National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Railroad Accident Number: ATL-00FR-005 

Rail System: Metropolitan Atlanta Rapid Transit Authority 

(MARTA) 

Train: Unscheduled train 166 

Accident Type: Train striking bucket of self-propelled lift 

containing two contract workers 

Location: MARTA Lenox rail transit station in Atlanta, 

Georgia 

Date and Time: April 10, 2000, about 2:30 a.m.

Fatalities/Injuries: Two fatalities 

About 2:30 a.m. on April 10, 2000, an unscheduled MARTA train struck the 

bucket of a self-propelled lift that was fouling the southbound main track at MARTAís 

Lenox Station in Atlanta, Georgia. Two MARTA contract workers who were repairing 

the station ceiling occupied the bucket. Both workers received fatal injuries when they 

were ejected onto the station platform. 

The Accident 

On May 17, 1999, MARTA entered into a contract with The Lions Group, Inc., to 

repair the ceilings of MARTA rail train stations in the Atlanta area. (See figure 1 for a 

diagram of the MARTA system.) The work involved the use of a self-propelled lift, 

which was positioned on the station platforms with the boom extended as necessary.1

During the course of the repairs, the boom and bucket sometimes had to be positioned 

over the track in such a way as to foul the track. MARTA assigned a flagman to the 

project.

 1

 The lift involved in this accident was a Genie Z-34/22N narrowbase, self-propelled, articulating, zero 

tailswing boom. 

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 I-75

North-South Rapid Rail Line

East-West Rapid Rail Line

Interstate Highways

I-20

I-285

East Point

College Park

SOUTH LINE

Airport

Lakewood/Ft. McPherson

Oakland City

West End

Dome/GWCC/Phillips Arena/CNN Center

West Lake

Ashby

Vine City

Hamilton E. Holmes

Bankhead

Peachtree Ctr

Civic Ctr

North Ave

Midtown

Arts Center

Five Points

Georgia State

King Memorial

Inman Park/Reynoldstown

Edgewood/Candler Park

Decatur

Avondale

Kensington

Indian Creek

NORTH LINE

WEST LINE

I-285

I-285

I-85

Buckhead

Medical Center

North Springs

Sandy Springs

Dunwoody

Doraville

Chamblee

Brookhaven/Oglethorpe Univ.

Lenox

Lindbergh Center

I-85

NORTHEAST LINE

EAST LINE

I-75

Garnett

Legend:

N

S

W E

Buckhead

Chamblee

Brookhaven/Ogleth

Lenox

Lindbergh Center

Figure 1. Map of the MARTA system, highlighting Lenox Station.

2 NTSB/RAB-03/02 
 

 

At the time of the accident, Lions employees had been working on the ceiling of 

MARTAís Lenox Station for about 4 months. Two Lions employees were scheduled to 

complete the work on the day of the accident, April 10. As was customary, the work was 

to be done between 2:00 and 4:00 a.m., when no MARTA trains were scheduled to 

operate in revenue service. 

About 1:35 a.m. on April 10, after the last scheduled train of the previous dayís 

operations (northbound train 166) had passed through the station, the flagman radioed the 

MARTA rail system control center and requested permission for the Lions workers to 

start repairs, some of which would require that the bucket of the lift be positioned over 

the southbound track. (Lenox Station has two tracks, one of which is normally used for 

southbound trains and the other for northbound trains. The tracks are separated by a 30-

foot-wide passenger platform.) 

About 2:00 a.m., the rail system control center advised the flagman that a safe 

clearance restriction, restriction No. 73, was in effect at Lenox Station.2

 The rail system

control center assistant superintendent deenergized the high-voltage third rail within the 

station to protect the workers in case they accidentally touched it during their work. 

(Because of the length of the trains and the fact that the third rails on either side of the 

station remained energized, deenergizing the third rail within the station did not prevent a 

train from obtaining power to enter the station.) He also lined the track away from the 

work site to the northbound track at Lenox Station. Because he did not place exit 

prohibits on the track to prevent the track from being re-aligned by mistake, the 

computerized system could still automatically line the track back through the work site. 

About 2:07 a.m., after the MARTA flagman had checked the power on the third 

rail for the Lenox Station southbound track and confirmed that it was deenergized, Lions 

workers began working on the station ceiling. The flagman did not set flags to protect the 

work area. As the work began on April 10, the flagman said, he was on the station 

platform observing the workers. 

Meanwhile, 18 MARTA passengers who had attended a late-night event in 

downtown Atlanta found themselves stranded at Lindbergh Center Station, south of 

Lenox Station. The passengers had planned to change trains at Lindbergh Center Station 

and to take a MARTA train north to Dunwoody Station, but they did not arrive at 

Lindbergh Center Station until about 2:00 a.m., after the last scheduled train had left the 

station. MARTA police became aware of the stranded passengers and notified the rail 

2

 Safe clearance requirements will be discussed later in this brief. 

3 NTSB/RAB-03/02 
 

system control center. The control center assistant superintendent decided to recall 

train 166 from Doraville Station to Lindbergh Center Station to serve the stranded 

passengers. 

According to the train operator, the control center assistant superintendent 

notified him about 2:15 a.m. of the need to return to pick up passengers at Lindbergh 

Center Station. The train operator said he was not advised of the safe clearance restriction 

on the track at Lenox Station and he was not aware that any work was being performed at 

the station. He said that during his trip southbound, he operated the train in manual 

control, governed by signal indication, moving between 50 mph and the maximum

allowed speed of 60 mph. 

The control center assistant superintendent stated that he remembered instructing 

the train to return southbound from Doraville Station to Lindbergh Center Station. He 

could not recall notifying the southbound train operator of the presence of the workers at 

Lenox Station by issuing safe clearance restriction No. 73. He did not notify the workers 

at Lenox Station that a train would be approaching. He stated that as the train moved 

southward, another controller asked him for assistance, and his attention was distracted. 

He said that when he again turned his attention to the movement of train 166, he used the 

public address system to let the stranded passengers at Lindbergh Center Station know 

that a train was en route to the station. While he was thus engaged, the rail system control 

center computer system routed the train through Lenox Station on the southbound track. 

The train arrived at Lenox Station about 2:30 a.m., while the two Lions workers 

were in the bucket of the lift positioned over the southbound track, replacing screws in 

ceiling tiles. The flagman said he heard the Lions workers shouting that a train was 

approaching. He said that he ran toward the train, attempting to stop it with hand signals. 

According to the train operator, the train was moving about 35 mph when it 

entered the station. He said his first indication of a problem was when he saw someone 

on the platform gesturing to him. He said that as soon as he realized that the person 

wanted him to stop, he placed the train brakes in emergency and moved the controller to 

the ìoffî position. The train did not stop before it struck the work boom and ejected the 

two Lions workers from the bucket to the station platform. (See figures 2 and 3.) One of 

the workers was killed instantly; the other died in the hospital. 

4 NTSB/RAB-03/02 
 

Figure 2. Damaged self-propelled lift. 

Figure 3. Lead car of April 10, 2000, Lenox Station accident train; window damaged by

contact with work boom of self-propelled lift.

5 NTSB/RAB-03/02 
 

Rules and Regulations 

Safe Clearance Procedures 

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

areas where workers are present. At the time of the accident, safe clearance restriction 

No. 73 was in effect for the work that necessitated fouling the track at Lenox Station. The 

MARTA Wayside Access Manual states that safe clearance procedures require that: 

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

must be accompanied by a qualified MARTA Flagperson or MARTA 

Supervisor while on the track wayside. 

In accordance with this requirement, the flagman had been assigned to the ceiling 

repair work. 

The safe clearance procedures also state that: 

The employee will contact the Central Controller or Yard Tower 

Supervisor by two-way radio requesting the Generic, Verbal, or Special 

restriction number from the Track Allocation Schedule. 

The flagman had obtained a safe clearance restriction (No. 73) from the control 

center assistant superintendent. 

The procedures further require that the controller confirm the restriction number, 

location, and special instructions with train operators and that he/she repeat the restriction 

notification hourly to train operators. The control center assistant superintendent did not 

follow these notification procedures on the day of the accident. 

The procedures state that ìif the work requires reduced train speed operations, the 

appropriate flags will be posted at the proper locations.î (Reduced train speed operations 

are to be observed if the track is being fouled.) The flagman stated that he did not place 

flags alongside the southbound track on either side of the station because (1) the lift unit 

was on the station platform, rather than on or near the tracks, (2) the last scheduled train 

had passed through the station, (3) he believed the track was blocked out by safe 

clearance restriction No. 73, and (4) flag placement had not been required during the 

preceding 4 months of work at Lenox Station. 

The flagman said that the track supervisor in charge of the work area had told him

that flags were not necessary when a safe clearance restriction was in effect. The track 

6 NTSB/RAB-03/02 
 

 

supervisor stated that the flagging rule requirements for the Lenox project were a ìgray 

areaî because the lift unit was on the station platform rather than on or near the tracks. 

He confirmed that he did not require flag protection for the work site. 

Single-Tracking Procedures 

Single-tracking procedures reroute trains to prevent them from entering areas 

where workers are present. MARTAís single-tracking rules require that the following 

steps be taken for an area being protected by a single-tracking restriction: 

• A schedule for track restrictions is established during the weekly track 

allocation meeting a week in advance of the restrictionís effective date; 

• The flagman is provided a copy of the work order; 

• The flagman confirms the order with the rail system control center; 

• The flagman places a red tag on the switch to be lined away from the work 

site; in addition, the flagman places flags, trip stops,3

 and shunt straps on the track; 

• The rail system control center lines the switch away from the work site and 

removes electrical power from the track; 

• The rail system control center places exit prohibits on the track section; and 

• The rail system control center has the flagman test the track power to ensure 

that electrical power has been removed from the track. 

MARTA did not require the use of single-tracking procedures at the Lenox 

Station work site. The rail system control center assistant superintendent, who was on 

duty and acting as a controller in the control center at the time of the accident, stated that 

he thought the control center was supposed to protect the southbound track at Lenox 

Station so that a train could not enter the work area. He said he normally lined the 

crossover switch to route trains away from the work area or required that trip stops be 

placed on the track north of Lenox Station to stop a southbound train. He also said he 

normally would have entered an exit prohibit that prevented the train control computer 

3

 A trip stop is a mechanical device that a flagman can manually position at trackside to trip the brake 

cock of a train so that it initiates an emergency brake application.

7 NTSB/RAB-03/02 
 

 

from routing trains into the station. He said he did not know why he had not followed 

these procedures on the day of the accident. His statements indicate that procedures 

associated with single tracking had been used previously during the ceiling work project 

to protect the Lenox work site. 

Contract Between MARTA and The Lions Group 

MARTAís contract with The Lions Group detailed how the ceiling work would 

be done and how the work area would be protected. The method of flagging and the rules 

required for that protection were specified in the contract, which stated: 

The request and the performance of work during non-revenue service must 

adhere to the procedures established from single trackingÖ. Non-revenue 

service occurs between 0200 hours to 0400 hours daily. 

The contract also stated: 

[MARTA] shall have the sole authority to determine the need for flagging 

services to protect its operating rail systemÖ. Flagging services will be 

needed when the Contractorís [Lionís] personnel and equipment are, or 

may be, working closer than 15 feet to centerline of a track or over 

tracksÖ. Flagging service will be needed if boom-equipped machinery 

will be working closer to a track centerline than boom lengths plus 15 feet, 

and if either permanent security fence or other physical barrier acceptable 

to [MARTA] is not in position between track and area of work. 

MARTAís safety director at the time of the accident4

 stated that work plans for 

the contractors were developed at a weekly work allocation meeting organized by 

MARTA. The meetings were attended by operations, maintenance, safety, and work 

project employees. The plans developed at the meetings called for protecting the work 

site at Lenox Station by safe clearance procedures rather than by the single-tracking 

procedures that were specified in the contract. 

4

 This manager left MARTA later in 2000. 

8 NTSB/RAB-03/02 
 

 

Personnel Training and Experience 

The flagman at the time of the accident had worked for MARTA for more than 2 

years and had attended rules classes in 1999. On February 9, 1999, he had passed the 

wayside access procedure tests, which outlined the proper flagging procedures and the 

process for obtaining permission to work on the main track. He understood, according to 

his test results, how to protect a work site with flags, trip stops, and shunt straps. He had 

also passed the test for wayside access procedures, including correctly answering a 

question regarding the proper flag placement to protect a work site. According to the 

flagman, at the time of the accident, he was providing the same level of protection that he 

had provided during the previous several months of work on the Lenox Station ceiling. 

The track supervisor had observed him on several occasions and had made no objection 

to the flagmanís not setting flags at the Lenox Station work site. 

The control center assistant superintendent had been hired in 1984 as a busdriver. 

He became a train operator in 1990. In 1994, he received 400 hours of training as a rail 

system control center operator, and he was certified as a control center operator in 1995. 

He was recertified in 1995 and 1996, and he was promoted to a supervisory position in 

the control center in 1997. On March 21 and 22, 2000, he was recertified as a control 

center operator. 

MARTA Rules Compliance Program 

According to MARTAís director of operations, supervisors made routine train 

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

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

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

rules compliance checks. 

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

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

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

no efficiency-testing5

 program under which rail supervisors systematically observed train 

operations and assessed compliance with selected operating rules. 

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

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

5

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

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

9 NTSB/RAB-03/02 
 

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

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

State Oversight 

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

(GDOT) as the State agency responsible for overseeing the MARTA system. This 

responsibility was delegated to the administrator for GDOTís Office of Intermodal 

Programs. As well as having the responsibility for the safety oversight of MARTA rail 

transit operations, the GDOT office is responsible for managing the planning and 

operations programs in support of the transit, railroad, marine, and aviation systems 

within the State. GDOTís staff for rail transit operations consists of a single individual. 

Federal Transit Administration regulations allow States some flexibility about 

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

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

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

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

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

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

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

inquiries related to transit safety. 

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

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

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

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

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

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

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

independent safety audits at MARTA, nor had it conducted any independent 

investigations of MARTA accidents. GDOT has the authority to audit and observe all 

MARTA operations. 

As a result of the accident, GDOT audited MARTAís operations. GDOT 

suggested that MARTA improve its rules testing and audit the performance and rules 

compliance of its employees. GDOT has accompanied MARTA managers who are doing 

the daily audits of employees that MARTA now requires and has determined that the 

audits are effective. 

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Probable Cause 

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

Authority (MARTA) Lenox Station on April 10, 2000, was MARTAís failure to require 

the use of single-tracking safety procedures to protect the work site and the failure of the 

rail system control center assistant superintendent and the flagman to follow all MARTA 

safe clearance procedures for protecting workers fouling the track. Contributing to the 

accident was MARTAís lack of an effective program to ensure that employees were 

complying with its safety rules. 

Adopted: August 8, 2003 

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