1 NTSB/RAB-06/07

E PLURIBUS UNUM

NATIONAL TRA SPORTATIO

N

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Railroad Accident Brief

Accident No.: DCA-05-MR-013 

Location: Chicago, Illinois 

Date: September 17, 2005 

Time: 8:35 a.m. central daylight time1

 

Railroad: Northeast Illinois Regional Commuter Railroad 

 Corporation (Metra) 

Property Damage: $6.35 million 

Fatalities: 2 

Injuries: 117 

Type of Accident: Derailment 

The Accident 

On Saturday, September 17, 2005, about 8:35 a.m., eastbound (inbound) 

Northeast Illinois Regional Commuter Railroad Corporation (Metra) train 504 derailed 

one locomotive and five cars at milepost (MP) 4.7 near West 47th and South Federal 

Street in Chicago, Illinois.2

 The train was being operated in the push mode from a cab 

control car at the lead end. The train had departed Joliet, Illinois, at 7:24 a.m. en route to 

the LaSalle Street station in downtown Chicago. The train crew consisted of an engineer 

in the cab control car and a conductor, an assistant conductor, and a collector in the 

passenger cars. 

The train derailed as it traversed a crossover from track 2 to track 1 that had a 

prescribed maximum operating speed of 10 mph. (See figure 1.) The train was traveling 

69 mph as it entered the crossover. The second through the fifth cars from the lead end of 

the train struck a steel girder that was part of a bridge that carried the tracks over 47th 

Street. Both turnouts of the crossover and one power switch machine were destroyed. 

Following the accident, Metra relocated the track to a new bridge adjacent to the original 

bridge. 

 1

 All times in this brief are central daylight times. 

2

 Eastbound trains are inbound trains originating at Joliet, Illinois, destined for the LaSalle Street 

station in Chicago; conversely, westbound trains are outbound trains departing Chicago. MP numbering 

decreases in the eastbound, or inbound, direction of travel. 
 

 2 NTSB/RAB-06/07

Figure 1. Train after derailment. (It was operating in push mode and traveling in 

the direction of the arrow.) 

Metra reported that 185 passengers and 4 crewmembers were on the train. There 

were 109 passengers, 4 crewmembers, and 4 others injured. Additionally, two passengers 

were killed. The derailment occurred during daylight hours, in sunny, clear weather with 

a temperature of 65° F. 

The Accident Sequence 

The crew of the train had reported for duty on Saturday morning at Joliet, Illinois. 

According to the work records, all crewmembers were in compliance with the hours-ofservice regulations. Before departing Joliet, the crew performed the required tests and 

inspections and held a job briefing that included a discussion of the placement of cars and 

locomotive for the train, the crew assignments, the cars that would be initially open to the 

public, and the track warrant3

 issued for their trip. The train departed Joliet on schedule, 

at 7:24 a.m. 

 3

 Track Warrant No. 109171 contained three track bulletins that affected the movement of trains on the 

Rock Island District: Bulletin A-101 was a Form A speed restriction, bulletin B-101 was a Form B for a 

track work zone on track 2, and bulletin D-101 was a Form D for a segment of track 1 that was to be out of 

service. 
 

 3 NTSB/RAB-06/07

Train 504 traveled on the Rock Island District from Joliet, MP 40.2, to Gresham, 

MP 9.8, arriving at 8:28 a.m.,4

 or 3 minutes late. The engineer stated that the trip to 

Gresham was uneventful, the weather was clear, and the signal indications were clearly 

visible. The track warrant showed track work on an upcoming portion of the track, 

between MP 6.68 and MP 6.2. A Form B, restricting train movements to provide 

protection for maintenance workers, had been issued for track 2, the track train 504 was 

on; the restriction was in effect between 8:00 a.m. and 5:00 p.m. Metra procedures 

required train engineers to contact the employee in charge of the work crew for 

permission to enter the work limits at the speed specified by the employee in charge. 

Metra designates the boundaries of a work zone by putting signs, referred to as 

“flags,”5 next to the track. Red flags are placed at each end of a work zone, and 

yellow/red advance flags are placed 1 mile in advance of the red flag. 

Operating rules state that the flags should not be installed before the time 

designated on the Form B. If the flags are not visible or installed by the designated time,6

the train engineer must still contact the employee in charge before entering the work 

zone. If the engineer cannot reach the employee in charge, he is to stop the train and ask 

the dispatcher for instructions. 

The yellow/red flag had not been installed 1 mile in advance of the work zone 

(MP 7.68) when train 504 passed that point at 70 mph about 8:30:58. a.m.7

 At 8:31:42 

a.m., signal 068, MP 7.0, displayed a clear signal indication (green aspect)8

 as the train 

slowed to 42 mph in preparation for the 40-mph speed restriction between MP 6.9 and 

MP 6.6 for the Norfolk Southern Railroad grade crossing at Englewood (MP 6.7). (See 

figure 2.) 

 4

 Train movement times were established by coordinating times from the event recorder on the lead 

cab control car with the Metra Consolidated Control Facility clock time. Train speeds were recorded on the 

lead cab control car event recorder. Train 504 had 17 scheduled station stops before the Gresham station. 

5

 The “flags” used by Metra are colored metal boards, red and yellow/red, affixed to metal posts driven 

into the ground at prescribed locations. If the flags are not placed, it is noted on a form. 

6

 Travel conditions and time schedule constraints can interfere with flags being installed at the exact 

prescribed times. Vandalism can result in flags being damaged or removed. 

7

 Signal information and train speeds were coordinated from the event recorder on the train and the 

wayside electronic and diagnostic signal logs. 

8

 A clear indication, either a green or green over red aspect, tells train engineers that they can proceed 

at the maximum speed authorized for their train. 
 

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Figure 2: Map. 
 

 5 NTSB/RAB-06/07

At 8:32:27 a.m., by which time the train had slowed to 4 mph and was passing the 

Englewood signal, which was displaying a clear signal indication, the engineer contacted 

the employee in charge. (The engineer told Safety Board investigators he had earlier 

attempted unsuccessfully to contact the employee in charge.) The employee in charge 

stated that he had given permission for the train to operate through the work zone at the 

authorized track speed, which was 40 mph. He said that he had believed the train had 

come to a stop and that the engineer had not mentioned that the yellow/red advance flag 

was not in place. The engineer stated that he had tried to notify his conductor of the 

missing advance flag. The conductor said that he had told the engineer his 

communication was being transmitted through the train’s public address system and that 

he would come up to the control cab to talk to him. Several passengers9

 stated that they 

had heard something unintelligible on the public address system. One passenger, who had 

been in the third car from the front, stated that the conductor was “hurrying” through the 

car with his hand-held radio. 

Between MP 6.65 and MP 6.55, the track curves to the left in a 3° 40' curve then 

straightens to and beyond the crossover at MP 4.7, near control point (CP) 48th Street,10

where the derailment occurred. There was no vegetation overgrowth or other sight 

obstructions along the 2-mile approach to CP 48th Street. About 8:33:45 a.m., after 

accelerating to 41 mph,11 the train passed a clear signal indication (green aspect) 

displayed at signal 058, 59th Street at MP 6.0. 

Signal data logs indicated that the next signal, at CP 53rd Street, was displaying 

an approach diverging12 indication (yellow over yellow aspect)13 and that the next signal 

after that, at CP 48th Street, was displaying a diverging clear14 indication (red over green 

aspect).15 However, the engineer told Safety Board investigators that the signal at MP 

5.39, CP 53rd Street, was displaying a clear indication (green over red aspect). He also 

said that he could see the signal at MP 4.73, CP 48th Street, and that it was displaying a 

clear indication. The signal and train movement records indicated that the crossover had 

been lined for the crossover move since about 7:41 a.m. 

Recorder data showed the train passed the approach diverging signal at CP 53rd 

Street about 8:34:40 a.m. at a speed of 57 mph and passed the diverging clear signal at 

CP 48th Street about 8:35:16 a.m. at a speed of about 69 mph. 

 9

 Four passengers noted this message on their Safety Board followup accident questionnaires. 

10 CP 48th Street is Metra’s name for the signal location near 47th Street in Chicago. 

11 The authorized speed through the work zone was 40 mph. 

12 An approach diverging indication (yellow over yellow aspect) tells a train engineer to proceed 

prepared to advance on diverging route at the next signal at prescribed speed through turnout. 

13 Signals logs showed this signal had displayed for 22 minutes 24 seconds before the train passed. 

14 A diverging clear indication (red over green aspect) tells a train engineer to proceed on diverging 

route at prescribed speed through turnout. 

15 Signal logs showed that this signal had displayed for 54 minutes 2 seconds before the derailment. 
 

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Track 2 leading to the crossover was designated by Metra as meeting the Federal 

Railroad Administration (FRA) standards for Class 4 track.16 Metra’s maximum 

allowable operating17 speed between MP 7.0 and MP 3.9 was 70 mph for passenger trains 

and 30 mph for freight trains, except between MP 6.9 and MP 6.6, where passenger and 

freight train speeds were restricted to 40 mph and 20 mph, respectively. In addition, all 

trains operating through the crossover at CP 48th Street, MP 4.7, were limited to 10 mph. 

This 10-mph speed restriction is intended to provide for a safe transition of equipment 

through the crossover. The train derailed about 8:35:19 a.m., when it was 242 feet past 

the CP 48th Street signal and operating at 69 mph, as it attempted to traverse the 

crossover. No emergency brake application was recorded before the derailment. (See 

figure 3.) 

Figure 3. The point of derailment (POD); the beginning of the crossover is in the 

foreground. 

 

The first supervisor to arrive after the accident stated to Safety Board 

investigators that when he asked the engineer what had happened, he responded, “I didn’t 

see it, I didn’t see it.” Metra officials stated that the engineer failed to comply with the 

approach diverging and diverging clear signal aspects, as well as with the 10-mph speed 

restriction through the crossover. Following two Metra internal hearings and a formal 

investigation, the engineer was dismissed from Metra service on May 31, 2006, and his 

train engineer’s license was revoked for a month (from September 21, 2005, to 

 16 FRA track safety standards (49 CFR 213.9) for class 4 track allow 80 mph for passenger trains and 

60 mph for freight trains. 

17 Metra System Timetable No. 1 was effective 3:01 a.m. Sunday, April 3, 2005. 
 

 7 NTSB/RAB-06/07

October 21, 2005). As noted above, train 504 had a recorded speed of 69 mph while 

traveling into the crossover. The excessive train speed and the severe angle of attack 

between the wheel flanges of the lead set of trucks of the cab control car and the gage 

corner of the curve closure rail caused the wheels to cross over the railhead and derail. 

The leading cab control car (8570) derailed first and passed through the 47th Street 

Bridge18 without impact. The second car (7331) derailed and scraped the bridge girder. 

The third through fifth cars (8548, 7488, and 7351) derailed, struck, and rode over the 

low girder of the bridge. (See figure 4.) 

Figure 4. Damage to the 47th Street Bridge and adjacent walkway and handrail. 

Engineer Attentiveness 

Although the accident trip was principally a routine trip, some activity along the 

tracks may have diverted the engineer’s attention from the aspects of the CP 53rd Street 

and CP 48th Street signals. The engineer would have been able to see the signal at CP 

53rd Street after exiting the curve at MP 6.55. Sight distance tests performed by Safety 

Board investigators showed that the CP 53rd Street approach diverging signal could be 

seen from a distance of about 3,223 feet and that the CP 48th Street diverging clear

signal could be seen from a distance of 1,860 feet.

 18 The 47th Street Bridge was a typical highway overhead crossing for the former Chicago, Rock 

Island and Pacific Railroad built in 1897-98. It was a 70-foot-through girder span, and the top of the girder 

projected 1.8 feet above the top of rail. 
 

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Two Metra signal department employees had completed their work at the CP 53rd 

Street crossover and were standing north of the signal waiting for train 504 to pass them 

so they could cross the tracks and return to their vehicle. The engineer did not mention 

the two workers during the postaccident Safety Board interviews; however, it is likely 

that he did observe them and their vehicle, to determine they were safely clear of the 

tracks. 

The engineer stated that he had observed other Metra employees who were 

filming a training video for Metra in the yard west of the train (on the engineer’s left), 

after the train passed the CP 53rd Street signal. The engineer told investigators that he 

had seen the employees, but spent only a brief time looking at them. He said: 

I really didn't pay too much attention to them, just kept my 

eyes forward until I looked down, noticed that the switch 

was lined for a diverging route. By the time I saw it, there 

was nothing I could do. I don't believe I was able to put the 

train into emergency. 

It is unclear whether or to what extent the presence of the Metra employees 

around the tracks diverted the engineer’s attention from the signal aspects displayed at 

CP 53rd Street and CP 48th Street. Most likely, the engineer did not observe the signal 

aspect at CP 53rd Street and assumed that it must have been a clear aspect, consistent 

with his belief that the subsequent CP 48th Street signal was displaying a clear aspect. He 

may also have assumed that the dispatcher would be routing his train on a direct route to 

the LaSalle Street station to keep his train on time,19 in light of the fact that all the other 

signal aspects he had passed after departing the stop at Gresham station had been clear.

Finally, it is also possible that the engineer was preoccupied with whether or how to 

notify others of the missing advance flag before the work zone. Although the 

investigation could not determine the exact reason for the engineer’s inattentiveness, it is 

clear that he did not observe or comply with the signal indications that he passed as he 

approached the crossover at CP 48th Street. 

Postaccident Actions 

After the accident, Metra placed crossover speed restriction signs in advance of 

crossover locations on the Rock Island District. The signs display the prescribed speed 

for the crossover and are intended to provide a point of reference for engineers to regulate 

the train’s speed prior to traversing a crossover. 

In addition, Metra has revised its procedures to require an engineer to reduce 

immediately a train’s speed by 5 mph when an approach diverging aspect is displayed. 

At the time of the accident, Metra’s rules did not require any immediate action in 

 19 Metra’s on time operating policy is that when a train arrives within 5 minutes of its designated 

arrival time it is still considered on time. 
 

 9 NTSB/RAB-06/07

response to an approach diverging signal aspect. An engineer only had to be prepared to 

cross over at the next signal at the prescribed speed for the turnout. 

Metra had a similar accident on October 12, 2003, when another Metra commuter 

train, operating in the opposite direction (outbound), derailed at the same crossover.20

The Safety Board determined that the probable cause of that accident was the engineer’s 

loss of situational awareness because of his preoccupation with certain aspects of train 

operations that led to his failure to observe and comply with signal indications. As a 

result, the Safety Board recommended on November 16, 2005, that Metra: 

R-05-13 

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

Following the Metra accident on September 17, 2005, the Safety Board issued an urgent 

safety recommendation to Metra on December 22, 2005, asking it to: 

R-05-18

Install an automatic train control system with cab signals and train control 

enforcement over the entire Joliet Sub District, until a positive train 

control system is installed. 

Metra responded21 that such an interim measure would cost nearly $125 million 

and take at least 9 years to accomplish and proposed an alternative. Instead, Metra is 

moving forward on the development and installation of an Electronic Train Management 

System (ETMS), which would control the train if an engineer failed to properly respond 

to a restricting signal. Metra is finalizing a contract with Wabtec to install ETMS on the 

Rock Island District. Phase I of the system will automatically enforce all permanent 

speed restrictions such as crossover moves or physical constraints such as curves. The 

funding for the Phase I work is in place and includes 12 miles that will be initially 

equipped. It will later be expanded to the remaining Rock Island District in Phase II after 

testing and FRA approval. ETMS cutover for Phase I is expected in October 2007 for the 

test period. Metra has had preliminary meetings with the FRA to discuss the ETMS 

project. Metra anticipates that material delivery will begin in the first quarter of 2007. 

The balance of the material should be delivered in 2007 with installation, testing, and 

FRA approval extending into 2008. 

 20 National Transportation Safety Board, Derailment of Northeast Illinois Regional Commuter 

Railroad Train 519 in Chicago, Illinois, October 12, 2003. Railroad Accident Report NTSB/RAR-05/03 

(Washington, DC: NTSB, 2005). 

21 Letters to the Safety Board in response to outstanding safety recommendations dated 

December 14, 2005, and January 24, 2006. 
 

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Engineer 

The engineer began his railroad employment as a switchman with CSX 

Transportation (CSXT) on October 10, 1998, at Riverdale, Illinois. He was certified as a 

locomotive engineer on June 29, 1999, and transferred about mid-year to through-freight 

service, operating freight trains between Garrett, Indiana, and Chicago, Illinois. During 

his last 3 years as an engineer on CSXT, he was operationally tested by supervisors on 

110 occasions, which resulted in 12 recorded failures. 

 While an engineer on CSXT, he maintained his certification pursuant to the FRA 

requirements in 49 Code of Federal Regulations (CFR) Part 240. However, he had 

several field administration sessions with his CSXT supervisor; the most recent, on 

March 20, 2005, was for failing to comply with CSXT Rule 3A (by using an 

unauthorized radio) and CSXT Rule 2 (by quarreling with a conductor while on duty and 

on company property).22 There was no record that CSXT gave this information to Metra. 

FRA regulations, 49 CFR 240.113, require an individual to furnish data on prior 

safety conduct as an employee of a different railroad when seeking certification with 

another railroad. On March 29, 2005, the engineer asked CSXT to give Metra a copy of 

his engineer’s certificate data, which showed that CSXT had re-certified him on 

December 31, 2003. However, he did not ask CSXT to provide a copy of his service 

record, as required by 49 CFR 240.113, and Metra claimed that it could not 

independently make this request of CSXT. Regardless, Metra hired the engineer on April 

18, 2005. Five days later, he voluntarily resigned from CSXT. Metra has since changed 

its method of reviewing employment records from other railroads. An applicant must 

now sign a general release form that allows Metra to request information from the 

applicant’s former employer(s). 

Metra certified the engineer as a locomotive engineer on August 30, 2005, after 

he had participated in an accelerated training program for which he qualified, because he 

had been employed and certified previously as an engineer by CSXT. His Metra training 

evaluation was noted as excellent. The supervisor of locomotive engineers rated him as a 

10 (on a scale of 1 to 10). He was qualified and began operating as an engineer, without 

being accompanied by another engineer, on the Rock Island District on August 30, 2005, 

18 days before the accident. 

Train 504 

The train consisted of cab car 8570 (the operating cab), coach 7331, cab car 8548, 

coach 7488, coach 7351, and locomotive 409. Cab car 8570 and coach 7351 were not 

 22 Previous sessions occurred on May 29, 2002, as a result of being late for work; July 7, 2003, for 

failing to follow instructions; December 14, 2003, for excessive lay-off pattern; and, December 27, 2004, 

for failure to comply with CSXT Train Handling and Air Brake Instructions. 
 

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carrying passengers at the time of the accident. The train was operating in the push mode, 

with cab car 8570 at the lead end and locomotive 409 at the trailing end. 

Metra passenger cars are constructed of stainless steel and are called "gallery 

cars" because they have two levels. The cars are 85 feet long,23 9 feet 9 inches wide, and 

16 feet 3 inches high, above the top of the rail. Each car has eight emergency windows 

for passenger egress (four per level) and another eight emergency windows (four per 

level) for emergency responder ingress.24 

The area above the center aisle is open and extends to the ceiling of the car with a 

railing on the side of the upper-level aisle. The 7300-series cars have 46 windows per car, 

whereas the 7400-series and 8500-series cars have 44 windows per car so the car can 

accommodate a handicapped restroom. The cars can hold 130 to 157 seated passengers, 

depending upon the car configuration.25 

At the center of the car is a vestibule-like area with platform-level doors on either 

side for entry and exit for a low track-level platform. The vestibule bisects the car, there 

are two sets of stairs for on either side (four stair wells), which lead to an upper-level 

narrow aisle and seating along the outside for some fixed single seats (some facing 

toward the center aisle), some with “walkover”26 seat backs, and fixed double seats at the 

bulkheads. The lower level has double seats on either side of the center aisle, most with a 

walkover seat back, and a few fixed single seats.27 

A postaccident inspection of the seats showed that some had sustained extensive 

damage. For example, car 7488 had 12 seat backs that had separated from their frames (3 

of the 12 seat backs had broken frames). Nine seat backs had lifted up and completely 

separated from their frames, exposing the two vertical posts that held the seat back onto 

the seat assembly. An inspection of car 7351 showed that 22 seat backs were dislodged, 

including 1 that had an exposed seat post. In car 8548, four seat backs were dislodged, 

including one that had completely separated from the seat frame. 

The fourth car (7488) sustained substantial impact damage at its right front corner 

from striking the bridge girder, and the damage extended rearward for a distance of about 

20 feet, resulting in open breaches in that area of the car body. The leading end/lower 

side-sills of the car were bowed outward about 2 inches and 15 inches on the left and 

right sides, respectively. Corresponding segments of car body sidewall, directly above the 

 23 Over the coupler faces. 

24 Passenger egress windows have signs on the inside of the train telling passengers how to remove the 

windows; while emergency responder ingress windows have signs on the outside of the train telling 

responders how to remove the windows. 

25 The 7300-series cars have seating for 157 passengers; the 7400- and 8500-series cars, when fitted to 

accommodate three wheelchairs, have seating for 130 and 137 passengers, respectively. Without 

accommodations for wheelchairs, there is seating for 138 and 146 passengers, respectively. 

26 Walkover seat backs can be moved across the seat to face either direction of travel. 

27 Some cars (8500-series and car 7488) have single seats on the lower level. 
 

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leading end/lower right side-sill, displayed severe sheet metal crushing and 

displacement/distortion damage where a 19-foot segment of car body floor had separated 

and lifted from its supporting structural members. The separated segment of car body 

floor, at the right front corner, had lifted at least 24 inches, resulting in seat backs located 

in that area of the car contacting the underside panel of the upper-gallery level. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of 

the September 17, 2005, derailment of Northeast Illinois Regional Commuter Railroad 

Corporation (Metra) train 504 in Chicago, Illinois, was the engineer’s inattentiveness to 

signal indications and his failure to operate the train in accordance with the signal 

indications and the speed restriction for the crossover at Control Point 48th Street. 

Contributing to the accident was lack of recognition by Metra of the risk posed by the 

significant difference between track speed and crossover speed at the accident location 

and its inaction to reduce that risk through additional operational safety procedures or 

other means. Also contributing to the accident was the lack of a positive train control 

system. 

Recommendations 

As a result of its investigation of the Chicago, Illinois, railroad accident, the 

National Transportation Safety Board made the safety recommendations listed below. For 

more information about these recommendations, see the safety recommendation letters28

to the recipients. 

To the Federal Railroad Administration:

1. Immediately require all rail passenger car seat backs be secured to the seat 

assembly. (R-06-24) 

2. Revise the language in 49 Code of Federal Regulations 238.233 to define 

seat to include all components of the seat assembly, such as seat cushions 

and seat backs, that could become dislodged when subjected to 

accelerations specified in that section. (R-06-25). 

3. Require all rail passenger car seat assemblies to be dynamically tested to 

withstand the accelerations specified in 49 Code of Federal Regulations

 28 These letters are available on the National Transportation Safety Board’s web site. 
 

 13 NTSB/RAB-06/07

238.233, and require both upward and downward vertical acceleration 

tests. (R-06-26) 

4. Establish crashworthiness standards for passenger car body floor structure 

systems. (R-06-27) 

To the Northeast Illinois Regional Commuter Railroad Corporation (Metra):

5. Conduct a risk assessment of all crossovers on your system and determine 

those that pose an unacceptable level of risk due to the speed differential 

between maximum allowable track speed immediately before the 

crossover and maximum allowable speed through the crossover. For those 

crossovers where an unacceptable level of risk is determined, develop 

guidelines and procedures to effectively manage those risks, including 

procedures for communicating those risks with train crews. (R-06-28) 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

Mark V. Rosenker 

Chairman 

Robert L. Sumwalt 

Vice Chairman

Deborah A. P. Hersman

Member 

Kathryn O’Leary Higgins

Member 

Adopted: December 21, 2006