National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Railroad Accident Number: ATL-00FR-004 

Rail System: Metropolitan Atlanta Rapid Transit Authority 

(MARTA) 

Train: MARTA train 103 

Accident Type: Train striking technicians fouling the track 

Location: Near MARTA Avondale Station in Decatur, 

Georgia 

Date and Time: February 25, 2000, at 8:13 a.m.

Fatalities/Injuries: One fatality and one serious injury 

On February 25, 2000, about 8:13 a.m., eastbound MARTA train 103 struck two 

automatic train control technicians who were inspecting signal equipment on the main 

track near Avondale Station in Decatur, Georgia. One of the technicians was fatally 

injured, and the other sustained serious injuries. 

The Accident 

On the morning of February 25, 2000, two MARTA automatic train control 

technicians were working near Avondale Station in Decatur, Georgia. (See figure 1 for a 

diagram of the MARTA system.) The more experienced of the two had assumed the role 

of senior technician; he telephoned the MARTA rail system control center at 8:03 a.m. to 

report that the technicians had completed their work on the track west of Avondale 

Station. He then asked permission to do an inspection in the Avondale Yard throat area1

east of the station platform because they had been told that an irregular track circuit had 

been showing on the east rail. He did not request a safe clearance restriction for the 

inspection. 

 1

 The throat area is a crossover track that enters the yard. 

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 I-7

North-South Rapid Rail Line 5

East-West Rapid Rail Line

Interstate Highways

I-20

I-285

East Point

College Park

SOUTH LINE

Airport

Lakewood/Ft. McPherson

Oakland City

West End

Dome/GWCC/Phillips Arena/CNN Center

West Lake

Ashby

Vine City

Hamilton E. Holmes

Bankhead

Peachtree Ctr

Civic Ctr

North Ave

Midtown

Arts Center

Five Points

Georgia State

King Memorial

Inman Park/Reynoldstown

Edgewood/Candler Park

Decatur

Kensington

Indian Creek

NORTH LINE

WEST LINE

I-285

I-285

I-85

Buckhead

Medical Center

North Springs

Sandy Springs

Dunwoody

Doraville

Chamblee

Brookhaven/Oglethorpe Univ.

Lenox

Lindbergh Center

I-85

NORTHEAST LINE

EAST LINE

I-75

Garnett

Legend:

N

S

W E

Avondale

Decatur

Kensington

Indian Creek

EAST LINE

Avondale

Figure 1. Map of the MARTA system, highlighting Avondale Station location. 

2 NTSB/RAB-03/03
 

The rail system control center controller gave the workers permission to inspect 

the eastern area. The controller did not ask them to apply for a safe clearance restriction, 

and he did not transmit a radio message advising train operators that a signal inspection 

was underway in the Avondale Yard throat area. 

The controller asked the senior technician to advise the yard tower of the 

techniciansí inspection activity. According to the yard tower supervisor, the senior 

technician telephoned the yard tower and asked permission to conduct an interlocking 

inspection in the yard throat area and mainline. The yard tower supervisor granted the 

request. He did not take any action to protect the two technicians. 

About 8:12 a.m., train 103, traveling eastbound, arrived at Avondale Station. 

West of the station platform, the train was diverted from the main track to the middle 

track. The train departed Avondale eastbound in automatic mode with a cab signalauthorized maximum speed of 25 mph. 

About this time, the technicians were at a relay box between the rails about 

1,000 feet east of Avondale Station, about 27 feet past the switch where the middle track 

converged with the main track. (See figure 2.) While at this location, they unlatched and 

removed the relay box cover. The technicians had not placed flagging devices to warn 

train operators of their presence, nor had they placed shunts on the rail to activate the 

signal system as a warning for approaching trains. 

Figure 2. Train approaching the accident location from Avondale Station. The relay box that the

technicians had opened is circled and indicated by the arrow. 

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The train operator said that as soon as she saw the technicians fouling the track, 

she placed the train brakes in the ìoffî mode and stopped the train. (When train brakes 

are put in the off mode, they go into the emergency braking position.) She said that she 

could not recall whether she had sounded the horn. She said her primary concern was to 

stop the train as quickly as possible. She stated that when she saw the technicians, one 

was bending over looking down and the other was standing and looking down. She also 

recalled that both technicians had their backs to the train when it struck them, about 

8:13 a.m. One of the technicians was fatally injured, and the other sustained serious 

injuries. 

Rules and Procedures 

The MARTA Wayside Access Manual covers maintenance and repair safety 

processes for wayside activities. MARTA also issues bulletins to guide roadway and 

automatic train control technicians who may need to foul the track. 

Safe clearance procedures are used for slowing or stopping trains moving through 

areas in which workers are present. The manual states that safe clearance is ìthe method 

by which an authorized MARTA employee may gain access to the main line or yard 

wayside during revenue service hours, but which does not involve de-energizing third rail 

power or re-routing trains.î The manualís safe clearance procedures require that: 

The employee contact the Central Controller or Yard Tower Supervisor by 

two-way radio requesting the Generic, Verbal or Special restriction 

number from the Track Allocation Schedule. 

MARTAís safe clearance procedures further require that the controller notify 

train operators of the restriction number, location, and special instructions and receive 

confirmation from the train operators upon their receipt of the information. After the 

controller notifies the train operators, he/she is to advise the employee requesting the 

restriction to proceed under the restriction. The controller is to repeat the restriction 

notification to train operators at hourly intervals. The safe clearance procedures also 

require that: 

All personnel requesting a Safe Clearance, Verbal, or Generic restriction 

must be accompanied by a qualified MARTA Flagperson or MARTA 

Supervisor while on the track wayside. 

According to MARTA officials, the safe clearance procedures in the manual often 

were not strictly followed. The officials stated, for example, that it had become common 

safe clearance practice for wayside employees to make the initial restriction request by 

two-way radio but for controllers not to advise train operators of safe clearance 

restrictions. Instead, controllers relied on train operators to monitor radio transmissions to 

4 NTSB/RAB-03/03
 

 

learn of any restrictions. (In this case, the technicians involved in the accident did not 

make the call by radio; they used the telephone to contact the controller and yard tower 

supervisor.) 

The safe clearance procedures state that they apply to MARTA employees 

attempting to ìgain access to the main line or yard wayside.î They do not stipulate that 

employees need to follow safe clearance practices only if they are carrying out ìworkî on 

the track. In practice, however, wayside employees interpreted the safe clearance 

procedures as applying only when they were actually doing repair or maintenance work 

that required fouling the track. When they did inspections that were not expected to foul 

the track (or to foul it only very briefly), they used an informal protective procedure, 

which involved having one worker watch for trains while the other(s) did the inspection. 

MARTAís safety director at the time of this accident2

 told Safety Board investigators that 

there were no written procedures for doing interlocking inspections on the right-of-way 

or any written requirement that one inspector watch for trains while another did the 

inspection. He indicated, however, that the accepted informal practice among MARTA 

track workers was for one inspector to watch for trains while another did the inspection. 

After the accident, the MARTA director of track stated that the technicians who 

had been struck had been required to protect themselves and to notify the rail system

control center when they needed to do work that required fouling the track. He indicated 

that if their work required fouling the track, they should have followed safe clearance 

procedures, which would have entailed obtaining a restriction number, after which the 

controller would have been required to make a radio announcement every hour to inform

trains moving in the work area that workers were on the track. The current MARTA 

safety director also stated that the safe clearance procedures covered in the Wayside 

Access Manual applied to the work being done at the time of the accident and that the 

technicians should have followed those procedures. 

Training 

Training records indicated that both technicians had attended and passed wayside 

access procedures training, which covered flagging procedures. They had also 

successfully completed periodic rules classes and passed rules examinations. 

2

 The MARTA safety director who served at the time of the accident left MARTA later in 2000. 

5 NTSB/RAB-03/03
 

 

MARTA Rules Compliance Program 

According to MARTAís director of operations, supervisors made routine train 

ride checks and discussed violations with operators who failed to comply with operating 

procedures. A report was made only if a train operator failed to comply with a bulletin 

order, make a station stop, or comply with a stop signal. No other records were kept on 

rules compliance checks. 

Before the accident, no MARTA employees except train operators were subject to 

a formal program of rules compliance checking. MARTA had no compliance program for 

operations center, maintenance-of-way, or signals employees. In addition, MARTA had 

no efficiency-testing3

 program under which rail supervisors systematically observed train 

operations and assessed compliance with selected operating rules. 

State Oversight 

On April 16, 1993, Georgia designated the Georgia Department of Transportation 

as the State agency responsible for overseeing the MARTA system. This responsibility 

was delegated to the administrator for GDOTís Office of Intermodal Programs. As well 

as having the responsibility for the safety oversight of MARTA rail transit operations, the 

office is responsible for managing the planning and operations programs in support of the 

transit, railroad, marine, and aviation systems within the State. GDOTís staff for rail 

transit operations consists of a single individual. 

Federal Transit Administration regulations allow States some flexibility about 

how actively they fulfill their rail transit oversight responsibilities. State agencies can 

delegate accident investigation duties to the transit agency and then review the transit 

agencyís reports. State agencies can also hire contractors to perform some of their 

oversight functions. GDOT contracts with a local urban transportation consulting firm to 

provide rail transit technical expertise and to supplement its single-member staff for this 

activity. The consulting firm wrote the GDOT transit safety plan, and the firm conducts 

all transit oversight investigations for GDOT. The firm also advises GDOT on all 

inquiries related to transit safety. 

The Federal Transit Administration requires GDOT to make an on-site safety 

review of MARTA every 3 years. The purpose of the review is to evaluate the efficacy 

and currency of the MARTA system safety plan and to ensure that MARTA is complying 

3

 Efficiency tests involve unannounced observations of operating employees, often with a test scenario

such as a red signal, to verify that appropriate rules are being followed. 

6 NTSB/RAB-03/03
 

with its plan. According to GDOTís management, GDOT did its first 3-year audit of 

MARTA at the end of 2001. The audit found the MARTA program deficient in employee 

training and certification, adherence to rules and procedures, and system modification 

review and approval processes. Before 2001, GDOT had not done any independent safety 

audits at MARTA, nor had it done any independent investigations of MARTA accidents. 

GDOT has the authority to audit and observe all MARTA operations. 

Postaccident Developments 

As a result of the accident, on March 10, 2000, MARTA issued General Order 00-

10, which specifically addresses ìthe protection and safety of all personnel whose job 

requires them to enter the MARTA rail system wayside for inspections....î MARTA 

subsequently incorporated protective requirements for workers conducting inspections in 

its operating rules, as reflected in its Wayside Access Manual, Appendix 1C, under the 

heading ìInspection Clearance Process.î The appendix states that: 

Inspection clearance is the method by which authorized MARTA 

employees may gain access to the mainline or yard rail right-of-way for 

inspection purposes only. The tools required for the specific inspection 

purposes are the only ones allowed to be used under this clearance 

process. This clearance does not require de-energizing the contact rail or 

restricting train operations. Trains operating in the inspection area may 

operate in automatic or manual cab signal (MCS) modes. 

The new rule requires that an inspection team consist of at least two people. At 

least one member of the team must be at least level 3 certified, and one of the members 

must be designated the ìDedicated Lookout Person.î The team may not enter the wayside 

until it obtains approval from the rail system control center. 

The new rule requires that the lookout: 

• Initiate contact with the rail system control center via the mainline two-way 

radio frequency and identify himself/herself as being in charge of the work team, 

• State the reason for the inspection, 

• Provide the exact location of the access and the limits of the inspection area, 

and 

• Request permission to enter the wayside. 

7 NTSB/RAB-03/03
 

The rail system control center is required to: 

• Notify all trains of the presence and location of wayside personnel by general 

broadcast (no acknowledgement is required from train operators), and 

• Grant permission for the team to enter the wayside, if all applicable 

requirements have been fulfilled. 

Once the team has permission to enter the wayside, the lookout must notify the 

control center if there is any delay in the teamís entering the wayside. The lookout must 

also notify the center whenever the team enters or exits the wayside. He/she is required to 

maintain two-way radio communication with the center at all times, and the 

communication link must be verified every 30 minutes. The lookout is also required to 

ìremain alert for trains while personnel are on the wayside.î 

Upon completion of the work and as soon as the team has exited the wayside, the 

lookout must tell the center by two-way radio that all personnel have cleared the wayside. 

Finally, the center is required to confirm the termination of the inspection clearance with 

the lookout and then to notify all trains by general broadcast that the inspection clearance 

has been terminated. 

After the accident, MARTA reviewed its operations and maintenance rules and 

practices and made the following changes: it improved its training of operations and 

maintenance employees in wayside access procedures, and it added a requirement that its 

supervisors do daily audits of employeesí compliance with rules and safety procedures. 

GDOT has accompanied MARTA supervisors while they do the audits and has 

determined that the audits are effective. 

Probable Cause 

The probable cause of the accident near the Metropolitan Atlanta Rapid Transit 

Authority (MARTA) Avondale Station on February 25, 2000, was the failure of MARTA 

to ensure that written safe clearance procedures were followed for employees doing 

inspections on the right-of-way. 

Adopted: August 8, 2003

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