NTSB/RAB-04/01 1 

E PLURIBUS UNUM

NATIONAL TRA S PORTATIO

N

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Railroad Accident Number: DCA-03-FR-004

Location: San Juan Capistrano, California 

Date and Time: April 1, 2003, 1:38 p.m. (Pacific standard time) 

Accident Type: Train striking maintenance-of-way workers 

Companies: Herzog Contracting Corporation 

 National Railroad Passenger Corporation 

 Southern California Regional Rail Authority 

Train: Amtrak train 774 

Injuries: None 

Fatalities: 2 

Synopsis 

About 1:38 p.m., Pacific standard time, on April 1, 2003, eastbound1 National 

Railroad Passenger Corporation (Amtrak) train 774 struck two maintenance-of-way 

workers at control point2 (CP) Avery near San Juan Capistrano, California. Both workers 

were fatally injured. According to event recorder data, train speed was 90 mph. The 

Amtrak 774 engineer said that he sounded the horn and placed the train into emergency 

braking moments before impact. The fatally injured workers were part of a five-person 

crew employed by Herzog Contracting Corporation (Herzog) to provide maintenance-ofway services under a contract with the Southern California Regional Rail Authority 

(Metrolink). The accident occurred on tracks owned by the Orange County 

Transportation Authority and operated by Metrolink. The weather was clear and dry, with 

a temperature of 66° F.

Events Preceding the Accident 

The maintenance-of-way crew reported for duty at 7:00 a.m. on April 1, 2003, at a 

field office at Sand Canyon, adjacent to Metrolink tracks at milepost (MP) 183.95 in 

Irvine, California. Their work involved inspecting switches and turnouts at various 

 1

 Directions used in this report are railroad timetable direction, which may vary from actual compass 

direction. Metrolink designates east and west as its railroad timetable directions on the Orange Subdivision. 

Eastbound is toward San Diego. 

2 Control points are locations where the train dispatcher can command signals and switches to direct 

train movements. 
 NTSB/RAB-04/01 2 

locations along the Orange Subdivision. The foreman/employee in charge3

 said he held a 

job briefing4

 with the crew at the first job site before they entered the right-of-way. No 

other job briefings were held, although the workers entered the right-of-way and 

inspected several locations before arriving at CP Avery about 1:30 p.m. 

At CP Avery, some of the crew noticed an Amtrak train pass just before they 

entered the right-of-way.5

 Meanwhile, Amtrak train 774 had departed Los Angeles 

eastbound toward the workers’ location. 

At CP Avery, the maintenance-of-way crew’s work involved checking the turnout 

for loose fasteners and other defects and recording measurements. Two individuals began 

work at the switch points, and the other three walked westward to the turnout frog.6 The 

employee-in-charge had earlier designated himself as the lookout and was one of those at 

the frog. The employee-in-charge told investigators that while at the frog he assisted with 

some measurements. He said that he did not formally designate anyone to serve as 

watchman while he performed this work but that “there was somebody [one of the other 

workers] looking for me.” The employee-in-charge did not have an audible warning 

device (whistle or horn) and a white disc with which to warn the other workers of an 

approaching train as required by Metrolink procedures. He told investigators that he 

planned to verbally warn the other employees if he needed to do so. 

When work was completed at the frog, the three workers walked eastward to join 

the other two workers who were near the switch points. The employee-in-charge said that 

he asked the two workers near the switch points if they were finished. When they 

answered that they were, he said he told them, “let’s go,” after which all five workers 

walked eastward. 

As they walked east, the employee-in-charge and two workers were walking clear 

of the tracks. Another of the workers was walking between the rails, and another was 

walking on the tie ends about even with the switch machine motor. All four workers and 

the employee-in-charge had their backs to the direction from which eastbound Amtrak 

train 774 was approaching. 

The train 774 engineer stated that he was operating on clear signals at the 

authorized track speed of 90 mph as he approached the accident site. He said that shortly 

after rounding the right-hand curve at Laguna Niguel Station, he noticed personnel on the 

right-of-way at CP Avery. He said he first sounded the whistle then put the brakes into 

emergency and shortly thereafter heard an impact. One of the workers walking clear of 

 3

 The employee-in-charge is “responsible for the safety, instruction, performance and On-Track Safety 

of all employees under his jurisdiction”. (Metrolink Roadway Worker On-Track Safety Manual section XII) 

4

 A job briefing is a short job-site meeting among workers where work tasks and safety precautions are 

discussed. 

5

 Metrolink train-dispatching records indicate westbound Amtrak train 775 passed CP Avery at 1:28 

p.m. 

6 Frogs permit rail wheel flanges to cross over opposing rails in turnouts. 
 NTSB/RAB-04/01 3 

the tracks said that he heard the train whistle just before train 774 struck and fatally 

injured the workers walking between the rails and on the tie ends. 

Figure 1: Accident location looking west. Figure 2: CP Avery viewed from 

eastbound train. 

Job Briefings 

The job briefing form completed that morning by the employee-in-charge before 

the crew began work had “track and time”7

 checked as the method of on-track safety to 

be used. Under the comments section of the form, the following was entered: “will be 

working under watchman[8

] authority.” The employee-in-charge said that his original 

plan was to obtain track and time but that he later decided to work under watchman 

procedures. All members of the crew signed the job briefing form. 

No further job briefings were conducted, although Metrolink procedures required 

the employee-in-charge to conduct follow-up briefings at each new work location. A 

follow-up briefing is also required when “on-track safety changes.” Shifting the lookout 

responsibility from one worker to another is such a change. 

Lookout Procedures 

The work at CP Avery was being performed under lookout procedures contained 

in Metrolink’s Roadway Worker On-Track Safety Manual. The manual describes the 

lookout duties and responsibilities as follows: 

Watchmen are responsible for the lives of their fellow workers. It is their 

responsibility to watch for approaching trains and signal employees to 

clear the tracks. Watchmen must...warn employees in time for them to 

clear tracks at least 15 seconds before the train arrives...(1) Sound a 

warning whistle or horn. (2) Hold the white disc at arm’s length above 

 7

 Under track and time, the train dispatcher stops train movements on a designated section of track. 

8

 The terms watchman and lookout are used interchangeably in the procedure. 
 NTSB/RAB-04/01 4 

your head. (3) Then, hold the white disc horizontally at arm’s length, 

toward the place designated in the Job Briefing where employees are to go 

to clear the tracks.9

This procedure also requires that the lookout devote full attention (“must not 

perform any other duties, even momentarily”) to detecting approaching trains. Should it 

be necessary to appoint a different lookout, the procedures require the crew to clear the 

track and hold a new job safety briefing. Metrolink procedures also state that employees 

“shall not foul the track except when necessary.” 

When using the lookout system, Metrolink requires a lookout to be able to 

provide a distinctive warning in advance of train arrival that allows employees to reach a 

predetermined point of safety at least 15 seconds before the train arrives. If field 

conditions exist that will not allow the 15-second clearance time with a single lookout, 

advance lookouts must be placed at a sufficient distance to provide a signal to the lookout 

at the work location. The lookout at the work location then signals the employees to clear 

the track. If advance lookouts are not used, an alternative system of protection, such as 

track and time, must be established. Advance lookouts were not in place at the time of the 

accident. 

Sight distance observations indicated that an approaching eastbound train first 

became visible when it was about 2,415 feet west of CP Avery. At a track speed of 90 

mph, the employee in charge had about 3 seconds to detect a train, sound a warning 

signal, and clear personnel from the track to meet the specified clearance time of 15 

seconds before train arrival. 

Rules Compliance 

The investigation identified a number of procedural infractions that preceded the 

accident: 

• A job briefing was not conducted at each new work location as required. 

• The employee-in-charge performed duties as a lookout without the 

required warning equipment. 

• The work location did not allow the employees to clear the tracks 15 

seconds before a train arrived with only a single lookout in place. 

• Lookout responsibility shifted while employees were fouling the track 

without the crew’s being alerted through a follow-up job safety briefing. 

• After the work was completed, the two employees who were later struck 

remained on the track, walking with their backs to an approaching train. 

 9 Roadway Worker On-Track Safety Manual, effective 7-12-2000, section 6.3.4 B. 
 NTSB/RAB-04/01 5 

• The employee-in-charge was not attentive to the approaching train 

movement. 

Metrolink Efficiency Testing Program 

One of the methods Metrolink uses to monitor the effectiveness of, and 

compliance with, Metrolink’s on-track safety procedures is to conduct rules compliance 

field audits, commonly referred to in the railroad industry as “efficiency tests.” 

Metrolink’s efficiency test program is described as providing “supervisors the 

opportunity to acknowledge a job well done or to correct operating or maintenance 

practice deficiencies.”10 These tests typically involve unannounced field observations, job 

site interviews, inspection of equipment, and review of paperwork such as job briefing 

forms. Results and corrective actions (if needed) are documented and tracked. 

Metrolink established a goal for Metrolink and Herzog managers/supervisors to 

conduct at least four efficiency tests per month per manager/supervisor. Statistics are kept 

on this efficiency testing and are provided on a monthly basis to the chief engineer. 

Metrolink provided records of efficiency tests on Herzog maintenance-of-way 

employees for the period June 2002 through March 2003. Approximately 70 Herzog 

personnel, including managers, supervisors, and craft employees are assigned to provide 

maintenance-of-way and structures services to Metrolink. These records indicate that on a 

systemwide basis, 123 tests were performed on Herzog employees during 68 

observations11 by 4 Metrolink managers. 

Of 15 total Herzog employee tests performed on the Orange Subdivision, 12 were 

performed at Sand Canyon, the location of a field office where Herzog employees and 

supervisors report on and off duty each work day. 

Records indicate that 10 tests had been performed on 412 of the employees 

involved in the accident during 6 observations by 1 Metrolink manager. Five of the six 

observations were performed at or near Sand Canyon, the field office location where the 

employees go on and off duty. 

Herzog Management Oversight of its Employees 

Metrolink’s standard operating procedure (SOP) 17 establishes a requirement for 

Herzog supervisors to monitor employees’ compliance with Federal Railroad 

Administration (FRA) requirements (one of which is roadway worker protection) by 

performing four efficiency tests per month. No efficiency tests are recorded as having 

been performed by Herzog managers/supervisors. 

 10 Metrolink Engineering and Construction Efficiency Test Program 2002-2003. 

11 A manager may record more than one test during a single observation of an employee. 

12 No tests were recorded for one of the employees. 
 NTSB/RAB-04/01 6 

Herzog representatives told Safety Board investigators that their supervisors 

performed field observations before the accident but that these observations were not 

documented and did not entail the same formal efficiency test format used by Metrolink. 

Metrolink Internal Audits 

Metrolink has developed a system safety program plan, which is a formal written 

document that identifies and assigns responsibility for all safety-related responsibilities 

within the organization. Metrolink first issued its system safety program plan in 1996. 

The current plan (dated June 2000) is described as “a means of integrating safety into all 

facets of SCRRA [Southern California Regional Rail Authority].” The current plan 

covers 26 system safety elements. Element 26 of the Metrolink system safety program 

plan, titled “Safety Management Assessment Program,” describes an internal safety audit 

process where one-half of the plan’s elements are audited each year. 

Attached to the plan are 20 SOPs covering safety-critical functions. Maintenanceof-way rules compliance and efficiency testing are included in the safety-critical 

functions. The SOPs are described as defining “standards and measurements of success 

and detail the process used to verify compliance with the SCRRA-mandated 

requirements, including FRA or industry standards.” 

The plan states that each of the 20 Metrolink SOPs in the plan will be audited 

annually. Metrolink officials told investigators that an internal safety audit of the 

roadway worker protection program had not been conducted before the accident. SOPs 

16, 17, and 19 (which cover the roadway worker program) had also not been audited 

before the accident. Metrolink managers told investigators that such an audit began in 

November 2003 and is ongoing. Among other things, the report recommends that 

Metrolink managers work with contractors to revise safety-critical SOPs so they are 

consistent with the safety plan as well as field activities. The audit also recommends steps 

to better include contractors in monitoring for compliance. 

Actions Taken Since the Accident 

Amtrak 

Amtrak issued a “rules alert” concerning this incident to its Southwest Division 

employees to heighten their safety awareness with regard to workers on the right-of-way. 

Herzog 

In addition to the safety stand-down meetings noted below, Herzog 

representatives stated that they now require that employees intending to work under a 

lookout system of protection review their plan with a manager who must approve it 

before the employees foul the track. Herzog also said that it has established an audit 
 NTSB/RAB-04/01 7 

procedure, adopted Metrolink’s efficiency test procedures, and has begun conducting 

efficiency testing.

Metrolink 

Metrolink, along with Herzog and other maintenance contractors, temporarily 

halted maintenance on the Metrolink right-of-way immediately after the accident and 

held safety stand-down meetings to review the incident and on-track safety procedures. 

Metrolink formed a safety team comprising Metrolink and contractor managers to 

review on-track safety procedures and to recommend improvements. As a result of the 

review, Metrolink revised its lookout procedures by requiring lookouts to warn 

employees working on the track in time for them to clear the track at least 20 seconds 

before a train arrives; an increase from 15 seconds. Metrolink reissued its Roadway 

Worker On-Track Safety Manual in February 2004 with more specific language on the 

requirements that lookouts perform no other duties and that follow-up job briefings be 

held at new work locations and when lookout responsibilities transfer to another 

employee. Metrolink revised its job briefing form on June 1, 2003, to include entries for 

the name of the assigned lookout(s) as well as the sight distance from the work location 

to the point at which a train can be visually detected. 

Metrolink representatives also reported that they implemented a more focused 

roadway worker efficiency test program that establishes 13 “safety-critical” tests. These 

tests cover job briefings, lookout duties, and lookout equipment. Metrolink’s revised 

program requires that each employee-in-charge be tested at least once per year on each of 

the 13 safety-critical tests. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of 

the accident was the inattentiveness of the assigned lookout as well as his failure to 

comply with applicable rules by posting advance lookouts or requesting another means of 

protection from train movements. Also contributing to the accident was the 

ineffectiveness of the Metrolink and Herzog efficiency test programs with regard to ontrack safety procedure compliance. 

Adopted: February 13, 2004