National 

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Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

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NTSB

Permit No. G-200

Railroad Accident Report

Derailment of Northeast Illinois Regional 

Commuter Railroad Train 519 in

Chicago, Illinois

October 12, 2003

NTSB/RAR-05/03

PB2005-916303 National Transportation Safety Board

Notation 7615A 490 LíEnfant Plaza, S.W.

Adopted November 16, 2005 Washington, D.C. 20594
National Transportation Safety Board. 2005. Derailment of Northeast Illinois Regional Commuter 

Railroad Train 519 in Chicago, Illinois, October 12, 2003. Railroad Accident Report NTSB/RAR-05/

03. Washington, DC.

Abstract: About 4:38 p.m. central daylight time on October 12, 2003, westbound Northeast Illinois 

Regional Commuter Railroad (Metra) train 519 derailed its two locomotives and five passenger cars as it 

traversed a crossover from track 1 to track 2 near Control Point 48th Street in Chicago, Illinois. The train 

derailed at a recorded speed of about 68 mph. The maximum authorized speed through the crossover was 

10 mph. There were about 375 passengers and a crew of 3 onboard. As a result of the accident, 47 

passengers were transported to eight local hospitals. Of these, 44 were treated and released, and 3 were 

admitted for observation. Damages from the accident exceeded $5 million. 

The safety issues discussed in this report are the adequacy of the locomotive engineerís performance, 

training, and qualifications, and the lack of a safety redundant system to address train crew performance 

deficiencies.

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

the Federal Railroad Administration and the Northeast Illinois Regional Commuter Railroad (Metra). The 

Safety Board also reiterated a previously issued safety recommendation to the Federal Railroad 

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

Records Management Division

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 PB2005-916303 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

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

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

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

Postaccident Inspections and Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Metra Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Metraís Locomotive Engineer Training Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Training of the Accident Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Engineerís Experience, Work Schedule, and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Work Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Engineerís Description of Operational Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Requirements for Engineers to Communicate Signals . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Safety Redundancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Simulator Training in Rail Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

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

Engineerís Management of Operational Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Developing Task Management Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Calling Out Signal Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Positive Train Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Recommendation Reiterated in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
iv Railroad Accident Report

Executive Summary

About 4:38 p.m. central daylight time on October 12, 2003, westbound Northeast 

Illinois Regional Commuter Railroad (Metra) train 519 derailed its two locomotives and 

five passenger cars as it traversed a crossover from track 1 to track 2 near Control Point 

48th Street in Chicago, Illinois. The train derailed at a recorded speed of about 68 mph. 

The maximum authorized speed through the crossover was 10 mph. There were about 375 

passengers and a crew of 3 onboard. As a result of the accident, 47 passengers were 

transported to eight local hospitals. Of these, 44 were treated and released, and 3 were 

admitted for observation. Damages from the accident exceeded $5 million. 

The National Transportation Safety Board determines that the probable cause of 

the derailment of Northeast Illinois Regional Commuter Railroad (Metra) train 519 was 

the locomotive engineerís loss of situational awareness minutes before the derailment 

because of his preoccupation with certain aspects of train operations that led to his failure 

to observe and comply with signal indications. Contributing to the accident was the lack of 

a positive train control system at the accident location.

In its investigation of this accident, the Safety Board examined the following 

safety issues:

ï Adequacy of the engineerís performance, training, and qualifications, and

ï Lack of a safety redundant system to address train crew performance 

deficiencies.

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

recommendations to the Federal Railroad Administration and the Northeast Illinois 

Regional Commuter Railroad (Metra). The Board also reiterates a previously issued safety 

recommendation to the Federal Railroad Administration.
1 Railroad Accident Report

Factual Information

Accident Synopsis

About 4:38 p.m. central daylight time1 on October 12, 2003, westbound Northeast 

Illinois Regional Commuter Railroad (Metra) train 519 derailed at a speed of about 68 

mph as it traversed a crossover from track 1 to track 2 in the vicinity of Control Point (CP) 

48th Street2 in Chicago, Illinois. The entire train, consisting of two locomotives and five 

passenger cars, derailed. The maximum authorized speed through the crossover was 10 

mph. There were about 375 passengers and a crew of 3 onboard. As a result of the 

accident, 47 passengers were transported to eight local hospitals. Of these, 44 were treated 

and released, and 3 were admitted for observation. Damages from the accident exceeded 

$5 million. 

Accident Narrative

The crew of the accident train went on duty at 1:41 p.m. on October 12, 2003, in 

Joliet, Illinois. The crew of three, consisting of an engineer, a conductor, and an assistant 

conductor, had been called from the extra board3

 for this Sunday assignment. The crew 

was scheduled to operate a commuter train on two round trips between Joliet and Chicago. 

The train was designated 518 for the eastbound trip to Chicago and 519 for the westbound 

return trip back to Joliet. 

Before the departure from Joliet to Chicago, the engineer received a track warrant 

from the dispatcher authorizing his train to occupy the track between Joliet and Chicago. 

Because maintenance-of-way crews were working along portions of tracks 1 and 2, the 

track warrant also included a Form B track bulletin that granted protection to the track 

workers. In addition, a Form D identified a portion of track 1 as out of service.

Train 518 departed Joliet with two locomotives and five cars at 2:24 p.m. for the 

41-mile trip to Chicago. The train was operated in the push mode.4

 It arrived at the 

Chicago LaSalle Street Station at 3:42 p.m., about 2 1/2 minutes ahead of schedule. The 

crew characterized the trip as uneventful.

1 All times in this report are central daylight time.

2 CP 48th Street is Metraís name for the signal location near 47th Street in Chicago.

3 An extra board employee does not have an assigned job but is called as necessary either to substitute 

for a regular employee who is unavailable for duty or to serve as a crewmember on an unscheduled 

assignment.

4 In the push mode, the motive power is at the rear of the train, which is operated from a control cab car 

on the head end. A train in the pull mode is operating conventionally. This ìpush-pullî configuration 

eliminates the need to turn or switch equipment at the end of each run, thus allowing quicker turnarounds at 

terminals.
Factual Information 2 Railroad Accident Report

The crew had about a 47-minute layover to prepare for the scheduled 4:30 p.m. 

departure of train 519 from Chicago to Joliet. The crew ate lunch near the terminal and 

prepared to depart. The conductor said that the crew participated in a ìgeneral job briefing 

before departure concerning which cars were being operated [and] what [they] expected to 

do at Gresham, which has a smaller platform.î The engineer asked the train dispatcher 

about any changes or voids on his track warrants; he was told that none existed. 

Train 519 departed Chicago, milepost (MP) 0.0, on schedule5 at 4:30 p.m.6 with the 

same equipment and consist as train 518, but the two locomotives were now at the lead in 

the pull mode. The engineer was alone at the controls of the lead locomotive. The 

conductor and assistant conductor were in the coaches to collect tickets. The first 

scheduled station stop was Gresham, MP 9.8, at 4:47 p.m. (See figure 1 for a diagram of 

the Metra route between Chicago and Joliet.)

Train 519 was routed onto track 1 as it left Chicago. The engineer was required to 

radio the foreman of the work crew before entering the protected section of track, located 

west of Gresham, to arrange for safe passage of the train, as he had done on his eastbound 

trip. The Form B restriction was in effect from 8:00 a.m. until 5:00 p.m. on both track 1 

and track 2. In addition, the Form D indicated that a portion of track 1, just west of 

Gresham, was out of service until 7:00 p.m. The train received a clear signal7 as it entered 

track 1. The engineer successfully conducted the required rolling air brake test. At 4:33:45 

p.m., the train reached 16th Street, which is the site of a crossover with a 25-mph 

maximum speed. The engineer said that he was somewhat surprised that his train was not 

routed through the 16th Street crossover from track 1 to track 2, as it had been on previous 

weekend trips. He said he was also thinking about the track crew that might still be 

working on track 1 near (west of) Gresham, and he decided he would call the foreman of 

the track crew when he reached 53rd Street, MP 5.3.

After train 519 departed the Chicago LaSalle Street Station, the dispatcher realized 

that track 1 would not be available for train 519 all the way to Gresham, as he had 

planned, because of work equipment that was authorized to be on track 1 east of 

Gresham.8 Therefore, train 519 would need to use a crossover from track 1 to track 2.

5 The crew used the same warrant it had used from Joliet to Chicago.

6 Times and speeds in this section were taken from data downloaded from event recorders on the 

trainís two locomotives.

7 The Safety Board acquired the data logs recorded by field signal equipment to obtain the clock times, 

track conditions, switch positions, and signal indication codes. A clear signal indicates that the train is 

permitted to proceed at track speed. It will not be required to reduce speed to diverge from one track to 

another, nor will it have to stop before reaching the second signal in advance of any clear signal. Generally, 

clear is the most favorable signal.

8 At 2:51 p.m., the dispatcher issued, via telephone, the track and time limits (Track and Time Form 

10.3.2) to a track foreman located at Gresham, MP 9.8. Limits were granted to permit track equipment 

occupancy on track 1 between Englewood, MP 6.7, and Gresham, until the foreman released these limits.
Factual Information 3 Railroad Accident Report

Figure 1. Metra route between Chicago and Joliet.

Chicago - LaSalle St

Station, MP 0.0

Gresham, MP 9.8

Longwood, MP 10.9

Washington Heights, MP 12.0

Blue Island, MP 15.7

Robbins, MP 17.0

Midlothian, MP 18.4

Oak Forest, MP 20.4

Tinley Park, MP 23.5

80th Ave, MP 25.0

Hickory Creek, MP 27.2

Mokena, MP 29.6

New Lennox, MP 34.0

Joliet, MP 40.2

 MP 9.8

Gresham

Norfolk Southern

Railway Crossing

Englewood

53rd St

48th St

Accident

Tower

Root St

35th St

Cermak Rd

Canadian National 

Railroad Crossing

16th St

 MP 6.7

 MP 5.3

 MP 4.7

 MP 3.9

 MP 3.6

 MP 3.1

 MP 1.7

 MP 1.1

Track 2

Diagram Not To Scale

Track curvatures not depicted

Track 1

Chicago -

LaSalle St

Station 

EAST

WEST

Joliet
Factual Information 4 Railroad Accident Report

The dispatcher said that he decided to use CP 48th Street because using other 

locations closer to the Chicago LaSalle Street Station would have required him to stop the 

train to allow time for signal safety protocols. The lining of the route at CP 48th Street, 

including both the crossover and signal displays, was started at 4:32:11 p.m. When the lining 

was completed at 4:36:12 p.m., the train was located about 8,600 feet east of the crossover. 

At 4:34:57 p.m., the train reached the signal at Cermak, MP 1.7; the engineer said 

that he saw a clear signal. He also said that he saw clear signals ahead and began scanning 

various locomotive gauges and attending to his speed. At 4:36:28 p.m., the train 

approached the signal at 35th Street, MP 3.1. He said that he was concerned that he was 

still operating on track 1 and that the work crew might still be working on the same track 

near Gresham. The engineer said that he reexamined his track warrant and track bulletin, 

wondering, ìIs there something else here I missed on my track bulletin?î 

The engineer said that as the train continued toward the next signal, near Root 

Street, he was thinking, ìWhy [is the dispatcher] keeping me on [track] 1?î He said he 

concluded that since he had already passed two interlockings without crossing over, he 

would probably be routed to cross over at Gresham. At this time, the train was traveling 56 

mph, 1 mph over the 55-mph maximum timetable authorized speed for passenger trains at 

that location.

At 4:37:01 p.m., the train reached the signal at the beginning of Root Street, MP 

3.6, which was displaying a clear indication. At this point, the track begins a 2,100-foot 

dip. As the engineer entered the dip, he adjusted his throttle to decrease the train speed in 

accordance with the 50-mph speed restriction across the dip. He said that as his train 

traveled through the dip, he was watching the rear of his train, anticipating accelerating 

when the rear of the train cleared the dip. Once the entire length of the train was 

completely out of the dip, the head end was close to the signal at the end of Root Street 

interlocking, MP 3.9. This signal displayed approach diverging. By rule, the engineer, 

upon receiving this signal, was to ìproceed prepared to advance on diverging route at next 

signal and through the turnout [CP 48th Street] at maximum authorized speed [10 mph].î

Instead of slowing down, the engineer increased the throttle from the 4th to 8th position. 

He said that he also checked various gauges, including his speedometer. He said he then 

checked the time, which was the last action he said he remembered performing before the 

train entered the crossover at CP 48th Street, MP 4.7.

The CP 48th Street signal at the crossover was displaying diverging clear, 

requiring the engineer to ìproceed on diverging route at prescribed speed [10 mph] 

through turnout.î He had not attempted to slow or stop the train. The train, traveling 68 

mph, derailed at the crossover. The accident occurred 4.65 miles and about 8 minutes after 

the train left the Chicago LaSalle Street Station. 

At the time of the derailment, the conductor and assistant conductor were still 

collecting tickets from the estimated 375 passengers.9

 Emergency brakes applied 

9 Because the train had just left the station and tickets were still being collected, the exact number of 

passengers onboard at the time of the accident could not be determined. 
Factual Information 5 Railroad Accident Report

automatically as the train derailed. The locomotives and cars separated. Both locomotives 

and all five of the passenger cars derailed, striking a Metra passenger-equipment wash 

building on track 6 at Metraís 47th Street Yard. The lead locomotive overturned onto its 

right side, facing south. The trailing locomotive derailed upright, facing north adjacent to 

the lead locomotive. The derailed passenger cars remained upright and parallel to the track 

structure. (See figure 2 for a photograph of the derailed locomotives and figure 3 for a 

photograph of the derailed passenger cars.) 

After the accident, the engineer used the radio to transmit ìEmergency, emergency, 

emergency. Train down at 47th Street.î He said that he did not remember a response. He 

said that he remembered that there was smoke in the locomotive and that he climbed up to 

get to the side door to exit the overturned locomotive. He said that once he found the 

conductor, he told him, ìIím not sure what happened. I saw a clear and I continued to 

believe I was on all clears because thatís what I saw.î

Upon notification of the accident, the Chicago Office of Emergency Management 

and Communications initiated the Chicago Fire Departmentís first response at 4:41 p.m. 

The initial response consisted of two engines, two hook and ladders, and a battalion chief. 

The first units arrived on scene at 4:44 p.m. Firefighters extinguished a fire in the lead 

Figure 2. The lead locomotive (on its side) and second locomotive at their final resting 

positions.
Factual Information 6 Railroad Accident Report

locomotive, and a hazardous materials support unit was called because of a locomotive 

fuel tank leak. Nineteen ambulances would eventually respond to the scene. Passengers 

were already getting off the derailed coaches when the first units arrived. The trainís 

locomotives and cars were searched and evacuated. Between 40 and 45 people were 

transported from the scene by ambulance. The remaining passengers were transported by 

bus from the scene. A command post was established to the west of the incident. 

Emergency responders remained on scene until 8:00 p.m.

Postaccident Inspections and Tests

Investigators conducted postaccident inspections of train equipment, track, and 

signals. No mechanical conditions of the equipment were identified as factors preventing 

compliance with the operational requirements of the train. Locomotive event recorders 

documented responses to the engineerís throttle and brake manipulations. Track structures 

in the accident area were determined to be consistent with Federal Railroad 

Administration (FRA) regulations. Damage at the point of derailment was consistent with 

an overspeed derailment. Investigators, through inspection and review of signal event 

recordings, determined that the signals displayed aspects for crossing over from track 1 to 

track 2 at CP 48th Street at the time of the accident. 

Figure 3. All five passenger cars derailed but remained upright. The trucks from the 

lead locomotive dislodged (foreground).
Factual Information 7 Railroad Accident Report

At the time of the accident, the temperature was 68° Fahrenheit, and visibility was 

10 miles. No witness, including the engineer, noted a weather-related visibility 

impediment. The investigators did not find any environmental factors, including the sunís 

position, structures, or a locomotive cab windshield condition that would have obstructed 

the engineerís view of the signal aspects. During postaccident interviews, the engineer 

stated that he had no difficulties seeing or distinguishing the signal aspects. Following the 

accident, investigators, who rode a similar train to the accident site at about the same time 

of day, noted that they had good signal visibility from inside the locomotive cab, which 

allowed them to see two or three signal aspects in front of the train. The engineer stated 

that his first indication of a problem was when the train hit the crossover switch. Sightdistance testing conducted, at night, after the accident revealed that the diverging clear 

signal was visible and discernable beginning about 7,900 feet (and about 1 minute 30 

seconds) before the crossover point.

The engineer had two cell phones with him during the trip⎯one was his personal 

phone and the other was provided by Metra. Phone records showed that neither had been 

used during the accident trip. No other electronic devices were found at the scene, and the 

locomotive radio had not been used from the time the train departed Chicago until it 

derailed.

Metra Profile

Metra operates 700 weekday trains over its 545-mile system and provides 300,000 

passenger trips daily and 80 million passenger trips annually. Metra has 12 routes. Four of 

those routes are operated under purchase-of-service agreements with the Union Pacific 

Railroad and the BNSF Railway Company (BNSF). The remaining eight routes are 

operated by Metra employees. The Metra equipment fleet includes 130 locomotives and 

more than 1,000 passenger cars. (See figure 4 for a map of Metraís system.)

The accident occurred on the Rock Island District, Joliet Sub District, one of the 

eight routes operated by Metra employees. The district encompasses the territory from the 

Chicago LaSalle Street Station to the Joliet Union Station.

Trains receive authority to enter and occupy the centralized traffic control limits 

from signal indications. Each train must receive a track warrant at its initial station unless 

otherwise instructed by the train dispatcher. 

Metraís Locomotive Engineer Training Program

General

According to Metraís Locomotive Engineer Training Program manual, the training 

program for Metra engineers is a 40-week course that combines classroom studies and 
Factual Information 8 Railroad Accident Report

field training with hands-on operation of commuter trains under the supervision of 

qualified Metra engineers. Candidates spend the first 90 days under the guidance of the 

supervisor and assistant supervisors of locomotive engineers. Classroom training includes 

the following topics: signal systems, operating and safety rules, mechanical and electrical 

systems, physical characteristics of Metra districts, and emergency procedures. 

Figure 4. The Metra system. (Star marks accident location.)

CHICAGO

ILLINOIS/WISCONSIN STATE LINE

McHENRY

ILLINOIS/INDIANA STATE LINE

COOK

DU PAGE

LAKE

WILL

Harvard Fox Lake

Antioch

Big Timber

Geneva

Aurora

JOLIET

179th St.

(Orland Park)

University Park

To

Kenosha

Metra Rock Island District

Chicago (LaSalle Street Station to Joliet)

GRESHAM
Factual Information 9 Railroad Accident Report

The training for new employees typically included time on a locomotive 

simulator.10 Engineer trainees spent 7 hours operating trains on the simulator and spent 

additional time observing other trainees on the simulator. The simulator utilized a 

predefined sequence of events and, therefore, did not allow the interactive altering of trip 

events that would challenge a traineeís acquired knowledge and skill or teach the 

development of task strategy management in operating a train safely during atypical 

situations. For example, it could not simulate signal changes, grade crossing malfunctions, 

signal malfunctions, train delays, or restrictions not specified in writing. 

Upon successful completion of the initial 90-day training period, the candidates 

are assigned to ìengineer trainersî (who are qualified Metra engineers) on specific 

districts. According to Metra, the engineer trainer serves as both an instructor and a 

mentor, with the goal of developing a high level of professionalism and aptitude in 

students. When this phase of the training is completed, the candidates take a certification 

exam. Upon completion of the program and achieving a satisfactory score on the 

certification exam, the students become qualified as engineers and are assigned to 

districts. According to Metra, the engineer trainees (candidates) must demonstrate 

proficiency on the signal system aspects and their operational meanings by achieving a 

100 percent rating on that part of the examination.

Training of the Accident Engineer

The 37-year-old engineer first qualified as a locomotive engineer with BNSF in 

May 2000; however, he was not used by BNSF as an engineer on a regular basis. 

On June 18, 2001, the engineer joined Metra as an assistant conductor trainee on the 

Rock Island District. He became an assistant conductor on July 16, 2001, and a week later 

was transferred to the Metra Electric District. In February 2002, he entered Metraís 

locomotive engineer training program. The 40-week program was suspended on September 

25, 2002, and the engineer continued to work as an assistant conductor. He took a military 

leave of absence from the railroad from January 3 to February 5, 2003. Upon the engineerís 

return to Metra on February 5, he reentered the training program, which had been restarted, 

but left a few days later for another military leave. He returned from his second military 

leave on June 16, 2003, and resumed his training as a student engineer. 

Because his military deployment coincided with the 10th week of his engineer 

training, which was when the class used simulators, he missed the simulator training. 

According to Metra, when he returned from his military deployment, he made 10 training 

trips. These trips were closely monitored by Metra officials. Based on his performance 

during these training trips, he was allowed to rejoin his engineer training class, which had 

moved into the on-the-job-training, revenue train service, phase of the program. To help 

compensate for the training components he had missed during his military absence, Metra 

assigned him to operating switch engines in the yard. He received his engineerís 

certification on July 21, 2003.

10 The simulator training was conducted at the Illinois Institute of Technology Research Institute in 

Chicago, which no longer offers such training. Metra representatives told the Safety Board that Metra is 

investigating alternative methods of providing simulator training. 
Factual Information 10 Railroad Accident Report

Engineerís Experience, Work Schedule, and Health

Experience

The engineer, as a trainee, made about 112 round trips between Chicago and Joliet 

under the supervision of an on-board qualified engineer.11 The engineer recalled operating 

the newer model locomotives only a few times after taking a new locomotive orientation 

class on June 17, 2003; he did not recall ever operating the new locomotives as multiple 

units. He had no record of any disciplinary actions for operating rules violations.

In the 2 1/2 months between his certification and the accident, the engineer worked 

24 days as a certified engineer for Metra commuter trains.12 He initially alternated 

between the Southwest and Rock Island Districts before being transferred to the 

Milwaukee District, where he worked 11 assignments. He had been reassigned to the Rock 

Island District 2 days before the accident. (See table 1.)

While working commuter service, he typically made two round trips per day, 

although on some assignments in which trips were not to the end of the line, he made 

more. After he became a qualified engineer who operated alone, he had made 23 

westbound trips from Chicago to Joliet. 

Work Schedule

On October 10, 2003, 2 days before the accident, the engineer had worked from 

6:12 a.m. to 6:00 p.m. The day before the accident, October 11, he worked from 7:24 a.m. 

until 5:51 p.m. He said that on the night before the accident, he had gone to bed no later 

than 9:30 p.m. He said that he awoke feeling rested. He also said that 6 hours is a normal 

amount of sleep for him. 

Health

The engineer reported being in good health. He had passed his last company 

physical examination (vision and hearing) in January 2003 and was allowed to operate a 

11 The majority of the trips took place before September 2002, before Metra suspended its engineer 

training program.

12 During this period, the engineer also worked in noncommuter service, such as in the yard or on a 

work train.

Table 1. Engineerís Assignments (July 25-October 11, 2003)

District Work Period Number of Days Worked 

Southwest July 25 1

Rock Island July 26-30 2

Southwest August 1 1

Rock Island August 5-14 3

Southwest August 15 1

Rock Island August 16-18 3

Milwaukee August 19-October 6 11

Rock Island October 10-11 2
Factual Information 11 Railroad Accident Report

locomotive without restrictions. He said that he had not taken any nonprescription 

medications within the 72 hours before the accident and did not take any prescription 

medications or illicit drugs.

After the accident, he provided toxicological specimens that were tested for the 

presence of alcohol and drugs pursuant to 49 Code of Federal Regulations Part 219, 

Subpart C. No drugs13 or alcohol were identified in either specimen.

Engineerís Description of Operational Concerns

During interviews with Safety Board investigators, the engineer discussed some 

operational concerns he had had soon after he began the accident trip. These included his 

uncertainty about the whereabouts of the maintenance-of-way crew, his approach to 

spotting the train at station platforms, and his unfamiliarity with the train equipment.

Between the time that the engineer became qualified and the day of the accident, 

he worked on the Rock Island, Milwaukee, and Southwestern Districts, with most of his 

time split between the Milwaukee and Rock Island Districts. When working on the 

Milwaukee District, he generally used older locomotives. The Rock Island District had 

some new locomotives that were longer and heavier and had greater horsepower (3,600 

versus 3,200) than the older locomotives that the engineer operated on the Milwaukee 

District. In addition, the controls on the new locomotives were on a desktop stand instead 

of on a stand on the engineerís left-hand side. 

On the Rock Island District, the engineer usually operated a train with one 

locomotive. The train he operated on the day of the accident used two of the new 

locomotives. He said that he believed this was the first time he had operated a train with 

two new locomotives coupled together.14 On the accident trip, he said, he had noticed that 

the two new locomotives accelerated more quickly than the locomotives on the 

Milwaukee District. He said that he had checked his speed more frequently than he 

normally would because his train was ìvery much quickerî than the trains he typically 

operated. He also stated that ì[the new locomotives] go so fast Ö you could find yourself 

5 to 10 miles Ö above the speed limit if youíre not paying attention.î He stated that the 

train was picking up speed in throttle position 3 to the point that he subsequently needed to 

apply braking.

13 Substances tested for included cannabinoids, cocaine, opiates, amphetamines, methamphetamines, 

phencyclidine, barbiturates, and benzodiazepines.

14 The two locomotives (MP36PH-3S) were the newest type of locomotive Metra uses in passenger 

service. 
Factual Information 12 Railroad Accident Report

Other Information

Requirements for Engineers to Communicate Signals

On February 20, 1996, the FRA, in response to two fatal train accidents,15 issued 

Emergency Order No. 20, Notice No. 1, (EO20) to reduce the risks that train passengers 

and crews face under certain operating conditions. EO20 was aimed at commuter and 

intercity passenger operators and freight railroads, where push-pull passenger operations 

are conducted. The order states in part:

FRA concludes that certain current conditions and practices on commuter and 

intercity passenger railroads pose an imminent and unacceptable threat to public 

and employee safety. Of greatest concern are push-pull and [multiple unit16] MU 

operations lacking the protection provided by cab signal, automatic train stop, or 

automatic train control systems.[17] 

EO20ís applicability for push-pull operations is as follows:

With regard to cab car forward and [multiple unit] MU operations over territory 

lacking at least cab signals, the immediate need is to ensure that signal indications 

are followed. FRA believes that certain operating rules, already in place on many 

railroads, will assist engineers in remembering and adhering to signal indications. 

One rule will require that signal indications for an approach or less favorable than 

an approach be called out by the engineer as they are seen. A designated 

crewmember elsewhere in the train will acknowledge the communication and, in 

the absence of an appropriate response to a restrictive indication that has been 

communicated, take action to ensure the appropriate response. This will serve as a 

simple device to help the engineer remember to abide by signal indications and 

will add safety redundancy by involving other crew members in responsibility for 

safety with regard to compliance with signals. 

In response to this order, Metra issued Special Instruction 5.16,18 directing that a 

Metra engineer who observes an approach or less favorable indication must orally 

15 (a) National Transportation Safety Board, Employee Fatality, National Railroad Passenger 

Corporation, Secaucus, New Jersey, November 27, 1996, Railroad Accident Report NTSB/RAR-97/01 

(Washington, DC: NTSB, 1997). (b) National Transportation Safety Board, Collision and Derailment of 

Maryland Rail Commuter MARC Train 286 and National Railroad Passenger Corporation AMTRAK Train 

29 Near Silver Spring, Maryland, February 16, 1996, Railroad Accident Report NTSB/RAR-97/02 

(Washington, DC: NTSB, 1997).

16 A multiple unit (MU) is a passenger train with carriages that have their own motors, either diesel 

(DMUs) or electric (EMUs), and do not need to be hauled by a locomotive.

17 In an automatic cab signal system, the signal indication is transmitted to and displayed in the 

enginemanís compartment or locomotive cab. An automatic train stop is a trackside system that works in 

conjunction with equipment installed on a locomotive to automatically apply the brakes and stop the train 

should the engineer not acknowledge a restrictive wayside signal within 30 seconds of passing it. An 

automatic train control is a system that enforces signal and some civil speed restrictions either by applying 

the brakes of a speeding train to slow it to the speed required by a restricted signal indication or by applying 

a full-service brake until either the train stops or the engineer operates the controls to reduce the train speed.

18 Special Instruction 5.16 does not apply where the maximum authorized speed does not exceed 

30 mph or where an automatic cab signal system is in place.
Factual Information 13 Railroad Accident Report

communicate the signal indication to a crewmember anywhere on the train or to a rulesqualified employee in the engine control compartment. Each transmission must be 

acknowledged by the designated crewmember. 

Neither the FRAís emergency order nor Metraís special instruction required the 

train 519 engineer to communicate to crewmembers the last two signals (approach 

diverging and diverging clear) encountered before the derailment; these signal indications 

are more favorable than an approach signal indication. 

Further, as part of this accident investigation, investigators noted that EO20 allows 

railroads to specify yard or terminal limits within which engineers are exempt from the 

order to call out signals. The terminal area for this line, designated by Metra, extended 

from the Chicago LaSalle Street Station to the Root Street Tower, which is almost 4 miles 

from the station. There are eight signals between the Chicago yard and the Root Street 

Tower that are never called out, regardless of their indications, because they are within 

Metraís defined terminal area. Metra officials told investigators that 

The territory between Chicago and Root Street was selected because of the 

already heavy volume of radio traffic involving scheduled train movements 

between Chicago and 47th Street Coach Yard. It was felt that adding the 

Emergency Order No. 20 signal calling into this territory could result in confusion 

from conflicting transmissions and be detrimental to safety.

Safety Redundancies

Metraís locomotive and cab car fleet, including train 519, have in-cab signal 

equipment that can be utilized on about 152 miles of the 545-mile Metra system. 

However, no wayside cab signal equipment was ever installed between the Chicago 

LaSalle Street Station and MP 15, along the route between Chicago and Joliet that 

includes the accident site. Wayside cab signal equipment is installed on this route from 

MP 15 to MP 40, Joliet. 

Simulator Training in Rail Industry

The Safety Board reviewed the practices of some large railroads to understand the 

industryís approach to training engineers on task-management skills. The Board found 

that, to the extent these skills are reinforced through training, such reinforcement is 

typically done during the engineer traineeís supervised rides. During these rides, the 

supervisor, typically a road foreman, generates hypothetical situations for the trainee to 

manage while operating the train. Simulator training, for many of the railroads surveyed, 

predominately emphasizes developing fundamental train handling skills, and the engineer 

trainee receives little or no exposure to situations requiring the simultaneous management 

of multiple tasks. 
Factual Information 14 Railroad Accident Report

Postaccident Actions

In the 2 1/2 months between his certification and the day of the accident, the 

engineer had been assigned to a number of districts. The variation in assignments was 

consistent with Metraís then-current policy of filling vacant positions with engineers from 

the extra board or from the bottom of the seniority roster. Since the accident, Metra has 

modified its practice of rotating newly certified engineers among districts. The present 

rule states that a newly promoted engineer will be held on an assigned extra board until the 

employee has obtained 70 starts, including those instances in which the employee is called 

out of turn.
15 Railroad Accident Report

Analysis

The Accident

Postaccident inspection of the accident train and wayside signal system revealed 

no defects that would explain the failure of the Metra train 519 engineer to slow his train 

in preparation for the 10-mph crossover near CP 48th Street. The accident occurred during 

daylight hours and in clear weather. Signal visibility testing conducted after the accident 

revealed that the approach diverging and the diverging clear signals would have been 

visible and discernable from the locomotive cab well in advance of reaching the signals. 

The accident train was traveling well over the maximum authorized crossover speed when 

it derailed upon reaching the crossover switch from track 1 to track 2. 

The train was traveling approximately 68 mph at the time of the derailment and 

there was no evidence that it had slowed before reaching the crossover. In postaccident 

interviews, the engineer stated that he had observed a clear signal when he was going 

through Cermak with additional clear signals along his line of travel on track 1, and that he 

had no difficulty seeing or distinguishing the signal aspects. He stated that his first 

indication of a problem was when the train hit the crossover switch.

General

The investigation determined that the train equipment, tracks, and signal system 

had all operated as designed. Recorded data from the locomotive event recorder and the 

wayside signal system revealed no anomalies. Environmental conditions and signal 

visibility at the time of the accident were adequate. The engineer was not using either of 

the cell phones he had in his possession. The postaccident toxicological testing for all 

crewmembers was negative. Therefore, the Safety Board concludes that the mechanical 

condition of the train, the track structure, the signal system, environmental conditions, cell 

phones, and drugs and alcohol were not factors in this accident.

The engineerís most critical task was to observe wayside signals and comply with 

signal indications; had he done so, the accident would not have happened. Therefore, the 

Safety Board attempted to determine what might have caused the engineer to fail to 

comply with two critical and consecutive wayside signals.

Engineerís Management of Operational Tasks

The Safety Board examined the engineerís account of the events leading up to the 

accident and his ability to manage the tasks he faced during the accident trip. The 
Analysis 16 Railroad Accident Report

investigation also focused on his exposure to nonroutine operations and his previous 

experience operating the train equipment. Neither of these factors, in and of themselves, 

was abnormal or unmanageable by the engineer. 

The engineer stated that he was surprised when he passed 16th Street without 

crossing over from track 1 to track 2. He had expected to be crossed over because he 

usually ran on track 2 during weekend service. He was also concerned about the 

whereabouts of the maintenance-of-way work crew, which he knew had been near 

track 1. He told investigators that his concerns prompted him to devote additional 

time and attention to scrutinizing his paperwork. However, the routing of the train and 

separating the train from work crew activity are the responsibilities of the train 

dispatcher. Instead of continuing to review his paperwork trying to understand why 

his train was being routed on track 1, the engineer could have contacted the train 

dispatcher by radio to discuss his concerns. 

The engineer stated that after passing 16th Street, he exited a curve, came out on 

straight track, and saw that the signal at Cermak was clear with clear signals ahead as far 

as he could see. He stated that he therefore felt comfortable that he had time to make some 

random safety checks, so he checked his gauges, speed, and track warrant. The engineer 

stated that he was visualizing his trip and thinking that he would want to call the foreman 

of the work crew upon reaching 53rd Street, so that he would have plenty of time to slow 

his train before reaching the area where they were working.

When an engineer changes territories, he often confronts unfamiliar 

equipment. An engineer on the Milwaukee District, for example, operates trains 

consisting of one or two older locomotives. On the Rock Island District, he is likely to 

operate a train consisting of one or two new locomotives, as the accident engineer did. 

The new locomotives have greater horsepower, respond differently to braking, and 

have different operating control stands, all of which can be complicating factors to an 

engineer who is unaccustomed to these differences. Because the accident engineer 

found the accident train to be ìquickerî than those to which he was accustomed, he 

stated that he referred to the speedometer more frequently than usual as he regulated 

his speed. The locomotive event recorder indicates that the throttle and braking 

actions by the engineer were appropriate and that the train was operated at normal 

speeds until it passed the approach diverging signal at the end of the Root Street 

interlocking. 

None of the fundamental tasks (train handling, signal recognition, and operating 

rules) faced by the engineer on the day of the accident was beyond his capabilities. 

However, when his belief that he was operating on clear signals was coupled with his 

unresolved concerns about the location of the work crew, when he would be crossed over, 

and other tasks, his ability to operate the train safely was affected. 

During postaccident interviews, the engineer indicated that when he saw multiple 

clear signals ahead he felt that he had some time to focus his attention elsewhere. 

Although much of his workload was self-imposed, the engineer demonstrated what often 
Analysis 17 Railroad Accident Report

happens to someone under a high workload:19 he increasingly focused on a particular part 

of the workload to the detriment of his handling of the overall situation. The engineerís 

excess attention to certain operating concerns, including the location of a maintenance-ofway work crew, where his train would be crossed over, and the regulation of his train 

speed, likely compromised his ability to maintain situation awareness,20 or an overview of 

all safety-critical tasks. The Safety Board, therefore, concludes that the cumulative

operating concerns of the engineer likely diverted his attention from the safety-critical task 

of observing and complying with signal indications. 

The Safety Board has investigated other railroad accidents in which the loss of 

situational awareness was a factor. For example, in its investigation of the collision of an 

Amtrak train with a Maryland Rail Corporation (MARC) train in Baltimore, Maryland,21

the Safety Board concluded that a factor in the accident was the engineerís unfamiliarity 

with the equipment. Specifically, the Amtrak engineer, with about 6 months of operating 

experience over the territory, had a train that was pulled by two locomotives of a type she 

had never operated. In addition, she had had limited experience operating locomotives as 

multiple units. As the engineer was approaching Baltimore station, she became overly 

concerned with and focused on maintaining her speed; as a result, she did not see either 

the cab or the wayside signals indicating that she should stop. She continued past the 

signals and collided with a southbound MARC train near the station.

The Safety Board determined that the probable cause of the accident was

The Amtrak engineerís loss of situational awareness in the moments before the 

collision because of excess focus on regulating train speed, which led to a failure 

to comply with the signal indications. Contributing to the accident was the 

engineerís lack of familiarity with and proficiency in the operation of the dieselelectric locomotives assigned for the trip.Ö

Developing Task Management Strategies

On the day of the accident, the engineer was confronted with a number of tasks that 

he should have handled more effectively. Training programs should help prepare students 

for ìreal-worldî situations and teach them how to prioritize conflicting tasks effectively. 

19 The concept of workload is the interface between the demands of the task and the resources or effort 

of the operator. During work overload situations, task demands continue to increase, and errors may result 

because of the operatorís inability to cope with the information rates imposed by the environment. See B.M. 

Huey and C.D. Wickens, eds., Workload Transition: Implications for Individual and Team Performance

(Washington, DC: National Academy Press, 1993).

20 Situation awareness is generally defined as a personís perception of the elements in the environment 

within a volume of time and space, comprehension of their meaning, and projection of their status in the near 

future. See M.R. Endsley, ìDesign and Evaluation for Situation Awareness Enhancement,î Proceedings of 

the Human Factors Society, 32nd Annual Meeting (Santa Monica, CA, 1988) 97-101.

21 National Transportation Safety Board, Collision of Amtrak Train No. 90 and MARC Train No. 437, 

Baltimore, Maryland, June 17, 2002, Railroad Accident Brief NTSB/RAB-03/01 (Washington, DC: NTSB, 

2003).
Analysis 18 Railroad Accident Report

One way that Metra attempted to prepare trainees was to have them use locomotive 

simulators; however, the engineer in this accident did not have simulator training because 

he was on a military deployment. Although simulators can help prepare engineers to 

operate trains safely under both normal and abnormal situations, the simulator training 

Metraís engineers took utilized a predefined sequence of events and, therefore, did not 

allow interactive altering of trip events that can challenge a traineeís knowledge and skills 

or teach the development of task strategy management during atypical situations. 

Therefore, even if the engineer had taken the simulator training, it is unlikely that it would 

have appreciably affected his performance leading up to the accident.

The aviation community recognizes that each pilot is responsible for managing 

multiple concurrent tasks (flying the aircraft, navigating, searching for traffic).22 Both 

research and accident investigations have shown that often pilots make mistakes not 

because they are under a work overload, but because they fail to monitor concurrent tasks 

in a timely manner. Interruptions, distractions, or preoccupation with one task to the 

detriment of another task are problems identified in numerous Safety Board accident 

reports. Some accidents were caused by pilots or crews who were preoccupied or distracted 

by ìhead-downî tasks, such as tending to paperwork or resolving a problem. Therefore, 

effective flight training goes beyond acquisition of basic piloting or ìstick and rudderî 

skills and provides the trainee with opportunities to manage both normal and challenging 

situations, including realistic interruptions, distractions, and concurrent task demands. 

Ambiguous problems for which the proper response is not obvious often cause 

pilots the most difficulty.23 In an emergency, such as a fire or an engine failure, for 

which a clear course of action is indicated, crewmembers tend to perform well. They do 

less well and sometimes neglect even the most basic elements of safe operation when 

they must spend time and attention on resolving an ambiguous problem. Consequently, 

much of the aviation industry has incorporated the concept of situational awareness in 

its pilot training and aircraft simulator scenarios to include both clear-cut and 

ambiguous problems. Crews learn from reviewing videotapes of their responses how 

well they managed, particularly whether they became fixated on a problem to the point 

that they left ìnobody minding the store.î

Simulators are often used to help flight crews develop task management 

strategies⎯the processes by which pilots manage the many tasks that must be done 

concurrently.24 The training teaches the crew how to allocate its attention to the different 

functions when an abnormality increases the workload.25A strategy involves monitoring, 

scheduling, and allocating the tasks and task resources. Such a strategy is particularly

22 K. Dismukes, Lessons from Aviation: Memory, Skilled Human Performance, and All-too-human 

Error (Moffett Field, CA: NASA Ames Research Center, 2002).

23 C. Bovier, ìSituation Awareness, Key Component of Safe Flight,î Flying Careers January (1997).

24 K. Funk, I. Colvin, J. Wilson, C. Suroteguh, and R. Braune, Cockpit Task Management (Oregon State 

University and NASA Ames Research Center, 2000).

25 P. Schutte and A. Trujillo, ìFlight Crew Task Management in Non-normal Situations,î Proceedings 

of the Human Factors and Ergonomics Society 40th Annual Meeting, 1996, (Santa Monica, CA: Human 

Factors and Ergonomics Society, 1996) 239-243.
Analysis 19 Railroad Accident Report

important in managing an abnormal situation, which requires the crew to devote more 

time and attention to the function related to the cause of the situation.

In surveying some large railroads, the Safety Board found that a traineeís task 

management skills are typically reinforced during supervised rides, if at all. Those railroads 

that use simulators do so primarily to develop train handling skills, not to prepare trainees to 

cope with situations requiring them to manage tasks simultaneously. Accidents can result not 

only from poor management of emergency situations, but also from a crewís failure to 

manage routine tasks and normal workload. Using locomotive simulators to present trainees 

with simultaneous operational challenges that they may face in the field can develop a 

traineeís ability to prioritize tasks and build confidence, thus preparing the engineer to 

operate safely even while coping with unusual or unexpected circumstances. The Safety 

Board concludes that training an engineer to develop task management skills may provide 

strategies that will allow the engineer to operate safely when encountering a high workload 

or atypical situations. The Safety Board believes that the FRA should develop guidelines for 

locomotive engineer simulator training programs that go beyond developing basic skills and 

teach strategies for effectively managing multiple concurrent tasks and atypical situations.

The Safety Board recognizes that the FRA will need time to develop simulator training 

guidelines that would be universally applicable to all railroads. The Safety Board believes that 

Metra does not need to wait for the FRA to complete its efforts, but rather, Metra should begin 

to use locomotive engineer simulator training to go beyond developing basic skills and teach 

strategies for effectively managing multiple concurrent tasks and atypical situations.

Calling Out Signal Indications

FRAís EO20 requirement for calling out certain signal indications is intended to 

add safety redundancy by involving other crewmembers in helping to ensure compliance 

with wayside signals in the absence of the protection provided by cab signals, automatic 

train stop, or an automatic train control system. In this situation, the approach diverging 

and diverging clear signals required the accident engineer to slow the train to 10 mph so 

that it could negotiate the crossover. The Safety Board understands that these signals did 

not meet FRAís definition of signal indications that must be called out.

Metra had designated several miles of track near where the accident occurred as a 

terminal area that was exempt from the requirement for signal callouts. Within this defined 

terminal area, there is no wayside cab signal equipment, positive train control, or other 

safety redundant system to compensate for human errors. Further highlighting the 

potentially severe consequences of failing to comply with signal indications through this 

area is the existence of a freight railroad crossing less than 2 miles from Chicago.

The accident engineerís most critical task was to observe and comply with wayside 

signal indications; however, he stated that when he saw multiple clear signals ahead he felt 

comfortable having time to focus his attention elsewhere. If he had been required to call out 

these upcoming signal indications over the radio, then he likely would not have perceived the 
Analysis 20 Railroad Accident Report

situation prior to the accident as an opportunity to divert his attention elsewhere; instead he 

likely would have been monitoring his location relative to each signal in preparation for 

making each callout. Therefore, calling out all signal indications would have better focused 

the engineerís attention on the safety-critical task of complying with the wayside signal 

system. Further, a crewmember hearing the engineer radio ìapproach divergingî would have 

expected the train to slow, so when it accelerated, a crewmember might have radioed the 

engineer for clarification or intervened. Although the calling out of signal indications does not 

prevent missed signals or incorrectly perceived called signals, the Safety Board concludes that 

had the engineer been required to call out all signal indications over the radio, there would 

have been a greater likelihood that he or another crewmember would have responded to the 

wayside signals. The Safety Board believes that Metra should require its train crews to call out 

all signal indications over the radio, including clear signals, at all locations that are not 

equipped with automatic cab signals with enforcement or a positive train control system. 

Currently, CSX Transportation (CSX) and the Norfolk Southern Railway 

Company (NS) require train crews to call all signal indications over the radio. Both CSX 

and NS have push-pull passenger operations on their systems: the Virginia Railway 

Express (VRE) and MARC. Accordingly, both VRE and MARC call out all signal 

indications when operating on these railroads. Further, several other railroads require train 

crews to call out signals under various circumstances and conditions. The Safety Board 

believes that the FRA should require train crews to call out all signal indications over the 

radio, including clear signals, at all locations that are not equipped with automatic cab 

signals with enforcement or a positive train control system. 

Positive Train Control

The Safety Board is concerned about the safety of railroad operations when 

backup systems are not available to intervene if a train crew operates a train improperly or 

fails to comply with wayside signals. Safety Board railroad accident investigations over 

the past three decades have shown conclusively that the most effective way to avoid trainto-train collisions is through the use of a positive train control system that will 

automatically assume some control of a train when the train crew does not comply with 

the requirements of a signal indication. In fact, positive train control has been on the 

Safety Boardís Most Wanted Transportation Safety Improvements list since the list was 

developed in 1990.26

In its investigation of the April 23, 2002, collision of a BNSF freight train with a 

Metrolink passenger train near Placentia, California,27 the Safety Board concluded that 

26 The Safety Board developed the Most Wanted Transportation Safety Improvements list, consisting of 

previously issued safety recommendations, to bring special emphasis to the safety issues the Board deems 

most critical. The list is reviewed, revised, and reissued as needed, or at least annually.

27 National Transportation Safety Board, Collision of Burlington Northern Santa Fe Freight Train With 

Metrolink Passenger Train, Placentia, California, April 23, 2002, Railroad Accident Report NTSB/RAR03/04 (Washington, DC: NTSB, 2003).
Analysis 21 Railroad Accident Report

Had a fully implemented positive train control system been in place on the 

Burlington Northern Santa Feís San Bernardino Subdivision at the time of the 

accident, the system would have intervened to stop the freight train before it could 

enter into the track area occupied by Metrolink 809, and the collision would not 

have occurred. 

The Safety Board has investigated numerous train accidents in which the probable 

cause or contributing cause was the inattention of the crewmembers to wayside signals. In 

its investigation of the head-on collision of two freight trains near Kelso, Washington,28

the Safety Board concluded that 

passive wayside light signals are not wholly adequate for preventing accidents 

because they do not always capture a train crewís attention or provide any safety 

redundancy or back-up when crewmembers misinterpret, disregard, or fail to pay 

attention to a signal.

The Safety Board also urged the railroad industry to recognize that human 

vigilance alone cannot prevent accidents. In fact, previous Board investigations identified 

many factors affecting a crewís performance and its ability to comply with signals, 

including multiple distractions,29 talking on a cell phone,30 dense fog,31 crew inattention,32

crew fatigue (or falling asleep) due to irregular work and sleep cycles,33 sleep disorders,34

and prescription medications causing drowsiness.35 After each of these investigations, the 

Safety Board stated that had the accident location had a positive train control system with 

a collision-avoidance component, the system could have detected that the engineer was 

not responding appropriately to the signal indications. After this detection, the positive 

train control system would have stopped the train.

28 National Transportation Safety Board, Head-On Collision and Derailment of Burlington Northern 

Freight Train with Union Pacific Freight Train, Kelso, Washington, November 11, 1993, Railroad Accident 

Report NTSB/RAR-94/02 (Washington, DC: NTSB, 1994).

29 NTSB/RAR-97/02.

30 National Transportation Safety Board, Collision of Two Burlington Northern Santa Fe Freight Trains 

Near Clarendon, Texas, May 28, 2002, Railroad Accident Report NTSB/RAR-03/01 (Washington, DC: 

NTSB, 2003).

31 National Transportation Safety Board, Collision Involving Three Consolidated Rail Corporation 

Freight Trains Operating in Fog on a Double Main Track near Bryan, Ohio, January 17, 1999, Railroad 

Accident Report NTSB/RAR-01/01 (Washington, DC: NTSB, 2001).

32 NTSB/RAR-03/04.

33 National Transportation Safety Board, Collision and Derailment Involving Three Burlington 

Northern Freight Trains near Thedford, Nebraska June 8, 1994, Railroad Accident Report NTSB/RAR95/03 (Washington, DC: NTSB, 1995).

34 National Transportation Safety Board, Collision of Two Canadian National/Illinois Central Railway 

Trains near Clarkston, Michigan, November 15, 2001, Railroad Accident Report NTSB/RAR-02/04 

Washington, DC: NTSB, 2002.

35 National Transportation Safety Board, Collision and Derailment of Union Pacific Freight Trains 

MPRSS-21 and AJAPRB-21 at Des Plaines, Illinois, October 21, 2002, Railroad Accident Brief 

NTSB/RAB-04/04 (Washington, DC: NTSB, 2004).
Analysis 22 Railroad Accident Report

The Safety Board concludes that this Metra accident is another in a series of 

accidents that could have been prevented had there been a positive train control system at 

the accident location. Such a system could have detected the engineerís lack of response to 

signal indications and then could have either stopped the train or slowed it to a speed at 

which it could have safely moved through the crossover. The Safety Board believes that 

Metra should install a positive train control system on its commuter train routes. 

The most recent positive train control related safety recommendation issued to the 

FRA was a result of the Safety Boardís investigation of the train collision involving three 

freight trains in Bryan, Ohio,36 and it was reiterated following the Placentia, California, 

accident: 

R-01-6

Facilitate actions necessary for development and implementation of 

positive train control systems that include collision avoidance, and require 

implementation of positive train control systems on main line tracks, 

establishing priority requirements for high-risk corridors such as those 

where commuter and intercity passenger railroads operate.

This recommendation is currently classified ìOpenñAcceptable Response.î

The FRA issued a final rule that became effective on June 6, 2005, that establishes 

performance-based standards for processor-based signal and train control systems. 

According to the FRA, this rule will facilitate the introduction and implementation of train 

control systems by providing technology-neutral performance-based criteria for 

determining safety. Additionally, the FRA provided the Safety Board with information 

about several positive train control development projects that it continues to fund, and the 

FRA participated in the Positive Train Control Symposium sponsored by the Board in 

March 2005. However, the Board remains concerned about the lack of positive train 

control systems on many passenger train routes and is convinced that these systems 

provide the best approach to reduce human-error accidents. Therefore, the Safety Board 

reiterates Safety Recommendation R-01-06 to the FRA.

36 NTSB/RAR-01/01.
23 Railroad Accident Report

Conclusions

Findings

1. The mechanical condition of the train, the track structure, the signal system, 

environmental conditions, cell phones, and drugs and alcohol were not factors in this 

accident. 

2. The cumulative operating concerns of the engineer likely diverted his attention from 

the safety-critical task of observing and complying with signal indications.

3. Training an engineer to develop task management skills may provide strategies that 

will allow the engineer to operate safely when encountering a high workload or 

atypical situations.

4. Had the engineer been required to call out all signal indications over the radio, there 

would have been a greater likelihood that he or another crewmember would have 

responded to the wayside signals. 

5. The October 12, 2003, Metra accident is another in a series of accidents that could 

have been prevented had there been a positive train control system at the accident 

location.

Probable Cause

The National Transportation Safety Board determines that the probable cause of 

the derailment of Northeast Illinois Regional Commuter Railroad (Metra) train 519 was 

the locomotive engineerís loss of situational awareness minutes before the derailment 

because of his preoccupation with certain aspects of train operations that led to his failure 

to observe and comply with signal indications. Contributing to the accident was the lack of 

a positive train control system at the accident location.
24 Railroad Accident Report

Recommendations

As a result of its investigation of the October 12, 2003, derailment of Metra train 

519 in Chicago, Illinois, the Safety Board makes safety recommendations as follows:

New Recommendations

To the Federal Railroad Administration:

Develop guidelines for locomotive engineer simulator training programs 

that go beyond developing basic skills and teach strategies for effectively 

managing multiple concurrent tasks and atypical situations. (R-05-9)

Require train crews to call out all signal indications over the radio, 

including clear signals, at all locations that are not equipped with automatic 

cab signals with enforcement or a positive train control system. (R-05-10)

To Northeast Illinois Regional Commuter Railroad (Metra):

Use locomotive engineer simulator training to go beyond developing basic 

skills and teach strategies for effectively managing multiple concurrent 

tasks and atypical situations. (R-05-11)

Require your train crews to call out all signal indications over the radio, 

including clear signals, at all locations that are not equipped with automatic 

cab signals with enforcement or a positive train control system. (R-05-12)

Install a positive train control system on your commuter train routes. 

(R-05-13)

Recommendation Reiterated in This Report

The National Transportation Safety Board reiterates the following safety 

recommendation to the Federal Railroad Administration:
Recommendations 25 Railroad Accident Report

R-01-6

Facilitate actions necessary for development and implementation of 

positive train control systems that include collision avoidance, and require 

implementation of positive train control systems on main line tracks, 

establishing priority requirements for high-risk corridors such as those 

where commuter and intercity passenger railroads operate.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER ELLEN ENGLEMAN CONNERS

Acting Chairman Member

DEBORAH A. P. HERSMAN

Member

Adopted: November 16, 2005

Deborah A. P. Hersman, Member, filed a concurring statement on November 16, 

2005.

Notation 7615A

Member HERSMAN, concurring:

Although I concur with the findings and with the recommendations contained in 

this report, I would have preferred the report to include recommendations that 

would provide interim safety solutions that railroads and FRA can implement 

relatively quickly while work continues on the development of PTC and on new 

regulations.

Despite the many resources invested by the Federal government and the rail 

industry to develop technologies, like PTC, that provide safety overlays for 

controlling the movement of trains, widespread implementation of these systems is 

still many years away, particularly for publicly-funded commuter operators such as 

Metra that operate over various railroad properties. It is reasonable to recommend 

that Metra should implement a PTC system on its routes at some time in the future; 

it is unreasonable to expect that this commuter rail operator will be able to do so in 

the near term. In the meantime, there may be other technologies that are more 

practical for Metra to install to achieve greater safety protection while it moves 

toward the implementation of a more complete train control system like PTC (e.g., 

additional route miles outfitted for operation of the cab signals, automatic train stop 

(ATS), or other redundant technologies, some of which are already operational on 

certain routes or portions of routes operated by Metra).

In that same vein, the recommendation to FRA to require train crews to call signal 

indications should also include a recommendation that the agency take immediate 

steps to tighten loopholes in Emergency Order 20. This emergency order is 
Recommendations 26 Railroad Accident Report

designed specifically for the protection of push-pull and multiple unit operations on 

commuter and intercity passenger railroads, such as Metra, where trains operate at 

speeds faster than 30 mph over routes where there are no operable cab signals, ATS 

or ATC. In part, the emergency order requires a crew member in the controlling cab 

to call signals to another crew member elsewhere on the train. Application of the 

emergency order is limited to areas outside yard or terminal limits as set by the 

railroad. Railroads may be setting such limits beyond what was originally 

envisioned, excluding many miles of their operations. FRA should review existing 

yard and terminal limits to determine if they are appropriate and do not dilute the 

intent of the emergency order. Emergency Order 20 is further limited to only those 

signals that require the train to stop or operate at restricted speed at the next signal. 

It does not apply to signals indicating a diverging clear, as in the case of this 

accident, even though the diverging signal required the train to slow down 

significantly, from 68 mph to 10 mph, as it approached the crossover. The result is 

that Emergency Order 20, despite its purpose of protecting train movements of 

commuter and intercity passenger operations by requiring engineers to call signals, 

was not applicable in the train movement immediately preceding this accident.

The Board is recommending in this report that FRA require all railroads to call out 

all signals at all locations that are not equipped with PTC or with automatic cab 

signals with enforcement. While this recommendation may improve rail operational 

safety, it calls for a new Federal regulation that must be implemented through the 

lengthy rulemaking process. In the meantime, commuter and intercity passenger 

operations carrying thousands of passengers each day would continue to pose a risk 

to their passengers from signals missed by train crews. (In fact, a similar accident to 

this one has already occurred earlier this year at this same location.) I would have 

preferred that this report recommend to FRA that while it pursues the rulemaking, it 

also revise Emergency Order 20 to require train crews on commuter and intercity 

passenger operations to call signals at all locations where the signal indicates that 

the train must be slowed significantly before the next signal.

Furthermore, the recommended rulemaking to require calling all signals would 

apply to freight railroads, as well as commuter passenger operations, all across the 

country. Although it seems intuitive that such a requirement would have a 

positive impact on the attentiveness of the engineer, there currently is no hard data 

to scientifically support the theory. In fact, I have reservations about the 

effectiveness of calling signals on passenger operations where the conductors or 

other crew members are not in the locomotive cab, because 1) they cannot see the 

signals to confirm or challenge the signals called by the engineer, and 2) they 

often are occupied with other duties in the passenger cars. I would have liked the 

recommendations to include a suggestion that FRA collect data on railroadsí 

compliance with, and the safety effectiveness of, Emergency Order 20. The data 

could then be used to justify the signal-calling requirement on a much broader 

segment of railroads.

Finally, to compliment the recommendations, I would have preferred the probable 

cause to include additional contributory causes. It may be true that the lack of 

PTC contributed to this accident, but so did the lack of other redundant 

operational safety measures, such as improved training and oversight of crew 

compliance with signals, signal calling by the crew and operational cab signals. 

The probable cause would have been more accurately stated if it said that 

contributing to the accident was the lack of PTC and any other redundant 

operational safety measures that enhanced crew compliance with the signals.
27 Railroad Accident Report

Appendix A

Investigation

The National Response Center notified the National Transportation Safety Board 

of the accident about 7:00 p.m. on October 12, 2003. The Safety Board immediately 

dispatched a Chicago-based investigator and a Washington D.C.-based investigator to the 

scene. Two additional investigators were assigned once it was determined that their 

expertise was needed. No Board Member participated in the on-scene investigation. 

No hearings or depositions were held in conjunction with this accident. 

The Northeast Illinois Regional Commuter Railroad, the Federal Railroad 

Administration, the Brotherhood of Locomotive Engineers, the United Transportation 

Union, the Brotherhood of Railroad Signalmen, and the Illinois Commerce Commission 

were all parties to this investigation.