National 

Transportation

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 Amtrak Train No. 58, 

City of New Orleans, Near Flora, Mississippi 

April 6, 2004

NTSB/RAR-05/02

PB2005-916302 National Transportation Safety Board

Notation 7642A 490 LíEnfant Plaza, S.W.

Adopted July 26, 2005 Washington, D.C. 20594
National Transportation Safety Board. 2005. Derailment of Amtrak Train No. 58, City of New

Orleans, Near Flora, Mississippi, April 6, 2004. Railroad Accident Report NTSB/RAR-05/02.

Washington, DC.

Abstract: About 6:33 p.m. central daylight time on April 6, 2004, northbound National Railroad

Passenger Corporation (Amtrak) train No. 58 (City of New Orleans), derailed on Canadian National

Railway Company railroad track near Flora, Mississippi. The entire train, consisting of one locomotive,

one baggage car, and eight passenger cars, derailed near milepost 196.5 while traveling about 78 mph. The

train was carrying 61 passengers and 12 Amtrak employees. The derailment resulted in 1 fatality, 3 serious

injuries, and 43 minor injuries. The equipment costs associated with the accident totaled about $7 million.

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

Canadian National Railway Company's continuous welded rail maintenance and inspection procedures and

standards, Amtrak's emergency response training of its employees, and the Federal Railroad

Administration's oversight of continuous welded rail maintenance programs and Amtrak's emergency

response training of its employees.

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

Federal Railroad Administration, the Canadian National Railway Company, and Amtrak.

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

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

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

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

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

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

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

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

purchase this publication, order report number PB2005-916302 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

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

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

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

Contents

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

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

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

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

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Local Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

CN Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Amtrak Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Amtrak Train-Operating Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CN Track Maintenance Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

FRA Inspection Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Signal Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Event Recorder Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Site Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Track Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Postaccident Track Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Continuous Welded Rail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Track Maintenance History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

CN CWR Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

CN Track Inspections and Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

CN Track Maintenance Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Regulatory Oversight of CWR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

FRA Track Safety Program and CWR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

FRA Track Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Postaccident FRA Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Preaccident Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Postaccident Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Amtrak Personnel Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Amtrak Emergency Preparedness Training for Communities . . . . . . . . . . . . . . . . . . . . 29

CN Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Madison County Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Superliner Passenger Car Emergency Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Previous Derailment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Contents iv Railroad Accident Report

Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Track Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Track Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

CN CWR Maintenance and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

FRA Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Amtrak Crewmember Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . 39

Emergency Responder Training Provided by Amtrak . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Passenger Train Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Emergency Window Handles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Appendixes 

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

B: Emergency Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

C: Previous Safety Board Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
v Railroad Accident Report

Executive Summary

About 6:33 p.m. central daylight time on April 6, 2004, northbound National

Railroad Passenger Corporation (Amtrak) train No. 58 (City of New Orleans) derailed on

Canadian National Railway Company railroad track near Flora, Mississippi. The entire

train, consisting of one locomotive, one baggage car, and eight passenger cars, derailed

near milepost 196.5 while traveling about 78 mph. The train was carrying 61 passengers

and 12 Amtrak employees. The derailment resulted in 1 fatality, 3 serious injuries, and 43

minor injuries. The equipment costs associated with the accident totaled about $7 million.

The National Transportation Safety Board determines that the probable cause of

Amtrakís City of New Orleans accident on April 6, 2004, near Flora, Mississippi, was the

failure of the Canadian National Railway Company to properly maintain and inspect its

track, resulting in a rail shift and the subsequent derailment of the train, and the Federal

Railroad Administrationís ineffective oversight to ensure the proper maintenance of the

track by the railroad.

The safety issues addressed in this report are:

ï The Canadian National Railway Companyís continuous welded rail

maintenance and inspection procedures and standards,

ï Amtrakís emergency response training of its employees, and

ï The Federal Railroad Administrationís oversight of continuous welded rail

maintenance programs and Amtrakís emergency response training of its

employees.

Other items discussed in this report include:

ï Establishment of incident command during emergency response and

ï Operation of handles to remove emergency windows to allow egress from

damaged cars.

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

recommendations to the Federal Railroad Administration, the Canadian National Railway

Company, and Amtrak.

1 Railroad Accident Report

Factual Information

Accident Synopsis

About 6:33 p.m. central daylight time1 on April 6, 2004, northbound National

Railroad Passenger Corporation (Amtrak) train No. 58 (City of New Orleans) derailed on

Canadian National Railway Company (CN) track near Flora, Mississippi. The entire train,

consisting of one locomotive, one baggage car, and eight passenger cars, derailed near

milepost (MP) 196.5 while traveling about 78 mph. Six of the passenger cars rolled onto

their right sides, and three of those cars came to rest on a hill that sloped down below the

tracks. The last two cars were almost upright. The train was carrying 61 passengers and 12

Amtrak employees. The derailment resulted in 1 fatality, 3 serious injuries, and 43 minor

injuries (including injuries to 2 emergency responders). The equipment costs associated

with the accident totaled about $7 million.

Accident Narrative

Northbound Amtrak train No. 58, City of New Orleans, originated at New Orleans,

Louisiana, on April 6, 2004, bound for Chicago, Illinois. (See figure 1 for a map showing

the trainís route and the accident location.) The train consisted of a locomotive, a baggage

car, and eight Superliner passenger cars.2

According to the conductor, the train had successfully completed the required air

brake test before departure. Train No. 58 departed New Orleans about 1:55 p.m. The trip

from New Orleans to Jackson, Mississippi, was uneventful. At Jackson, which is a

passenger stop, a crew change for engineers occurred. The inbound and outbound

engineers discussed the condition of the train. The inbound engineer said that ìeverything

was fineî and the braking and power were good. 

The train departed Jackson, Mississippi, at 6:02 p.m., with the new engineer. After

the train left Jackson, the engineer performed a running air brake test, which he said was

successful. The conductor recalled making a safety announcement before the train left

Jackson.

1 All times are central daylight time.

2 The Superliner cars on the train were one sleeper car, one dining car, one lounge car, one crew

dormitory car, and four coach cars. 
Factual Information 2 Railroad Accident Report

According to the conductor, after leaving Jackson the train passed a wayside train

defect detector at MP 209.2, and no defects were detected. He also recalled that a railroad

employee observing the passing Amtrak train notified him that the portable marker at the

rear of the train was functioning, although he did not remember the employee or the

employeeís location at the time of the observation.

Near MP 197, while the train passed a block signal displaying a clear indication

(green aspect), the engineer said he looked at the track ahead of the train and observed

something that was ìnot right.î (The train was traveling about 78 mph at the time.) Ahead

of the train were two bridges over the Big Black River flood plain, with a filled levee

between the bridges. According to the engineer, the track between the bridges looked

ìpretty bad.î He immediately started a service application of the brakes. The engineer

described what happened next as follows:

I get up to it and I can see that the rail is kinked, and my engine goes through. I

think the baggage car went through it too, and I started to feel everything moving

and shaking. I knew something wasnít right. And my engine is already through it,

and Iím not looking in the mirror, Iím looking ahead and I can see the right, or

east rail rolling over, [so] I shot it.3

Figure 1. Map showing train route and accident location.

3 Shot it is railroad jargon for applying the air brakes in emergency.

LITTLE ROCK

New Orleans

JACKSON

LA

AR

AL

MS

Memphis

Flora 
Factual Information 3 Railroad Accident Report

About 30 minutes after departing Jackson (6:33 p.m.) the conductor felt the train

start to derail, and then, he said, ìÖ things got worse and worse.î He stated that the car he

was in turned over on its side. Once the car came to rest, he became aware that he was still

breathing, and then he heard a lot of moaning from the passengers.

The entire train derailed beginning on the filled levee about halfway between the two

bridges over the Big Black River. The locomotive and the baggage car reached the second

bridge and came to rest upright, although the rear of the baggage car hung over the right side

of the bridge. The remaining eight cars derailed to the right of the track. (See figure 2 for a

photograph of the derailed train and figure 3 for a diagram of the accident aftermath.) The

first passenger car, a transition sleeper car,4 separated from the baggage car and went off the

fill to the right of the track before it reached the second bridge. The transition sleeper and the

seven cars following it remained coupled. The transition sleeper, the dining car, the lounge,

and the first coach car rolled to the right 90° and came to rest on their sides on the flood plain

below the bridge. The last four cars in the train did not reach the second bridge and were on

the filled area of the track between the bridges when they derailed. The first of these cars

rolled on its side on the downward slope of the raised fill and came to rest at about a 110°

angle from upright. The second car tipped over 90°, the third car leaned at about a 45° angle,

and the last car came to rest near the tracks in an upright position. 

4 Part of this car is a rest area and dormitory for the on-board crewmembers, and part of the car is a

sleeper for passengers. This car is always coupled to the baggage car with the rest of the passenger cars

behind.

Figure 2. Wreckage of derailed train.
Factual Information 4 Railroad Accident Report

The engineer told investigators that after the locomotive stopped he looked back

and all he could see was dust on both sides of the train. He announced ìemergencyî on the

radio three times. He then contacted the train dispatcher and requested help for the

passengers and crew of the train. The engineer shut down the electrical system that

provides high voltage electricity through the train. Then he walked back through the

locomotive toward the derailed cars.

The conductor could hear the engineer talking on the radio to the CN train

dispatcher. He also heard a car attendant calling 911. The conductor heard the train

Figure 3. Diagram of wreckage.

Not to scale 

Concrete Span Bridge 

over Big Black River 

flood plain 

Locomotive 

Coach 

Coach 

Coach 

Coach 

Sleeper 

Lounge 

Dining Car 

Transition Sleeper 

Baggage Car 

N 
Factual Information 5 Railroad Accident Report

dispatcher on the radio say that emergency responders had been notified and were on the

way. He then contacted Amtrakís Consolidated National Operations Center.5

The evacuation process started, and the conductor remembered someone opening

an emergency window exit. Then he left the train with the rest of the passengers and crew.

Emergency Response

Local Emergency Response

The first 911 call was made from the train by an Amtrak employee at 6:37 p.m. At

6:52 p.m., the first firefighter, the Flora Volunteer Fire Department chief, arrived on scene

near Ratliff Road. (The map in figure 4 shows the derailment area, including the location

of the command post, the triage area, the staging area, the helicopter landing area, and

Ratliff Road.) The road crossed the tracks at MP 196.85, but there were no roads between

this point and the accident site, so the only access to the derailed cars was by the railroad

tracks and across the Big Black River railroad bridge.

5 The Consolidated National Operations Center, in Wilmington, Delaware, is Amtrakís 24-hour

operations center. It handles many functions, including train crew assignments, nationwide locomotive and

rail car deployment, and coordination of train operations with host railroads when trains are operating on

freight railroads.

Figure 4. Map of derailment area.

49 

1 

2 

3 

4 

1 

2 

3 

4 

Command Post 

Triage Area 

Staging Area 

Helicopter Landing Zone 

Big Black River 

Ratliff Road 

Livingston-Vernon Road 

Point of derailment 
Factual Information 6 Railroad Accident Report

According to the Flora Volunteer Fire Department chief, when he arrived on scene he

went to the derailment location and began to assess the passenger cars and to triage the injured

passengers. Approximately 21 minutes after the accident, the Kearney Park Volunteer Fire

Department requested the assistance of the Madison Fire Department. Five minutes later, the

Madison County Sheriffís Office officially requested the Madison Fire Department to

respond to the scene. At 6:55 p.m., the chief requested mutual assistance from the Gluckstadt

Volunteer Fire Department. The chief told investigators that although he did not officially

establish a command post or assume incident command, he did direct firefighters during the

initial passenger extrication and triage. He stated that he assigned several 3-person crews

from the Flora, Kearny Park, and Gluckstadt Volunteer Fire Departments to search all the cars

and gather the passengers at a collection point south of the derailment location.

At 7:05 p.m., the Madison County sheriff arrived on scene and began to direct the

emergency response. The conductor told National Transportation Safety Board

investigators that he informed the sheriff that there were about 61 passengers on board the

train. The passenger manifest was lost on the train when the derailment occurred, but it

was later located in the dining car by city of Madison6

 Fire Department firefighters. 

The Madison Fire Department was not notified of the accident during the initial

dispatch of emergency responders, but approximately 52 minutes after the derailment, the

emergency medical services (EMS) director for the Madison Fire Department arrived on

scene after traveling more than 20 miles from Madison. He immediately began to look for

the command post and the incident commander in order to find out what resources were

needed. Approximately 15 minutes later, he approached the Madison County sheriff,

assuming that the sheriff was the incident commander. During this meeting with the

sheriff, the EMS director learned that there was no command post or incident commander.

At 7:45 p.m., he established a command post south of the derailment. The EMS director

assumed incident command under the Unified Command System with the assistance of

the Madison County sheriff. A representative from CN was present at the command post.

Once the command post was established, the EMS director began to assign emergency

response activities, including extricating and triaging passengers and moving them to a

collection point. About 7:50 p.m., a CN representative offered the use of CNís hy-rail7

vehicles to transport injured passengers from the accident scene, across the Big Black

River, and up to Ratliff Road. Emergency responders reached the accident site by driving

for 1 mile on a dirt road that paralleled the railroad right-of-way followed by walking

approximately 1/2 mile on the railroad tracks across the Big Black River.

The EMS director then tasked the operations manager for American Medical

Response (a private medical transportation company) with setting up a triage area at the

north end of Ratliff Road and a helicopter landing zone south of the triage area. The EMS

director wanted to direct all the people from the accident scene to the triage area to ensure

an accurate accounting of persons and to organize the transport of the injured from the

6 Throughout this report the city of Madison will be referred to as ìMadison,î and Madison County

will be referred to as ìMadison County.î

7 A hy-rail vehicle, or hy-rail, is a truck that has flanged wheels attached to the front and rear so it can

travel over railroad tracks and easily get on or off the track at a road crossing.
Factual Information 7 Railroad Accident Report

scene. The EMS director had ambulances waiting at the staging area located at Ratliff

Road and Livingston-Vernon Road. As the injured were transported off hy-rail vehicles,

the ambulances were dispatched to the triage area to transport the injured to area hospitals.

By 7:57 p.m. it was estimated that 50 persons were injured but could walk, 1 or 2

were moderately8 injured, 1 needed immediate transportation by helicopter, and 1 had

been fatally injured.

By 8:12 p.m. all persons had been evacuated from the train. Between 8:34 p.m.

and 10:24 p.m., 58 persons were transported to hospitals. Uninjured passengers were

transported to a shelter. A final search of the train was conducted at 9:50 p.m., and by

10:25 p.m. all persons had been located and counted.

A total of 21 agencies (fire, police, and municipal and private ambulance

companies) responded to the derailment. Appendix B contains a list of those agencies.

CN Emergency Response

At 6:35 p.m., the CN dispatcher received an emergency broadcast from the

engineer of Amtrak train No. 58. The CN dispatcher immediately notified the CN police

dispatcher that Amtrak train No. 58 had derailed on the Yazoo Subdivision near MP 196.2.

The engineer had requested police, ambulance, and fire department response. The CN

police dispatcher immediately notified the Madison County Sheriffís Office and the Yazoo

County Sheriffís Department.

A CN assistant superintendent who overheard the emergency radio broadcast knew

that the accident site was not accessible by road. He therefore requested all engineering

employees in the area to respond. Two CN employees with hy-rail trucks responded

immediately. The assistant superintendent radioed them and asked them to direct

emergency responders to the accident scene from the south across the Big Black River.

About 7:00 p.m., the assistant superintendent arrived at the accident scene. He

noticed emergency responders arriving at the scene on foot and in all-terrain vehicles

(sometimes referred to as quads). He told the ambulance personnel that since ambulances

would not be able to reach the site, the CN hy-rail vehicles could be used to transport

injured passengers from the accident site to the staging area and the ambulances. The

Madison County sheriff agreed with this plan for transporting the injured passengers.

Amtrak Emergency Response

At 6:50 p.m., the CN train director in Homewood, Illinois, notified Amtrakís

operations center that Amtrak train No. 58 had derailed at MP 195.6,9

 north of Jackson,

8 As patients are triaged, they are usually assigned a color code based on the severity of their injuries.

In this case, the emergency responders used green to signify those persons that were injured, but still able to

walk; yellow was used to signify those persons who were moderately injured; red was used to signify a

critical injury; and black was used to signify a confirmed fatality.

9 The derailment actually occurred at MP 196.5.
Factual Information 8 Railroad Accident Report

Mississippi, at 6:35 p.m. The notification further stated that some derailed cars were on

their sides, injuries were reported, and local police and rescue personnel and CN

representatives were en route to the accident scene. At 6:51 p.m., the operations center

notified the Amtrak police about the derailment. Between 6:51 p.m. and 7:00 p.m., the

operations center dispatchers continued internal notifications.

Amtrakís Customer Services Group provided assistance to passengers after the

accident. On the day of the accident, group representatives went to a shelter the Red Cross

had established for passengers in the Flora accident. The group arranged for hotel

accommodations, needed clothing and medicine, and continuing transportation.

Counselors from Amtrakís Employee Assistance Program arrived on site the day after the

accident to provide mental health services for passengers and Amtrak employees.

Injuries

A total of 58 persons (passengers and crew) were transported to six Jackson,

Mississippi, area hospitals.10 One Amtrak employee was subsequently transferred to North

Oaks Medical Center in Hammond, Louisiana. Two emergency responders transported

themselves to area hospitals where they were treated and released.

The derailment resulted in 1 passenger fatality, due to a traumatic impact injury, 1

passenger with serious injuries, and 34 passengers with minor injuries. Amtrak employees

sustained two serious and seven minor injuries. Two emergency responders received

minor injuries. (See table 1.)

Table 1. Injuries.

10 Not all persons transported to hospitals were injured.

Injury Typea Train Crew

Emergency

Responders Passengers Total

Fatal 0 011

Serious 2 013

Minor 7 2 34 43

Total 9 2 36 47

a 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as ìany injury which results in death within 30 days of 

the accidentî and serious injury as ìan injury which: (1) requires hospitalization for more than 48 hours, commencing 

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

fingers, toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or 

(5) involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface.î
Factual Information 9 Railroad Accident Report

Damage 

As a result of the derailment, about 273 feet of the main track were destroyed,

which required the installation of 7 track panels11 and about 1,100 feet of rail. A multispan

concrete bridge spanning the Big Black River flood plain sustained damage to the

concrete structure on the east side wall. The track damage was approximately $100,000.

Two cars, the transition sleeper and the dining car, were damaged beyond repair.

Amtrak estimated monetary damage to the equipment as shown in table 2. 

Table 2. Estimated damage to rail equipment.

Personnel Information

Amtrak Train-Operating Crew

Engineer. The engineer was hired by Amtrak on December 22, 1998. He was

promoted to engineer after he completed the Amtrak engineer class on March 10, 2000.

He was assigned to on-the-job training as a student engineer from March 11, 2000, to

January 30, 2001, when he was certified as a train service engineer. He was recertified as a

train service engineer on January 23, 2003. He qualified on the CN operating rules and

territorial characteristics in 2003. During the month before the accident he had transited

the accident territory about 21 times. He received Amtrakís PREPARE (Passenger

Railroad Emergency Preparedness and Response Education) training on January 7, 2001.

11 Track panels are generally 39 feet long. They are preconstructed sections of two rails affixed to

crossties.

Car Number Car Type Damage Estimate

82 Locomotive $50,000

1223 Baggage $55,000

32036 Transition Sleeper $2,000,000

38009 Dining $2,000,000

33013 Lounge $700,000

31592 Coach $700,000

34069 Coach $650,000

34087 Coach $350,000

32005 Sleeper $215,000

34135 Coach $176,000

Total $6,896,000
Factual Information 10 Railroad Accident Report

Conductor. The conductor was hired by Amtrak on April 13, 1993. He had

previously been employed as a conductor by the Illinois Central (IC) Railroad in 1973,

and worked the same territory on which the accident occurred. He was qualified on the CN

operating rules on January 30, 2004, and completed air brake instruction on March 21,

2002. He received Amtrakís PREPARE training on September 11, 2002.

Assistant Conductor. The assistant conductor was hired by Amtrak in April

1999. On June 18, 2002, he began his current assistant conductor position. He was

qualified on the operating rules on February 6, 2004, and on the territorial characteristics

on July 7, 2003. He received air brake instruction on July 23, 2002, and Amtrakís

PREPARE training on April 25, 2002.

CN Track Maintenance Personnel

Track Supervisor. The track supervisor was hired in 1963 by the IC Railroad. He

was promoted to general foreman in 1976. He became the supervisor for the Yazoo

Subdivision in 1997.

Track Inspector. The track inspector was hired by the IC Railroad in 1971 and

worked for 5 years on a bridge gang. He later transferred to the track department and was

promoted to track inspector in 1978. He has spent most of his career inspecting track

throughout the Yazoo Subdivision. He regularly attended annual training on the operating

rules and Federal Railroad Administration (FRA) regulatory guidelines covering track

standards, which allowed him to maintain his qualifications as a track inspector.

Track Foreman. The track foreman went to work for the IC Railroad as a laborer

in 1969. He was promoted to track foreman in 1972, and 5 years later he became a track

inspector. He worked various jobs before he began his current track foreman position in

1999. He was responsible for the portion of the Yazoo Subdivision from MP 144 to

MP 217. 12

The track foreman attended a required 1-day on-track safety training class

annually, annual operating rules training, FRA training in 2002, and a 2-day training

session on standard practices circulars that included CNís continuous welded rail (CWR)

engineering policies.

Track Welder. The track welder was hired by the IC Railroad in August 1996. In

July 1999, he took a welder helper position, and in August 2000, a welder position. He had

worked on the Yazoo Subdivision since 2002, and was currently assigned to Yazoo City,

Mississippi, along with a welder helper.

The welder had attended periodic annual training, which included welding

instruction, CNís practices and procedures contained in the standard practices circulars,

and the operating rules. He had been trained on the FRA regulatory guidelines covering

track standards, which allowed him to inspect track and supervise remedial actions.

12 The operating timetable designated the Yazoo Subdivision from MP 5.4 to MP 218.6.
Factual Information 11 Railroad Accident Report

FRA Inspection Personnel

Track Inspector. The track inspector went to work for the IC Railroad as a track

laborer in 1972. Over the next 30 years he worked as a track foreman, a machine operator,

a track inspector, a track supervisor, and a road master for the Kansas City Southern

Railroad. He was hired by the FRA in January 2003.

The inspector received classroom training covering 49 CFR Part 213, ìTrack

Safety Standards,î and Part 214, ìRailroad Workplace Safety,î of 1 week each. These

classes also covered the use of the ìTrack Safety Standards Compliance Manual.î His

other training included a 1-week orientation class, accident investigation, photography,

report writing, and computer classes. Since starting with the FRA, he had attended two

regional workshops that lasted several days and included various classes. He also had had

5 months of on-the-job training with senior inspectors, and he said, ìI do have a mentor,

and [on-the-job training] is the largest part of it Ö.î

Toxicological Information

The Amtrak engineer, conductor, and assistant conductor provided blood and urine

specimens for toxicological testing as required by 49 CFR Part 219, Subpart C. Northwest

Toxicology, Inc., Salt Lake City, Utah, conducted the tests. Specimens were screened for

cannabinoids, cocaine, opiates, amphetamines, methamphetamines, phencyclidine,

barbiturates, and benzodiazapines. All results were negative for the presence of alcohol

and cited drugs.

Meteorological Information

In the Flora, Mississippi, area on April 6, 2004, the lowest overnight temperature

was 45° Fahrenheit (F) about 4:00 a.m. The temperature rose to about 79° F in the

afternoon. At the time of the accident, the weather was clear with a few broken clouds,

there was a light breeze less than 10 mph, and the temperature was about 77° F. Before the

accident there had been several weeks of little or no precipitation. 

The weather on dates related to this accident is described in table 3. The weather

data were recorded at Jackson, Mississippi, about 40 miles southeast of Flora, Mississippi.

On April 9, 2004, 3 days after the accident, the rail temperature near the point of

derailment was measured at 114° F at 5:45 p.m. April 9 was sunny with a few clouds, and

the maximum ambient temperature was 82.9° F.
Factual Information 12 Railroad Accident Report

Table 3. Weather conditions in accident area (Jackson, MS) on selected dates.a

Operations Information

Train movements on the CN Central Division, Yazoo Subdivision, are governed by

the CN/IC Railroad U.S. Operating Rules, Second Edition, the August 10, 2003, revision.

The trains were authorized by signals using a centralized traffic control system operated

by a train dispatcher in Homewood, Illinois.

CN train crews used the Central Division Timetable/Special Instructions, effective

August 10, 2003, for specific instructions about the territory. The timetable/special instructions

indicated that the maximum speed for passenger trains in the area of the accident was 79 mph.

Signal Information

The derailment occurred on a single main track in centralized traffic control

system territory that was signaled for movement in both directions, between the north end

of control point Ragin, MP 198.0, and the south end of control point South Anding,

MP 191.8. The traffic control system consisted of color-light wayside signals, power

operated switch machines, and coded electronic track circuits controlled by the train

dispatcher in Homewood, Illinois.

Date

Max. / Min.

Temp. 

(°F)

Avg. 

Wind 

Speed 

(mph)

Visibility

(miles) Sky Cover

Precipitation 

(inches)

January 29b 56 / 24 2.1 9ñ10 Clear to 9 a.m.

Overcast 9 a.m. to 

midnight.

0.00

March 6c 73 / 50 5.1 10 Clear all day. 0.00

March 9d 67 / 45 12.7 10 Clear with a few 

clouds 3ñ6 p.m.

0.00

March 10d 62 / 36 4.4 9ñ10 Clear all day. 0.00

April 6 80.6 / 39.2 0ñ6.91, 

avg. 2.3 

10 Clear with a few 

broken clouds 

4ñ9 a.m.

0.00

April 7 80.6 / 51.8 0ñ9.21 10 Partly cloudy all 

day.

Trace

April 8 80.6 / 51.8 0ñ12.7 0.25ñ10 Partly cloudy. 0.00

April 9 82.9 / 50 0ñ8.06 5ñ10 Clear with few 

clouds 1ñ5 p.m.

0.00

a

 Source: National Climatic Data Center, Asheville, North Carolina. 

b Date rail plug was installed.

c

 Date track condition was inspected and reported.

d

 Dates crossties were installed and area of repaired rail was tamped.
Factual Information 13 Railroad Accident Report

Event Recorder Information

According to the data from the event recorder, at 6:32:00 p.m. (event recorder

time),13 the train was traveling 77 mph with the locomotive throttle in notch T3. The

automatic brake pressure and the brake cylinder pressure indicated that the brakes were

released and fully charged. At 6:32:13, the horn was sounded, and 1 second later the bell

was activated. At 6:32:46 and 6:33:07, the alerter was acknowledged while the train speed

and throttle remained unchanged. The throttle position was increased to notch T4 at

6:33:24. One second later the train speed increased to 78 mph. At 6:33:26, the horn was

again sounded. At 6:33:27, the automatic brake handle was moved from the release

position to the suppression position. One second later, the automatic brake pipe pressure

began to decrease.

The automatic brake handle was moved from suppression to emergency at

6:33:33 p.m. The event recorder indicated that the pneumatic control switch14 had opened

and the brakes had an engineer-initiated emergency. With the throttle indicating ìidle,î the

train speed dropped and brake cylinder pressure increased until the speed decreased to

0 mph, 13 seconds later. The data further indicated that the locomotive traveled

approximately 398 feet during those 13 seconds.

Site Description

The derailment occurred near Flora, Mississippi, at MP 196.5. The single track

was oriented north and south. The train was traveling north when the derailment occurred.

The milepost numbers decreased northward. 

Between MP 197.0 and MP 196.5, the track was straight with a very slight

descending grade of 0.13 percent. The Big Black River Bridge was between MP 196.7 and

MP 196.6. From MP 196.5 to MP 194.75 the track was level as it crossed the flood plain

of the Big Black River. Part of the track through the flood plain was on a 6- to 8-foot fill

area, or levee, between the bridges. At the end of the fill was a multispan concrete bridge

over the remainder of the Big Black River flood plain. Beyond the flood plain from

MP 194.75 to MP 194 there was an ascending grade of 0.34 percent. From MP 194 to near

MP 192.9 there was an ascending grade of 0.14 percent reaching a flat area for

approximately 1/2 mile. A train traveling in this area in either direction descends on a

slight grade to the flood plain.

Between 22 and 24 trains operated through the territory daily. Two of those trains

were the northbound and southbound City of New Orleans passenger trains. The reported

annual tonnage was about 44.4 million gross tons.

13 All times in this section are from the event recorder. The event recorderís independent clock may

indicate a time that differs from the correct time if the clock has not been calibrated recently.

14 The pneumatic control switch is activated by the emergency application of the brakes and translates

this pneumatic activity into an electrical signal to drop the engine to idle and disable the power.
Factual Information 14 Railroad Accident Report

CN designated the track as FRA Class 4 track, which permitted a maximum

authorized speed of 60 mph for freight trains and 80 mph for passenger trains, according

to 49 CFR Part 213, ìTrack Safety Standards.î 

Track Information

The track in the accident area was CWR on wooden ties secured with tie plates15

and cut spikes. The rail was 136-pound rail manufactured by Tennessee-USA in October

1979. CN did not maintain records of track installation dates, and railroads are not

required to keep such records. 

Postaccident Track Condition 

The first point of derailment was identified as MP 196.5, on the fill between the

bridges. In January 2004, a 12-foot 11 1/2-inch portion of the east rail in this location was

replaced with a replacement rail plug and bolted into place. The postaccident inspection of

the gage side of the east rail revealed gouge marks 19.6 feet north of the rail plug. The

west rail on the gage side opposite these marks exhibited similar gouge marks. The east

rail was rolled over and spread east off the multispan bridge. The bolts of the north joint of

the replacement rail plug had been sheared off, and the joint bars, bolts, and rail were

separated. The south joint had strike marks on the joint bars on the gage side. The west rail

was intact and resting in its original prederailment position.

The intact west rail at the derailment site showed abrasion marks between the rail

spikes and the inside base of the rail that indicated longitudinal movement of the rail. (See

figure 5.) This rail movement was 2 inches. The east rail showed very little sign of

longitudinal rail movement.

Just south of the derailment site, the rail was box anchored16 at every tie on the

200-foot approach to the Big Black River Bridge. The rail on the open deck portion of the

Big Black River Bridge was anchored on every tie with elastic metal clip fasteners.17 (See

figure 6.) The anchor applies pressure on the top of the base of the rail. If a rail moves

longitudinally, shiny areas appear where the anchor contacts the rail. No shiny areas were

found on the open deck portion of the bridge.

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

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

16 Box anchoring places rail anchors on both rails across from each other against each side of a tie.

17 This type of fastener replaces both spikes and rail base anchors; it fastens the rail to the crosstie and

also retards rail movement.
Factual Information 15 Railroad Accident Report

North of the 200-foot approach to the Big Black River Bridge, in the direction of

the derailment site, was evidence that rail anchors had been applied to every other tie from

the gage side. (See figure 7.) Investigators found 281 crossties in the area and 295 anchors

placed against the sides of the ties. If the ties were box anchored on every other tie, that is,

two anchors on each rail on every other tie, there would have been 281 anchors on each

rail. The west rail had 144 anchors (51.25 percent), and the east rail had 151 anchors

(53.74 percent). Additional anchors were lying on the ballast near by or away from the

sides of the crossties.

Figure 5. Abrasion marks on west rail.

Figure 6. Elastic metal clip anchors.
Factual Information 16 Railroad Accident Report

Ballast. The crossties were surrounded by limestone ballast approximately 24

inches deep and 12 inches wide on the outside for shoulder support. The areas between the

ties (the tie cribs) were filled with ballast. Near MP 196.6 at the north approach to the Big

Black River Bridge were signs of improper drainage from fouled ballast.18 (See figure 8.)

Title 49 CFR 213.103, the FRA regulation regarding ballast, states that 

all track shall be supported by material which will restrain the track laterally,

longitudinally, and vertically under dynamic loads imposed by railroad rolling

equipment and thermal stress exerted by the rails, provide adequate drainage for

the track, and maintain proper track crosslevel, surface, and alignment.

Tie Plates. The CWR was seated in 14- by 7 3/4-inch double-shoulder tie plates.19

The tie plates were designed with eight holes punched to accommodate two rail-holding

spikes on both the field and the gage sides of the rails and two holes to secure the plate to

the ties on each side of the rails. The rails were fastened to the crossties with 6-inch cut

track spikes. Each tie plate had at least two spikes: a rail-holding spike on both the gage

side and the field side. Additional spikes anchoring the plates to the ties were present at

irregular intervals, particularly on the gage side.

Figure 7. Ties with few anchors, indicated by arrows.

18 Fouled ballast refers to dirt intermixed with ballast.

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

help properly position the tie plate and prevent the rail from shifting laterally.
Factual Information 17 Railroad Accident Report

Crossties. The wooden crossties, or ties, were 8 feet 6 inches long with an

average spacing of 19 1/2 inches between the centerlines of the crossties. Federal

regulations, at 49 CFR 213.109, specify the condition of crossties required to provide

support for the rail: they must not be ìÖ broken through, split or otherwise impaired to

the extent the crossties will allow the ballast to work through, or will not hold spikes or

rail fasteners.î Each class of track requires a minimum number of ties that do not display

the above defects for each 39-foot section of track. Class 4 track must have a minimum of

12 crossties in good condition for each 39 feet of rail on tangent (straight) rail and curves

of equal to or less than 2°. 

Several crossties near the point of derailment were broken through and split and

showed signs of not holding the spikes. (See figure 9.) Neither the number nor the pattern

of defective ties exceeded those allowed by the regulations. The crossties and track

surface had been rehabilitated in 1998. CN had planned to do the next rehabilitation

project for this area in the first quarter of 2005, but after the Flora accident, it accelerated

the schedule. (See Postaccident Actions in the Other Information section of this report.)

Continuous Welded Rail 

CWR is subject to mechanically induced outside forces when loaded and to

thermally induced internal forces from expansion or contraction. CWR must be

longitudinally restrained to prevent rail movement caused by these mechanical and

thermal forces. Longitudinal restraint in CWR generally takes the form of additional rail

anchors, solid crossties, and compacted ballast.

Figure 8. Fouled ballast.
Factual Information 18 Railroad Accident Report

According to the American Railway Engineering and Maintenance-of-Way

Association (AREMA),20 the magnitude of force that may be developed within CWR,

independent of its length, is directly proportional to the difference in temperature between

the ìneutral rail temperatureî21 and the current rail temperature. On a sunny, cloudless day,

rail temperature can increase up to 50° F above the ambient temperature.

Neutral rail temperature is the temperature at which there are no thermally induced

forces in the rail. When the temperature of rail is different from the neutral temperature,

internal forces develop within the rail. Rail anchors are an integral part of the track

restraint system for CWR. Rail anchors prevent or restrict the longitudinal movement of

the rail, localizing the compressive or expansive forces in the rail and allowing these

localized forces to be uniformly distributed throughout the whole track structure. Without

the restraint of sufficient, effective, and evenly distributed rail anchors, if temperatures are

higher than the neutral temperature, the rail will expand. The expected amount of

expansion or contraction of an unrestrained rail can be calculated using a standard formula

that multiplies the rail length by the change in temperature and by the standard coefficient

of expansion for steel rail.22 For example, a 1-mile section of unrestrained CWR can

expand as much as 18.5 inches if it experiences a 45° F change in temperature. CNís CWR

program contains a CWR thermal expansion table that lists for given lengths of CWR how

Figure 9. Ties that are broken and not holding spikes.

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

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

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

and maintenance of railway infrastructure.î

21 This is the same as the anchoring temperature, when the rail is free of any internal longitudinal

forces.

22 The internal stress of restrained rail is the product of the coefficient of expansion and the modulus of

elasticity of the steel multiplied by the change in temperature.
Factual Information 19 Railroad Accident Report

much the length of the rail changes at various changes in temperature. (An abbreviated

portion of CNís thermal expansion table is in table 4.) In the absence of proper anchoring,

compressive forces within the rail may build up and overcome the lateral restraint at the

weakest point in the track, which may create a track buckle. These forces may lift the rail

out of the tie plates. Because ìrail tends to expand in the direction of least resistance, it

often expands upward sufficiently to free it from lateral restraint,î which allows the rail to

move laterally.23 To prevent such problems, rail anchors must be in good condition and

properly placed. They must also retain their clamping strength and be tight against the side

of the tie.

Table 4. CN CWR Thermal Expansion Table.

Railroads determine the temperature at which CWR will be under the least amount

of stress throughout seasonal temperature changes, and this temperature is a railroadís

preferred rail laying temperature. The intent is to lay rail at a temperature at which the rail

is subject to no internal forces and that closely matches the rail temperatures found for the

rail for the majority of the year. For example, CNís preferred rail laying temperature for

most of Canada is 90° F, and the preferred rail laying temperature for the Central Division

is 105°. In CNís ìPolicy on Continuous Welded Rail,î dated April 2003, the preferred rail

laying temperature is defined as the target temperature for CWR installation and

anchoring. 

Track Maintenance History 

Since the beginning of 2004, several track maintenance procedures had been

performed in the area near the point of derailment (MP 196.5). On January 29, welders cut

out a 12-foot 11 1/2-inch portion of the east rail with a crushed rail head. When the piece

of rail was cut out, the remaining rail pulled apart, and the replacement rail plug had to be

2 1/2 inches longer to fill the opening. The replacement rail plug was 13 feet 2 inches

long. At that time, the rail plug was bolted rather than welded into place. The welder told

investigators that the temperature was cold when the rail was repaired. The meteorological

report for that day showed overcast conditions with a high of 56° F. After using a rail

thermometer on the rail plug, the welder entered 60° F on the repair record, called a Non23 W.W. Hay, Railroad Engineering, 2nd ed., p. 588 (New York, NY: John Wiley and Sons, 1982).

Temp. 

Change (°F)

200 

(ft.)

400 

(ft.)

600 

(ft.)

800 

(ft.)

1000 

(ft.)

1200

 (ft.)

1400 

(ft.)

1600 

(ft.)

35 5/8 in. 1 1/8 in. 1 3/4 in. 2 1/4 in. 2 7/ in.8 3 3/8 in. 4 in. 4 1/2 in.

40 5/8 in. 1 1/4 in. 1 7/8 in. 2 5/8 in. 3 1/4 in. 3 7/8 in. 4 1/2 in. 5 1/8 in.

45 3/4 in. 1 1/2 in. 2 1/8 in. 2 7/8 in. 3 5/8 in. 4 3/8 in. 5 1/8 in. 5 3/4 in.

50 3/4 in. 1 5/8 in. 2 3/8 in. 3 1/4 in. 4 in. 4 7/8 in. 5 5/8 in. 6 3/8 in.

55 7/8 in. 1 3/4 in. 2 5/8 in. 3 1/2 in. 4 3/8 in. 5 1/4 in. 6 1/4 in. 7 1/8 in.

55 1 in. 1 7/8 in. 2 7/8 in. 3 7/8 in. 4 7/8 in. 5 3/4 in. 6 7/8 in. 7 3/4 in.
Factual Information 20 Railroad Accident Report

Compliance Work Report. The work report was submitted to the track supervisor to report

the condition of the anchor pattern and ballast; the rail adjustment amount; the location,

weight, and temperature of the rail; and the type of repair. 

The work report also had an entry for how the rail temperature of the rail plug

related to the preferred rail laying temperature of 105° F. The welder said that he had not

filled in that section of the report. Further, he explained that he did not know the formula

to make those calculations and indicated that he would need guidance or training to do the

calculations and complete that part of the form.

The welder also explained that the dispatcher had allotted him 1 hour to make the

repair because of the amount of train traffic in the area. The time allotted was not enough

to weld the joints or to heat and expand the CWR, so he inserted a plug using joint bars at

both ends. Because the rail pulled apart, or contracted, when the piece of rail was cut out,

as noted above, and the welder had to add a longer piece of rail to fill the space, he was

required to fill out a Non-Compliance Work Report.

According to CN instructions, the welder was required to assess the status of the

rail anchors for 200 feet from the repair site in each direction. On the Non-Compliance

Work Report submitted for January 29, 2004, he had circled ìYesî to indicate that

ìAnchoring Pattern [was] in Accord With IC Policy.î He also added the word ìCorrectedî

at the bottom of the page. He told investigators that he wrote this so that the supervisor

would know that he had corrected the crushed head and replaced it with a good piece of

rail. There were no records to indicate that the plug had been adjusted or shortened to the

length of the rail replaced before the derailment. 

CNís rail insert procedure required the welder to mark on the rail the difference in

length between the piece of rail removed and the replacement rail. The welder could not

recall whether he had marked or written on the rail. No markings were found on the rail

plug after the derailment.

One month before the accident, on March 6, 2004, an operating crew reported a

track problem near MP 196.5. The conductor on the local train said that the track appeared

to bow out on the east rail. The local track inspector found two locations near the

derailment site with irregularities. He corrected a 1-inch-wide gage condition at the plug

inserted in January but was unable to repair a profile24 problem at the north end of the

multispan bridge over the flood plain. He opted to reduce the train speed through the area

to 25 mph for freight trains and 30 mph for passenger trains.

The track inspector told investigators that he remembered that some anchors were

missing around the rail plug, but he did not remember seeing any rail movement to

indicate that the rail was beginning to buckle. The inspection records submitted by the

track inspector did not indicate that any action was necessary in connection with the rail

anchor conditions.

24 Profile is the relative elevation of the two rails along the track. A profile condition is when the track

structure dips or heaves. The dip normally occurs under the load of a train. The profile measurement is the

deviation (up or down) at the mid-ordinate of a 62-foot chord.
Factual Information 21 Railroad Accident Report

A few days later, the track foreman returned to the area to replace ties. Inserting

the ties in two locations reinforced the correction of the gage problem and repaired the

profile problem at the north end of the bridge. According to testimony by the track

foreman, he ìput the [existing] anchors back onî the area where the plug was inserted. As

shown in figure 10, the new ties were not box anchored on every other tie. He maintained

the speed restriction set earlier by the track inspector.

The track supervisor visited the area where the inspector and the foreman had

performed the track work. He told investigators that he thought it was around March 16.

He noted that ìthey had left a couple anchors out on a tie.î Other than the missing anchors,

however, he said, ìÖ everything was to my satisfaction that day Ö.î

CN had a table depicting the number of trains and the tonnage necessary to

compact the track area that had been disturbed by the track work. Following CN railroad

guidance for the number of trains and tonnage necessary to compact track after track

work, train speeds were restricted to 25 mph for freight trains and 30 mph for passenger

trains between MP 196.6 and MP 196.2 from March 6 to March 24. On March 24, the

track supervisor determined that the necessary number of trains and tonnage had traversed

the track, and he increased the train speeds to 60 mph for freight trains and 79 mph for

passenger trains.

The track supervisor told investigators that he entered the data from the NonCompliance Work Report into a computerized rail defect tracking system (RDTS). He

stated that the RDTS does not have a function that highlights anything that needs

immediate attention when he accesses the system. He said that he believed that a system

that alerted him to conditions that needed to be addressed would be an improvement. 

Figure 10. New ties with few anchors. Bracket indicates new ties. Arrows indicate anchors.
Factual Information 22 Railroad Accident Report

The CN engineering superintendent stated that the RDTS was primarily used for

tracking defective rails and that he does not use the system a lot. He added that the RDTS

does not provide an overview of rail defects and that it could be improved.

The CN division engineer said that the track supervisor handles the data from the

Non-Compliance Work Report that are entered into the RDTS. He stated that the

engineering superintendent audits some of the forms or checks field conditions, but not for

every rail plug. According to the CN regional engineer, the RDTS has two functions: to

store data about defective rail that has been replaced and to track corrective actions. He

stated that he was not aware of a feature to alert the system user to locations where rail

length has been changed, but that the system has the ability to sort the data by subdivision

or by location where rail has been replaced. 

CN CWR Program 

CNís CWR program in effect in 2004 was its ìPolicy on Continuous Welded Rail,î

dated April 2003. This document superseded the IC railroadís CWR program, which had

been submitted to the FRA in February 1999. However, one employee told investigators

that he had not received the latest CWR policy until after the derailment. 

The introduction to CNís April 2003 CWR program regarding rail expansion states

that ìthe distance that rail expands and contracts is directly proportional to the change in

the temperature of the rail.î CNís instructions (CN Standard Practices Circular (SPC) No.

3205, ìContinuous Welded Rail,î revision 2, January 2003) to the maintenance-of-way

employees identified the preferred rail laying temperature range of 105° F to 130° F. The

instructions, under ìGeneral,î continue as follows:

CWR will be installed and anchored within the [preferred rail laying temperature

range] without further adjustment. CWR installed below the [preferred rail laying

temperature] must be de-stressed25 as soon as possible after laying. De-stressing

must be completed before any seasonal increase in temperature.

The more specific instructions under ìMaintenanceî were as follows:

Precautions must be taken to monitor the length of rail installed during rail

changes.

c) Ö the amount of rail added or removed will be marked on the rail and

[reported] to the Track Supervisor.

d) Track Supervisor will be responsible for the locations and amounts of rail

added or removed. These locations, must, if required, have correct length plug

installed and welded prior to the onset of warm weather.

25 De-stressing is the procedure used to readjust a railís temperature to the desired value. It typically

consists of cutting the rail and removing rail anchoring devices, allowing for the necessary expansion and

contraction, and then reassembling the track.
Factual Information 23 Railroad Accident Report

From interviews with the local maintenance-of-way employees, the consensus was

that adjusting for the seasonal increase in temperature was to be completed before May 1.

The track supervisor stated, however, that when the accident occurred, he had 15 other

locations where 2 to 3 inches of rail had been added during the winter that were on the

priority list for welding before the warm weather.

Federal Regulations 

Title 49 CFR 213.119(b) requires that railroads with CWR have in their CWR

programs ìrail anchoring or fastening requirements that will provide sufficient restraint to

limit longitudinal rail and crosstie movement to the extent practical.î The CWR

regulations further state that railroads shall have in effect: 

Procedures which specifically address maintaining a desired rail installation

temperature range when cutting CWR including rail repairs, in-track welding, and

in conjunction with adjustments made in the area of tight track, a track buckle, or

a pull-apart. Rail repair practices shall take into consideration existing rail

temperature so tható

(1) When rail is removed, the length installed shall be determined by taking into

consideration the existing rail temperature and the desired rail installation

temperature range; and 

(2) Under no circumstances should rail be added when the rail temperature is

below [the desired rail installation temperature range designated by the railroad],26

without provisions for later adjustment.27

CN Track Inspections and Testing

Hy-Rail. The tracks were inspected from a hy-rail vehicle in the derailment site on

April 4, 2004, 2 days before the accident, by a CN employee qualified under 49 CFR

213.7, ìDesignation of qualified persons to supervise certain renewals and inspect track.î

The record of this inspection showed no track defects. However, the same track inspector

had entered a crosslevel variance of 1 1/4 inches at MP 196.6 on the inspection reports

from the previous week.

Ultrasonic Rail Testing. CN tests its rail ultrasonically four to five times annually.

The last seven tests were conducted on April 3, July 18, September 12, September 15, and

December 8, 2003, and January 15 and April 2, 2004. Sperry Rail Service conducted the

most recent ultrasonic rail test on April 2. The defect closest to the derailment that was

found during this test, and repaired the same day, was a transverse detail fracture of 30

percent at MP 197.06, about 0.6 of a mile south of the derailment location.

26 CNís range is 105° F to 130° F.

27 Title 49 CFR 213.119(c).
Factual Information 24 Railroad Accident Report

Track Geometry Measurements. CN had tested the track geometry on the Yazoo

Subdivision with its geometry test car.28 The most recent tests were performed on

February 19, 2004, and December 5, July 10, and February 26, 2003. These four tests

measured 22 separate locations that produced data indicating 20 locations of profile

(crosslevel) deviations and 2 locations of wide gage between MP 196.0 and MP 197.0.

The regulation allows profile variances for Class 4 track not to exceed 2 inches and wide

gage not to exceed 1 inch. None of the nonstandard measurements exceeded the allowed

variance specified by the regulations for Class 4 track.

The number of noted variances also increased from February 2003 to February

2004. In February 2003, the geometry tests had two notations of variances between

MP 196.0 and MP 197.0. For this same mile, 10 variations were found with the geometry

test car in February 2004.

CN Track Maintenance Procedures

CNís track maintenance procedures were assembled in its Standard Practices

Circulars (SPCs). SPC 3601 addresses application and maintenance of rail anchors. The

SPC that addresses general CWR maintenance is SPC 3205, ìContinuous Welded Rail.î

Following are relevant excerpts from that SPC discussing track buckling and the

importance of rail temperature:

39. When practicable, rail will not be added to CWR track. In the event that

replacement rail of the same length cannot be installed and additional rail must be

added the following guidelines will be met: when repairing a rail failure and rail

ends have pulled apart, the distance separation of the two rail ends will be noted.

If rail heaters or expanders are not available to assist in bringing the rail back to its

original length, the length of the replacement rail, installed with a joint gap not

exceeding 1/2 inch, plus the distance of separation will be marked on the rail and

reported to the Track Supervisor.

Locations of track buckle susceptibility are at bottoms of grades, track abutting

immovable objects (switches, crossing frogs, road crossings, etc.), areas of

recently disturbed track, marginal tie or anchor condition, fouled ballast, light

ballast section or locations where heavy train braking or accelerating occurs.

Indications of tight rail are bunched or pushing ties which are plowing ballast, rail

running whether through rail anchors or with the anchors, rail lifting up under the

spike heads, rail pushing against both shoulders of the tie plates, canting rail on

curves, gaps at the ends of the ties indicating lateral movement of the track or

track having a kinky alignment.

When these signs are apparent, immediate remedial action will be taken by either

placing a speed restriction or adjusting the rail.

28 This car takes dynamic measurements of the track geometry, which, among other things, includes

degree of curves, gage, and rail elevation.
Factual Information 25 Railroad Accident Report

44. When it is evident that the neutral temperature of a section of rail has been

decreased to a level that a track buckle may occur, the neutral temperature should

be adjusted back to the Preferred Rail Laying Temperature. The method of destressing involves removing rail anchors, cutting the rail and removing rail to

achieve the correct rail laying temperature.

Regulatory Oversight of CWR

FRA Track Safety Program and CWR

The FRA regulations covering CWR are at 49 CFR 213.119, ìContinuous Welded

Rail, General,î which states, in part:

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

with written procedures which address the installation, adjustment, maintenance

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

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

The FRA headquarters staff is responsible for reviewing the plans submitted by

railroads in accordance with the regulation, as noted above. The plans are reviewed for

CWR installation, adjustment, anchoring, rail temperatures (during installation, repair, and

maintenance), monitoring, appropriate speeds, inspection, training for employees working

on CWR, and record-keeping. The FRA enforces a railroadís own CWR program, as

detailed in the railroadís written CWR plan and standards (if any). A CWR defect noted by

the FRA generally reflects the failure of a railroad to comply with its own CWR standards.

CNís former owner, the IC, submitted its first CWR policy, dated February 1999,

to the FRA. In 2003 CN submitted an updated version of its CWR policy. Before the

accident, FRA headquarters staff had not reviewed either of the CWR programs

submitted. After the accident, the FRA headquarters staff reviewed CNís CWR program.

(See Postaccident Actions in the Other Information section of this report.)

FRA Track Inspections

The FRA ìTrack Safety Standards Compliance Manualî cross-references sections

of the Track Safety Standards with instructions and codes for defects found. Selected

sections contain information for FRA inspectors regarding what they should look for

during an inspection and how to code defects that are found. The Manual states the

following regarding the identification and documentation of instances of noncompliance: 

A defect is a condition that is not in compliance with the Track Safety Standards.

Defects are noted on inspection reports, which serve as notification to the railroad

of FRAís awareness of the defectís existence Ö. An FRA inspector may choose to

also take a violation for the defect, and so note the decision on the inspection

form. Ö
Factual Information 26 Railroad Accident Report

In many cases, documenting conditions of noncompliance is sufficient to achieve

compliance with the Track Safety Standards. However, there are many instances

where a condition warrants a violation. When recommending a violation, the

inspector must prepare a well-documented narrative report describing the

seriousness of the condition. Ö

A non-complying condition under one set of circumstances may warrant a defect,

while the same condition under a different set of circumstances may warrant a

violation. The enforcement discretion considerations in Part 209, Appendix A

require the Inspector to consider the inherent seriousness of the condition.

The Manual is available on the Internet. This access to the Manual gives railroads

the opportunity to learn what FRA inspectors look for during inspections based on the

different sections of the Track Safety Standards from 49 CFR Part 213. 

The section of the Manual covering 49 CFR 213.119 contains instructions to FRA

inspectors concerning the CWR programs submitted by railroads:

Inspectors must be aware of the procedures in effect before inspecting each

railroad. When conducting inspections, the Inspector must make observations to

determine if the railroad is following its basic safety procedures.

Further, the Manual explains that there are procedures for a railroad to perform

maintenance work on the track without complying specifically with the guidelines of its

CWR program. However, a railroad must have a method of recording this work and a

process through which the work is later corrected to comply with the railroadís CWR

program. The Manual stresses the point that just recording the noncompliance situation is

not enough; the followup work to correct the noncompliance is necessary to avoid a track

defect violation.

The FRA inspector based in Petal, Mississippi, was responsible for a territory

covering north central Mississippi south to the Gulf Coast, which includes the area around

Flora. The inspector had copies of CNís two CWR programs (February 1999 and April

2003), and he stated that he used them to check CNís compliance with its own CWR

maintenance instructions. He said he used the FRA ìTrack Safety Standards Compliance

Manualî to guide his inspections. He said that during his inspections he specifically

checks an employeeís awareness ìÖ of whatís in [the railroadís] program and [the

employeeís] noticing the conditions Ö in the field.î

This FRA inspector, accompanied by CNís track inspector, had conducted two

recent track inspections before the derailment: for 3 days in June 2003 and 3 days in

February 2004. These inspections were not identified as followup inspections, and even

though several defects were noted, no violations were filed. The FRA inspector stated that

two of the inspection reports from June 2003 contained comment items. He explained that

information about upcoming program maintenance work schedules for a particular portion

of a territory guided his decision whether to write in the comment section. His goal was to

inspect the Amtrak and hazardous materials routes twice a year.
Factual Information 27 Railroad Accident Report

From the June 2003 track inspection, the inspectorís comment on June 10

pertained to the area between MP 145 and MP 180. The comment was ìÖ [at] numerous

locations tie distribution is marginal, rail anchors are ineffective against longitudinal

displacement.î The inspectorís comment on June 11, 2003, pertained to the area between

MP 180 and MP 217. The comment was ìÖ numerous locations [have] marginal effective

ties and the rail anchors are not controlling longitudinal displacement.î

The FRA track inspector stated that the CN inspector who was with him during the

inspections agreed with the conditions noted in the comments, but the FRA inspector did

not expect the railroad to ìfollow through with the repairsî on those items, and he noted

that the railroad was not required to make the repairs because they were not entered as

defects. In interviews, the FRA track specialist, who was the FRA inspectorís technical

advisor, said he also did not expect the railroad to make repairs based on comment items.

Postaccident FRA Inspections

The FRA conducted a walking inspection of the track on either side of the

derailment on April 8, 2004. The report from that inspection noted 4 fouled ballast

locations and identified 28 loose rigid rail braces at the turnouts at a nearby siding. The

four fouled ballast locations were at MPs 197.6, 196.3, 196.1, and 195.8. The fouled

ballast locations also had profile deviations of 1/2 to 3/4 inch. The regulation allows for a

2-inch profile deviation in Class 4 track.

The FRA performed a focused inspection on the entire Yazoo Subdivision29

April 26ñ28, 2004. The report from this inspection included 7 record-keeping defects and

130 track defects that required remedial action by CN. In addition, the FRA found 24

occurrences of failure to comply with CNís written CWR procedures (insufficient

anchors), 5 locations with insufficient anchorage to restrain rail movement in turnouts, and

1 location where the crosstie condition was unacceptable, at MP 188.0. 

Equipment

Maintenance, inspection, and repair records for the locomotives and all cars in the

train were reviewed. Additionally, the locomotives and all cars on the train were

mechanically inspected and evaluated after the accident. The results of those inspections

are detailed below.

Preaccident Inspections

Each car in the train was mechanically inspected prior to departure. There were no

unrepaired defects at the time of departure. Additionally, all the cars were up to date in

Amtrakís ongoing preventative maintenance program. 

29 The Yazoo Subdivision includes the territory inspected by the FRA before the accident, but it is

larger than that territory. 
Factual Information 28 Railroad Accident Report

The locomotive was within all required inspection parameters, and the required

information was recorded and maintained on the locomotive unit.

Postaccident Inspections

The foundation brake rigging, wheels, and underframe were inspected on the

locomotive unit and each car after the accident. The overturned cars were inspected in

both the horizontal and vertical positions. Each car and the locomotive unit had friction

burns from metal-to-metal contact. Those marks were lighter under the locomotive unit

and baggage car than under the rest of the train.

A significant impact mark was noted on the number 7 wheel and brake disk of the

transition sleeper, and a similar mark was noted on the number 5 brake disk of the dining

car. The connecting rods and lateral guide links were deformed rearward, beginning at the

trailing end of the transition sleeper and continuing toward the rear of the train. Those

components on the leading end of the transition sleeper were not bent.

Inspection of the wheels, brake disks, and brake pads of the trailing car (an

unoccupied coach car) indicated normal contact and wear patterns. The wheels and brake

disks were worn smooth and were shiny, but were within their respective tolerances. All

the brake pads were worn, but none had reached its condemning limit, or the point at

which it required repair.

A postaccident air brake test equivalent to an initial terminal air brake test was

performed on the locomotive unit and baggage car, and they successfully completed it.

Because the passenger cars had damaged components, a postaccident air brake test could

not be performed on them. However, brake pipe pressure was maintained on the rear car

for 2 days after the accident. Each passenger car in the train displayed normal contact and

wear patterns similar to those on the trailing car. The locomotive engineer stated that the

brakes had handled as expected throughout the trip.

Emergency Preparedness

Amtrak Personnel Emergency Preparedness Training

Amtrak has developed an emergency preparedness training program for its

crewmembers as required by 49 CFR Part 239. The purpose of Amtrakís 8-hour Passenger

Railroad Emergency Preparedness and Response Education (PREPARE) is to prepare

operating crewmembers and on-board employees to respond to train emergencies. Amtrak

had until January 29, 2001, to ensure that all current crewmembers received the initial

PREPARE training.30 The regulation requires refresher training once every 2 years after

the initial training has been completed.

30 Title 49 CFR 239.101.
Factual Information 29 Railroad Accident Report

In the weeks following the accident, Amtrak provided Safety Board investigators

with the emergency preparedness training records for all the Amtrak employees on the

accident train. According to the training records provided by Amtrak from its database

after the accident, 8 of the 12 crewmembers on board the train had attended a PREPARE

training course in the 2 years before the accident. For the remaining four crewmembers,

Amtrakís records indicated that one crewmember had never received PREPARE training,

and three were not current because they had gone more than 2 years without the required

training. More than a year after Amtrak provided its training records, Amtrak located

additional records that were not in the database. These records show that three more

crewmembers were current with PREPARE training, bringing to 11 the number of

crewmembers who had received the required training.

On March 14, 2003, Amtrak officials told Safety Board investigators that Amtrak

is ìcurrently improving Ö technological resources to afford [Amtrak] the opportunity to

better track PREPARE training for all active on-board service personnel.î Amtrak hopes

that these improvements will allow it ìto better monitor the status of all active employeesí

PREPARE training.î

Amtrak Emergency Preparedness Training for Communities

On June 9, 1999, an Amtrak emergency preparedness manager provided training to

approximately 21 members of the Yazoo City Fire Department, the Bentonia Volunteer

Fire Department, the Benton Volunteer Fire Department, and the Tri-Community

Volunteer Fire Department in Yazoo, Mississippi. The training course was Amtrakís

Passenger Train Emergency Response course, known as SAFE 015.31 The same Amtrak

emergency preparedness manager conducted another SAFE 015 course in Meridian,

Mississippi, on February 23, 2004. A Ridgeland Fire Department captain attended the

training in Meridian. According to records provided by Amtrak, no firefighters from 8 of

the 10 fire departments that responded to the Flora accident have attended any training

provided by Amtrak. (See appendix B.)

CN Emergency Preparedness Training

According to CN, since November 2003 it has provided nine training opportunities

for emergency responders from Madison and Yazoo Counties. This training included CN

911 Tank Car/TRANSCAER/Emergency Responder and Grade Crossing Collision

Investigation presentations. State, local, and volunteer firefighters, paramedics, and

emergency management agencies were invited to attend these training opportunities.

A 2-day training session was conducted in Canton, Mississippi, (Madison County)

February 11ñ12, 2004. The first day was for emergency responders, and the second day

was for law enforcement responders. Two 2-hour sessions were offered on February 11 for

all emergency management and fire department personnel within a 1 1/2-hour drive of the

Canton area. CN sent a notice for the February 11 training to representatives from 40

31 SAFE 015 includes instruction on safety on railroad property and equipment, contacts for the regionís

railroads, familiarization with Amtrakís equipment and crew, and emergency access to the passenger cars

and locomotives, among other subjects.
Factual Information 30 Railroad Accident Report

emergency response agencies in the Canton area. According to records provided by CN,

the notice was not sent to the following agencies that responded to the derailment on

April 6, 2004: Madison County Emergency Management Agency, Madison Fire

Department, Flora Volunteer Fire Department, Kearney Park Volunteer Fire Department,

Gluckstadt Volunteer Fire Department, Southwest Madison Volunteer Fire Department,

Bentonia Volunteer Fire Department, Camden Volunteer Fire Department, and Farmhaven

Volunteer Fire Department. A total of 6 firefighters from the Flowood Fire Department, 18

firefighters from the Canton Fire Department, and 1 firefighter from the Jackson Fire

Department attended the training on February 11. None of these departments responded to

the derailment.

Madison County Emergency Preparedness Training

The Madison County Emergency Management Agency director told investigators

that the Madison County emergency plan was not implemented as a result of this accident.

In addition, according to the director, there had not been any countywide disaster drills

before the accident.

Survival Factors

Superliner Passenger Car Emergency Windows

During an on scene inspection of the sleeper car, Safety Board investigators noted

an emergency window handle that had been partially pulled free from the rubber grommet

surrounding the window. One screw had pulled right through the rubber grommet. The

window handle is normally attached to the grommet with two steel screws that are about 1

1/4 inch long and have a head diameter of 1/4 inch. When investigators attempted to open

the window, the second screw also pulled right through the rubber grommet, leaving the

grommet and window in place, preventing removal of the window for emergency egress.

(See figure 11 for a photograph of the emergency window handle.) The grommet was not

marked with a date of manufacture. 

Title 49 CFR 239.107 requires that a representative sample of emergency windows

be tested at least once every 180 days and that the window inspection and maintenance

records be kept for 2 calendar years. Prior to the accident, Amtrakís Preventive

Maintenance and Standard Maintenance Procedures outlined requirements to test and

remove only one emergency window during each maintenance cycle (typically every 3

months). These procedures did not require documentation of which emergency window

was removed and inspected. 

Title 49 CFR 238.113 requires that each main level of a passenger rail car have a

minimum of four emergency windows and that the windows allow rapid and easy removal

without the use of tools. All windows on the Superliner passenger cars are emergency

windows. Each is equipped with a handle to remove a rubber grommet that surrounds the

window and holds it in place. Once the rubber grommet is removed from the window

assembly, the window itself can be moved. 
Factual Information 31 Railroad Accident Report

Since the accident, Amtrak has informed Safety Board investigators that it will

increase to four the minimum number of emergency windows tested per car during each 3-

month cycle for all Superliner, Surfliner, and Viewliner passenger cars. If a failure is

detected during the inspection, the same number of additional windows will be tested to

ensure compliance and operability. 

Amtrak has stated that it will also record in its maintenance database the location

of each window tested on each car, and its Standards and Compliance Group will

randomly audit the database. According to Amtrak, this new procedure will ensure that

every emergency window on each passenger car will be tested at least once every 4 years.

Additionally, at Amtrakís request, as of July 2004, both emergency window handle

manufacturers began stamping the date of manufacture on the handle area of the window

gasket assembly.

Other Information

The last train over the accident location before the arrival of train No. 58 was a

southbound freight train, CN G89291-04, at 4:30 p.m. on April 6. It consisted of 2

locomotive units, 132 loaded freight cars, and 3 empty freight cars. The empty cars were

the 21st, 24th, and 30th from the head end. The train weighed 17,118 tons and was 8,200

feet long. Thirty-two cars were set out at Jackson, Mississippi. After the derailment, those

32 cars were mechanically inspected at Jackson, and the remainder of the train was

inspected at Collins, Mississippi. No defective cars were found during those inspections.

Figure 11. Emergency window handle that partially pulled free from 

rubber grommet.
Factual Information 32 Railroad Accident Report

Previous Derailment

On July 18, 1997, the IC Railroad (the previous owners of the railroad) had a

derailment at MP 196.8. According to the FRA database, 12 cars of a 125-car train

derailed. Two hazardous materials cars released their product, and 4,000 local residents

were evacuated. There were no deaths or injuries. The database indicates that the cause of

the derailment was ìtrack alignment irregularity (buckled/sunkink).î 32

Postaccident Actions

CN. CN has started the track structure rehabilitation program that was planned for

the first quarter of 2005. The local engineering superintendent stated that since May 2004,

crews have replaced 52,322 defective ties, about one-third of the existing ties, reapplied

rail anchors, added ballast, and tamped the ballast around and under the ties between

MP 164 and MP 217. CN also installed 34,853 new ties, which accounted for about a third

of the ties, and surfaced the track between MP 92.7 and MP 124.0.

FRA. After the accident, the FRA headquarters staff reviewed CNís CWR

program. The results of that review were sent to CN in a June 22, 2004, letter that

recommended that CN clarify several terms and phrases used in the CWR program. One

of the phrases CN was asked to clarify was ìonset of warm weather.î As of July 26, 2005,

the FRA had not received a response to its request for clarification.

After the accident, Safety Board investigators asked the FRA whether it had

audited Amtrakís records of employee training. The FRA had no record of this type of

audit for the region in which the Flora accident occurred. However, between April 26 and

29, 2004, the FRA reviewed employee training records as part of an audit of Amtrakís

passenger train emergency preparedness program (49 CFR Part 239) for the Northwest

Region of the Pacific Division, which includes Amtrakís operations in Oregon,

Washington, Idaho, and Montana. For one group of employees, one-third (10 out of 30)

had not received the PREPARE training within 2 calendar years. For a second group of

employees, two-thirds (four out of six) did not have the PREPARE training within 2

calendar years. The FRA filed two violations based on these findings.

Mississippi Emergency Management Agency Emergency Preparedness

Training. Since the accident, the Mississippi Emergency Management Agency has

conducted incident command system training in Madison and Yazoo Counties. The 16-

hour course was conducted in Madison County on April 28 and 29, 2004, and in Yazoo

County on May 17 and 18, 2004. The purpose of this course was to provide the necessary

training for all agencies in every county to be familiar with the National Interagency

Incident Management System that was standardized for all responses by the Mississippi

governorís Executive Order 851 in October 2001. Attendees of these courses included

emergency responders from agencies that responded to the April 6, 2004, derailment: fire

departments (including volunteer agencies), emergency medical services, law

enforcement, emergency management, the American Red Cross, and the Mississippi

Department of Health.

32 Sunkink refers to a heat induced expansion of the rail that results in misalignment of the rail.
33 Railroad Accident Report

Analysis

The Accident

The Amtrak City of New Orleans passenger train derailed on April 6, 2004, at

approximately 6:33 p.m. between two bridges near Flora, Mississippi. The engineer noted

that the rail ahead of the train and between the bridges was ìkinked,î and he attempted to

slow the train from 78 mph. Before he could stop, the train reached the irregularity, and

the train started derailing. The engineer applied the emergency brakes while the train

continued to derail. The derailing train stripped the east rail out from under the

locomotive; the engineer said he could see the right hand rail roll over in front of the

locomotive. The derailed locomotive continued rolling onto the second bridge before it

stopped. The train broke away from the baggage car (directly behind the locomotive) and

tipped over to the right. Most of the passenger cars slid to a stop on their sides at the

bottom of the flood plain of the Big Black River. Only the locomotive, the baggage car,

and the unoccupied last car remained upright.

Exclusions

None of the Amtrak on-board personnel reported any significant problems or

unusual events involving the equipment during the trainís preaccident journey. The

engineer said that the train had handled as expected and he did not recall any signal or

train control problems. Postaccident inspections of the train, subsequent tests of the

braking systems, and a review of vehicle maintenance records did not indicate any

problems with the train equipment. Therefore, the Safety Board concludes that Amtrak

train No. 58 and its related equipment functioned as intended and did not cause the

derailment. 

A review of the event recorder data with respect to train handling showed that

before the locomotive passed over the track irregularity, the engineer handled the train in

accordance with accepted practices and procedures. Postaccident drug and alcohol testing

results for the train operating crewmembers were negative. The work-rest histories of the

train-operating crewmembers indicated that fatigue had no role in the accident. Therefore,

the Safety Board concludes that the operation of the train was not a factor in the accident. 

The postaccident testing of CN signal equipment and the train control system

demonstrated that they worked as intended. No communications problems were reported

among the train-operating crewmembers or between the train crew and the dispatcher. 
Analysis 34 Railroad Accident Report

Track Condition

The conditions leading to the rail shift at the point of derailment had developed

over time since the plug had been inserted in the rail in January 2004. When the welder

installed the plug, he had three options for adjusting the CWR correctly: cut the plug to the

same dimensions as the original piece of rail and heat the rail on both sides of the plug

before installation; secure the existing rail with additional anchors before cutting out the

defective piece to prevent the cold rail from shrinking away from the cut; or insert a plug

longer than the original piece of rail and return later, before the onset of warm weather, to

adjust the rail to the proper length. The welder chose the third option and marked the

correction form to note that this plug needed adjusting before the ìonset of warm

weather.î Because an increase in temperature can increase the potential for track failure in

CWR, the phrase ìbefore the onset of warm weatherî is inadequate for specifying when an

adjustment needs to be made. Adjusting CWR correctly in relation to temperature changes

requires monitoring of actual temperatures.

According to the testimony of the track maintenance employees, informal policy

set May 1 as the date for the onset of warm weather. On the day of the accident, April 6,

the air temperature was approximately 80° F with broken clouds. Three days later, a

similar day with a temperature of 82.9° F and a few clouds, the rail temperature was

measured to be 114° F. Rail temperatures can be much greater than the ambient

temperature, depending on the amount of radiant heating by the sun. The rail plug was

inserted at a temperature of 60° F in January. The standard neutral rail temperature for the

surrounding rail should have been the same as the preferred rail laying temperature of

105° F. When the plug was inserted at the lower temperature and fitted against the existing

rail, it changed the neutral rail temperature of the existing rail to well below the original

neutral rail temperature. When the weather changed, the entire rail, including the rail

insert with the lower neutral temperature and the rail on both sides of the insert, heated up

and expanded, creating internal compression forces in both the existing rail and the new

plug, which was tight against the existing rail. 

Three critical components of the track structure that help secure the rail and

counter the forces during an increase in temperature that causes the rail to expand are the

number and pattern of effective anchors applied tightly against the sides of the crossties,

the effectiveness of the ties in holding the spikes to prevent the rail from lifting from the

compressive forces, and the presence of ballast tamped around the tie and applied to the

shoulders to prevent the ties from moving.

Approximately 50 percent of the anchors were ineffective. There were split ties

and ties in marginal condition with reduced spike-holding ability. Even though several

locations had fouled ballast, there appeared to be enough shoulder ballast to prevent the

track from moving laterally. The ineffective anchoring and the marginal tie condition were

the weakest of the three rail restraints.

When the rail expanded in the heat and tried to ìrunî longitudinally, it moved

northward away from the Big Black River Bridge. Exacerbating that movement was the
Analysis 35 Railroad Accident Report

speed reduction through the derailment site between March 6 and March 24, 2004. As a

train approached the speed reduction from either direction, the train brakes were applied.

Because of the frictional forces between the wheels and the rail during deceleration, the

rail was pushed ahead of the train. At the bridge the rail was anchored solidly with elastic

clips, and the rail could not move longitudinally in that area. However, because the rail

was not anchored effectively in the area away from the bridge, its ability to move

longitudinally increased the compressive forces within the rail between the bridge

structures. With the adequate shoulder support from the ballast preventing the track

structureís lateral movement between the bridges, the east rail could move only upward to

relieve the forces within it. The east rail started to bow, and the spikes were lifted out of

the ties because the ties were split and could not hold the spikes effectively. The rail is

designed to rest in a metal tie plate with raised portions against the outside and inside of

the rail that help prevent lateral movement when secured to ties imbedded in well-tamped

ballast. Once the rail bowed high enough to clear the raised portions on the tie plates, the

rail moved more easily outward. At MP 196.5, the east rail moved enough laterally to

widen the gage of the rail and allow the wheels of train No. 58 to drop between the rails.

The west rail remained intact, resting on the tie plates, and appeared to be moderately

secure. The Safety Board concludes that the inadequately restrained east rail lifted out of

the tie plates because of expansion caused by warm temperatures resulting in the rail

shifting and the gage widening, causing the wheels of the train to drop between the rails. 

Track Maintenance

CN CWR Maintenance and Inspection

CNís instructions for the maintenance of CWR addressed the installation of rail

plugs and the adjustment required before the onset of warm weather if a plug is installed

during cold weather. Because he did not use rail heaters or expanders to achieve the

desired CWR adjustment at the time the rail plug was installed in January 2004, the welder

was required to mark the rail for later adjustment and make a report to the supervisor.

Many of the conditions that can cause rail to be susceptible to buckles and compression

forces, as noted in CNís CWR maintenance instructions, existed at the accident location.

These include location at the bottom of a grade, abutting an immovable object (the Big

Black River Bridge), location in an area of recently disturbed track (ties were inserted in

March), marginal tie or anchor condition, and heavy train braking. The track welder

installed the plug in January 2004. He entered both the temperature of the inserted piece of

rail and the number of inches of added rail into the repair form. He was also required to

mark the rail plug with the amount of rail added. However, no markings were found on the

plug after the accident, so it is unlikely that the rail had been marked. The track welder

also noted on the repair form that he had checked the anchor pattern for 200 feet from the

insert in both directions and the proper number of anchors were there. However,

postaccident observations found that only about half of the anchors were in functioning

positions against the sides of the ties, and those anchors were not enough to retard or

restrain the longitudinal rail movement. It is unlikely that the condition of the anchors had

changed much between January and the time of the accident.
Analysis 36 Railroad Accident Report

Further, on March 6, 2004, the track inspector made repairs at the location of the rail

insert. He remembered seeing that some of the anchors were missing but since he did not

see any rail movement (longitudinally) he considered their absence to be inconsequential. A

few days later, the track foreman put some new ties under the rail plug. The foreman

recalled that the rail anchors that were removed from the old ties were put on the new ties.

The postaccident examination showed that anchors were not applied box style on every

other tie of the new ties as required by the CWR program. Following these 2 separate days

of work by the track inspector and the track foreman, the track supervisor visited the site to

evaluate the work performed by them and the welder. He told investigators that the work

was satisfactory but noted that a couple of anchors had been left off.

Between January and March 2004, four maintenance employees (welder, track

inspector, track foreman, and track supervisor) had been at or near MP 196.5 on four

different occasions, and all four employees said they had examined the condition of the

anchors. However, even though CNís standard for anchors in CWR was full box

anchoring on every other tie, none of the four employees adjusted or added anchors

although half of the anchors were missing or not against the sides of the ties. Further, CN

did not have an adequate system to alert key personnel of critical maintenance activities,

such as followup rail adjustments before the onset of warm weather. The Safety Board

concludes that although CN had written instructions for maintaining CWR and preventing

track buckling, track employees at multiple levels did not follow or ensure adherence to

these instructions. The Safety Board also concludes that had the employees who

maintained the track at the accident site followed the written procedures the rail shift

condition likely would not have occurred. Therefore, the Safety Board believes that CN

should establish an audit program to verify that employees follow the current written track

maintenance and inspection procedures, including rail anchoring requirements and

specifically maintaining the preferred rail laying temperature. 

FRA Oversight

The FRA is responsible for determining the adequacy of a railroadís CWR

program, but the FRA did not review either the old IC program or the CN program before

the accident. This type of oversight deficiency was identified by the Safety Board during

its investigation of a January 18, 2002, derailment near Minot, North Dakota.33 The FRAís

failure to evaluate rail carriersí CWR programs until after serious rail accidents is

particularly disturbing given the movement of trains carrying passengers and hazardous

material over rail routes throughout the country and the serious consequences that can

result when a derailment occurs. Since the Flora accident, the FRA has reviewed CNís

CWR program and has asked the railroad to clarify certain details within the program. One

of the details the FRA has asked CN to clarify is the specific meaning of the phrase, ìonset

of warm weather.î This is important in connection with the Flora accident because the

CWR where the oversized rail plug was inserted near the derailment site needed to be

adjusted before it was affected by the increasing temperature. 

33 National Transportation Safety Board, Derailment of Canadian Pacific Railway Freight Train 292-

16 and Subsequent Release of Anhydrous Ammonia Near Minot, North Dakota, January 18, 2002, Railroad

Accident Report NTSB/RAR-04/01 (Washington, DC: NTSB, 2004).
Analysis 37 Railroad Accident Report

Before the Flora accident, although the FRA inspector had the railroadís CWR

program and he found areas in which the ties were marginal and the rail anchors were

ineffective against longitudinal displacement, he did not write up any defects, nor did he

identify instances where anchors were not applied box style on every other tie. However,

such instances were found and identified as defects after the accident prompted a more

focused FRA inspection. 

The FRA inspector had several methods available to inform the railroad of

corrections necessary to improve the track conditions. The most severe was to note a

defect and file a violation on that defect. An alternative was for the inspector to note a

defect, but not file a violation, which gives the railroad time to correct the problem. A

third method, which he used, was to write comments to the railroad, although this method

has no enforcement element. Later, the FRA inspector and the FRA track specialist agreed

that the railroad was not required to respond to written comments and they did not expect

the railroad to make repairs based on comment items. 

In his written inspection comments to CN in June 2003, the FRA inspector

characterized the anchoring as ìineffective against longitudinal displacement,î indicating

that the rail could move because of changes in temperature. However, in a February 2004

return visit to the same territory, the FRA inspector did not comment on the condition of

the anchors, and no records were found to indicate that anchors had been applied between

June 2003 and February 2004 to meet CNís CWR program requirement that anchors be

applied box style on every other tie. An inspection after the derailment found that

approximately 50 percent of the anchors in the area of the accident were missing or not

properly positioned. Although the FRA inspector had brought the anchor deficiencies to

CNís attention about 10 months before the accident, he did not link this deficiency to CNís

CWR program and communicate the problem in a formal wayóas a defectóthat would

have likely prompted corrective action by CN. The Safety Board concludes that although

an FRA preaccident inspection identified track deficiencies, the FRAís oversight was not

effective in ensuring corrective action by CN. The Safety Board believes that the FRA

should emphasize to its track inspectors the importance of enforcing a railroadís CWR

program as a part of the Federal Track Safety Standards, and verify that inspectors are

documenting noncompliance with the railroadís program. 

Emergency Response

Immediately following the derailment, an Amtrak crewmember in the dining car of

the accident train called the Madison County Sheriffís Office (911) on his cellular

telephone to report the accident. He was able to provide the 911 dispatcher with detailed

information about the number of passenger cars derailed, the number of passengers, and

the location of the derailment.

The Madison County 911 dispatcher immediately dispatched people from the

Madison County Sheriffís Office, the Kearney Park Volunteer Fire Department, and the

Flora Volunteer Fire Department. Within 16 minutes of the derailment, the Madison
Analysis 38 Railroad Accident Report

County Sheriffís Office arrived on scene. Approximately 3 minutes later, the first

firefighter (the chief of the Flora Volunteer Fire Department) arrived on scene. The

location of the derailment was approximately 1 1/2 miles from the nearest paved road.

Although the derailment occurred in a remote area, emergency responders were able to

find the derailment site and respond quickly.

When the chief of the Flora Volunteer Fire Department arrived on scene, he

immediately began to triage the injured passengers on the train. As the first responding

firefighter (and most senior responder on the scene), the chief should have established a

command post, declared himself incident commander, and initiated the formal

management of the emergency response. If he had established command, the resources

needed for the emergency response could have been better managed at the beginning of

the response. 

During the period in which there was no official command post or incident

commander, emergency responders were responding to the scene and assisting with

injured passengers. The emergency responders were gathering the passengers together to

ensure that everyone was either evacuated or in the process of receiving medical

treatment. The establishment of the command post and the staging and triage areas by the

EMS director organized the emergency response operations already in progress. The

establishment of incident command made it easier to allocate proper resources to the

search for and triage of passengers and the extrication and medical transport of injured

passengers. 

The survival of victims of a mass disaster may be directly attributable to the

decisions made by medical and fire rescue personnel at the scene. These critical decisions

include the allocation of resources, such as medical, fire, and rescue personnel and

equipment. The purpose of the incident command system at the scene of a disaster is to

methodically allocate resources and objectively make important decisions in an

emotionally charged atmosphere with potentially life or death consequences.

The Madison County Emergency Management Agency director told investigators

that there had not been any countywide disaster drills before the accident. Such drills

provide emergency response agencies the opportunity to test their response,

communication, and coordination with each other. A disaster drill also provides an

opportunity to test the effectiveness of the incident command system in managing an

emergency. Madison County emergency responders at the Flora accident were able to

work well and effectively together even though they had not practiced or drilled together

before the accident. However, the lack of an established incident command during the

early stages of the response could have had a serious negative effect on the overall

response.

Since the accident, the Mississippi Emergency Management Agency has

conducted incident command system training for emergency responders in Madison and

Yazoo Counties. The 16-hour course was conducted in Madison County in April 2004 and

in Yazoo County in May 2004.
Analysis 39 Railroad Accident Report

Emergency Preparedness

Amtrak Crewmember Emergency Preparedness Training

During emergency situations, particularly those involving passenger evacuations,

the train crew and on-board service personnel are responsible for managing and directing

the safe evacuation of passengers. Passengers rely on the training, experience, and

leadership of the on-board service personnel. Required periodic emergency situation

training should prepare the train crewmembers to perform their duties confidently when

emergency situations occur. This periodic training is important because policies and

procedures change over time, both skills and memory erode unless exercised and

emergencies are rare, and the training is required by Federal regulation. Although Amtrak

is required to train current and new employees in emergency procedures, of the 12

crewmembers on train No. 58, 1 had gone more than 2 years without retraining. Title 49

CFR Part 239 has been in effect since January 1, 1999; therefore, Amtrak has had ample

time to train all of its crewmembers.34

The Safety Board has long been concerned with the emergency preparedness

training of Amtrak crewmembers and has previously made six recommendations (Safety

Recommendations R-79-36, R-83-24, R-83-72, R-89-35, R-93-23, and R-98-59) to

Amtrak regarding this issue. (Appendix C has a list of previous Safety Board

recommendations relating to the issues addressed in this accident.) Safety

Recommendation R-79-36,35 which asked Amtrak to establish a program to train

crewmembers in the proper procedures for care of passengers in derailment and

emergency situations, was classified ìClosedóAcceptable Actionî on October 8, 1980,

after Amtrak said that all employees had received training and that an ongoing training

program was in place. In response to Safety Recommendations R-83-2436 and R-83-72,37

Amtrak developed an advanced 4-hour course on emergency procedures for on-board

crewmembers and supervisory personnel.38 Safety Recommendation R-89-3539 asked

Amtrak to develop procedures and equipment for evacuation of passenger cars involved in

34 Title 49 CFR 239.101 provided a 2-year grace period commencing on January 29, 1999, for

completing the initial training for current employees and training within 90 days of hire for new employees.

After the initial training, periodic training is then to occur at least once every 2 years.

35 National Transportation Safety Board, Rear End Collision of Conrail Commuter Train No. 400 and

Amtrak Passenger Train No. 60, Seabrook, Maryland, June 9, 1978, Railroad Accident Report NTSB/RAR79/03 (Washington, DC: NTSB, 1979).

36 National Transportation Safety Board, Derailment of Amtrak Train No. 5 (the San Francisco Zephyr)

on the Burlington Northern Railroad, Emerson, Iowa, June 15, 1982, Railroad Accident Report

NTSB/RAR-83/02 (Washington, DC: NTSB, 1983).

37 National Transportation Safety Board, Fire Onboard Amtrak Passenger Train No. 11, Coast

Starlight, Gibson, California, June 23, 1982, Railroad Accident Report NTSB/RAR-83/03 (Washington,

DC: NTSB, 1983).

38 Safety Recommendation R-83-24 was classified ìClosedóAcceptable Actionî on October 12, 1984,

and Safety Recommendation R-83-72 was classified ìClosedóAcceptable Actionî on June 3, 1986.

39 National Transportation Safety Board, Derailment of National Railroad Passenger Corporation

Train 7, on Burlington Northern Railroad near Saco, Montana, August 5, 1988, Railroad Accident Report

NTSB/RAR-89/03 (Washington, DC: NTSB, 1989).
Analysis 40 Railroad Accident Report

an accident and train employees in those procedures and equipment. Amtrak updated its

emergency evacuation procedures manual and provided annual refresher training to all

train and engineering and on-board crews. Safety Recommendation R-89-35 was

classified ìClosedóAcceptable Actionî on January 16, 1990. In response to Safety

Recommendation R-93-23, Amtrak now provides all on-board service personnel with

comprehensive training in first aid, cardiopulmonary resuscitation, and the use of the

public address system.40, 41 Safety Recommendation R-98-59 asked Amtrak to implement

effective controls to monitor and ensure that all train crews and on-board service personnel

receive the necessary initial and recurrent emergency training to provide for passenger

safety.42, 43 In response, Amtrak established a computerized database that tracks the

attendance of all on-board crewmembers in initial and recurrent training in passenger

emergency preparedness and response education. However, Amtrak had difficulty locating

accurate training records for 4 of the 12 crewmembers after this accident because the

database had not been updated. Amtrak also centralized the training records into a single

database for compliance monitoring by Amtrakís human resources office.

Despite the existence of an employee training database, an Amtrak on-board

employee in this accident had not had training as required by Federal regulation. Amtrakís

continued failure to provide passenger emergency training to its crews has the potential to

put the traveling public at risk should an emergency occur on an Amtrak train. Although it

was not a factor in this accident, the Safety Board concludes that Amtrak was not assuring

that all of its crewmembers received emergency preparedness training. 

For almost 2 years, Amtrak officials have been telling Safety Board investigators

that Amtrak is ìcurrently improving Ö technological resources to afford us the

opportunity to better track PREPARE training for all active on-board service personnel.î

Amtrak hopes that these improvements will allow it ìto better monitor the status of all

active employeesí PREPARE training.î However, because of the importance of this issue

and Amtrakís continued failure to ensure all employees receive PREPARE training, the

Safety Board believes that Amtrak should report to the Board within 90 days a schedule

for training its employees who have not received emergency preparedness training as

required by 49 CFR Part 239. 

According to the regulation all Amtrak employees that worked on trains had to be

trained for emergency response by January 29, 2001, and retrained every 2 years

thereafter. However, Amtrak has failed to meet this requirement. The FRA is

40 National Transportation Safety Board, Derailment and Subsequent Collision of Amtrak Train 82 with

Rail Cars on Dupont Siding of CSX Transportation Inc. at Lugoff, South Carolina, July 31, 1991, Railroad

Accident Report NTSB/RAR-93/02 (Washington, DC: NTSB, 1993).

41 Safety Recommendation R-93-23 was classified ìClosedóAcceptable Actionî on

December 5, 2000.

42 National Transportation Safety Board, Derailment of Amtrak Train 4, Southwest Chief, on the

Burlington Northern Santa Fe Railway near Kingman, Arizona, on August 9, 1997, Railroad Accident

Report NTSB/RAR-98/03 (Washington, DC: NTSB, 1998).

43 Safety Recommendation R-98-59 was classified ìClosedóAcceptable Actionî on

December 5, 2000.
Analysis 41 Railroad Accident Report

responsible for ensuring that Amtrak is in compliance with this regulation, but Safety

Board investigators identified only one FRA audit of Amtrakís emergency preparedness

training. Moreover, that audit occurred after the accident and in one location in a different

region. Before the Part 239 regulation was in effect, this issue had surfaced in six Amtrak

accident investigations over 18 years, resulting in recommendations to improve

emergency training. Further, since Amtrakís failure to ensure such training surfaced in

another accident after the regulation required the training, the Safety Board concludes that

the FRA was not conducting periodic audits of Amtrakís passenger train emergency

preparedness plan to ensure that all crewmembers were receiving the required emergency

preparedness training. Therefore, the Safety Board believes that the FRA should establish

an audit and enforcement program to verify that Amtrak complies with initial and periodic

emergency preparedness training for all crewmembers systemwide, as required by 49 CFR

Part 239. 

Emergency Responder Training Provided by Amtrak

Amtrak has provided its ìPassenger Train Emergency Responseî course to

emergency responders in Yazoo County. However, very few responders from Yazoo

County responded to the accident, and most of their formal training from Amtrak occurred

approximately 5 years before the accident. Amtrak is required by 49 CFR 239.101(a)(5) to

provide training to emergency responders along passenger rail routes. According to

records provided by Amtrak, no firefighters from Madison County (the Flora Volunteer

Fire Department, the Kearney Park Volunteer Fire Department, the Gluckstadt Volunteer

Fire Department, the Madison Fire Department, the Southwest Madison Volunteer Fire

Department, the Camden Volunteer Fire Department, the Canton Volunteer Fire

Department, and the Farmhaven Volunteer Fire Department) have attended any training

provided by Amtrak. The lack of the training was demonstrated by the delayed

implementation of an incident command system. However, these problems stem more

from a lack of preparedness among the volunteer fire departments than from a lack of

training provided by Amtrak.

Passenger Train Equipment

Emergency Window Handles

An emergency window on the sleeper car had a handle that partially pulled free

from the rubber grommet around the window, preventing removal of the window for

emergency egress. Therefore, the Safety Board concludes that the handle on an emergency

window on the sleeper car was found to have failed. Without knowing the date of

manufacture of the gasket, investigators were unable to determine how the age of the

rubber may have affected the failure of the screws to remain attached to the grommet.

Prior to the accident, Amtrakís Preventive Maintenance and Standard Maintenance

Procedures outlined requirements to test and remove only one emergency window during

each maintenance cycle (typically every 3 months). These procedures did not require

documentation of which emergency window was removed and inspected. 
Analysis 42 Railroad Accident Report

Since the accident, Amtrak has informed the Safety Board that it will increase the

number of emergency windows tested on all Superliner, Surfliner, and Viewliner

passenger cars from one to a minimum of four during each 3-month cycle. The new

requirement for number of windows tested will increase the total number of emergency

windows tested and inspected to 16 annually. According to Amtrak, this new procedure

will ensure that every emergency window will be tested on each passenger car at least

once every 4 years.

Amtrak has stated that it will also record the location of each window tested on

each car in its electronic maintenance database. According to Amtrak, its Standards and

Compliance Group will randomly audit this database. Additionally, Amtrak has asked

both of its emergency window handle manufacturers to begin adding a date of

manufacture stamp to the handle area of the window gasket assembly.

Because Amtrak appears to be taking an appropriate approach to testing,

maintaining, and documenting the emergency windows on the entire fleet, a safety

recommendation to address the failed emergency window handles in this accident is not

necessary. However, the Safety Board will continue to monitor and document this issue in

future accident investigations to ensure that the emergency window handles function as

designed.
43 Railroad Accident Report

Conclusions

Findings

1. Amtrak train No. 58 and its related equipment functioned as intended and did not

cause the derailment. 

2. The operation of the train was not a factor in the accident. 

3. The inadequately restrained east rail lifted out of the tie plates because of expansion

caused by warm temperatures resulting in the rail shifting and the gage widening,

causing the wheels of the train to drop between the rails. 

4. Although the Canadian National Railway Company had written instructions for

maintaining continuous welded rail and preventing track buckling, track employees at

multiple levels did not follow or ensure adherence to these instructions. 

5. Had the employees who maintained the track at the accident site followed the written

procedures the rail shift condition likely would not have occurred. 

6. Although a Federal Railroad Administration preaccident inspection identified track

deficiencies, the Federal Railroad Administrationís oversight was not effective in

ensuring corrective action by the Canadian National Railway Company.

7. Although it was not a factor in this accident, Amtrak was not assuring that all of its

crewmembers received emergency preparedness training.

8. The Federal Railroad Administration was not conducting periodic audits of Amtrakís

passenger train emergency preparedness plan to ensure that all crewmembers were

receiving the required emergency preparedness training.

9. The handle on an emergency window on the sleeper car was found to have failed.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

Amtrakís City of New Orleans accident on April 6, 2004, near Flora, Mississippi, was the

failure of the Canadian National Railway Company to properly maintain and inspect its

track, resulting in a rail shift and the subsequent derailment of the train, and the Federal

Railroad Administrationís ineffective oversight to ensure the proper maintenance of the

track by the railroad.
44 Railroad Accident Report

Recommendations

As a result of its investigation of the April 6, 2004, derailment of Amtrakís train

No. 58, the City of New Orleans, near Flora, Mississippi, the National Transportation

Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Emphasize to your track inspectors the importance of enforcing a railroadís

continuous welded rail program as a part of the Federal Track Safety

Standards, and verify that inspectors are documenting noncompliance with

the railroadís program. (R-05-05)

Establish an audit and enforcement program to verify that Amtrak

complies with initial and periodic emergency preparedness training for all

crewmembers systemwide, as required by 49 Code of Federal Regulations

Part 239. (R-05-06)

To the Canadian National Railway Company:

Establish an audit program to verify that employees follow the current

written track maintenance and inspection procedures, including rail

anchoring requirements and specifically maintaining the preferred rail

laying temperature. (R-05-07)

To the National Railroad Passenger Corporation (Amtrak):

Report to the Board within 90 days a schedule for training your employees

who have not received emergency preparedness training as required by 49

Code of Federal Regulations Part 239. (R-05-08)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER RICHARD F. HEALING

Acting Chairman Member

ELLEN ENGLEMAN CONNERS DEBORAH A. P. HERSMAN

Member Member

Adopted: July 26, 2005
Recommendations 45 Railroad Accident Report

Deborah A. P. Hersman, Member, filed the following dissenting opinion on 

July 28, 2005. 

Notation 7642A

Member HERSMAN, dissenting:

I voted against the recommendations made in this report because I believe we

have missed the mark -- the probable cause of this accident has to do with CNís

lack of compliance with their own CWR program. In order to make a positive

change, we must rely on the actions of the railroad and appropriate FRA oversight

to prevent similar accidents from occurring in the future. What did not contribute

to the cause or the severity of this accident was the currency of Amtrak crewís

PREPARE training.

RECS #2 and #4 - Emergency preparedness training

I cannot reconcile the fact that 50% of the recommendations issued in the report

are focused on the emergency preparedness training of the Amtrak crew whose

actions were appropriate during the accident. Moreover, there is no finding in the

report that such training or lack of training was causal to the accident or even a

contributing factor. Nor is there any discussion in the report about any

inappropriate action or inaction by the Amtrak crew during the accident sequence.

Amtrak crew members notified CN dispatch, Amtrakís CNOC, and local 911 via

radio or cell phones as soon as possible after the derailment. A call made to local

911 by a member of the crew provided detailed information about the trainís

location, the number of passengers aboard and the general conditions of the

accident. The fact that local responders arrived on scene within 16 minutes of the

derailment is a testament to the accurate information provided, even though the

crew member called from his cell phone in the overturned dining car and the

derailed train was approximately 1 1/2 miles from a paved road. I agree that

Amtrak was not in compliance with the emergency preparedness provisions of 49

CFR Part 239. However, FRA has the responsibility to enforce this regulation.

Our role is to identify the probable cause and make recommendations to prevent

similar accidents from occurring. Neither the training of the crew nor their actions

post accident were a factor in this accident; in fact, their actions were entirely

appropriate. However, by devoting two of four recommendations to the issue of

Amtrakís emergency preparedness training, the report implies otherwise.

RECS #1 and #3 - Continuous Welded Rail (CWR)

The two recommendations to FRA and CN regarding CWR are consistent with the

probable cause, but I would have preferred to see more specificity with respect to

certain areas of CWR programs. With only 119 track inspectors at the state and

federal level overseeing the safety of more than 200,000 miles of track, we must

rely on the railroads to develop robust CWR programs and follow through on

implementing them.

While we ask FRA to enforce CWR programs and verify that inspectors are

documenting noncompliance, we do not ask FRA to review all CWR programs to
Recommendations 46 Railroad Accident Report

ensure that railroads have in effect (as per the CWR regulations) procedures

which specifically address maintaining a desired rail installation temperature

range when making rail repairs (49 CFR 213.119). It is unacceptable that CN has

not responded to FRAís request from over a year ago to clarify what it means by

the ìonset of warm weatherî in its CWR program.

As early as 1971, the FRA recognized that installation temperature and anchoring

were fundamental CWR issues. Disturbing CWR beyond the installation

temperature is widely understood to affect the rail. The failure of CN to effect a

more permanent repair to the CWR in the vicinity of the accident is identified in

our findings as a factor in this accident. Furthermore, it was not an isolated

occurrence on the CN, according to the track supervisor who stated that there

were 15 other locations where 2 to 3 inches of rail had been added during the

winter but had not yet been welded at the time of the accident.

I believe that there are other areas that we might have addressed to improve the

safety of CWR. For example, we could ask FRA to: 1) review best practices

(several Class I railroads have not had any reportable accidents caused by buckled

rail in a year) and draft a model CWR program; or 2) compare submitted

proposals to the AREMA manualís section on CWR (1988) which provides basic

guidance. These recommendations could constitute improvements to the existing

program without being overly prescriptive.

Additionally, I remain concerned about the many situations in which ìtemporaryî

repairs become long-term or permanent. We could recommended that, in light of

this accident and others involving derailments due to temporary repairs of CWR,

FRA review the nature and duration of ìtemporaryî repairs to CWR and

determine when delays in making such temporary repairs more permanent is

acceptable. (One Class I railroad achieves permanent repairs on CWR in a much

more expedited fashion because it makes temporary repairs operationally

inconvenient).

Finally, in the report, there is some discussion of a CN computerized rail defect

tracking system (RDTS) which appears to be underutilized or ineffective. Yet

another major Class I railroad uses a rail tracking program that readily identifies

those locations in CWR that may be vulnerable to buckling because more

permanent repairs have not been made to rail cuts or plugs inserted and may be

subjected to excessive longitudinal forces. Why wouldnít we recommend that CN

improve their data collection and tracking systems?

The draft report was timely and thorough, and I commend the staff and the parties

on their work. However, I believe we missed an opportunity to address the root

cause of derailment through our recommendations. We shouldnít wait for another

accident to develop a more complete record of weaknesses in CWR maintenance.

We already possess enough information to make needed recommendations to

improve the safety of CWR.
47 Railroad Accident Report

Appendix A

Investigation

The National Transportation Safety Board was notified about 8:30 p.m. eastern

daylight time on April 6, 2004, that an Amtrak train had derailed near Flora, Mississippi.

The Safety Board launched a railroad accident investigation team to the site. The team

included Vice Chairman Mark Rosenker (accompanied by a public affairs representative

and a family affairs representative) and investigative groups for operations, track, signals,

mechanical, human performance, and survival factors/crashworthiness factors.

Parties to the investigation included the Federal Railroad Administration, the

Canadian National Railway Company, Amtrak, the Madison County sheriff, United

Transportation Union, and the Brotherhood of Locomotive Engineers and Trainmen. 
48 Railroad Accident Report

Appendix B

Emergency Responders 

The agencies in the following list responded to the Flora accident:

1. Flora Volunteer Fire Department

2. Gluckstadt Volunteer Fire Department

3. Ridgeland Fire Department 

4. Bentonia Volunteer Fire Department

5. Canton Volunteer Fire Department

6. Madison County Sheriffís Office 

7. Madison Police Department

8. Yazoo County Emergency Management Agency

9. American Medical Response

10. Acadian Ambulance Service

11. University of Mississippi Medical Center ñ Air Care

12. Kearney Park Volunteer Fire Department 

13. Madison Fire Department

14. Southwest Madison Volunteer Fire Department

15. Camden Volunteer Fire Department

16. Farmhaven Volunteer Fire Department

17. Madison County Emergency Management Agency 

18. Yazoo County Sheriffís Office

19. Mississippi Emergency Management Agency

20. EmergyStat Ambulance Service 

21. University Hospital and Clinics ñ Holmes 
49 Railroad Accident Report

Appendix C

Previous Safety Board Recommendations 

The Safety Board has issued numerous recommendations to Amtrak to improve

the emergency response and emergency training of its employees and emergency

responders in communities through which Amtrak trains travel; and to the FRA to

improve exit window and CWR maintenance and inspection procedures and intervals.

Listed below are 10 recommendations issued from 1979 through 2004. Eight

recommendations asked Amtrak to upgrade training in emergency response. One

recommendation to the FRA asked for improvements in maintenance and inspection of all

emergency window exits, and another recommendation to the FRA requested compliance

with correct CWR inspection procedures.

Emergency Preparedness and Passenger Safety Training

Accident. On June 8, 1978, a Conrail commuter train, consisting of 4 selfpropelled cars, struck the rear of an Amtrak passenger train consisting of 1 locomotive and

14 cars at Seabrook, Maryland. The impact caused eight cars of the Conrail train and eight

cars of the Amtrak train to derail, injuring 16 crewmembers and 160 passengers.

Relevant findings. Emergency personnel were unfamiliar with the trainís

emergency equipment because Amtrak and Conrail had not provided training and

familiarization for railroad emergencies to local rescue organizations. Passengers on both

trains had little or no guidance in evacuating the trains and obtaining medical assistance.

Crewmembers lacked knowledge of emergency procedures, including how to manually

open doors.

Relevant recommendations.

R-79-35 to Amtrak

Arrange for a program along passenger train routes for training and familiarizing emergency rescue organizations in the type of equipment being

used. 

Issued 3/21/1979; ClosedóAcceptable Alternate Action, 10/8/1980

Amtrak said it prepared an emergency procedures manual and distributed it to fire

departments and rescue squads along Amtrak routes. The manual covered the entry to

Amtrak equipment and evacuation of passengers and crewmembers during emergencies.

Amtrak said it did not have funding to undertake a training program throughout the system

and that the booklet was designed to be self-instructive.
Appendix C 50 Railroad Accident Report

R-79-36 to Amtrak

Establish a program to train crewmembers in the proper procedures for

care of passengers in derailment and emergency situations. 

Issued 3/21/1979; ClosedóAcceptable Action, 10/8/1980

Amtrak said newly hired and existing on-board service crewmembers had been

trained in a standard Red Cross multi-media first aid training program by fully qualified

instructors since early 1978. Amtrak said the training program was ongoing for newly

hired and existing employees and said it trained 1,173 on-board service personnel in fiscal

year 1979 and expected to train an additional 1,200 employees in fiscal year 1980. All

new employees receive, as part of their regular training, detailed training in emergency

procedures. Amtrak said it trained 636 employees in fiscal year 1979 and expected to train

600 in fiscal year 1980.

Accident. On June 15, 1982, an Amtrak passenger train with 315 persons on board

derailed near Emerson, Iowa, while traveling 74 mph when it encountered flood waters

over the top of washed-out rails. The accident resulted in 1 passenger fatality and 27

injuries.

Relevant findings. Emergency personnel were not aware, prior to the accident, of

Amtrakís emergency evacuation procedures booklet, and thus were not informed of the

proper procedures to be used in entering and evacuating passenger cars. Amtrakís training

program in emergency procedures for its on-board employees was not effective in

providing adequate assistance to passengers involved in the accident. 

Relevant recommendations.

R-83-23 to Amtrak

Provide copies of Amtrakís emergency evacuation procedures booklet to

all emergency response organizations not possessing those procedures

from the original distribution, along all designated passenger train routes. 

Issued 2/28/1983; ClosedóAcceptable Action, 10/12/1984

Through the National Safety Council, Amtrak said it distributed 2,140 emergency

evacuation manuals to emergency medical service units throughout the country, and

planned to distribute 1,000 more copies. Amtrak said 15,000 copies had already been

distributed in the previous 2 years. It also said instructional meetings with emergency

medical services and fire departments groups were held in Arkansas, Nebraska, and

California, and more meetings would be held on request.

R-83-24 to Amtrak

Review and revise, where necessary, the training and retraining programs

for on-board employees in emergency procedures, including the operation

of emergency exits, to improve on-board employee competence to render

effective assistance to passengers in emergency situations. 
Appendix C 51 Railroad Accident Report

Issued 2/28/1983; ClosedóAcceptable Action, 1/11/1985

Amtrak said it developed and distributed to its field offices an updated, advanced

4-hour course on emergency procedures. The course contained instructions pertaining to

several train types and was expanded to include transfer of passengers from stalled trains

and evacuation from tunnels. The course uses lecture, discussion, and role play techniques

to teach proper response to an emergency as well as hands-on experience in extinguishing

a fire under controlled conditions.

Accident. On June 23, 1982, an Amtrak 10-car passenger train with 307 persons

on board stopped at Gibson, California, after fire and dense smoke were discovered in a

sleeping car. Two passengers died, 2 passengers were injured, and 57 passengers and 2

train crewmembers were treated for smoke inhalation.

Relevant finding. Amtrak and railroad operating personnel should be given

hands-on training in procedures for emergency evacuation from passenger equipment.

Relevant recommendation.

R-83-72 to Amtrak

Include both Amtrak supervisory personnel and on-board service personnel

in refresher training programs covering the changes in Amtrak emergency

procedures. Arrange with all railroads, over which Amtrak trains are operated, emergency training for train crew employees qualified for assignment

to passenger service. 

Issued 7/8/1983; ClosedóAcceptable Action, 8/20/1986

Amtrak said it developed emergency procedures refresher training for supervisors

and on-board service employees and a course for front-end train crews and contract

railroad crews. It also said that new crews and contract crews must take a 3-day course

that includes emergency procedures.

Accident. On August 5, 1988, an Amtrak passenger train derailed near Saco,

Montana. Five passengers and 1 Amtrak service crewmember were seriously injured, and

87 passengers and 13 Amtrak service employees received minor injuries.

Relevant finding. Difficulties were experienced by crewmembers and emergency

responders in extricating passengers from the overturned cars, including a passenger from

a designated handicapped sleeping compartment that was not equipped with an emergency

window.
Appendix C 52 Railroad Accident Report

Relevant recommendation.

R-89-35 to Amtrak

Develop procedures and equipment for evacuation of passenger cars

involved in an accident, and train employees in those procedures and

equipment. 

Issued 5/31/1989; ClosedóAcceptable Action, 1/16/1990

Amtrak said it had previously distributed 50,000 copies of its emergency

evacuation procedures manual. The manual was updated in 1989, and distributed. Amtrak

said initial and refresher emergency situation training was being given to all train crews

annually, and its new training programs were being presented to police, fire, and medical

response personnel. Amtrak said its evacuation procedures were effective and it did not

plan to institute additional procedures.

Accident. On July 31, 1991, an Amtrak passenger train, consisting of 2

locomotives, 3 baggage cars, and 15 passenger cars, derailed 6 cars in Lugoff, South

Carolina. The derailed passenger cars collided with freight train hopper cars stored at a

nearby siding. Eight passengers were killed, 12 passengers were seriously injured, and 12

on-board service personnel and 53 passengers sustained minor injuries.

Relevant finding. On-board service crewmembers were not required to attend

periodic training in first aid or emergency procedures and failed to follow appropriate

established emergency procedures, such as using the public address system to inform

passengers about the emergency, and give related instructions or to locate passengers who

had medical expertise and might have been able to render assistance.

Relevant recommendation.

R-93-23 to Amtrak 

Require that all on-board service personnel periodically take training in the

emergency operating rules in first aid, cardiopulmonary resuscitation, and

the use of the public address system during train emergencies. 

Issued 11/30/1993; ClosedóAcceptable Action, 12/5/2000

Amtrak said that it provides all on-board crewmembers with comprehensive

training called PREPARE (Passenger Railroad Emergency Preparedness and Response

Education). It contains training in the following: cardiopulmonary resuscitation,

emergency first aid, prevention of disease transmission, communications procedures,

situational awareness, passenger evacuation, and rail equipment familiarization. The

course is required every 2 years.

Accident. On August 9, 1997, an Amtrak passenger train with 294 passengers and

18 Amtrak employees on board derailed near Kingman, Arizona. Traveling at 89 mph, the
Appendix C 53 Railroad Accident Report

train derailed after it encountered a hump in the tracks and crossed a bridge that had been

damaged by a flash flood. Ten Amtrak employees and 173 passengers were injured.

Relevant finding. Amtrakís current system for providing emergency training for

train crews and on-board service personnel has not been effective, which has resulted in

personnel being provided differing levels of emergency situation training.

Relevant recommendation.

R-98-59 to Amtrak

Implement effective controls to monitor and ensure that all train crews and

on-board service personnel received the necessary initial and recurrent

emergency training to provide for passenger safety. 

Issued 9/16/1998; ClosedóAcceptable Action, 12/5/2000

Amtrak said its human resources division developed guidance for training Amtrak

employees and established a central repository of training information and accurate

record-keeping procedures. When an employee completes an internal or external course,

Amtrak said the information is recorded in a database and checked periodically.

Emergency Window Exit Maintenance and Inspection

Accident. On February 16, 1996, a Maryland Rail Commuter (MARC) train

collided with an Amtrak passenger train near Silver Spring, Maryland. The MARC train

consisted of one locomotive and three cars. The Amtrak train had 2 locomotives and 15

cars. All three operating crewmembers and eight passengers on the MARC train were

killed in the derailment and subsequent fire. Eleven passengers on MARC and 15 of the

182 crewmembers and passengers on the Amtrak train were injured.

Relevant finding. Prescribed inspection and maintenance test cycles are needed to

ensure reliable operation of emergency windows in all long-distance and commuter rail

passenger cars.

Relevant recommendation.

R-97-18 to the Federal Railroad Administration: 

Provide promptly a prescribed inspection and maintenance test cycle to

ensure the proper operation of all emergency exit windows as well as provide that the 180-day inspection and maintenance test schedule is prescribed in the final rule. 

Issued 8/28/1997; ClosedóAcceptable Alternate Action, 7/27/2001

The FRA issued a final rule, effective July 12, 1999, that included significant

passenger safety upgrades. It included a requirement for mechanical inspection every 3

months of a representative sample of emergency window exits for proper operation. The
54 Railroad Accident Report

rule requires the FRA to notify railroads of inspection results and require railroads to

correct deficiencies. Before the rule became effective, the FRA issued an emergency order

on April 20, 1996, requiring window exit inspections and repair of deficiencies.

Welded Rail Inspections

Accident. On January 18, 2002, a Canadian Pacific Railway freight train derailed

31 of its 112 cars near Minot, North Dakota. Five tank cars carrying anhydrous ammonia

ruptured, resulting in a vapor plume covering the derailment site and surrounding area.

One resident was killed and about 60 area residents were rescued. As a result of the

accident, 11 people sustained serious injuries and 322 people, including 2 train

crewmembers, sustained minor injuries.

Relevant finding. FRAís oversight of Canadian Pacific Railwayís CWR program

was ineffective because the agency neither reviewed the program nor ensured that its track

inspectors had copies of the program to determine if the railroad was in compliance with

it.

Relevant recommendation.

R-04-03 to the Federal Railroad Administration 

Instruct Federal Railroad Administration track inspectors to obtain copies

of the most recent continuous welded rail programs of the railroads that fall

within the inspectorsí areas of responsibility and require that inspectors use

those programs when conducting track inspections. 

Issued 3/15/2004; ClosedóAcceptable Action, 6/22/2005

The FRA said it would issue a technical bulletin, which will be a rewrite of its

track compliance manual, to emphasize the requirement that 

inspectors must be aware of the procedures in effect before inspecting each

railroad. When conducting inspections, the inspector must make observations to

determine if the railroad is following its basic safety procedures.

The FRA also said that inspectors were reminded of this requirement during

technical workshops in 2004.