances from eight Florida counties and six medical helicopter services responded to

the accident and transported injured passengers to eight area hospitals. Before the

passengers were transported, emergency responders performed on-scene triage. State and

local law enforcement officers helped emergency responders with the passengers and

provided security and traffic control at the accident scene until the derailment was cleared

from the track on April 21.

As a result of the Crescent City derailment, the chairman of the Board of County

Commissioners for Putnam County declared a state of emergency for the county between

April 18 and 25, 2002, (1-week period) and implemented the Putnam County

Comprehensive Emergency Management Plan. The Florida Division of Emergency

Management had last certified the plan in June 1999, and the Putnam County Board of

Commissioners had last certified it in October 1999.

15 The Florida State Warning Point is a 24-hour communications center that coordinates all State and

local resources during an emergency.
Factual Information 8 Railroad Accident Report

When Safety Board investigators interviewed the training coordinator for Putnam

County Emergency Services (incident commander) after the accident, he said that he had

had problems getting accurate information from Amtrak about the number of people on

the train. He said that soon after he came on-scene, the conductor told him that 468 people

were on board the train and gave him a ìgreeter list.î16 The incident commander said that

the conductor also gave him a passenger list that showed the passengersí locations by car

and room, but the greeter and passenger lists did not match. He said that he and other

emergency responders spent time attempting to verify the accuracy of the two lists. On

April 19, Amtrak gave him a computer printout list with information that did not fully

correlate with either of the other two lists.

According to Amtrak, at the time of the accident, the passenger accountability

procedures described in its Service Standards Manual for Management Employees were in

place on the Auto Train, as well as its other long-distance, overnight, and reserved trains

(including all Metroliner and Acela Express trains).17 (See appendix B for referenced

procedures.) The passenger accountability procedures outlined in this manual, used in

conjunction with the information from the updated passenger manifest, are intended ìto

ensure that the Conductorís Ticket Collections Pouch provides an accurate list of everyone

on-board who may not be ticketed or appear on the manifest.î Conductors are to fill out

form NRPC 3085 for each person who does not have a ticket or does not appear on the

manifest. One copy of this form is to be kept in the conductorís ticket collections pouch

and another copy is to be given to Amtrak station personnel at the next open, staffed

station along the route. The Amtrak station personnel are to use this form to update the

passenger manifest in the electronic reservation system.

The incident commander said that he was never provided an accurate count of

people on the train. During postaccident interviews, the Auto Train conductor told the

deputy chief of Operations for Putnam County Emergency Services that 437 passengers, 3

infants, and 28 crewmembers, for a total of 468 people, had been on the train. By

gathering information from Amtrak, Putnam County Emergency Services, and medical

records, Safety Board investigators determined, about 5 months after the accident, that

446 people had been on the accident Auto Train.

On June 6, 2002, Amtrak officials conducted a debriefing in Palatka, Florida, with

representatives of all the emergency responder agencies involved in the accident, in

accordance with 49 Code of Federal Regulations (CFR) 239.105. The debriefing had

about 80 attendees (including a Safety Board representative) and was intended to

determine the effectiveness of the emergency plans that were implemented; to critically

review the roles, responsibilities, and performance of the agencies involved; and to

16 A greeter list shows the names of all those who made a reservation to travel on that train on that day.

When the passengers arrive to board the train, they check in with an Amtrak employee who ìgreetsî them

and checks off their names. It is not uncommon for someone to make a reservation for a particular day and

then not to show up.

17 See Amtrakís Service Standards Reference Manual for Management Employees, Chapter 16 ìTrain

Service Crew Functions and Accountabilities,î Part D ìPassenger On-Board Record Procedures,î reissued

November 2002.
Factual Information 9 Railroad Accident Report

improve emergency planning and response to future accidents and incidents. Although the

debriefing minutes prepared by Amtrak do not discuss the issue of passenger

accountability, some of the emergency responders involved in the on-scene command

structure stated during the debriefing that the emergency responders found it difficult to

account for the passengers because of the different lists Amtrak provided.

Injuries

The derailment resulted in 4 passenger fatalities, 35 serious passenger injuries, and

104 minor passenger injuries. Amtrak on-board employees sustained one serious and one

minor injury. One emergency responder received a minor injury. (See table 1.)

Table 1. Injuries*

* Title 49 CFR 830.2 defines fatal injury and serious injury as follows: ìFatal injury means any injury which results in death

within 30 days of the accident.î ìSerious injury means any injury which: (1) Requires hospitalization for more than 48 hours,

commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple

fractures of fingers toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any

internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body

surface.î The minor injury category includes all other persons, not cited in the other injury categories, who were reported

treated by area hospitals within 24 hours following the incident.

Damage

The 3rd through 23rd cars derailed during the accident. The first 16 cars in the

train behind the locomotive units were Amtrak Superliner passenger cars; these were

followed by 24 autorack cars. After the derailment, the locomotive units and first two

passenger cars remained on the rails. The next 14 passenger cars and the 7 succeeding

autorack cars derailed. The 7 derailed autorack cars remained generally in-line. The

remaining 17 autorack cars stayed on the rails. (See figure 5 and table 2 for the

postaccident disposition of the 2 locomotive units and the first 23 cars of the train.)

Amtrak 

Employees

Emergency 

Responders Passengers Total

Fatal 0 0 4 4

Serious 1 0 35 36

Minor 1 1 104 106

Total 2 1 143 146
Factual Information 10 Railroad Accident Report

Table 2. Information on postaccident disposition of the locomotive units and first 23 cars 

of the Auto Train.

Figure 5. Postaccident disposition of 2 locomotive units and first 23 cars in accident train. 

(See table 2 for specific information concerning each locomotive unit and car.)

Consist Number Car Number Car Type Car Orientation

1 838 Locomotive Not derailed

2 843 Locomotive Not derailed

3 39002 Transition Sleeper Not derailed

4 32502 Sleeper Not derailed

5 32084 Sleeper Over right-of-way, leaning to the right

6 32074 Sleeper Lying on right side, in ditch

7 32503 Sleeper Lying on right side, in ditch

8 33101 Lounge Lying on right side, in ditch

9 38052 Diner Car Lying on right side, in ditch

10 32501 Sleeper Lying on right side, in ditch

11 32100 Sleeper Lying on right side, in ditch

12 32090 Sleeper Lying on left side, perpendicular to right-ofway

13 34129 Coach Leaning 25°+/- to right, 45°+/- to right-ofway

14 34125 Coach Upright, perpendicular to right-of-way

M.P. 722

No. 1

M.P. 722.24

No. 2

No. 3

No. 4

NORTH

No. 5

No. 6

No. 7

No. 8

No. 9

No. 10

No. 11

No. 12 No. 13

No. 14

No. 15

No. 16

No. 17

No. 18 No. 19

No. 20

No. 21

No. 22

No. 23

No. 24 No. 25

APPROXIMATE START

OF DAMAGED TRACK

APPROXIMATE END

OF DAMAGED TRACK

LOCATION OF

36" CULVERT

POINT OF DERAILMENT

START OF CONCRETE TIE

RETAINING WALL

END OF CONCRETE TIE

RETAINING WALL

SCALE

( IN FEET)

0 25 50 100 N
Factual Information 11 Railroad Accident Report

The disposition of the derailed cars, particularly the passenger cars, reflected the

accordion effect of railcars when they derail, alternately folding together in parallel

fashion, perpendicular to the track. (See figure 6.)

15 34126 Coach Lying on left side, 80°+/- to right-of-way

16 34120 Coach Leaning 25°+/- to left, 75°+/- to right-of-way

17 33100 Lounge Leaning 45°+/- to left, 55°+/- to right-of-way

18 38054 Diner Car Leaning 27°+/- to right, 45°+/- to right-ofway

19 9030 Autorack Derailed upright, 15°+/- to right-of-way

20 9031 Autorack Derailed upright, 15°+/- to right-of-way

21 9019 Autorack Derailed upright, leaning to right

22 9035 Autorack Derailed upright, over right-of-way

23 9004 Autorack Derailed upright, over right-of-way

24 9036 Autorack Derailed upright, over right-of-way

25 9001 Autorack Derailed upright, over right-of-way

Figure 6. Aerial view of derailment showing accordion 

effect of derailed cars.
Factual Information 12 Railroad Accident Report

Amtrak estimated the cost of damage to the equipment at $8.13 million. About

1,000 feet of the main track was destroyed during the derailment, which required the

installation of 25 1/2 track panels. CSXT estimated the cost of track damage at about

$150,000.

Personnel Information

Amtrak Train-Operating Crew

The train-operating crew for the Auto Train reported for duty at the Sanford Auto

Train terminal at 3:00 p.m., about 2 hours and 8 minutes before the accident. The train

crew18 for this train was two engineers,19 a conductor, and an assistant conductor. All trainoperating crewmembers except the engineer were regularly assigned to this train. The

engineer had been called from the extra list because the regularly assigned engineer was

off duty. The 72-hour histories of all the train-operating crewmembers, including the

engineer, indicated that their work schedules met Hours of Service Act requirements.20

Each operating crewmember had been promoted by Amtrak and was qualified over the

Auto Train route. Both the engineer and the assistant engineer were certified according to

Federal regulations.21

CSXT Track Maintenance Personnel

Roadmaster. The roadmaster for this territory was one of seven who reported to

the assistant regional track engineer in Jacksonville, Florida. The roadmasterís territory

was called ìPecan,î and it ran from Palatka to Sanford, Florida. The roadmaster was the

local supervisor responsible for track maintenance through the accident area. He

supervised an administrative clerk, a section foreman with associated trackmen, and a

track inspector. The roadmaster requested, coordinated, and oversaw the surfacing gang

foreman when the surfacing gang was in the roadmasterís territory. The roadmaster was

responsible for ordering and ensuring that all track material and ballast were available for

work to be done.

18 In this report, ìtrain crewî generally refers to the operating crew, including two engineers, the

conductor, and the assistant conductor. The term does not include the on-board service managers or the onboard service personnel.

19 The Auto Train operates with two locomotive engineers. In this report, the engineer of record is

referred to as the ìengineer,î while the other engineer is referred to as the ìassistant engineer.î

20 See 49 CFR Part 228.

21 See 49 CFR Part 240.
Factual Information 13 Railroad Accident Report

The roadmaster was hired as a trackman on May 1, 1962, by a predecessor railroad

and promoted to apprentice foreman in 1963. He became a track foreman in 1965, a rail

gang supervisor in 1967, and a rail gang foreman 6 months later. In 1970, he was

promoted to assistant roadmaster. He was promoted to roadmaster on June 1, 1974. He

had been roadmaster for the railroad,22 including the accident area, since July 1977.

Section Foreman. The section foreman was hired as a trackman on July 13, 1971.

He subsequently became an apprentice foreman and then section foreman. He had been

section foreman in the vicinity of the accident since 1977.

Surfacing Gang. The surfacing gang was a regional asset and was sent to

locations based on roadmaster requests and as directed by the assistant regional track

engineer. The surfacing gang foreman was hired as a trackman on May 3, 1971. He had

been a surfacing gang foreman since 1978. The foreman was familiar with the accident

area. Although there were several surfacing gangs, this surfacing gang usually worked on

the Pecan territory, including the vicinity of the accident. The surfacing gang consisted of

a Mark III track liner-tamper machine23 operator, a ballast regulator machine operator, and

the surfacing gang foreman.

Track Inspector. The track inspector was hired as a trackman on December 7,

1970. He became an apprentice foreman on March 9, 1971, and a foreman inspector on

March 21, 1972. On November 11, 1974, he was promoted to foreman. He was appointed

as assistant roadmaster of Baldwin, Florida, on June 1, 1981, and as roadmaster on the

Brooksville Subdivision at Tallahassee, Florida, on October 10, 1983. In October 1995, he

transferred to the Pecan territory as a trackman. This employee had been the track

inspector on the Pecan territory through the accident area for 6 years (since 1996) prior to

the accident.

Train Information

Amtrak Auto Train P052-18 was about 4,000 feet long and weighed about

3,227 tons.24 The train consisted of a 2-unit diesel-electric locomotive25 followed by 16

Amtrak Superliner passenger cars26 and 24 loaded Amtrak autorack cars. Superliner cars

weigh between 150,000 and 160,000 pounds (unoccupied). Autorack cars are unique to

the Auto Train and are of three types: bi-level autocarriers, tri-level autocarriers, and tri22 The generic term railroad includes the entire system of track, together with stations, land, rolling

stock, and other property used in rail transportation.

23 The Fairmont Mark III machine aligned and tamped the track in one operation.

24 This was the consist list weight and did not include the two locomotive units. The weight is

approximate within 5 percent of actual weight. Passenger and automobile weights are not critical to train

operation and handling because passengers and automobiles account for less than 5 percent of total train

weight even if the train is fully loaded.

25 General Electric P40 ìGenesisî locomotive units, AMTK 838 and AMTK 843.

26 Superliners: 8 sleeper cars, 2 dining cars, 2 lounge cars, and 4 coaches.
Factual Information 14 Railroad Accident Report

level van carriers. Of the 24 autorack cars on Auto Train P052-18, 18 were bi-level

autocarriers and 6 were tri-level autocarriers. Loaded bi-level autocarriers weigh about

122,000 pounds and loaded tri-level autocarriers weigh about 164,000 pounds.

Superliner cars require electrical power from the locomotive units for air

conditioning and lights. Placing the Superliner cars nearest the locomotive units in the

Auto Train consist minimizes transmission distance and simplifies connections. Autorack

cars do not have conduits and piping because they do not require electricity. Because the

autorack cars are typically placed on the end of the train, they do not need to transmit

electrical power.

After the accident and prior to further movement, the locomotive units and the

nonderailed car air brake systems were tested and inspected according to FRA regulations

for Class I (49 CFR 238 Subpart D) and general locomotive (49 CFR 232.105) brake

system safety requirements. The derailed cars had damage that precluded meaningful air

brake tests, so they were not tested. The locomotive units and the first 2 cars were tested as

a single block, and the last 17 autorack cars were tested as another block. The tested

locomotives and cars functioned as designed. A review of the maintenance and service

records for each Amtrak locomotive unit and car revealed no conditions that would affect

dynamic movement.

The train was equipped with a two-way EOT 23404 (Amtrak) Pulse Sentry II

telemetry device.27 (Not all passenger trains are required to have two-way EOT devices.

See appendix C for information concerning EOT regulations for passenger trains.) On

April 23, 2002, Safety Board investigators tested the accident train EOT equipment at

Sanford, Florida. The EOT equipment was mounted on the first postaccident northbound

Auto Train, and the test was conducted prior to the trainís departure. The test trainís lead

locomotive unit, AMTK 838, had been the lead unit of the accident train. The EOT device

was the same one that had been in place on the end of the accident train. After the initial

terminal train air brake test was complete, tests were conducted to evaluate the EOT

device. The two-way EOT device functioned as designed by immediately initiating an

emergency brake application at the rear of the train when the locomotive EOT device was

activated. An additional test was conducted after a service brake application was made, in

accordance with the accident event sequence as recorded by the event recorder. Again, the

EOT emergency activation took place without delay when the locomotive EOT device

was activated.

The cars on the Auto Train had been equipped with a form of electronically

activated pneumatic brakes. Amtrak had been using the electronically activated braking

system on the Auto Train on a trial basis, but because the system had some reliability

problems, it was disconnected and not being used at the time of the accident.

27 The engineer could make an emergency application of the train air brakes using the two-way EOT

device by manually activating the EOT switch in the locomotive cab. At the time of the accident, the

technology to enable simultaneous, automatic application of the brakes at the end of the train with the

engineerís emergency application of the brakes was not available. Since the accident, an automatic

emergency EOT application feature has reached the final development stage and may soon be ready for

testing and FRA approval for use.
Factual Information 15 Railroad Accident Report

With electronically activated brakes, the signal to apply or release each carís

brakes travels much more quickly than it does with traditional pneumatically activated

brakes. Electronic activation takes place virtually instantaneously, while pneumatic

activation takes place at a speed of about 800 feet per second. The lag time that the

pneumatic signal takes to move back through the train to apply (or release) the brakes is

eliminated with an electronic signal.

The electronically activated braking system installed on the Auto Train was

redundant in that if the electronic system failed, the train could still be operated in normal

full pneumatic mode. In addition, to ensure reliability in an emergency, when the Auto

Train was operating in the electronically activated braking mode and the engineer placed

the brakes in emergency, the signal would be sent pneumatically, in the traditional manner,

through the trainline.

Signal Information

The derailment occurred on a single main track in traffic control system territory

signaled for movement in both directions, between the north end of control point Seville,28

MP 725.6, and the south end of control point Huntington, MP 717.8. The traffic control

system consisted of Union Switch and Signal (US&S) color-light wayside signals, US&S

Model 23A power-operated switch machines, and coded and electronic track circuits

controlled by the AA dispatcher in Jacksonville, Florida. Timetables, train bulletins, and

wayside signal indications governed the method of operation.

Postaccident investigation included examination of the dispatcherís data log event

recorder in Jacksonville and dragging equipment/hot box detector equipment at Orange

City (MP 755.4), Barberville (MP 734.7), and Satsuma (MP 711.9).29 Operational tests

were conducted at the south end of Seville (MP 727.5), the north end of Seville

(MP 725.6), and north and southbound automatic signal 723. Switch obstruction and point

detection tests were performed at the south and north ends of Seville. All signal equipment

was found to function as designed.

Track Information

General

The derailment occurred just inside the Putnam County line, near the town of

Crescent City on CSXT single main track.30 Based on the visible on-site evidence, train

crew testimony, and event recorder data, the point of derailment was MP 722.24.

28 Control points are specific geographic locations used to designate the limits of a trainís authority to

occupy track.

29 This location was north of the accident site.

30 This was the CSXT Sanford Subdivision of the Jacksonville Service Lane.
Factual Information 16 Railroad Accident Report

The bi-directional railroad track was maintained to FRA Class 4 track31 standards,

which permitted a maximum authorized speed of 79 mph for passenger trains and 60 mph

for freight trains. There was a permanent speed restriction of 60 mph for passenger trains

for the curve where the derailment occurred.32

The train derailed in a 3-degree, 11-minute left-hand curve, northbound in the

direction of the accident train movement. The total curve was 1,395 feet long and was

located between MP 722.41 and MP 722.15. The circular curve body was 651 feet long,

with spirals,33 each 372 feet long, at either end. The outside rail of the curve was designed

to be 6 inches higher than the inner rail, which gave the curve a superelevation34 of

6 inches.

The track was oriented geographically and by timetable in a north-south direction.

The elevation or grade of the track through the accident area, from MP 724.08 to

MP 721.80, varied between 0.19 percent descending to 0.73 percent ascending.

Preaccident CSXT Inspections

FRA regulations required that the accident area track be inspected twice a week.35

Employees designated by CSXT and qualified under FRA regulations conducted daily

CSXT track inspections through the accident curve.36 The last preaccident CSXT daily

track inspection over this area was conducted by the roadmaster, when he traversed

southbound over the derailment area in a Hy-Rail vehicle37 late in the morning of April 18,

2002. The roadmaster did not note any anomalies. Between 2:30 and 3:30 p.m. that day,

the roadmaster also traveled northbound over the derailment area, riding in the locomotive

cab of Amtrak train 98. He noted no track deviations in the derailment area at that time.

The CSXT track inspector for the accident curve was responsible for inspecting

about 75 miles of track between Sanford and Palatka, Florida. The inspector had a

ìplaybookî based on work-time standards that outlined the amount of time he was

expected to spend on any given inspection task in his territory. The inspector stated that he

thought he had enough time to conduct his inspections and that if he needed help he could

31 Railroad track is classified from Class 1, the slowest, to Class 9, the fastest, according to the

maximum train speed it is designed to carry. The faster and higher the class of track, the heavier the track

structure and the lower the tolerances for deviations from FRA regulation standards.

32 Railroads, like highways, have a general overall speed restriction but also designate lower speed

limits for selected areas, such as curves, bridges, etc.

33 Railroad curves transition from straight or ìtangentî track into ìspiralsî of track of gradually

increasing curvature, which lead to the actual circular curve of fixed radius. As a train leaves a curve, the

transition is reversed from curve to spiral to tangent.

34 Superelevation is the vertical distance that the outer rail is raised above the inner rail on a curve to

resist the centrifugal force of moving trains. Superelevation acts like a banked roadway curve to balance the

centrifugal forces.

35 See 49 CFR 213.233.

36 See 49 CFR 213.7.

37 This is an inspection made from a pickup truck or similar road vehicle equipped with retractable

railroad wheels so that it can travel along the railroad track.
Factual Information 17 Railroad Accident Report

request and obtain it. He said he inspected mainline track like that through the accident

area from a Hy-Rail vehicle traveling 25 to 30 mph, during which time he also inspected

parallel tracks, such as sidings. He inspected mainline track twice a week on

nonconsecutive days, and he walked designated curves, including the accident curve, once

every 3 months.

An FRA track safety specialist reviewed CSXT preaccident track inspection

records for the track between Palatka and Sanford for the period from April 2001 through

April 18, 2002, as part of the investigation of this accident. Four exceptions were found

regarding the track inspection records; the exceptions concerned the recordsí failure to

indicate that the CSXT inspector had been simultaneously inspecting the track being

traversed, the siding, and/or the main track.

Track Structure

The track through the accident area consisted of anchored steel continuous welded

rail (CWR) on treated wooden ties secured with tie plates38 and cut spikes. The inside

curve rail was 132-pound39 rail made by Tennessee Steel in 1971 and installed at this

location in 1993. The outside curve rail was 136-pound rail made by Bethlehem Steel in

1994 and installed in 1995.

The rail lay on double-shoulder tie plates40 that were 7 3/4 inches wide and

14 inches long, secured by five 6-inch cut track spikes per tie plate, and distributed as

three rail-holding and two plate-holding spikes. The tie plates rested on treated 7-inch by

9-inch wooden ties that were 8 feet, 6 inches long, with an average spacing of

19 1/2 inches between tie centers. The rail was longitudinally restrained by box

anchoring41 every other crosstie. The rail anchors were predominantly Woodings springclip-type anchors with random Channel Loc drive-on-type rail anchors. (See figure 7 for

a diagram illustrating the relationship between rail, rail anchors, ties, tie plates, and

spikes.)

FRA Track Safety Program and CWR

The FRA regulations covering CWR are at 49 CFR 213.119. Title

49 CFR 213.119, ìContinuous Welded Rail, General,î states, in part:

Each track owner with track constructed of CWR shall have in effect and comply

with written procedures which address the installation, adjustment, maintenance

and inspection of CWR, and a training program for the application of those

procedures, which shall be submitted to the FRA by March 22, 1999.

38 Tie plates are rectangular pieces of steel placed under the rail to distribute the weight of a train over a

greater area of the tie than the base of the rail alone.

39 Railroad rail is designated by the weight of the rail in a 1-yard length; generally, the heavier the rail,

the larger the rail.

40 A tie plate shoulder is a small raised portion of metal that forms a ridge next to the base of a rail to

help properly position the tie plate and prevent the rail from shifting laterally.

41 Box anchoring places rail anchors on both rails across from each other against each side of a tie.
Factual Information 18 Railroad Accident Report

The FRA reviews each plan for compliance with various general principles, which

are detailed in the regulations for numerous aspects of CWR use, including installation,

adjustment, anchoring, rail temperatures (during installation, repair, and maintenance),

monitoring, appropriate speeds, inspection, training for employees working on CWR, and

record-keeping, among other issues. The FRA enforces the railroadís own CWR program,

as detailed in the railroadís written CWR plan and standards (if any). An FRA violation

concerning CWR generally reflects the failure of a railroad to comply with its own CWR

standards.

Rail Anchors

Rail anchors are an integral part of the track restraint system for CWR. Rail

anchors prevent or restrict the longitudinal movement of the rail, localizing the

compressive or expansive forces in the rail and allowing these localized forces to be

uniformly distributed throughout the whole track structure. Without the restraint of

sufficient, effective, and evenly distributed rail anchors, if ambient temperatures are high,

the rail will expand and compressive forces may build up and overcome the lateral

Figure 7. Diagram showing the relationship between ties, rails, tie plates, spikes, and 

rail anchors. The insert is a cross section showing how the rail anchor grips the rail.

RAIL

SPIKE

TIE PLATE

TIE

RAIL ANCHOR
Factual Information 19 Railroad Accident Report

restraint at the weakest point in the track, which may create a track buckle. Conversely, in

extreme cold weather, unrestrained rail may contract to break at a weak point. To prevent

such problems, rail anchors must be in good condition and properly placed. They must

also retain their clamping strength and be tight against the side of the tie.

After the accident, Safety Board investigators examined the track that was still

intact to the north and south of the point of derailment. Of 1,550 ties inspected, 799 ties

were required by CSXT to be box-anchored.42 Of these, 334 ties were missing one or more

anchors or had one or more anchors that were not snug against the ties. Of the total 3,196

anchors required through the area inspected,43 622 were judged by postaccident

investigators to be missing or not snug against the ties.

In postaccident statements, CSXT track maintenance employees indicated that

they considered the rail anchor pattern44 in the area of the accident curve prior to the

derailment to be ìstandard.î The track inspector for the curve stated that ìWeíve got some

worn anchors out there but itógenerally it was standard. There [were] a few anchors

missing here and there.î He further stated, regarding the rail anchors, ìNothing, in my

opinion, that was dangerous or wouldnít hold, wasnít doing its job, enough of them. There

[were] adequate anchors.î

Federal Regulations. The FRA requires that railroads with CWR have ìrail

anchoring or fastening requirements that will provide sufficient restraint to limit

longitudinal rail and crosstie movement to the extent practicalÖ.î45

Industry Practices. With respect to recommended practices for rail anchor

application and maintenance, the American Railway Engineering and Maintenance-ofWay Associationís (AREMAís)46 Manual for Railway Engineering, published in 2001,

states that rail anchors should be ìfull bearing against the tie or tie plate.î In his book

Railroad Engineering,47 William W. Hay, Mgt. E., M.S., Ph.D., professor emeritus of

railway civil engineering for the University of Illinois, Urbana, Illinois, stated that ìIf the

anchor moves away from the tie, it loses its purpose and should be driven back to its

proper position or removed and reapplied.î Rail anchor manufacturers instruct users to

install rail anchors snug against the tie.

42 There are four anchors per tie (one anchor on each side of a tie for each rail).

43 Total computed as 799 ties times 4 anchors per tie.

44 Rail anchor pattern refers to the pattern used for distribution of the rail anchors along a section of

track. In this case, the rail anchor pattern used was to box-anchor every other tie.

45 See 49 CFR 213.119(b).

46 AREMA is an independent industry association that sets recommended standards of practice for

railroad construction and maintenance. AREMAís stated purpose is ìThe development and advancement of

both technical and practical knowledge and recommended practices pertaining to the design, construction

and maintenance of railway infrastructure.î

47 W.W. Hay, Railroad Engineering, 2nd ed., p. 588 (New York, NY: John Wiley and Sons, 1982).
Factual Information 20 Railroad Accident Report

CSXT Standards. According to CSXT Maintenance Bulletin MWI 1113-01,

Performance for Large Scale Track Work,

48 if the volume of anchor deviations exceeds

1 percent at any 100 consecutive new ties requiring anchors, this qualifies as an anchor

defect. Deviations include missing anchors, anchors not snug against ties, anchors not

holding, and anchors not installed correctly. Rework limits require remedial action when

the number of missing anchors at new ties reduces the standard anchor pattern by

10 percent or more within any 39-foot length of track.

According to the CSXT assistant chief engineer for track maintenance, CSXTís

work performance standards for rail anchors noted above apply only to large system-wide

production teams; CSXT local maintenance crews are not required to adhere to these

standards. Instead, ìnormal maintenance practicesî for crews on the local level are

established empirically through on-the-job training. The local roadmaster and/or track

inspector perform quality control on these crewsí operations as part of their normal duties.

Roadbed

The roadbed is the foundation on which the rails and ties of the track are placed.

The roadbed distributes the weight of the train over the earth and provides a firm

foundation for the track structure.

The curve through the accident area was built on about 10 feet of earthen fill,49

which created an embankment for the track to cross a low area. The top of the

embankment formed the railroad roadbed. After the accident, CSXT contracted with

AMEC Earth and Environmental, Inc., a geotechnical survey group headquartered in

Nashville, Tennessee, to take accident curve and embankment soil-boring samples to

determine whether any factors that could have weakened the subgrade were present. The

borings included samples taken from down the center of the track. The drilling revealed 3

to 5 feet of ballast below the top of the ties, with dense sand underneath.50 The earth

beneath and around the embankment was made up of sand with silt clay and sand over

highly plastic clay. The contractor found no zones of extremely loose or soft material in

the borings.

The curve embankment was bordered at the base by drainage ditches on each side

connected by a drainage culvert through the fill. A 36-inch-diameter cast-iron culvert ran

perpendicular to and underneath the track about 150 feet north of the point of derailment

(MP 722.24). The culvert had about 7 feet of fill cover above it. The culvert was

undamaged and its ends were clear of debris.

48 Specialized non-local work gangs that are maintained at the regional or system level usually perform

large-scale track work.

49 The fill was measured from the ditch line to the top of the subgrade.

50 These samples were taken after CSXT had widened the roadbed following the accident to

accommodate an access road. A 3-D laser survey was also conducted after the accident for roadbed areas

just north and south of the accident site. The survey results indicated that the soil-boring findings with

respect to embankment depth were representative of preaccident conditions at the accident site. (The

engineering firm Phillips & Jordan, Inc., was in charge of the laser survey.)
Factual Information 21 Railroad Accident Report

After the accident, the CSXT chief regional engineer for the Jacksonville District

stated that the area of the derailment/culvert had a relatively narrow roadbed. He was also

asked if he had any idea how the roadbed became narrow. He stated:

Well, in a lot of the cases, our roadbeds become narrow because we continue to

elevate the track by surfacing our track and raising the track structure. And that

narrows up the amount of slope weíve got for the retaining of ballast. Thatís in a

lot of cases.

CSXT has no requirement to maintain one specific roadbed width; instead, it

requires roadbed widths to be adequate to support the ballast section. CSXT standard

engineering plan 2601, ìCSXT Roadbed Sections for New Construction,î requires a 30-

foot roadbed width15 feet to each side from the centerline of the track at the top of the

subgradefor single main tracks, sidings, and heavy tonnage tracks.

Ballast

The term ìballast sectionî refers to the total cross-sectional area of the ballast,

including the ballast between the ties, under the ties, and off the ends of the ties. The

ballast that extends out51 beyond the ends of the ties at the same height as the tops of the

ties and then slopes down to the sub-ballast or roadbed at a ìnaturalî 2 to 1 ratio is called

the ìshoulder ballast.î Based on AREMA testing, the shoulder ballast provides about

20 percent of the trackís lateral restraint and the ballast around and underneath the ties

accounts for the remaining 80 percent.

The track at the point of the derailment and much of the track through the curve

was destroyed in the derailment, which precluded exact measurement of some dimensions

of the ballast section. Postaccident observations by Safety Board investigators of the intact

track to the north and south of the point of derailment showed that, in many places, the

ballast did not fill the tie cribs52 between the crossties. Many cribs were half full in the

center and less than half full toward the ends. There was little or no ballast off the ends of

the ties (shoulder ballast), particularly on the inside of the curve. (See figure 8 indicating

the ballast condition of track in the area of the accident.)

In postaccident statements, the CSXT chief regional engineer for the Jacksonville

District stated that (prior to the installation of a ballast-retaining wall on March 6, 2002)

the ballast on the inside of the curve was ìleanî and less than the minimum standard but

that the outside curve ballast exceeded 12 inches. During postaccident interviews, the

CSXT track inspector for the accident curve said that (prior to the installation of a ballastretaining wall on March 6, 2002) the ballast was not up to standard because it was on a

steep embankment. He said, ìIt wasnít maintained to standards with the 12 inches of

ballast on the high side and 6 inches on the low, two-to-one.î

51 Perpendicular to the longitudinal axis of the track.

52 The tie crib is the space between two ties.
Factual Information 22 Railroad Accident Report

Figure 8. Ballast conditions in accident curve.
Factual Information 23 Railroad Accident Report

FRA Regulations. The FRA regulation regarding ballast (general),

49 CFR 213.103, states:

Unless it is otherwise structurally supported, all track shall be supported by

material which will-

(a) Transmit and distribute the load of the track and railroad rolling equipment to the subgrade;

(b) Restrain the track laterally, longitudinally, and vertically under

dynamic loads imposed by railroad rolling equipment and thermal stress

exerted by the rails;

(c) Provide adequate drainage for the track; and

(d) Maintain proper track crosslevel, surface, and alinement.

Industry Practice. The recommended railroad industry practice for ballast in the

AREMA Manual for Railway Engineering, published in 2001, states:

2.1.1.5.2.2, Ballast Section Shoulder Width (BSW)

The BSW is proportioned in accordance with Chapter 16, Economics of Railway Engineering and Operations, Part 10, Construction and Maintenance Operations and is to provide additional lateral strength to the track.

The measure is made from the end of the crosstie to the point of beginning of the Ballast

Side Slope (BSS), and is made in the plane of the top of the crosstie.

A value for BSW of not less than 12-inches is recommended for standard gage construction of CWR in main track service or as may be defined by individual railway company

standards.

2.1.1.5.2.3, Ballast Side Slope

The BSS run component of the ballast section is proportioned to provide confining pressure to that part of the ballast section expected to transmit the vertical load from the bottom of the crosstie to the top of the sub-ballast.

The BSS run component is measured in the plane of the top of the crosstie, and the rise

component is measured perpendicular to the run component.

A BSS value of 2:1 is commonly used.

CSXT Standards. The CSXT Engineering Department Field Manual, dated

July 21, 2000, page 13, Subpart D ñ ìTrack Structure, Parts a, b, c, and d, 103.0.0 Ballast;

General,î states:

Ballast section will be maintained in accordance with Standard Plan 2602 with

particular attention to maintaining proper ballast section and drainage at or around

road crossings, turnouts, and rail crossings at grade.

CSXT Standard Engineering Plan 2602 requires that the ballast shoulder extend

6 inches straight out from the end (and level with the top) of the ties to the shoulder slope

on tangent (straight) track and on the inside of curves, and 12 inches on the outside of

curves. The 12-inch (outside curve) width is to continue into the tangent at each end of the

curve for 100 feet and then to taper to 6 inches in the succeeding 50 feet.
Factual Information 24 Railroad Accident Report

Track Maintenance

Shoulder Ballast Cleaning. From September 18 through October 13, 2000,

CSXT conducted shoulder ballast cleaning operations on the railroad, including the curve

through the accident area. The shoulder ballast cleaning was intended to improve the

drainage of the track. Fouled or clogged ballast can trap water and create soft spots under

the track. In some soil conditions, like those found in the coral sand of Florida, the fouling

material can also form a hardpan of cement-like material. A shoulder ballast cleaning

machine removes fouled ballast from the shoulder area of the track, cleans the ballast, and

returns the cleaned ballast to the shoulder, allowing water to drain out and away from the

track.

Within a few months of the fall 2000 CSXT shoulder ballast cleaning, the track

through the accident area experienced ballast retention problems that prompted CSXT

maintenance activities. (See appendix D for a chronological list of track maintenance

operations on the accident curve following the shoulder ballast cleaning.) According to the

local CSXT track supervisors and inspector, the ballast was migrating down the inside of

the curve embankment. No problems were recorded concerning ballast retention on the

outside of the curve. Because of the loss of ballast on the inside, the tie ends to the inside

of the curve would drop, causing the outside tie ends to rotate upwards, increasing the

superelevation.

Surfacing. Surfacing is the process of raising the track and leveling it on the

roadbed while simultaneously aligning it into place. The surfacing process is typically

accompanied by the addition of new ballast and/or the reapplication of ballast recovered

from off the sides of the track, which is then tamped between and around the ties. Between

January 2001 and April 18, 2002, CSXT maintenance crews repeatedly surfaced the

accident curve to reestablish the correct superelevation and maintain the track geometry.

The regional surfacing gang mechanically surfaced the track through the accident

curve with a track liner-tamper machine53 (and ballast regulator) on October 9 and 11,

2001; November 19, 2001; February 26, 2002; and March 11, 2002. On at least four

occasions between October 2001 and April 18, 2002, local track maintenance crews spotsurfaced54 the track using hand-powered tamping tools. When the surfacing gang foreman

was asked after the accident if it was unusual to surface the same area of track repeatedly

within 6 months, he said it was ìnot really standardî and ìthat would indicate a problem.î

53 The Mark III track liner-tamper machine used in this area aligned and tamped the track in one

operation.

54 Spot-surfacing refers to surfacing parts or short sections of track.
Factual Information 25 Railroad Accident Report

On October 9, 2001, the regional CSXT surfacing gang began surfacing the

accident curve, starting south of the southern end of the curve and moving north

(MP 722.5 though MP 722.1).55 This was the only time in the 7 months preceding the

accident that the entire curve was surfaced. All subsequent surfacing operations on the

curve consisted of surfacing shorter sections of track. The surfacing gang foreman stated

that the entire curve was to be surfaced with a 1-inch raise, using available ballast from the

track. At the time of the work, the rail temperature was noted as 92° F.

After the track liner-tamper machine had measured the curve and the ballast

regulator had made an initial pass, the liner-tamper machine surfaced and aligned the

south spiral of the curve and the curve itself. Upon beginning the north spiral, the foreman

noticed that the track liner-tamper machine was not lining the track properly. He said that

the machine was taking the north end of the curve too much to the outside. The foreman

made some manual adjustments to line the track back toward the inside of the curve, and

the surfacing gang used the liner-tamper machine to line the track in the manual mode. A

25-mph slow order was then placed on the track in that area.

After the track liner-tamper machine was repaired, the surfacing gang returned 2

days later, on October 11, to finish and reline the north end of the curve, beginning around

where the gang members had initially noticed the problem with the machine. The

surfacing gang foreman stated that the machine double-tamped the ties (on a single pass of

the machine) and that the gang was able to get 6 inches of ballast on the inside of the

curve. This work involved the end of the curve and the north curve spiral for about

450 feet. After the accident, the surfacing gang foreman was asked if he felt confident the

curve had been put back in its proper position and alignment by this surfacing work. The

foreman replied, ìNo, sir, I donít feel that we got the curve back to where it was supposed

to be. Thatís the reason why I recommended that they leave the 25-mile-an-hour slow

order on there.î The foreman further stated that to properly prepare the curve for 60-mph

traffic, the entire curve needed to be relined.

On November 19, 2001, the surfacing gang machine spot-surfaced portions of

track near the north end of the curve (about MP 722.21 to MP 722.1). The foreman said, ìI

think that we mainly started in the body of the curve and come to the north end.î The gang

did not reline the entire curve. The foreman recorded an ambient temperature of 75° F and

a rail temperature of 83° F. Following this work, the slow order for this area was removed.

All surfacing requires breaking the tie-ballast bond when the track is raised and

aligned. As such, surfacing ìdisturbsî the track. According to CSXT rules at the time of

the accident, a ìTrack Disturbance Reportî must be filled out and submitted at the end of

the month whenever the track is disturbed (such as when rail repairs, tie installation, or

surfacing is conducted) if the rail temperature is below 100° F in a geographic region

55 A CSXT assistant track inspector stated that he unloaded 6 to 8 carloads of ballast in the curve in

October 2001, prior to the October 9, 2001, surfacing operation. The section foreman stated that he unloaded

an estimated three cars of ballast in the curve sometime during 2001. The exact locations of the ballast

applications were not identified in either case. CSXT did not provide the Safety Board with written

documentation verifying that these ballast applications had taken place.
Factual Information 26 Railroad Accident Report

south of North Carolina and Tennessee.56 The roadmaster uses the reports to identify areas

that need additional attention, and the reports may be used for follow-up rail adjustment.

No Track Disturbance Reports were filed with CSXT for the October and November

surfacing operations. The surfacing gang foreman stated that he completed Track

Disturbance Reports for the October and November 2001 work, but he did not submit the

reports at the end of each month as required.

On February 5, 2002, hand-tamped surfacing was conducted for MP 722.3 through

MP 722.1. As a consequence of this work, a slow order was established for MP 722.3

though MP 722.1. This slow order remained in effect through March 13, 2002, because of

successive maintenance activities on this section of the track during this period.

On February 26, 2002, the regional surfacing gang, under the supervision of the

local section foreman,57 performed more machine spot-surfacing on the accident curve

from MP 722.3 through MP 722.1. According to the section foreman, they tamped the

track twice ìbecause it would not stay up.î The recorded rail temperature was 90° F, and

the ambient high and low temperatures that day were 75° and 45° F, respectively.

Section 119.786 of the CSXT Engineering Department Field Manual states that

ìWhere a curve over 1° in CWR track will be disturbed at a rail temperature of 50° F or

below, the Roadmaster or his designated representative will set reference stakes within the

area to be disturbed at [specified locations] before work is performed.î Using the

reference points provided by the stakes, the roadmaster is to record the amount of

movement between 10 and 15 days after the work has been completed. The term

ìmonumentingî58 is often used to describe such activities.

In accordance with section 119.786, the track was not monumented during the

February 26 surfacing work. On February 27, the ambient high and low temperatures for

the area were 68° and 36° F, respectively. By February 28, the ambient high and low

temperatures for the accident area were 55° and 36° F, respectively. During a postaccident

interview, the assistant chief engineer for track maintenance stated, ìIn retrospect, had it

been recognized that the temperature could possibly get that low the night the track was

surfaced [the night of February 26 and 27], we could possibly have gone out and staked

the track.î He further stated, ìIf you donít monument the track prior to the work being

done, youíve lost any legitimate reference point. You know, you canít reference back to

something after youíve changed it.î

The CSXT chief regional engineer for the Jacksonville District stated that he had

inspected the derailment curve with the roadmaster and the regional engineer on March 1,

2002. He said he was briefed on a plan of building a ìballast-retaining wallî in early

March 2002, and he was asked his opinion. He said he thought it was worth attempting.

56 North of these geographical limits, a Track Disturbance Report would be required if the track were

disturbed and the rail temperature were below 90° F.

57 The local section foreman substituted for the surfacing gang foreman, who was in training.

58 Monumenting consists of establishing known reference points against which any subsequent

movement of the track can be measured.
Factual Information 27 Railroad Accident Report

On March 6, 2002, the track inspector had the local track maintenance personnel

construct a ballast-retaining wall of used concrete ties along the inside of the curve.

Regional engineering managers were aware of this operation. Used concrete crossties

were placed on the inside of the curve about 4 feet below the track level (the embankment

was about 10 feet high at this location) to form a shallow, ballast-retaining wall. Concrete

crossties were stacked 2 ties high (creating a wall about 16 inches high) end-to-end on the

inside of the curve down from the toe of the shoulder ballast slope for about 240 feet along

the track. The concrete ties were not secured into the embankment. (The point of

derailment was near the south end of the ballast-retaining wall.) A number of CSXT

maintenance and management personnel familiar with this section of track indicated that

the ballast-retaining wall appeared to prevent further ballast migration down the slope.

They also indicated that the ballast section on the curve was holding to standard after the

wall was constructed. (See figure 9 for a representation of the relative location of the

ballast-retaining wall, showing the general relationship between various roadbed and track

elements.)

On March 8, 2002, three-quarters of a hopper car of ballast, about 70 tons, was

spread on the north end of the accident curve. (The section foremanís personal notes

documented this ballast application.)

On March 11, 2002, the regional surfacing gang conducted machine spot-surfacing

from MP 722.3 to MP 722.2.59 During this operation, the surfacing gang used the ballast

Figure 9. Conceptual drawing of cross section of the roadbed in the accident curve 

showing the estimated location of the ballast-retaining wall, as well as some roadbed, 

track, and ballast section elements.

59 Because no Track Disturbance Report was filed on this work, this information came from the

surfacing gang foremanís notes.

Approx. Scale: 1/4" = 1'

5' 10'

8'6" TIE

6"

12"

BALLAST FILL

SAND FILL

RAIL

CSX standard

ballast profile

for curve

(2:1 slope)

6"

BALLAST

CSX standard

inside shoulder ballast width

CSX standard

outside shoulder ballast width

Superelevation

Approximate location of

ballast-retaining wall
Factual Information 28 Railroad Accident Report

that had been deposited on March 8 to help establish the track. The liner-tamper machine

started in the body of the curve and moved northward through the spiral of the curve to

create a 1-inch lift. Because the surfacing gang foreman ìforgot to make out a Track

Disturbance Report,î he did not record any rail temperature. (See figure 10 for a visual

representation of the relative locations of the surfacing work carried out on the curve

between October 9, 2001, and March 11, 2002.)

The Florida Department of Transportation railroad track safety inspector walked

the accident curve on April 8, 2002, before conducting a Hy-Rail track inspection on

April 9, which was his last inspection in the accident area before the derailment. He said

that during his walking inspection, he found an area60 where crossties needed to be

replaced, and he contacted the CSXT track inspector. The CSXT track inspector placed

speed restrictions of 30 mph for passenger trains and 25 mph for freight trains over the

affected track. The Palatka track maintenance crew repaired the track by installing five

crossties the same day at MP 722.4. After replacing the ties, the maintenance employees

spot-surfaced the area, hand-tamped the ballast, and dressed it with a backhoe and by

hand. The section foreman recorded the rail temperature as 92° F. During his April 8 and 9

inspections, the Florida Department of Transportation railroad track safety inspector noted

no exceptions to the track ballast or rail anchor conditions, and he did not note any rail

movement.

Figure 10. Relative locations of machine surfacing operations conducted on the accident curve between October 9, 2001, and March 11, 2002.

60 About 300 feet south of the subsequent point of derailment.

MP 722.1

MP 722.5

MP 722.24 POD 

N

.1

.5

10/9/01

.1

.3

10/11/01

.1

.2

11/19/01

.1

.3

2/26/02

.2

.3

3/11/02
Factual Information 29 Railroad Accident Report

Postaccident FRA and State Track Inspections

After the accident, it was not possible to inspect the track at or about the point of

derailment (MP 722.24) because the track structure was destroyed.

However, an FRA track safety specialist inspected the CSXT track in the accident

area to the south of the derailment, from MP 723.0 to MP 722.3, and found 22 exceptions

or defects that did not meet FRA Class 4 Track Safety Standards. Four of the exceptions

were for more than the allowable number of defective ties per 39 feet of straight track.

Three of these four exceptions were located between MP 723.0 and MP 722.8, with the

fourth at MP 722.3. Seven other exceptions were for more than the allowable number of

defective ties per 39 feet of curved track (greater than 2 degrees) between MP 722.7 and

MP 722.6. Based on these exceptions, FRA regulations required the track classification to

be reduced to Class 3 for the affected areas. Eleven exceptions were noted for a metal

object between the base of the rail and the tie plate, which would cause an undesirable

concentrated load. These exceptions were spread over the .7 mile of track inspected, and

FRA regulations required the track classification to be reduced to Class 2 for the affected

area.

A Florida Department of Transportation track safety inspector inspected the track

from MP 722.0 to MP 721.5 (north of the point of derailment) after the accident, and he

found five track defects that did not meet FRA Class 4 Track Safety Standards. All five of

these track defects were for a metal object between the base of the rail and the tie plate (tie

plate shoulder). FRA regulations required that the track classification be reduced to

Class 2 within the affected area.

CWR Temperature Control

CWR is subject to mechanically induced outside forces when loaded and to

thermally induced internal forces from expansion or contraction. CWR must be

longitudinally restrained to prevent rail movement caused by these mechanical and

thermal forces. Longitudinal restraint in CWR generally takes the form of additional rail

anchors and ballast; elastic clips in lieu of rail-holding spikes; and/or more, larger, or

heavier ties.

When the longitudinal mechanical and thermal compressive forces in CWR build

to a point at which they exceed the track structureís ability to restrain them, a track buckle

will occur. According to AREMA, the magnitude of force that may be developed within

CWR, independent of its length, is the product of the difference in temperature between

the ìneutral rail temperatureî61 and the current rail temperature, multiplied by the crosssectional area of the rail and the factor of 195 pounds per square inch (psi).62 In the

daytime, rail temperature is commonly about 30° F above the ambient temperature.

61 This is the same as the anchoring temperature.

62 The internal stress of restrained rail is the product of the coefficient of expansion and the modulus of

elasticity of the steel, times the change in temperature.
Factual Information 30 Railroad Accident Report

Thermally induced longitudinal rail forces result when restrained CWR seeks to

expand or contract beyond its force-free or neutral rail temperature state. The neutral rail

temperature is the temperature of the steel rail under conditions free of internal forces due

to thermal stress or strain. Because any difference in rail temperature from the initial

laying (or adjusting) temperature, when the rail is anchored or restrained, determines the

magnitude of the thermally induced internal longitudinal rail forces, the proper selection

and control of CWR installation temperature is very important. Consequently, each

railroad develops its own well-defined CWR installationóor neutral railótemperatures

for different geographical and climatic locations. These temperatures are intended to

minimize the thermally induced internal longitudinal rail forces throughout the range of

seasonal temperature change. The CSXT neutral rail temperature for the accident area was

100° F.

If the rail temperature is below the designated neutral temperature at the time of

CWR installation, the rails are artificially heated to the neutral temperature and then

immediately anchored. Conversely, if the rail temperature at the time of CWR installation

is above the neutral rail temperature, the rail is cooled, usually by spraying it with a

coolant, and then anchored.

Without track maintenance, neutral rail temperature will change over time due to

movement of the track as the track structure degrades due to the effects of rail traffic and

weather. Curved track is more susceptible than straight track to changes in neutral rail

temperature. Theoretically, properly constructed and maintained CWR track should not

move, and neutral rail temperature should remain unchanged. However, on a practical

basis, some movement usually occurs, particularly in curves. The centrifugal forces

produced by trains traveling around a curve and the thermal movement of the track (often

called ìbreathingî) with seasonal temperature variation will change the neutral rail

temperature. It is common for railroads to realign some curves and adjust the rail every

spring because track will not expand exactly back to the position it held before it

contracted during the winter, thus altering the railís free force or neutral temperature

condition.

Neutral rail temperature can also change as a result of maintenance activities such

as surfacing. As has been described, surfacing involves raising the track and leveling the

roadbed on which it rests and then aligning the track back into place. Raising the track

from the roadbed breaks the restraining bond of the ties and the ballast, which allows the

rail to expand or contract to a new force-free neutral rail temperature.63 If the surfacing

involves a length of track that is five or fewer ties long (ìspot surfacingî), the neutral rail

temperature may not significantly change. However, if the surfacing involves longer

lengths of track, the force-free or neutral temperature will likely change significantly,

especially if the difference between the current rail temperature and the designated neutral

rail temperature is great. Under such circumstances, the CWR should be adjusted.

63 Even though the rail may still be anchored, the rail of the lifted track is free of restraint because only

the ties and anchors are attached to the freed rail. Nothing restrains the railís longitudinal movement.
Factual Information 31 Railroad Accident Report

Rail is adjusted by removing rail anchors, heating or cooling the rail and/or adding

or removing small sections of rail, and then reanchoring the rail. The rail in curved track

can also be adjusted by lining the curve outwards. Failure to adjust rail that has been

disturbed may result in a track buckle later when the weather becomes warm enough that

the difference between the new force-free (neutral) rail temperature and the current rail

temperature is so great that the track structure cannot be restrained.

Railroads attempt to adjust rail that has undergone documented maintenance

activities at the earliest opportunity (usually in the spring before the first hot weather

occurs). According to the CSXT roadmaster for the Crescent City accident area, local

track maintenance forces usually start adjusting rail that has been disturbed during the

winter season when the ambient temperature starts to warm to the upper 80s (° F), usually

in April.

Operations Information

The derailment occurred on the CSXT Sanford Subdivision, which was controlled

by the CSXT train dispatcher in Jacksonville, Florida.

The Auto Train is listed on Amtrak train schedules as train Nos. 52 and 53. Two

Auto Train train sets travel between Sanford, Florida, and Lorton, Virginia; one train runs

each way daily. The northbound schedule calls for a departure from Sanford at 4:00 p.m.

for an arrival in Lorton at 8:30 a.m. the next day. Auto Trains make no scheduled

intermediate station stops, except to change operating crewmembers at Florence, South

Carolina.

Including the Auto Train, Amtrak operates seven scheduled passenger trains on the

CSXT Sanford Subdivision each day, Monday through Saturday. Six trains are operated

on Sunday. Four of these trains, Nos. 91 and 92 (the Silver Star) and Nos. 97 and 98 (the

Silver Meteor), operate between New York City and Miami, Florida. These trains are

similar to each other in equipment and consist. Train Nos. 1 and 2 (the Sunset Limited) are

operated between Orlando, Florida, and Los Angeles, California. These trains run on

alternating days, No. 1 on Tuesdays, Thursdays, and Saturdays; No. 2 on Mondays,

Wednesdays, and Fridays.

Passenger traffic through the accident area totaled 48 trains per week, while freight

traffic totaled 74 trains per week. Freight train traffic volume for the 12 months before the

accident was 18.89 million gross tons. CSXT classified this track as heavy tonnage track.

The closest passenger station to the accident location is Palatka, Florida, which is

about 24.2 miles north of the accident location. De Land, Florida, which is the nearest

passenger station to the south, is about 27.8 miles from the accident site.
Factual Information 32 Railroad Accident Report

Meteorological Information

At 4:53 p.m. on April 18, 2002, the weather conditions at Daytona Beach (about

28 nautical miles from Crescent City) were reported by the National Climatic Data Center

as: winds at 9 knots with gusts to 15 knots; visibility 10 miles; few clouds at 3,000 feet;

temperature of 80.6° F. By 5:53 p.m., the temperature had fallen to 78.8° F. The day was

mostly sunny.

On April 20, 2002, at 2:42 p.m., the rail temperature at the accident site area was

recorded as 120° F, and the ambient temperature was 88° F. The day was partly sunny. On

April 24, 2002, at 5:00 p.m., the rail temperature was measured at 108° F, and the ambient

temperature was 83° F. The day was partly sunny.

On April 25, 2002, at 1:00 p.m., the rail temperature was 108° F, and the ambient

temperature was 86° F. At 2:00 p.m., the rail temperature was 120° F, and the ambient

temperature was 86° F. At 5:00 p.m., the rail temperature was 120° F, and the ambient

temperature was 87.8° F. The day was partly sunny.

Between April 1 and April 18, 2002, maximum daily high temperatures in the

Crescent City area ranged from 73° to 89° F. The minimum daily low temperatures ranged

from 57° to 71° F. In the days immediately following the accident, the expected high

temperatures ranged from 83° to 88° F.

Table 3 shows the high and low temperatures in the Crescent City area for each of

the days when the curve was mechanically surfacedOctober 9 and 11, and

November 19, 2001; and February 26 and March 11, 2002as well as for the 3 days

following each surfacing operation.
Factual Information 33 Railroad Accident Report

Table 3. High and low temperatures recorded in the Crescent City area for the days when 

surfacing work took place on the accident curve (in boldface) and the 3 days following 

each surfacing operation. (Source: Record of River and Climatological Observations, 

National Climatic Data Center, Asheville, North Carolina.)

* Asterisk indicates that temperatures were recorded at Daytona Beach, Florida, rather than Crescent City, Florida. 

Toxicological Information

Complete medical records for the Amtrak Auto Train engineer and assistant

engineer were obtained from Amtrak and provided to the Safety Boardís Medical Officer

for review. No medical condition or use of prescription medication likely to cause

performance degradation was found.

The four members of the trainís operating crew provided blood and urine samples

for toxicological testing pursuant to 49 CFR Part 219, Subpart C. Northwest Drug Testing

of Salt Lake City, Utah, conducted the testing. Samples were screened for cannabinoids,

cocaine, opiates, amphetamines, methamphetamines, phencyclidine, barbiturates,

benzodiazepines, and ethyl alcohol. All results were negative for the presence of alcohol

and cited drugs.

Day High Temperature (° F) Low Temperature (° F)

October 9, 2001 81* 71*

October 10 79 61

October 11 87 64

October 12 80 64

October 13 89 70

October 14 84 64

November 19, 2001 75 58

November 20 71 57

November 21 75 57

November 22 77 61

February 26, 2002 75 45 

February 27 68 36 

February 28 55 36

March 1 66 48 

March 11, 2002 74 53

March 12 84 56

March 13 79 54

March 14 78 54
Factual Information 34 Railroad Accident Report

Disaster Preparedness

Area Emergency Response Training

On December 17, 1991, Amtrak train 87, the Silver Meteor, derailed in Palatka,

Florida, which, like Crescent City, is in Putnam County. The derailed train struck two

homes and blocked the street north of the Palatka Station.64 There were no fatalities.

Eleven passengers were seriously injured and 41 sustained minor injuries. Five operating

crewmembers and four on-board service employees sustained minor injuries. Because of

this prior Amtrak accident in the area, some emergency responders were already

somewhat familiar with Amtrak equipment.

On September 19, 1997, an Amtrak emergency preparedness manager provided

Passenger Train Emergency Response training65 to 63 members of various emergency

response agencies in Putnam County. Personnel who received the Amtrak training and

responded to the Crescent City derailment included the chief of the Crescent City Fire

Department, who was the initial incident commander; the training coordinator for Putnam

County Emergency Services, who was the final incident commander; and the Putnam

County Sheriffís Office communications captain. Amtrak subsequently provided similar

training to emergency responders from the surrounding counties.

Amtrak Personnel Emergency Preparedness Training

Amtrak has developed an emergency preparedness training program for its

crewmembers as required by 49 CFR Part 239. Amtrak has named this training program

ìPREPAREî (Passenger Railroad Emergency Preparedness And Response Education).

The purpose of this 8-hour course is to prepare operating crewmembers and on-board

employees to respond to a train emergency.

Amtrak provided Safety Board investigators with the emergency preparedness

training records for all the Amtrak employees on the accident train. According to these

records, all four operating crewmembers66 had attended the PREPARE training in the 3

months prior to the accident. Of the 24 Amtrak on-board service personnel, 17 had

received Amtrakís PREPARE training between January and March 2002, 5 had received

the training in December 2000, and 1 received the training in April 2000. One on-board

service person did not receive the PREPARE training prior to the accident.

64 National Transportation Safety Board, Palatka, Florida, December 17, 1991, Railroad Accident

Report NTSB/RAR-93/02* (Washington, DC: NTSB, 1993).

65 SAFE 015 course.

66 Engineer, assistant engineer, conductor, and assistant conductor.
Factual Information 35 Railroad Accident Report

Auto Train Event Recorder Information

Each Auto Train locomotive unit event recorder was downloaded shortly after the

accident, and investigators noted the times of the recorded events as indicated by the EOT

device and the locomotive event recorders. Event recorder data from both the lead

locomotive, AMTK 838, and the trailing unit, AMTK 843, indicated that the train was

moving at 56 mph at the time of the initial brake application as the train approached

MP 722.

During the accident sequence, the event recorder on the lead locomotive unit

recorded the trainline pressure at the rear of the train that was transmitted by the EOT

telemetry device. The trainline air pressure at the end of the Auto Train was stable at

108 psi67 for several seconds after the first locomotive passed over the track buckle at

5:07:54 p.m.

According to the event recorder information, the engineer initiated a service brake

application at 5:07:57 p.m. He initiated an emergency brake application at the head end of

the train at 5:08:01 p.m. By 5:08:02 p.m., the trainline pressure at the head of the train was

98 psi, the rear-end trainline pressure was 108 psi, and the train speed was 55 mph. At

5:08:04 p.m., the trainline pressure at the head of the train was zero and the rear-end

trainline pressure was 108 psi. At 5:08:05 p.m., the pressure at the rear of the train

dropped 2 psi to 106 psi and remained at 106 psi for 7 seconds. At 5:08:11 p.m., the EOT

went into emergency. The trainline pressure at the rear end dropped to zero at 5:08:12 p.m.

At 5:08:15, the engineer activated the EOT device. (See appendix E for more detailed

event recorder information.)

Survival Factors

Superliner Passenger Car Windows

Amtrak Superliner passenger railcars are fitted with exterior sidewall windows on

both the lower and upper level decks. They are provided in two configurations, a

nonremovable and a removable window design. The removable design is identified as an

ìEmergency Exit windowî (pursuant to FRA requirements), from which the window

panel can be extracted in an emergency. Both window designs fundamentally consist of a

window glazing element fitted into a window frame. The window glazing consists of

parallel, dual-pane, 1/4-inch-thick transparent monolithic polycarbonate glazing sheets,

held together by an aluminum perimeter frame. There is 1/4 inch of airspace between the

two glazing sheets. The window frame is kept in place by a rubber grommet fitted around

the window perimeter, which is (on the outside of the railcar) somewhat round in cross

section and protrudes about 1/2 inch beyond the plane of the railcar car body sidewall

surface. Examination of undamaged Superliner railcars indicated that the edges of the

window grommets, at the point of contact with the railcar car body sidewall panel, form a

67 The Auto Train trainline was set for 110 psi.
Factual Information 36 Railroad Accident Report

tight fit against the railcar car body sidewall panel without any apparent gaps or voids, and

the car body sidewall panels were observed to be square, true, and in plane, and without

apparent warpage or other deformation.

The exterior right-side sidewall panels of Superliner railcars #32074, #32503,

#33101, #38052, #32501, and #32100 exhibited denting, abrasive markings, and battering

damage. They also displayed obvious rounded indentions in the roofline between the

transverse structural members of the roof. Such damage, which was most prominent in

Superliner railcars #32501 and #32100, was consistent with a car body sidewall and

roofline that had come into contact with objects along the railroad right-of-way and/or the

terrain and/or damaged trackage right-of-way (track ballast, crossties, and/or running rail)

during a derailment and subsequent rollover of the railcar. Examination of the damage

indicated that the sidewall and roofline elements had become severely warped and

displaced from their normal configurations, in a manner consistent with the action that

could have contributed to the dislocation of the window grommets and the dislodgment of

the window framing structures. Small tufts of vegetation and remnants of splintered trees

(severed branches and clusters of leaves) of a character similar to the trees along the

perimeter of the track right-of-way were also found embedded in crevices of the mangled

window frame elements of several of the damaged Superliner railcars. Remnants of

dislodged and splintered trees were found along the track right-of-way near where the

Superliner railcars came to rest.

Amtrak technical staff represented to Safety Board investigators that the damage

sustained by the Superliner exterior sidewall window assemblies and their component

elements in this accident was to a degree that was far beyond original intended design

criteria. (See figure 11 for postaccident views of railcars with compromised windows.)

Four passengers assigned to deluxe bedrooms in Superliner railcar #32100 who

were inside the railcar prior to the derailment were found (by emergency responders)

outside the railcar after the derailment. All four sustained fatal injuries. Two passengers

assigned to deluxe bedrooms in Superliner railcar #32501 who were inside the railcar

prior to the derailment were found (by emergency responders) outside the railcar, one fully

and one partially, after the derailment. Both persons sustained serious injuries.

Superliner Sleeper Car Folding Armchairs

The deluxe bedrooms in Amtrak Superliner sleeper cars contain a folding armchair

that is not secured to the floor or other attachment point. During the derailment, several

armchairs became wedged in the doorways of deluxe bedrooms in cars that were on their

sides. Two passengers reported that they were injured when they were struck by armchairs

or when they were thrust out of armchairs and against some hard surface.
Factual Information 37 Railroad Accident Report

The typical service location of the folding armchair is an open space of the deluxe

bedroom, facing a sofa, in an area measuring about 4 feet by 4 feet. The armchair can be

repositioned to accommodate the needs of the user or moved elsewhere in the railcar.

When not needed, it can be folded and stowed, although it is usually in use during daytime

operations and positioned in its normal service area. The armchair is constructed of a

welded stainless steel frame structure, tubular stainless steel legs, an upholstered seatFigure 11. Postaccident Superliner sleeper cars. Top photo shows car 32503 with damaged lower level sidewall windows and largely undamaged upper level windows. Bottom photo shows car 32100 with compromised sidewall windows on both levels.
Factual Information 38 Railroad Accident Report

bottom cushion, an upholstered seatback cushion, and folding upholstered armrests. The

chair weighs about 55 pounds. In its open configuration, it measures about 25 inches wide

by about 28 inches deep by about 25 1/2 inches high. When folded, it measures about

23 inches wide by about 25 inches deep by about 10 inches high. The folding armchair

cannot be readily moved through the sliding main access door of the deluxe bedroom

without first folding it. (See figure 12 showing the folding armchair.)

Investigators could find no regulatory requirements that specifically address

provisions for folding armchairs in passenger railcars. Regulatory requirements

addressing the category ìinterior fittings and surfaces,î which includes passenger railcar

seating, are at 49 CFR 238.233. The regulations apply to passenger railcar equipment

Figure 12. Exemplar of Superliner sleeper car folding armchair.
Factual Information 39 Railroad Accident Report

ìordered on or after September 8, 2000 or placed in service for the first time on or after

September 9, 2002.î These regulations state that ìEach seatÖ shall be securely fastened

to the car bodyÖ.î All the passenger railcars involved in this accident went into service

before September 8, 2000.

Amtrak technical personnel told Safety Board investigators that they have received

a proposal from a firm for a device that would provide anchorage for the armchair in its

unfolded and folded configurations. Amtrak expects that the device, when installed, will

fulfill the safety criteria detailed at 49 CFR 238.233.

Testing and Research

Track Forces Induced by CSXT Coal Train N16815

CSXT coal train N16815 had passed over the accident curve a few minutes before

the Auto Train on the day of the accident. The coal train was traveling southbound, in the

opposite direction of the northbound Auto Train, when it passed through the accident

location at 39 mph. The coal train was made up of 2 six-axle locomotive units and 95

loaded coal cars with a gross trailing weight of 12,950 tons. (This was about 136 tons per

car or 17 tons per wheel.) The cars were equipped with conventional body-mounted brake

rigging and ABDW freight brake valves.

When interviewed by Safety Board investigators, the coal train-operating crew

reported the same general events, control inputs, and speeds that had been recorded in the

recovered coal train event recorder data. The coal train crewmembers told investigators

that the track in the accident area was not rough and that they experienced no track

irregularities when they passed over it. The coal train crew recalled no abnormalities in

train-handling or train slack.68 The crewmembers said they made no emergency

applications of the coal train air brakes nor did they undertake any other braking activity

while passing through the accident curve.

Safety Board investigators conducted computer simulations for the CSXT coal

train at the New York Air Brake (Knorr) Train Dynamic Services facility in Fort Worth,

Texas, from July 15 through 18, 2002. Party representatives from Amtrak, CSXT, the

FRA, and the Brotherhood of Locomotive Engineers were present. The CSXT coal train

simulations were performed to determine whether the coal train had placed any excessive

forces on the track in the area of the derailment prior to the passage of the Auto Train.

Data from the coal trainís locomotive event recorder were used, as well as information

concerning the track profile and the coal trainís equipment types and weights. The

simulations were designed to show in-train forces. Some in-train forces are transferred to

the track structure, but these simulations were not designed to show a direct relationship

between the track and the in-train forces.

68 Train slack is unrestrained free movement between the cars in a train.
Factual Information 40 Railroad Accident Report

The computer simulations indicated that because the coal train passed over the

accident area with little change in control inputs and because the train was negotiating

small changes in track curvature and grade, it imparted expected amounts of force to the

track structure. No significant in-train forces were identified. Within their limitations, the

simulations indicated that the coal trainís passage over the accident trackage in the

minutes before the derailment had placed no unusual burden on the track structure. (The

routine passage of a train that imparts relatively moderate force to the track structure may

trigger a track buckle if sufficient weaknesses exist in the trackís structure or if there are

problems with the trackís maintenance.)

CWR-SAFE Program

Track buckling is a phenomenon that occurs suddenly because of track instability.

The main determining factors for track buckling are the lateral track resistance, which is

largely influenced by the amount of shoulder ballast and the strength of the tie-ballast

bond; the longitudinal rail force, which is primarily a function of the neutral rail

temperature and rail anchor condition; and the trackís lateral alignment condition.

To determine if a track buckle was feasible in the accident curve under the

conditions at the time of the derailment, the Safety Board asked the Volpe Center in

Cambridge, Massachusetts, to perform a track buckling analysis with a computer software

program called ìCWR-SAFE,î which had been developed for the FRA. The computer

program determines the ìallowable temperature increaseî for buckling prevention and the

buckling safety margin. CWR-SAFE also includes a program for risk-based buckling

safety evaluation, with the key output being ìprobability of buckling versus rail

temperature.î The Safety Board provided Volpe with factual track information to

formulate the parameters for the buckling analysis.

After assuming the parameters to replicate the site conditions, Volpe ran the

computer model to reconstruct the neutral rail temperature that would result in a buckle.

For track with wooden ties, assuming a relatively ìweakî lateral resistance condition in

line with the reported ballast conditions, recent surfacing, tie replacements for a 3-degree

curve with Class 3 (1.75-inch) lateral alignment defects,69 and an estimated rail

temperature (ambient temperature estimate of 85° F + 30° F) of 115° F at time of

derailment, the analysis indicated that if the neutral rail temperature were between 60 and

65° F, the track may be prone to buckle.

The graph in figure 13 shows the CWR-SAFE program results as a function of

curvature for track with Class 3 line defects and a rail temperature of 115° F. The program

indicated that the neutral rail temperature requirement for buckling was 62° F.

Analysis was also performed for different conditions and parameters. Had the

actual rail temperature at the time of the derailment been higher, at 120° F, then the neutral

69 Although the track in the accident area was classified as Class 4, postaccident track inspections

required a reduction to Class 2; so, as an approximation, the intermediary Class 3 line defect assumption was

used.
Factual Information 41 Railroad Accident Report

Figure 13. Graph representing CWR-SAFE track buckling analysis (given a rail temperature of 115° F and Class 3 track).

Minimum neutral rail temperature requirements for buckling 

prevention (Rail temperature = 115 o F; Class 3 line defect)

40

45

50

55

60

65

70

75

80

0123456

Minimum neutral rail temp. ( ̊F) required for buckling 

Crescent City

derailment (≅ 62 ̊ F)

PARAMETERS: PARAMETERS: 

Rail: 132 pound 

Ties: wood 

Tie spacing: 20 inches 

Ballast: granite 

Lateral resistance: 75 ppi (recently surfaced) 

Tie ballast friction coefficient: 1.2 

Torsional resistance: 60 in-kips/rad/in 

Vertical modulus: 4000 psi 

Longitudinal resistance: 200 psi 

Line defect: 1.75 in. (Class 3) 

Rail temperature: 115° F 

Curvature (degrees)
Factual Information 42 Railroad Accident Report

rail temperature required for buckling would also have been higher by 5° F, or 67° F. Had

the lateral alignment condition been ìbetterî than the assumed Class 3, then the neutral

rail temperature required for buckling would have been reduced. (For instance, had the

alignment condition been Class 4, a reduction of 5° F would have resulted). Conversely,

had the lateral alignment been ìworseî (larger than 1.75 inch), the neutral rail temperature

required for buckling would have increased. The CWR-SAFE program also showed that

Class 4 accident track with a rail temperature of 120° F was similar with respect to

buckling propensity to Class 3 track at 115° F.

Postaccident Developments

As a result of this derailment and a subsequent Amtrak derailment in Kensington,

Maryland, the FRA conducted a ìfocused inspectionî in August 2002 of all CSXT track

on which Amtrak and commuter rail trains operate. In addition to their normal inspection

activities, FRA inspectors were instructed to pay particular attention to CSXTís

procedures required under 49 CFR 213.119 concerning CWR track. According to the

FRAís audit report, of the 4,770 route miles inspected, 511 track miles did not conform to

CSXTís standard ballast section requirements. With respect to the Sanford Subdivision, of

the 212 route miles inspected, 14.6 track miles did not conform to ballast section

requirements. In addition, six substandard anchor locations were found on the Sanford

Subdivision. The FRA issued numerous exceptions with respect to the results of this

focused inspection.

Also as a result of this accident and the subsequent Kensington derailment, CSXT

provided refresher training (over and above annual training) to tamper operators and

surfacing team supervisors, re-emphasized the need to submit Track Disturbance Reports,

and re-emphasized the need to conduct track tamping procedures. CSXT also now

requires that Track Disturbance Reports be submitted weekly rather than monthly.

On July 31, 2002, CSXT issued Technical Bulletin 005, entitled Equipment

Malfunctions During Surfacing Operations. Among other requirements, the bulletin stated

that ìif a tamper malfunctions during surfacing operations in a manner that adversely

affects the quality of the raising, aligning, or ballast compaction,î the limits of the affected

area, including the entire curve, must be checked and reworked if necessary with a fully

functioning tamper machine. This technical bulletin remains in effect until replaced by a

CSXT Maintenance of Way Instruction.

After the Crescent City accident, CSXT widened the track roadbed through the

accident area to a width of about 30 feet. The roadbed was extended to accommodate an

access road parallel to the track.
43 Railroad Accident Report

Analysis

This analysis is organized into five main sections. The ìAccidentî section will

discuss the events that took place on the day of the accident, as well as those issues that the

Safety Board was able to exclude from involvement in the accident. The second main

section will address ìTrack Condition and Maintenanceî and discuss the environment and

events in the years and months preceding the accident that led to the derailment. The

remaining three sections, ìDerailment Dynamics,î ìPassenger Accountability,î and

ìRailcar Crashworthiness,î concern safety issues that developed as a result of the

derailment.

Accident

Synopsis

The Auto Train derailed on April 18, 2002, in a left-hand curve near Crescent City,

Florida, about 5:08 p.m., about an hour after departing its origin point at Sanford, Florida,

heading northward to its destination of Lorton, Virginia. The train made no station stops

from 4:08 p.m., when it departed Sanford, until the accident occurred. The train stopped

and waited on the mainline at Seville, Florida, till 5:00 p.m. for a CSXT southbound coal

train to pass it. About 8 minutes later, while traveling in the curve outside Crescent City,

the Auto Train engineer saw a track irregularity, which he referred to as a ìkink,î just

before the locomotive passed over it. Despite being jolted as the locomotive moved over

the track irregularity, the engineer managed to initiate a service application of the train air

brakes. A few seconds later, he made an emergency application of the automatic air

brakes. The train derailed. The engineer activated the two-way EOT device about

15 seconds after making the emergency air brake application.

Exclusions

None of the Amtrak on-board personnel reported any significant problems or

unusual events involving the equipment during the trainís 1-hour preaccident journey. The

engineer said that the train handled as expected, and neither he nor the assistant engineer

recalled any signal or train control problems. Postaccident inspections of the Auto Train;

subsequent tests of the locomotive controls, braking systems, and EOT device; and review

of vehicle maintenance records did not indicate any problems with the Amtrak train

equipment. Therefore, the Safety Board concludes that the Auto Train and its related

equipment functioned as designed and did not cause the accident.

The investigation examined a number of Amtrak train-operating crew human

performance factors that might have affected the accident. Review of the event recorder

data with respect to train handling showed that before the locomotive passed over the
Analysis 44 Railroad Accident Report

track irregularity, the engineer handled the Auto Train in accordance with accepted

practices and procedures. Postaccident drug and alcohol testing results for the trainoperating crewmembers were negative. The work-rest histories of the train-operating

crewmembers indicated that fatigue had no role in the accident. Therefore, the Safety

Board concludes that the accident was not caused by improper train handling, drug or

alcohol use, or crewmember fatigue.

Postaccident testing of the CSXT signal equipment and train control system

demonstrated that they worked as designed. No communications problems were reported

among the train-operating crewmembers or between the train crew and the dispatcher.

Therefore, the Safety Board concludes that neither the signal equipment, the train control

system, nor the communications caused or contributed to the severity of the accident.

Within 7 minutes of the accident, the first emergency responder arrived on-scene.

About 12 minutes after the accident, the chief of the Crescent City Fire Department

arrived on-scene and assumed incident command, but he had accidentally left his radio at

the fire station. He began organizing the response but left the command post to assess the

accident. The training coordinator for Putnam County Emergency Services, en route to the

scene, attempted to contact the fire chief but was unable to do so because the chief had no

radio with him. After he had arrived on-scene, and after several minutes of being unable to

contact the fire chief, the training coordinator, as the highest-ranking emergency responder

on-scene, assumed incident command about 5:46 p.m.70 By the time the training

coordinator assumed incident command, less than 40 minutes had elapsed since the

accident, so this minor organizational problem did not significantly delay or impair the

effectiveness of the emergency response.

The training coordinator immediately established a command post, a staging area,

and a triage area. In all, 441 emergency responders responded to the accident, so there

were nearly as many emergency responders as people on the train. All of the more than

400 passengers were evacuated from the trainís 16 passenger cars within 2 hours of the

accident. The Safety Board concludes that the overall emergency response to the accident

was timely and effectively managed.

Track Buckle

The Auto Train engineer stated that as the train approached the point of the

derailment, he saw that both rails ahead of the train were out of alignment. He said that the

rails were parallel to one another and out of alignment to the outside of the curve by about

10 inches. When he subsequently reported the derailment to the dispatcher, he described

this misalignment as ìa bad kink in the rail.î The term ìkinkî refers to the track

irregularity more properly called a track buckle.

70 The training coordinator was following established incident command guidelines when he assumed

incident command. Because the training coordinator was the senior emergency responder on-scene, incident

command authority would probably have been transferred to him under regular procedures had the fire chief

been at the command post when the training coordinator arrived.
Analysis 45 Railroad Accident Report

The investigation examined whether the passage of the southbound CSXT coal

train N16815, shortly before the Auto Train, might have triggered the track buckle. When

a railroad wheel rolls on the rail, a longitudinal wave is created in front of the wheel as the

wheel slightly depresses and ìpushesî the rail before it. This imparts compressive

dynamic force into the rail. Track buckles may be induced or triggered by the passing of a

train when the compressive dynamic forces are added to preexisting thermal forces. Once

track begins to buckle out of alignment under a train, the buckle will become

progressively more severe as each wheel impacts the rail.

A track buckle may occur toward the rear of a passing train, where it may or may

not cause a derailment. If the train is moving slowly enough and the cars are heavy

enough, the train may negotiate the buckle and continue without the train crewís noticing

it. The coal train that preceded the Auto Train over the accident curve (moving in the

opposite direction) was traveling at 39 mph, which was 21 mph below the speed

restriction of 60 mph. The coal train was made up of 2 six-axle locomotive units and 95

loaded coal cars, weighing about 136 tons each. Thus, the coal train was likely moving

slowly enough and its cars were heavy enough that a track buckle could have developed

under the coal train unnoticed by its crew.

Although a track buckle might form ahead of a train, such buckles more typically

form at the rear of a passing train, due to the progressive force imparted as each car of the

train moves over the susceptible area. The Auto Train engineer stated that the buckle was

already in the track ahead of the Auto Train when he saw it, not that he saw it forming.

Therefore, the Safety Board concludes that the track buckle that caused the derailment of

the Auto Train probably originated during the passage of CSXT coal train N16815 over

the accident curve.

Track Condition and Maintenance

The events that led to the development of a track buckle at this location had

evolved for more than a year prior to the accident and concerned the track conditions at

the accident curve, as well as the track maintenance activities that took place at and near

this site. Specifically, the investigation indicated that the roadbed width of the track on the

curve embankment, the ballast condition of the track, the rail anchoring in the area, the

surfacing operations undertaken by CSXT at this location, and the rail temperature

practices used during and after the surfacing operations all contributed to the track

instability that allowed the track buckle to form. Individually, perhaps none of these

factors would have generated the track buckle; in combination, they created the unstable

track environment conducive to the sudden development of a buckle on April 18, 2002.

Roadbed, Ballast, and Rail Anchor Conditions

The CSXT standard engineering plan for new roadbed requires a 30-foot-wide

roadbed. CSXT does not have a specific roadbed width maintenance requirement; instead,

it requires roadbeds to be maintained so that they adequately support the ballast section.
Analysis 46 Railroad Accident Report

Based on the known tie dimensions and CSXT track standards for existing track, Safety

Board investigators calculated that the minimum roadbed width for the track on the

accident curve, assuming it met the established CSXT standards, was 15 feet.71 Visual

evidence indicated that the roadbed in the accident curve was likely narrower than this

minimum.72

The CSXT chief regional engineer for the Jacksonville District stated that the area

of the derailment had a relatively narrow roadbed. He also stated that in some cases,

CSXT ìroadbeds become narrow because we continue to elevate the track by surfacing

our track and raising the track structure.î Because the roadbed in the accident curve had

narrowed so that it could not adequately retain the normal ballast profile, ballast migrated

down the inside slope of the embankment in the months before the accident, necessitating

repeated resurfacing operations.

Despite the narrow roadbed, it appears that the ballast had not begun to migrate

significantly until early in 2001. In fall 2000, about 18 months before the accident, CSXT

had conducted shoulder ballast cleaning operations through the accident curve, in an effort

to improve track drainage. The shoulder ballast cleaning removed fouled ballast from the

shoulder area of the track, cleaned the ballast, and returned the cleaned ballast to the

shoulder. However, according to the local CSXT track supervisors and inspector, in the

months after the cleaning, ballast began migrating down the inside of the curve

embankment. Evidently, by breaking up the hardpan soil supporting the ballast, the

cleaning process had freed the ballast and allowed it to move down the inside of the curve

embankment.

Adequate ballast is crucial to ensuring the trackís lateral support and restraint.

Because of the trackís narrow roadbed and the consequent ballast migration, CSXT could

not maintain sufficient ballast around the ties and rail at the roadbed track level at the top

of the embankment to provide adequate support and restraint. In an attempt to halt ballast

migration down the inside slope of the accident curve, CSXT constructed a ballastretaining wall of used concrete ties on March 6, 2002, about 6 weeks before the accident

occurred. The CSXT track inspector for this area acknowledged that before the installation

of the ballast-retaining wall, the ballast levels supporting the track at the accident curve

were not sufficient to meet CSXT standards. In particular, with respect to the shoulder

ballast, he stated, ìIt wasnít maintained to [CSXT] standards with the 12 inches of ballast

on the high side and 6 inches on the low, two-to-one.î

71 The ballast depth dictates the length of the 2:1 ballast shoulder slope. Because the ties were 7 inches

deep and the minimum ballast depth beneath the ties was 8 inches, the ballast profile depth was 15 inches.

Thus, a 2:1 ratio means the length of the ballast shoulder slope was 30 inches on each side of the track.

According to CSXT standards, the inside curve ballast shoulder width should have been 6 inches and the

outside curve ballast shoulder width should have been 12 inches. The length of a tie was 8 feet, 6 inches, or

102 inches. Therefore, the minimum roadbed width necessary to support the CSXT ballast shoulder profile

for the accident curve was 30+6+102+12+30 inches = 180 inches, or 15 feet.

72 Because the derailment forces largely destroyed the roadbed and track in the immediate area of the

accident, investigators could not measure the roadbed at this location after the accident took place. However,

investigators examined the roadbed immediately preceding and beyond the derailment site.
Analysis 47 Railroad Accident Report

Safety Board investigators inspected the track adjacent to the derailment site after

the April 18, 2002, accident and found that in many places the ballast did not fill the tie

cribs between the crossties. Many cribs were only half full in the center and even less full

toward the ends. Investigators found little or no ballast off the ends of the ties, let alone a

full ballast shoulder up to the tops of the tie ends. Therefore, the Safety Board concludes

there was insufficient ballast on the accident curve prior to the accident to meet CSXTís

own standards and to ensure that the CWR was being adequately restrained.

In August 2002, the FRA conducted a focused inspection of all CSXT track on

which Amtrak trains and commuter rail traffic operate. According to the final FRA report,

of the 4,770 CSXT route miles the FRA inspected, 511 track miles did not conform to

CSXTís own ballast section requirements.

Rail anchoring restricts the longitudinal movement of the rail, which localizes the

compressive or expansive forces in the rail so that these forces are distributed uniformly

throughout the track structure. Postaccident inspection of the undamaged track north and

south of the derailment site revealed a number of locations where rail anchors were

missing or where rail anchors were not snug against ties. Nineteen percent of the rail

anchors required through the accident curve were determined to be missing or not snug

against ties.

A rail anchor that is not snug against the tie allows longitudinal rail movement in

one direction to the extent of the distance or gap between the tie and the anchor.

Longitudinal rail movement may be due to thermal expansion, which is a function of rail

length. The free expansion or contraction in a 3-foot length of rail with a 50° F difference

in rail temperature throughout a day would be about .008 inch. (In a 1/4-mile length of

rail, this would total about 3 1/2 inches.) Therefore, to adequately restrain the rail, a rail

anchor must be snug against a tie, because if the gap between the tie and anchor is (as in

the cited example) greater than .008 inch, theoretically, the anchor would never contact the

tie or provide any restraint. Thus, a rail anchor that is not snug against a tie is unlikely to

provide significant rail restraint. AREMA, rail anchor manufacturers, and industry experts

agree that for rail anchors to be effective, they should be against the tie. In the rail anchor

standard in its Maintenance Bulletin MWI 1113-01, Performance for Large Scale Track

Work, CSXT states that anchors not snug against ties constitute a defect. The Safety Board

concludes that missing rail anchors and ineffective rail anchoring contributed to track

instability through the accident curve.

Although the FRA does not have a minimum requirement for the number of

effective anchors for CWR track, CSXT has, as noted above, established its own rail

anchoring standards. However, only CSXTís large system-wide track maintenance

production teams are required to adhere to the anchoring standards in Maintenance

Bulletin MWI 1113-01. Because CSXT does not require its local maintenance-of-way

crews to use such standards, they typically rely on the experience and judgment of local

supervisors, which might not be adequate to ensure a safe track condition. Therefore, the

Safety Board believes that CSXT should require all track maintenance employees,

including large system-wide track maintenance team members and local maintenance-of-
Analysis 48 Railroad Accident Report

way crew members, to use a consistent rail anchor standard that includes a requirement

that rail anchors be maintained snug against ties.

Track Alignment After Surfacing

On October 9, 2001, regional CSXT surfacing gang members began to surface the

full curve from MP 722.5 to MP 722.1, working from south to north. While working on

the northern end of the curve and into the north curve spiral, they realized that the track

liner-tamper machine they were using was not lining the track properly. By manually

adjusting the machine, they were able to finish surfacing the curve. Two days later, on

October 11, after the liner-tamper machine was repaired, the surfacing gang members used

it to re-line and tamp the track from the point at which they estimated the machine had

first experienced problems and continued north through the rest of the curve and spiral.

The gang members did not record the exact location at which the liner-tamper machine

went out of alignment, nor did they document the exact location at which the machine was

subsequently restarted 2 days later. Therefore, the repaired liner-tamper machine may well

have been started at a point in the curve beyond where the machine had actually first

deviated, which would have resulted in a discontinuity in the constant smooth transition of

the curve and the introduction of a slight deviation or ìnotchî in the curve that provided a

weak point in the track.

This area of the track was repeatedly machine-surfaced in the months before the

accident. On November 19, 2001, the surfacing gang machine-surfaced portions of track

on the northern section of the curve. On February 26, 2002, the curve was machinesurfaced from MP 722.3 to MP 722.1; and on March 11, 2002, the curve was machinesurfaced from MP 722.3 to MP 722.2. At no time during these surfacing processes was the

curve measured or checked against a reference point to ensure that the alignment was

correct or that a smooth transition was maintained.

If an alignment deviation was introduced somewhere near the middle of the curve

during the work on October 11, 2001, the subsequent surfacing operations would not have

corrected it. The deviation would have remained a weak point in the curve alignment.

Given that surfacing work is recorded to the nearest 1/10th of a mile, it is reasonable to

suppose that the point of derailment, MP 722.24, fell within the weak anomaly area

introduced on October 11, 2001.

Therefore, the Safety Board concludes that the problems with the liner-tamper

machine on October 9, 2001, and the re-implementation of the repaired machine well into

the curve on October 11 introduced a track misalignment and caused a weak point in the

curve that was susceptible to later buckling. On July 31, 2002, CSXT issued Track

Bulletin 005, notifying its track maintenance workers that if a liner-tamper machine broke

down during a surfacing operation in a way that ìadversely affected the quality of the

raising, aligning or ballast compaction,î they should (among other requirements) check

and, if necessary, resurface the entire curve.
Analysis 49 Railroad Accident Report

CWR Temperature Control

Track buckling occurs when the difference between the current rail temperature

and the neutral (force-free) rail temperature creates thermally induced internal

longitudinal rail forces strong enough to overcome the trackís lateral restraint. These

thermally induced forces will accumulate at the weakest point in the track, which will

create a track buckle when the lateral restraint is overcome.

To determine what conditions led to the development of the track buckle at the

Crescent City curve, it was necessary to establish the current rail temperature when the

track buckle developed. Although no one measured the rail temperature at the accident

curve around 5:00 p.m. on April 18, 2002, when the track buckle likely developed,

meteorological reports indicate that the ambient temperature about that time was in the

low 80s (° F), and the day was mostly sunny. When the rail temperature was measured 2

days after the accident, during the late afternoon of April 20 (a partly sunny day), the rail

temperature at the accident site area was 120° F at a time when the ambient temperature

was in the high 80s (° F). On April 24 (a partly sunny day) at 5:00 p.m., the ambient

temperature was 83° F, and the rail temperature was 108° F. Given that the ambient

temperature on April 18 was similar to that on April 24, a neutral rail temperature of at

least 108° F seems likely. In addition, April 18 was a mostly sunny day while April 24 was

only partly sunny. The cumulative effect of hours of nearly continuous sunshine on metal

rail by late afternoon on the day of the accident likely increased the rail temperature by a

further significant increment. Therefore, it seems probable that the rail temperature about

5:00 p.m. on the day of the accident was well above 108° F. A current rail temperature of

between 110° and 120° F is entirely feasible.

The CWR-SAFE computer program, which determines the ìallowable temperature

increaseî for buckling prevention and the buckling safety margin, indicated that CWR

may buckle when the difference between the neutral rail temperature and the current rail

temperature is 50° F or more, depending on the condition of the ballast and track

structure.73 For the Crescent City accident curve, the CWR-SAFE program predicted a

neutral rail temperature for buckling of between 60° and 65° F.

Given a neutral rail temperature of 60° to 65° F and an increase in rail temperature

of 50° F, the resulting current rail temperature of around 115° F on the afternoon of the

accident could have resulted in a track buckle. Consequently, investigators attempted to

determine how a neutral rail temperature in the 60° to 65° F range might have developed

for the rail in the accident curve.

Numerous maintenance operations were performed in the accident area in the

6 months before the derailment. The repeated surfacing operations have already been

noted. These maintenance operations were carried out in the cooler months of the year,

when rail temperatures were well below the CSXT neutral rail temperature standard of

100° F. No rail adjustments were performed after these maintenance operations broke the

73 The better the track structure, the greater the difference in temperature the track can withstand.

Conversely, the weaker the track structure (particularly if it is deficient in ballast), the less rail temperature

change the track can withstand before buckling.
Analysis 50 Railroad Accident Report

bond between the ballast and the ties. (Under these conditions, appropriate rail adjustment

according to CSXT procedures would have consisted either of removing the rail anchors,

heating the rail, and then reanchoring it, or of realigning the curve.)

Proper rail temperature control is critical during the period immediately after the

track has been disturbed and until the track is reestablished and firmly stabilized in the

ballast. On February 26, 2002 (about 7 weeks before the accident), the CSXT regional

surfacing gang machine-surfaced the track segment from MP 722.3 through MP 722.1,

which encompassed the point of derailment (MP 722.24). The rail temperature was

measured at 90° F when the work was completed on February 26.

After this surfacing, the ambient temperature in the area decreased for the next 3

days while the track was in the post-surfacing stabilization process. The following were

the daily high and low ambient temperatures from February 26 through March 1:

The track was exposed to a range of relatively low temperatures during the 3-day

period following the February 26 surfacing, while the track was most subject to

movement.74 Temperatures during this period were in the 60s (° F) and lower, making the

CWR-SAFE criteria of a 60° to 65° F neutral rail temperature not only feasible but

probable.

Adequate ballast could have helped to restrain, if not prevent, the rail from

significantly contracting. Given the lack of ballast, which would have allowed the track to

move with relative ease, the rail could have contracted to a low neutral rail temperature,

causing the curve to ìchordî (shrink) inward, which would have made it prone to buckle

when the weather warmed. When about 70 tons of ballast was dumped on the north end of

the accident curve on March 8, the rail had already had ample time (10 days) to contract to

a new and lower neutral rail temperature without sufficient ballast restraint. Because the

track in the curve did not have sufficient ballast, it was inadequately restrained after being

disturbed on February 26. CSXT and industry maintenance practices for surfacing CWR

track recommend that track not be surfaced until sufficient ballast is distributed to provide

the necessary restraint. Insufficient restraint, caused by insufficient ballast, will permit the

track to move during stabilization or possibly not to stabilize at all. A later application of

ballast, such as CSXTís addition of 70 tons of ballast to the curve on March 8, will not

correct this problem, because movement may have already occurred. Therefore, the Safety

Board concludes that the accident curve chorded inward because there was insufficient

February 26 75° F 45° F

February 27 68° F 36° F

February 28 55° F 36° F

March 1 66° F 48° F

74 A slow order was in effect for MP 722.3 though MP 722.1 from February 5 through March 13, 2002.
Analysis 51 Railroad Accident Report

ballast in the track at the time of the February 26, 2002, surfacing to prevent track

movement as the track stabilized.

On March 11, the accident curve was resurfaced, this time between MP 722.3 and

MP 722.2, a segment containing the point of derailment. The liner-tamper machine started

in the body of the curve and moved northward to create a 1-inch lift. The high and low

daily temperatures in the days after this surfacing were as follows:

These ambient temperatures were somewhat higher than those in effect during the

February 26 through March 1 period but were still well below those needed to achieve the

desired neutral rail temperature standard of 100° F. Although less likely than the track

disturbed during February 26 to fall to the 60° to 65° F neutral rail temperature range

necessary for buckling, the track involved in this surfacing would still have developed

significant compressive forces that would tend to further stress a buckle-prone weak point

in the curve.

As has been stated, with the decline in ambient temperature that occurred after the

February 26 surfacing operation (coupled with the lack of ballast on the curve from

February 26 until March 8), the rail contracted and the track chorded inward. To detect

track movement, CSXT requires curves over 1 degree in CWR track to be monumented if

the temperature falls below 50° F during surfacing. However, CSXT procedures do not

require monumenting if the temperature falls below 50° F during the stabilization period

following surfacing work. (Monumenting consists of establishing known reference points

against which any subsequent movement of the track can be measured.)

The temperature during the February 26 surfacing work was well above 50° F, so

the track was not monumented. During the post-surfacing stabilization period, however,

temperatures fell below 50° F. When the track was resurfaced on March 11, there was no

way to determine whether the track had moved since the February 26 work, because the

track had not been monumented on February 26. Therefore, the Safety Board concludes

that because the curve was not monumented when it was surfaced on February 26, 2002,

the crew resurfacing the track on March 11, 2002, did not know whether the track had

moved since February 26, 2002. Had the crew members known the track had moved, they

could have adjusted the curve appropriately. Therefore, the Safety Board believes that

CSXT should modify its procedures to ensure that when a curve is surfaced, it is also

monumented, if local temperatures are predicted to fall below 50° F during the postsurfacing stabilization period.

March 11 74° F 53° F

March 12 84° F 56° F

March 13 79° F 54° F

March 14 78° F 54° F
Analysis 52 Railroad Accident Report

According to CSXT rules, each time the track is disturbed, a Track Disturbance

Report is to be filled out and submitted for later rail temperature reference. At the time of

the accident, CSXT required that Track Disturbance Reports be submitted monthly. (Since

the accident, CSXT has required that Track Disturbance Reports be submitted weekly.)

Roadmasters use the reports to identify areas that need additional attention, particularly

when the weather gets warmer. The reports are also used to direct follow-up track

adjustment. The CSXT regional surfacing gang foreman, who had performed most of the

surfacing operations through the accident curve, admitted that on several occasions he had

not submitted the required monthly Track Disturbance Reports after disturbing the track.

Consequently, no timely record was available to the roadmaster indicating the necessity of

performing appropriate track adjustments following the track disturbances. Also, despite

the fact that regional engineering personnel were aware of the surfacing gang foremanís

assignments and locations, no one from CSXT ever checked to ensure that the disturbance

reports were submitted after the surfacing was done.

According to the roadmaster, local maintenance crews usually start adjusting rail

that has been disturbed during the winter season when the ambient temperature rises to

approach the upper 80s (° F), which in the Crescent City area typically occurs in April.

The temperature on April 18, 2002, reached the low 80s (° F), and temperatures in the mid

to high 80s (° F) were experienced in the days after the accident. Thus, when the accident

occurred, area temperatures were nearing the range at which track adjustments were

normally carried out. Therefore, the Safety Board concludes that had the Track

Disturbance Reports been submitted in a timely fashion, the roadmaster might have used

them to prioritize the track adjustment work to be carried out on track disturbed during the

winter, including the accident curve.

In summary, regarding CSXT track maintenance, the Safety Board notes that the

Crescent City investigation showed that the CSXT program was inadequate in two general

respects. First, CSXT failed to establish some needed track standards. Second, CSXT

failed to ensure that its track maintenance workers routinely fulfilled the requirements of

its existing track standards.

With reference to the former problem, CSXT did not have adequate requirements

at the time of the accident for ensuring effective rail anchoring, for monumenting curves

when temperatures were expected to fall below 50° F during the track stabilization period

following surfacing, or for relining the entire curve if the liner-tamper machine broke

down during a surfacing operation. CSXT has since addressed the liner-tamper machine

procedure deficiency, and the Safety Board has proposed safety recommendations to

provide appropriate requirements for rail anchoring and monumenting.

However, the provision of new written requirements in these areas will not solve

the underlying quality control problem concerning CSXT track maintenance indicated by

this investigation. The Safety Board found that although CSXT had written standards for

ensuring the maintenance of an adequate ballast section to restrain the track and for

conducting surfacing operations according to established practices and rules (such as

drafting and submitting Track Disturbance Reports at specified intervals), CSXT track

employees sometimes did not fulfill these requirements. Given these deficiencies, it
Analysis 53 Railroad Accident Report

appears that CSXT did not have an effective quality control program that ensured strict

adherence to written track standards among its track maintenance employees. Therefore,

the Safety Board concludes that CSXT did not provide adequate oversight to ensure that

its track maintenance activities were carried out in accordance with its own standards.

In addition, when the FRA conducted an August 2002 focused inspection of CSXT

track used by Amtrak and commuter rail trains, FRA inspectors found numerous instances

of track conditions that did not conform to CSXT requirements. The FRA findings,

coupled with the repeated failures by CSXT track personnel to fulfill established CSXT

track standards and practices revealed during this accident investigation, suggest that

CSXT may have a quality control problem with its track maintenance operations,

particularly in the area of track surfacing. Therefore, the Safety Board believes that CSXT

should develop a systematic quality control program to ensure that track-surfacing

personnel consistently conduct track-surfacing operations in accordance with CSXT

standards.

Derailment Dynamics

Auto Train Consist

The first 16 cars in the train were Amtrak Superliner passenger cars; 24 autorack

cars followed them. After the derailment, the two locomotive units and the first two

passenger cars remained on the rails. However, the remaining 14 passenger cars and 7 of

the autorack cars derailed. The 7 derailed autorack cars remained generally in-line. The

other 17 autorack cars stayed on the rails. The disposition of the derailed cars, particularly

the passenger cars, reflected the accordion effect of railcars when they derail, alternately

folding together in parallel fashion, perpendicular to the track. The rapid and violent

movements, including the laying over of some of the passenger cars, involved the

dissipation of such large forces in such a relatively short distance that they probably

caused the majority of the injuries and fatalities.

Traditionally, passenger trains are configured with unoccupied nonrevenue cars

(such as express and baggage cars) up front and closest to the locomotive, so that these

unoccupied cars will absorb the impact and forces of a collision and/or derailment. The

Auto Train, however, is a unique type of passenger train, and its consist is set in

accordance with the attributes of its special cars.

When trains are made up, it is generally desirable to place the heaviest cars in the

front, behind the locomotive units, and the rest of the cars in descending order by weight.

This type of consist is advantageous because it minimizes the in-train forces during

movement, starting, and stopping, and especially during emergency braking. Superliner

cars typically weigh between 150,000 and 160,000 pounds (passengers and baggage

generally add no more than 5 percent to the car weight). Eighteen of the 24 autorack cars

on the train were bi-level autocarriers, weighing about 122,000 pounds each, loaded, and 6

were tri-level autocarriers, weighing about 164,000 pounds each, loaded. Thus, most
Analysis 54 Railroad Accident Report

(75 percent) of the autorack cars in this consist were about 30,000 pounds lighter than the

Superliner cars, and even the six tri-level autocarriers were only slightly heavier than the

Superliner cars. Consequently, from a train density standpoint, the on-average heavier

Superliner cars were optimally located near the front of the Auto Train consist.75

Two-Way End-Of-Train Device Activation

According to locomotive event recorder information, it was not until about

10 seconds after the engineer put the train in emergency (at 5:08:01 p.m.) and about

7 seconds after the air brakes went into emergency (at 5:08:04 p.m.) that the emergency

braking signal actually reached the rear of the train (at 5:08:11 p.m.). There were likely

two reasons for this time gap; a pinched trainline air hose between cars and the engineerís

delay in activating the two-way EOT device to initiate an emergency brake application at

the rear end.

Investigators deduced that a pinched trainline air hose between cars kept the

pneumatic signal from reaching the rear of the train when the air brakes went into

emergency at the head end. About 7 seconds later, the derailment forces caused a break in

the trainline air hose beyond the pinched area, which caused the remainder of the train to

go into emergency. The engineer did not activate the EOT device until 5:08:15 p.m., about

15 seconds after he had put the train into emergency. By that time, the EOT device

activation was unnecessary, because the full train was already in emergency due to the

break in the trainline.

Had the engineer immediately activated the two-way EOT device when he put the

air brakes in emergency, the rear of the train would have gone into emergency with the

head end, which would have minimized car movement. The 7-second delay between the

trainís air brakes going into emergency and the emergency signal reaching the end of the

train allowed the cars at the rear of the train to continue to move into the forward cars,

which were braked and/or stopping.

The delay would have been avoided if the two-way EOT device had been

automatically activated at the same moment the engineer put the trainís air brakes in

emergency. The Safety Board has previously discussed the benefits of automatic

activation of EOT devices on trains. In the Bloomington, Maryland, freight train accident

report,76 the Safety Board noted that CSXT had installed automatic two-way EOT devices

on all its new locomotives. However, this was not the case. CSXT had actually installed

automatic-ready two-way EOT devices, which could not, when installed, effect the

simultaneous, automatic application of the brakes at the end of the train with the

engineerís emergency application of the brakes. To function properly, the installed devices

75 In addition, the passenger cars on the Auto Train, which require electrical power from the locomotive

units, are placed nearest the locomotives to minimize electricity transmission distance and connections. The

autorack cars do not have conduits and piping because they do not require electricity, and because they are

typically placed on the end of the train, there is no need to transmit electrical power to or through them.

76 National Transportation Safety Board, Derailment of CSX Transportation Coal Train V986-26 at

Bloomington, Maryland, January 30, 2000, Railroad Accident Report NTSB/RAR-02/02 (Washington, DC:

NTSB, 2002).
Analysis 55 Railroad Accident Report

need the additional installation of a computer card encoded with the necessary information

technology (software). This technology was not yet available when CSXT installed the

devices nor at the time of the Crescent City derailment. Since the Crescent City accident,

however, automatic two-way EOT application technology (as provided through the

encoded computer cards) has reached the final development stage and should soon be

ready for use.

The Safety Board concludes that had the two-way EOT device been activated

when the Auto Trainís air brakes were put in emergency, the severity of the injuries

resulting from the derailment might have been lessened, because the continued forward

momentum of the majority of the trainís cars into the stopped passenger cars would have

been reduced. At the time of the accident, Amtrak locomotives were not equipped with

automatic two-way EOT devices. Consequently, the Safety Board believes that Amtrak

should install automatic two-way EOT emergency activation devices on all Amtrak

locomotives equipped with manual devices.

Passenger Accountability

The accident Auto Train was an all-reserved passenger train that was to travel

nonstop between Sanford, Florida, and Lorton, Virginia. To account for the Auto Train

passengers, Amtrak was using the paper on-board record system described in its Service

Standards Manual for Management Employees (refer to appendix B for detailed

procedures). Given that the train made no scheduled stops for passengers, if this had been

a reliable system, Amtrak should have been able to determine soon after the train departed

from Sanford exactly how many passengers were on board the Auto Train by using the

passenger manifest and the contents of the conductorís ticket collections pouch. Even

though the accident occurred only about an hour after the train departed from Sanford, this

still should have been sufficient time to develop a comprehensive list. Nevertheless, the

incident commander told investigators that he had difficulty obtaining accurate

information from Amtrak about the number of people on board the train.

When he arrived on the scene on April 18, the incident commander was told that

468 people were on the train. Subsequently, he was provided with both a greeter list and a

passenger list, but the information on the two lists did not match. The incident commander

later complained that emergency responders had to spend time attempting to verify the

accuracy of the two lists. The day after the accident, Amtrak gave the incident commander

a computer printout list, which contained information that did not match either of the two

lists provided on April 18. In fact, Amtrak never provided the incident commander an

accurate count of the persons on board the train. Even during postaccident interviews,

long after the initial emergency response, Amtrak was still erroneously reporting the total

number of people on board the train as 468.

Using information gathered and correlated from three sourcesAmtrak, Putnam

County Emergency Services, and medical recordsit took Safety Board investigators

almost 5 months to determine the number of Auto Train occupants at the time of the
Analysis 56 Railroad Accident Report

accident. The total number of people on board the train was 446, a discrepancy of 22 from

the figure of 468 people that Amtrak gave in the immediate response phase.

In a derailment, the survival of passengers and crewmembers might well depend

on emergency responders, who in turn depend on a complete and accurate accounting of

all people on the train to ensure that they locate, evacuate, and treat (if necessary) all those

on board. If the passenger list does not include every passenger on the train, emergency

responders may leave passengers behind. If the passenger list includes people not on the

train, emergency responders may be needlessly exposed to prolonged risks as they search

for nonexistent passengers. To facilitate an effective emergency response, the incident

commander must have an accurate passenger list as soon as possible.

This is not the first time the Safety Board has identified passenger accountability

as an issue in an Amtrak accident. Following the September 1993 Amtrak accident in

Mobile, Alabama,77 in September 1994, the Safety Board recommended that Amtrak:

R-94-7

Develop and implement procedures to provide adequate passenger and

crew lists to local authorities with minimum delay in emergencies.

Amtrak responded to the recommendation with a plan to develop a satellite and

long-distance messaging system between long-distance trains and corporate offices. One

benefit of this proposed new communications system was to be improved passenger

manifests. However, following a 1997 Amtrak accident in Kingman, Arizona,78 Amtrak

told the Safety Board that passenger manifests were unrealistic on unreserved trains, due

to the number of station stops such trains make. Amtrak indicated, however, that computer

systems could provide passenger lists for reserved trains. As a result of this new

information, the Safety Board closed Safety Recommendation R-94-7 (Reconsidered) on

August 31, 1998, and issued a new recommendation urging Amtrak to:

R-98-58

Expedite the development and implementation of a passenger and crew

accountability system on reserved trains.

77 National Transportation Safety Board, Derailment of Amtrak Train No. 2 on the CSXT Big Bayou

Canot Bridge Near Mobile, Alabama, September 22, 1993, Railroad Accident Report NTSB/RAR-94/01

(Washington, DC: NTSB, 1994).

78 National Transportation Safety Board, Derailment of Amtrak Train 4, Southwest Chief, on the

Burlington Northern Santa Fe Railway near Kingman, Arizona, August 9, 1997, Railroad Accident Report

NTSB/RAR-98/03 (Washington, DC: NTSB, 1998).
Analysis 57 Railroad Accident Report

On September 14, 1999, the president of Amtrak Intercity testified during the

Safety Boardís public hearing on the Bourbonnais, Illinois, accident79 that Amtrak had

made an investment of $24 million and contracted with Motorola to develop an automated

system for accounting for train passengers. He described the system as a simple hand-held

device to be used by the conductor, which would scan the tickets and record a passenger

name. There was to be a central processing unit on the train for downloading information

from the hand-held device. This information was to be transmitted to the Amtrak national

reservation system and made available to a number of locations. As such, the passenger

data would be readily available to emergency responders. The Amtrak official said the

system was scheduled for implementation in 2000.

Because Amtrak had indicated that an automated passenger accountability system

was in imminent development, the Safety Board classified Safety Recommendation R-98-

58 ìClosed--Acceptable Actionî on December 5, 2000. However, Amtrak has not

implemented such an accountability system. Since Safety Recommendation R-98-58 was

closed, Amtrak has failed to provide a timely and accurate passenger count to emergency

responders during at least four Amtrak accidents (including this one).80 Earlier this year,

an Amtrak official stated in a letter81 to a Safety Board staff member:

While Amtrak continues to explore realistic technological alternatives to enhance

the efficiency of recording ticketed and non-ticketed passengers, we feel that the

passenger accountability system presently in place is a reliable one.

Therefore, Amtrak still uses, and appears likely to continue to use, the paper onboard record system outlined in its Service Standards Manual for Management Employees

to account for passengers on its long-distance, overnight, and reserved trains. However, as

the Crescent City accident indicated, this system is prone to error, delay, and confusion.

The system could not provide an accurate list months after the accident, much less during

the crucial emergency response period. Therefore, the Safety Board concludes that the

paper record passenger accountability system in use for long-distance, overnight, and

reserved trains on the Amtrak system cannot be relied upon to provide an accurate and

timely passenger manifest in case of emergency.

Amtrak uses the same paper record system that performed so poorly on the Auto

Train for all its long-distance, overnight, and reserved trains. Amtrak operates the

following trains that fall into one or more of these categories:

79 National Transportation Safety Board, Collision of National Railroad Passenger Corporation

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

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

NTSB, 2002).

80 The other three accidents took place in Syracuse, New York, in February 2001; Nodaway, Iowa, in

March 2001; and Kensington, Maryland, in July 2002.

81 Letter dated March 14, 2003, from Amtrak Chief Transportation Officer, Operations Standards and

Compliance, to Safety Board investigator concerning the July 29, 2002, Amtrak Train 30 derailment in

Kensington, Maryland.
Analysis 58 Railroad Accident Report

Since issuing Safety Recommendation R-94-7 nearly 9 years ago, the Safety Board

has investigated nine accidents involving Amtrak trains from this list in which passenger

accounting has been less than satisfactory during the emergency response. As has been

noted, the Safety Board has repeatedly made recommendations to Amtrak concerning this

issue, and Safety Board staff members have met with Amtrak representatives both

formally and informally to resolve this longstanding problem. To date, Amtrak has not

taken effective action to address this safety issue. Consequently, the Safety Board believes

that Amtrak should develop and implement an accurate passenger and crew accountability

system for all its long-distance, overnight, and reserved trains that will immediately

provide an accurate count of the people on board the train in case of emergency.

In addition to facilitating effective occupant evacuation and treatment during an

emergency, having more complete information about those on board a train could benefit

U.S. rail transportation in other ways. An accurate listing of all people on board a train that

includes information concerning the identity of each person would be useful for purposes

of security as well as safety. To ensure that a passenger and crew identification system

meets all safety and security needs, the two Federal agencies primarily responsible for

railroad safety and security should collaborate in its creation. Therefore, the Safety Board

believes that the Federal Railroad Administration and the Transportation Security

Administration should, in cooperation, develop and implement an accurate passenger and

crew accountability system for all long-distance, overnight, and reserved passenger trains

that will immediately provide an accurate count and identity of the people on board the

train in case of emergency at any time during the trip.

Railcar Crashworthiness

Superliner Passenger Car Windows

The investigation examined the construction, intended design criteria, and

performance expectations of the Superliner railcar sidewall window when operating in its

normal performance environment. The means of retention of those windows, which

principally relies on a window grommet to keep the window assembly in place within the

Sunset Limited Cardinal 

Southwest Chief Auto Train 

California Zephyr City of New Orleans 

Empire Builder Silver Palm 

Coast Starlight Silver Star

Crescent Silver Meteor 

Texas Eagle Acela Express

Capitol Limited Metroliner 

Three Rivers Empire Service 

Lake Shore Limited 
Analysis 59 Railroad Accident Report

car body sidewall opening, was also evaluated. The investigation identified evidentiary

artifacts, consisting of obvious rounded indentions in the roofline edge (between the

transverse structural members of the railcar roof), small tufts of vegetation and remnants

of splintered trees found within and adhering to crevices in the car body, and battering

damage on the railcar sidewall panels, all of which were consistent with the extensive

damage that resulted from the substantial, and somewhat prolonged, severely abrasive

action of the trees along the perimeter of the trackage right-of-way in this area. Further,

the residue track ballast and soil found within the railcars was consistent with the railcars

having been overturned and dragged along the trackage right-of-way for some distance.

Therefore, the catastrophic breaches of the Superliner exterior sidewall windows

in this accident resulted from the severe abrasive action of the trees along the track that

came into contact with the exterior sidewalls of the railcars during the derailment, which

resulted in the sidewall and roofline elements of the railcar becoming severely warped and

displaced from their normal configurations. The abrasive contact of the trees against the

sidewall windows also dislocated the window grommets (which keep the window

assemblies in place within the car body sidewall openings) and subsequently dislodged the

framing structures of the sidewall windows. With no means of retention, the loosened

windows were unable to resist the force of the passengers who were thrust against the

windows during the vehicle dynamics of the derailment, which resulted in the passengers

falling out through the car body sidewall openings as the railcars overturned. Four

passengers of Superliner sleeper car #32100 who were ejected through breached windows

received fatal crushing injuries, and two passengers of Superliner sleeper car #32501 who

were ejected (one fully and one partially) through breached windows were seriously

injured.

Accordingly, given the design configuration of the Superliner railcar exterior

sidewall windows, the operational history of the equipment, the vehicle dynamics of the

derailment, the evidentiary artifacts examined, and the severe damage sustained by the

windows (as described), the damage sustained by the windows and their component

elements in this accident far exceeded the original intended design criteria and

expectations.

Superliner Sleeper Car Folding Armchairs

As currently configured, each deluxe bedroom in an Amtrak Superliner sleeper car

contains an unsecured folding armchair. Two Auto Train passengers reported that they

were injured during the derailment when they were struck by such armchairs or when they

were thrust out of the armchairs, indicating that the unsecured armchairs pose an occupant

injury hazard during a derailment.

FRA regulations state, at 49 CFR 238.233, that passenger railcar seating fixtures

ìordered on or after September 8, 2000, or placed in service for the first time on or after

September 9, 2002,î must be securely fastened to the car body. Anchoring occupant

seating substantially reduces the risk of occupants being injured by the seating in a

derailment. However, because the Amtrak Superliner cars involved in this accident were

put in service before September 8, 2000, the FRA requirements concerning seating
Analysis 60 Railroad Accident Report

anchoring are not applicable to them. Although Amtrak has indicated that it is pursuing an

equipment remedy, some Amtrak trains currently travel with unsecured folding armchairs

on Superliner sleeper cars. The Safety Board concludes that in its present unsecured

configuration, the folding armchair on Amtrakís Superliner sleeper cars constitutes an

unwarranted hazard. Therefore, the Safety Board believes that Amtrak should, within 1

year, install restraint systems for the unsecured folding armchairs in all its in-service

Superliner sleeper cars. The restraint systems should meet the safety criteria established at

49 CFR 238.233.
61 Railroad Accident Report

Conclusions

Findings

1. The Auto Train and its related equipment functioned as designed and did not cause

the accident.

2. The accident was not caused by improper train handling, drug or alcohol use, or

crewmember fatigue.

3. Neither the signal equipment, the train control system, nor the communications

caused or contributed to the severity of the accident.

4. The overall emergency response to the accident was timely and effectively managed.

5. The track buckle that caused the derailment of the Auto Train probably originated

during the passage of CSX Transportation coal train N16815 over the accident curve.

6. There was insufficient ballast on the accident curve prior to the accident to meet CSX

Transportationís own standards and to ensure that the continuous welded rail was

being adequately restrained.

7. Missing rail anchors and ineffective rail anchoring contributed to track instability

through the accident curve.

8. The problems with the liner-tamper machine on October 9, 2001, and the reimplementation of the repaired machine well into the curve on October 11 introduced

a track misalignment and caused a weak point in the curve that was susceptible to

later buckling.

9. The accident curve chorded inward because there was insufficient ballast in the track

at the time of the February 26, 2002, surfacing to prevent track movement as the track

stabilized.

10. Because the curve was not monumented when it was surfaced on February 26, 2002,

the crew resurfacing the track on March 11, 2002, did not know whether the track had

moved since February 26, 2002.

11. Had the Track Disturbance Reports been submitted in a timely fashion, the

roadmaster might have used them to prioritize the track adjustment work to be carried

out on track disturbed during the winter, including the accident curve.

12. CSX Transportation did not provide adequate oversight to ensure that its track

maintenance activities were carried out in accordance with its own standards.
Conclusions 62 Railroad Accident Report

13. Had the two-way end-of-train device been activated when the Auto Trainís air brakes

were put in emergency, the severity of the injuries resulting from the derailment might

have been lessened, because the continued forward momentum of the majority of the

trainís cars into the stopped passenger cars would have been reduced.

14. The paper record passenger accountability system in use for long-distance, overnight,

and reserved trains on the Amtrak system cannot be relied upon to provide an

accurate and timely passenger manifest in case of emergency.

15. In its present unsecured configuration, the folding armchair on Amtrakís Superliner

sleeper cars constitutes an unwarranted hazard.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the April 18, 2002, derailment of Amtrak Auto Train P052-18 near Crescent City, Florida,

was a heat-induced track buckle that developed because of inadequate CSX

Transportation track-surfacing operations, including misalignment of the curve,

insufficient track restraint, and failure to reestablish an appropriate neutral rail

temperature.
63 Railroad Accident Report

Recommendations

As a result of its investigation of the April 18, 2002, Crescent City derailment

accident, the National Transportation Safety Board makes the following safety

recommendations:

To CSX Transportation, Inc.:

Require all track maintenance employees, including large system-wide

track maintenance team members and local maintenance-of-way crew

members, to use a consistent rail anchor standard that includes a

requirement that rail anchors be maintained snug against ties. (R-03-06)

Modify your procedures to ensure that when a curve is surfaced, it is also

monumented, if local temperatures are predicted to fall below 50° F during

the post-surfacing stabilization period. (R-03-07)

Develop a systematic quality control program to ensure that tracksurfacing personnel consistently conduct track-surfacing operations in

accordance with CSX Transportation standards. (R-03-08)

To the National Railroad Passenger Corporation (Amtrak):

Install automatic two-way end-of-train emergency activation devices on all

Amtrak locomotives equipped with manual devices. (R-03-09)

Develop and implement an accurate passenger and crew accountability

system for all Amtrak long-distance, overnight, and reserved trains that

will immediately provide an accurate count of the people on board the train

in case of emergency. (R-03-10)

Within 1 year, install restraint systems for the unsecured folding armchairs

in all your in-service Superliner sleeper cars. The restraint systems should

meet the safety criteria established at 49 Code of Federal

Regulations 238.233. (R-03-11)

To the Federal Railroad Administration:

In cooperation with the Transportation Security Administration, develop

and implement an accurate passenger and crew accountability system for

all long-distance, overnight, and reserved passenger trains that will

immediately provide an accurate count and identity of the people on board

the train in case of emergency at any time during the trip. (R-03-12)
Recommendations 64 Railroad Accident Report

To the Transportation Security Administration:

In cooperation with the Federal Railroad Administration, develop and

implement an accurate passenger and crew accountability system for all

long-distance, overnight, and reserved passenger trains that will

immediately provide an accurate count and identity of the people on board

the train in case of emergency at any time during the trip. (R-03-13)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

Ellen G. Engleman Mark V. Rosenker

Chairman Vice Chairman

John J. Goglia

Member

Carol J. Carmody

Member

Richard F. Healing

Member

Adopted: August 5, 2003
65 Railroad Accident Report

Appendix A 

Investigation

The Safety Board was notified at 5:35 p.m. eastern daylight time on April 18,

2002, that an Amtrak Auto Train had derailed near Crescent City, Florida. The Board

launched a railroad accident investigation team to the site. The team included a Board

Member (accompanied by a public affairs representative and two family affairs

representatives) and investigative groups for operations, track, signals, mechanical, human

performance, survival factors, and crashworthiness factors.

Parties to the investigation included the Federal Railroad Administration; the

Florida Department of Transportation; Putnam County, Florida; CSX Transportation;

Amtrak; the American Railway Engineering and Maintenance-of-Way Association; the

Brotherhood of Locomotive Engineers; the Brotherhood of Maintenance of Way

Employes; and the United Transportation Union.

The Safety Board held 2 days of sworn interviews as part of its investigation. The

first interviews were held at Palatka, Florida, on April 22, 2002, and more were held at

Jacksonville, Florida, on July 24, 2002. Parties to the interviews were the Federal Railroad

Administration, the Florida Department of Transportation, CSX Transportation, Amtrak,

the Brotherhood of Maintenance of Way Employes, and the Brotherhood of Locomotive

Engineers. Twelve witnesses were interviewed in Palatka and 11 in Jacksonville.
66 Railroad Accident Report

Appendix B 

Passenger On-Board Record Procedures from Amtrak Service 

Standards Manual for Management Employees
Appendix B 67 Railroad Accident Report
68 Railroad Accident Report

Appendix C 

Passenger Train Two-Way End-Of-Train Device Regulations

As a result of previous Safety Board recommendations,1 the Federal Railroad

Administration (FRA) published a final rule2

 on January 2, 1997, amending the regulations

governing train and locomotive power braking systems to require two-way end-of-train (EOT)

devices3 on a variety of freight trains. Passenger trains were exempted from the requirement

because of the superior braking ratios of passenger cars and the presence of emergency brake

valves (ìconductorís valvesî) on each passenger car, which provide safety assurances not

present on traditional freight trains.

Until recently, Amtrak had been increasing the number of express and mail cars on its

long-distance intercity trains. Such cars, including the autorack-type cars on the Auto Train, are

not equipped with emergency brake valves because they are unoccupied. ìMixed trainsî like

the Auto Train, which blend passenger and express service or autorack cars, are also usually

much longer than most regular passenger trains. As the number of express cars increased on

mixed passenger trains, the FRA became concerned that these trains were becoming more like

freight trains than passenger trains, suggesting that the original rationale for exempting

passenger trains from two-way EOT requirements may no longer apply. The FRA was also

concerned about a mixed trainís ability to stop within normal signal spacing after determining

that there is a blockage in the trainline. Consequently, after conducting braking research

through the Volpe Center, the FRA and Amtrak formulated two-way EOT device requirement

criteria for mixed passenger trains as part of the Railroad Power Brakes and Drawbars

regulations, 49 CFR Part 232.

As a consequence, the above-referenced regulation became effective on May 1, 1998.

The following information summarizes the changes in the new regulation.

1 See Safety Recommendation R-89-82 to the FRA to ìRequire the use of two-way end-of-train telemetry

devices on all cabooseless trains for the safety of railroad operations,î from Collision and Derailment of Montana

Rail Link Freight Train With Locomotive Units and Hazardous Material Release, Helena, Montana, February 2,

1989, Railroad Accident Report NTSB/RAR-89/05 (Washington, DC: NTSB, 1989); and Safety Recommendation

R-95-44 to the FRA to ìSeparate the two-way end-of-train requirements from the Power Brake Law notice of

proposed rulemaking, and immediately conclude the end-of-train device rulemaking so as to require the use of

two-way end-of-train telemetry devices on all cabooseless trains,î from Rear-End Collision of Atchison, Topeka,

and Santa Fe Railway Freight Train PBHLA1-10 and Union Pacific Railroad Freight Train CUWLA-10 Near

Cajon, California, December 14, 1994, Railroad Accident Report NTSB/RAR-95/04 (Washington, DC: NTSB,

1995).

2 Title 49 CFR 232.23 paragraphs (e) and (g) revised, and adding paragraph (h).

3 A two-way EOT device consists of two radio telemetry devices, one in the controlling locomotive cab, and

one mounted on the coupler and connected to the air brake hose (trainline) at the end of the train. The device

provides the trainline pressure at the end of the train along with other customized information to the engineer in the

controlling cab, and it can activate an emergency air brake application at the end of the train to overcome a

possible trainline blockage and stop the train if necessary.
Appendix C 69 Railroad Accident Report

I. Passenger Trains Exempted from Two-Way EOT Requirement

A. Passenger trains operating at 30 mph or less;

B. Passenger trains on which the last car is equipped with an emergency brake

valve that is readily accessible to a crewmember who has radio

communication with the engineer; and/or

C. Passenger trains with 12 or fewer cars4 with a car located no less than

halfway back in the consist that has an emergency brake valve readily

accessible to a crewmember; and/or

D. Passenger trains with 13 to 24 cars with a car no less than two-thirds of the

way back in the consist that has an emergency brake valve readily

accessible to a crewmember.

II. Passenger Trains Required to Have a Two-Way EOT

A. Those not exempted as specified above; and/or

B. Passenger trains that travel over 30 mph; and/or

C. Passenger trains with more than 24 cars.5

III. Operating Constraints on Passenger Trains Exempt from Two-Way EOT

Requirements

When operating in mountain grade territory (average grade of 2 percent or

greater for over 2 continuous miles), a passenger train that is exempted from

having a two-way EOT must position a crewmember in radio communication

with the engineer in the rearmost car equipped with a readily accessible

emergency brake valve 10 minutes before the train descends the heavy grade

and the crewmember must not leave until the train has traversed the heavy

grade.

IV. Actions Concerning the En Route Failure of a Two-Way EOT on a Passenger

Train

A. If a passenger train is required to have a (operable) two-way EOT device,

and the device fails, the train is not permitted to descend a heavy grade (an

average grade of 2 percent or more for 2 continuous miles) until an

operable device is installed or an alternative method of initiating an

emergency brake application from the rear (end) of the train is achieved.

4 A Roadrailer, etc., is considered to be a car.

5 The term ìcarsî in this context does not include locomotive units, unless the locomotive unit is

ìdead-in-tow,î in which case the unit is treated like a car.
Appendix C 70 Railroad Accident Report

B. Passenger trains that develop en route failure of the two-way EOT device

may continue to operate over track that is not in heavy grade territory as

long as a crewmember occupies the rearmost car with a readily accessible

emergency brake valve and remains in constant radio communication with

the locomotive engineer. Also, the engineer must periodically test the

braking characteristics of the train by making running brake tests. Each en

route failure must also be corrected at the next location where necessary

repairs can be conducted or at the next location where a required brake test

is to be performed.
71 Railroad Accident Report

Appendix D 

Chronological List of Track Maintenance Operations on Accident 

Curve Following Shoulder Ballast Cleaning

Date Activity

MP 

Location Rail Temp. Slow Order Dates Remarks

09-18-00 to 

10-13-00

Shoulder 

ballast 

cleaning

Thru curve

01-29-01 Surfacing 721.9-

722.3

03-20-01 Surfacing 722.4-

722.9

03-22/23-

01

Surfacing 722.1-

722.3

03-27-01 Surfacing 722.1-

722.3

05-26-01 Rail defect 722.5-

722.6

05-26-01 to 06-04-01 Not test car 

defect

05-30-01 Rail changed 722.5 128° F

07-03-01 Surfacing 722.2- 

722.3

07-03-01 to 07-06-01 Handtamped

08-04-01 Surfacing 722.2- 

722.3

08-04-01 to 08-08-01 Handtamped

08-06-01 Surfacing 722.2 96° F 08-04-01 to 08-08-01 Handtamped

10-09-01 Surfaced full 

curve

722.1-

722.5

92° F 10-05-01 to 11-23-01 Liner-tamper 

machine 

problems 

10-11-01 Surfaced half 

curve

722.1-

722.3

See above Liner-tamper 

machine

11-19-01 Spotsurfaced722.1-

722.21 

83° F See above Liner-tamper 

machine

12-20-01 Spotsurfaced722.24 Handtamped

01-25-02 Spot in ties 

and surface

722.3 90° F 01-25-02 to 01-27-02 Handtamped

02-05-02 Surfacing 722.1-

722.3

02-05-02 to 03-13-02 Handtamped

02-26-02 Spotsurfaced722.1-

722.3

90° F See above Liner-tamper 

machine
Appendix D 72 Railroad Accident Report

03-06-02 Concrete tie 

ballastretaining wall 

installed

See above

03-08-02 Added 70 

tons of 

ballast

722.1-

722.3

See above

03-11-02 Surfaced 722.2-

722.3

See above Liner-tamper 

machine

03-25-02 Rail grinding None required

04-08-02 Replaced 5 

ties

722.4 92° F Put on and removed 

same day

Handtamped

04-09-2 Removed 

spikes and 

plates from 

under rail

722.3

04-18-02 Derailment 

occurred

722.24
73 Railroad Accident Report

Appendix E 

Summary of Key Event Recorder Data

Event Time Feet Speed Throttle Load EOT AB BC PCS Emer EOT 

Emer. 

Event 

# EDT ft mph notch amps psi psi psi Reqst. 

1 17:07:54 1362 56 Notch 8 832 108 110 0 Off Off Off Locomotive 

passes over 

POD/kink

@ ~1341 

feet 

 17:07:55 1279 56 Notch 8 832 108 110 0 Off Off Off 

 17:07:56 1195 56 Notch 8 832 108 110 0 Off Off Off 

 17:07:57 1112 56 Notch 8 832 108 110 0 Off Off Off 

2 17:07:58 1028 56 Notch 8 824 108 105 0 Off Off Off Trainline 

pressure 

begins to 

drop 

 17:07:59 945 56 Notch 8 824 108 102 0 Off Off Off 

 17:08:00 862 56 Notch 8 832 108 100 1 Off Off Off 

3 17:08:01 780 55 Idle 744 108 99 9 Off Off Off Locomotive 

crew 

initiates 

emergency 

brake 

 17:08:02 698 55 Idle 0 108 98 3 Off Off Off 

 17:08:03 617 55 Idle 0 108 45 10 On Off Off 

 17:08:04 537 54 Idle 0 108 0 35 On Off Off 

 17:08:05 459 53 Idle 0 106 0 68 On Off Off 

 17:08:06 382 52 Idle 0 106 0 85 On Off Off 

 17:08:07 306 51 Idle 8 106 0 88 On Off Off 

 17:08:08 234 49 Idle 64 106 0 87 On Off Off 

 17:08:09 170 43 Idle 144 106 0 84 On Off Off 

 17:08:10 116 36 Idle 144 106 0 46 On Off Off 

4 17:08:11 74 28 Idle 48 106 0 16 On Off Off EOT 

registers 

emergency 

 17:08:12 42 22 Idle 24 0 0 1 On Off Off 

 17:08:13 20 15 Idle 16 0 0 0 On Off Off 

 17:08:14 7 8 Idle 8 0 0 0 On Off Off 

5 17:08:15 4 1 Idle 0 0 0 0 On Off On Engineer 

throws 

EOT switch

 17:08:16 3 1 Idle 0 0 0 0 On Off On 

 17:08:17 1 1 Idle 0 0 0 30 On Off On 

6 17:08:18 0 0 Idle 0 0 0 69 On Off On Locomotive 

stops