Railroad Special Investigation Report

Two Rear-End Collisions

Involving Chicago Transit Authority

Rapid Transit Trains

at Chicago, Illinois

June 17 and August 3, 2001

National 

Transportation 

Safety Board

Washington, D.C.

A

A

N TION

L TRA SPOR

ATIO

N

B OARD

SAF E T Y

N

T

E PLURIBUS UNUM 

NTSB/SIR-02/01

PB2002-917006

Railroad Special 

Investigation Report

Two Rear-End Collisions 

Involving Chicago Transit Authority 

Rapid Transit Trains 

at Chicago, Illinois

June 17 and August 3, 2001

NTSB/SIR-02/01

PB2002-917006 National Transportation Safety Board

Notation 7488 490 LíEnfant Plaza, S.W.

Adopted September 5, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2002. Two Rear-End Collisions Involving Chicago Transit

Authority Rapid Transit Trains at Chicago, Illinois June 17 and August 3, 2001. Special Investigation

Report NTSB/SIR-02/01. Washington, DC.

Abstract: Within a 2-month period in 2001, the Chicago Transit Authority (CTA) experienced two similar

rear-end collisions involving CTA rapid transit trains. Both accidents were preceded by the train operatorsí

having failed to comply with operating rules designed to prevent collisions. The investigation of the two

accidents highlighted deficiencies in the CTA managementís approach to ensuring rules compliance

among its operators. This special investigation report addresses the factors common to both collisions.

This special investigation report discusses the following safety issues: the adequacy of the CTAís

programs for ensuring compliance with its operating rules, the adequacy of the CTAís system safety

program plan and its internal safety audit program for identifying and resolving systemic safety issues, and

the adequacy of event recorders on rail transit vehicles.

As a result of this special investigation, the Safety Board makes recommendations to the Chicago Transit

Authority, the American Public Transportation Association, and the Federal Transit Administration.

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

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

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

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

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 PB2002-917006 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
iii Special Investigation Report

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

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

June 17 Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

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

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

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

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

August 3 Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Postaccident Tests and Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Background Information Related to Both Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

CTA Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

CTA Operator Training and Performance Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CTA Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Postaccident CTA Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

APTAís Standards Task Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

June 17 Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

August 3 Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Rules Knowledge Among CTA Operating Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Enforcement of Operating Rules on the CTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

CTA System Safety Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

APTA Guidance and Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

State Safety Oversight of Rail Rapid Transit Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

State Oversight of the CTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Event Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Previous Safety Board Event Recorder Recommendations . . . . . . . . . . . . . . . . . . . . . . 35

Event Recorder Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

APTA Event Recorder Working Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Positive Train Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Contents iv Special Investigation Report

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Recommendation Reclassified in this Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appendixes

 A: Brief: June 17, 2001, Chicago Transit Authority Accident . . . . . . . . . . . . . . . . . . . . . . 43

 Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

 Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

 B: Brief: August 3, 2001, Chicago Transit Authority Accident . . . . . . . . . . . . . . . . . . . . . 46

 Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

 Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

 C: CTA Brown and Blue Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
v Special Investigation Report

Introduction

Within a 2-month period in 2001, the Chicago Transit Authority (CTA)

experienced two similar rear-end collisions involving CTA rapid transit trains. Both

accidents were preceded by the train operatorsí having failed to comply with operating

rules designed to prevent collisions. The investigation of the two accidents highlighted

deficiencies in the CTA managementís approach to ensuring rules compliance among its

operators. This special investigation report addresses the factors common to both

collisions.

The first accident occurred about 11:40 a.m., central daylight time, on Sunday,

June 17, 2001, when CTA train 104, en route from downtown Chicago to OíHare Airport,

collided with standing CTA train 207 on the Blue Line near Addison Street Station. Each

train consisted of four passenger cars. About 75 passengers were on train 104, and about

40 passengers were on train 207. Eighteen passengers, an off-duty CTA employee, and

both train operators sustained minor injuries. The CTA estimated damages at $30,000.

The second accident occurred about 9:04 a.m., central daylight time, on Friday,

August 3, 2001, when CTA Brown Line train 416, en route from Kimball to downtown

Chicago, collided with standing CTA Purple Line train 505 on elevated tracks near Hill

Street. Each train consisted of six passenger cars. The accident occurred during morning

rush hour, and both trains had standing loads estimated at 90 passengers per car. Chicago

Police Department logs indicate that 118 people were transported to area hospitals with

minor injuries, none of which were life threatening. The CTA estimated damages at

$136,138.

This special investigation report discusses the following safety issues:

ï The adequacy of the CTAís programs for ensuring compliance with its

operating rules; 

ï The adequacy of the CTAís system safety program plan and its internal safety

audit program for identifying and resolving systemic safety issues; and

ï The adequacy of event recorders on rail transit vehicles.

As a result of this special investigation, the Safety Board makes recommendations

to the Chicago Transit Authority, the American Public Transportation Association, and

the Federal Transit Administration.

1 Special Investigation Report

Factual Information

June 17 Accident1

Accident Narrative

At 5:40 a.m.2 on Sunday, June 17, 2001, a train operator employed by the Chicago

Transit Authority (CTA) reported for duty at OíHare Station. The schedule called for her

to operate rapid transit trains for two round trips between the OíHare and Forest Park

Stations.

When she reported for duty, she received a rail service bulletin informing her that

the northbound3 Blue Line track between the Belmont and California Stations (see figure

1) was out of service for scheduled maintenance and that trains running in either direction

between the two stations would have to use the southbound track. 

1 See appendix A for an accident brief on this accident.

2 All times referenced in this report are central daylight time.

3 The CTAís convention is to designate north and south as its railroad directions. OíHare Airport is on

the north end of the Blue Line.

Figure 1. Location of June 17 accident.

N

O'Hare

Addison

Belmont

Logan Square

California

Western

to Downtown

Loop

Accident

Location
Factual Information 2 Special Investigation Report

Her first trip southbound from OíHare to Forest Park was uneventful. She then

operated another train back to OíHare. On this first northbound trip, she entered cab signal

territory at Western Station and stated that the cab signals cut in.4 She then proceeded out

of Western toward California Station, where she would need to cross over to the

southbound track. Upon her arrival at California Station, a pilot5

 boarded her train and

operated it through the single-track detour. She reported that the cab signaling system cut

back in at Belmont on this first northbound trip.

The cab signal system on the CTAís Blue Line, which displays the maximum

authorized speed in addition to signal indications, functions only for movements in the

direction of normal traffic. That is, northbound trains using the southbound track, as

required by the detour, would not receive cab signals from the signal circuits in the rails.

The lack of cab signals would then cause the train to be brought to a stop (see the ìCTA

Operationsî section of this report for more information). To prevent the stoppage of trains

during the detour period, the cab signals were cut out for that section of track by means of

a temporary card installed in the wayside signal equipment. Rail Service Bulletin R409-

01, in effect on the day of the accident, advised northbound operators that cab signals

would cut out at California and remain cut out until the train was past the detour point and

had returned to the northbound track at Belmont.

The train operator stated that she took a break after completing her first trip. She

then boarded the accident train, train 104, at OíHare and made her second trip southbound

to Forest Park. At Forest Park, she turned the train on a loop track and began the accident

trip northbound toward OíHare.

She stated that when her train entered cab signal territory at Western, the cab

signaling did not cut in. She said she proceeded out of Western toward the single-track

detour at 20 mph. If the cab signal system does not cut in within cab signal territory, the

operator is required by CTA operating rule 6.5.2 and standard operating procedure M-1-

100 to contact the operations control center and request authorization to proceed. The

operator of train 104 stated that she did not contact the operations control center before

proceeding, even though she knew the operating rules required it. She said that she

thought the absence of cab signals had something to do with the single-track detour.

As train 104 proceeded northbound, it was following two trains, 210 and 207.

When those trains reached the single-track detour at the California Station, the pilot

authorized them to proceed northbound through the single-track area. The pilot then

operated train 104 through the single-track area. (See figure 2.) The pilot stated that he

chose to operate train 104 through the detour area because he was familiar with the

operator of train 104 and knew that she was uncomfortable with abnormal operations,

such as single tracking.

4 A train with cab signals displays the governing signal aspect inside the cab of the train so long as the

train is operating in territory with a working cab signal system. The system is designed to cut out when a

train leaves cab signal territory and to cut back in when a train enters cab signal territory.

5 The CTA uses a pilot to control conflicting train movements over a temporary single-track detour. No

train can proceed through the detour area without obtaining specific authorization from the pilot or without

having the pilot on the train.
Factual Information 3 Special Investigation Report

After leaving the single-track area, train 210, the first of the three northbound

movements to go through the detour immediately before the accident, made a station stop

at Belmont. The train then proceeded north toward Addison and on to OíHare without

incident.

Train 207, the second of the three northbound movements, also made a station stop

at Belmont. That operator stated that the cab signal system had cut back in and functioned

normally as he neared the north end of the platform. As train 207 proceeded north from

Belmont, the operator said that he was stopped by the cab signal system as he approached

Addison Station where train 210 was stopped. Train 207 stopped about 200 feet behind

train 210. 

Meanwhile, train 104 had cleared the detour area and crossed back to the

northbound track. The pilot relinquished control to the train 104 operator at the south end

of Belmont platform. The operator then moved the train to the north end of the platform,

where she stopped to board and offload passengers. She stated that the cab signal system

did not cut in at Belmont.6

 She said that she knew trains were ahead of her so she operated

her train at about 15 mph out of Belmont without cab signal protection. 

Figure 2. Single-track detour.

6 The CTA cab signal system would not cut back in if, as in this case, a train occupied either of the two

track circuits immediately ahead of the train reentering the northbound track.

JUNE 17th

REAR-END

COLLISION

ADDISON

BELMONT

LOGAN SQUARE

CALIFORNIA

WESTERN

OUT OF SERVICE

SB

NB

SB

NB

COLLISION

LOCATION

 TO

O'HARE

 TO

DOWNTOWN

CAB

SIGNAL

TERRITORY

BLOCK

SIGNAL

TERRITORY
Factual Information 4 Special Investigation Report

She said that as she left the subway portal and exited a right-hand curve, she saw a

train (train 207) stopped about 100 feet ahead. She stated that she moved the control

handle to brake position 3 and then pulled the brake cord, but the train did not stop. She

said she then mistakenly hit a sander button7 while trying to depress the track brake

button.8 She indicated that when she did depress the track brake, it was too late to stop the

train. She estimated her sight distance at 100 feet and the impact speed as 10 mph.

She stated that leading up to the collision, there was nothing to distract her from

her duties and that she was aware of the train movement close ahead. Shortly after the

collision, CTA managers arrived, coupled the two trains together, and moved them to

Addison Station, where emergency personnel treated the injured.

Injuries

Eighteen passengers, one off-duty CTA employee, and both operators reported

injuries. Emergency medical personnel assessed the injured at Addison Station, and five

ambulances were used to transport the injured to area hospitals. None of the injuries was

life threatening. (See table 1.)

Damage

Equipment damage was limited to the couplers, anti-climbers, several broken

windows, and impact damage to electronics on the two trains. The CTA estimated the

damages at $30,000.

Personnel Information

CTA trains are crewed by a single operator. The operator of train 104 was first

employed with the CTA as a customer assistant on April 27, 1998. She had qualified as an

7 The sander button releases a quantity of sand just forward of the train wheels to provide increased

traction.

8 See the ìTrain Informationî section of this report for information on the train braking systems.

Table 1. Injuries resulting from June 17 accident.

Injury Scalea Employees Passengers Others Total

Fatal 0 0 0 0

Serious 0 0 0 0

Minor 3 18 0 21

Total 3 18 0 21

a

49 Code of Federal Regulations 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 5 Special Investigation Report

operator on June 2, 2000. She was certified as a switchman on December 11, 2000, and as

a flagman on March 14, 2001. A review of her training and operating history indicates that

she failed to qualify as an operator twice and spent an additional 32 hours in training

before successfully completing the program. She also failed the flagman training program

twice and was qualified on the third try after receiving remedial training. She failed

switchman training once and was qualified on the second try after receiving remedial

training.

She was referred for remedial training after rules violations on two separate

occasions during the 12 months preceding the accident. After accruing an excessive

number of safety violations in May 2001, she was required to participate in a corrective

case interview, the last step in the CTAís disciplinary process before discharge. At that

time, she was again referred for remedial training. She completed all remedial training

sessions successfully. Table 2 shows her operatorís training and operating history. 

Table 2. June 17 accident operatorís training and operating history.

Date Event CTA Action

4/27/98 Hired by CTA

5/11/98 Qualified as customer assistant

4/24/00 Began train operator training

5/7/00 Failed train operator test/evaluation 16 hrs. additional training

5/17/00 Failed train operator test/evaluation 16 hrs. additional training

6/2/00 Certified as Blue Line train operator

8/2/00 Began flagman training

8/10/00 Began switchman training

8/23/00 Failed flagman test 16 hrs. additional training

9/2/00 Ran red signal in training 8 hrs. additional training

11/1/00 Train handling violation Individual re-training

11/3/00 Failed switchman test 20 hrs. additional training

11/10/00 Failed flagman test 4 hrs. additional training

12/11/00 Certified as switchman

12/31/00 Ran red signal/ran through switch Individual re-training

2/15/01 Certified as flagman

5/9/01 Violation/took wrong line up Corrective interview

5/9/01 Excessive safety violations noted Individual re-training

6/17/01 Rear-end collision occurs Discharged
Factual Information 6 Special Investigation Report

She had been off duty for about 13 hours before reporting to work on the day of the

accident. She had been on duty for about 7 hours when the accident occurred. She reported

that she went to bed at 9:00 p.m. on the night before the accident and got up at 2:30 a.m.

She stated that she had had adequate rest before reporting for work on the day of the

accident, that her health was good, that she was not taking any medications, and that she

was not experiencing any problems that would interfere with her ability to perform her

job.

Train Information

Both the standing train (207) and the striking train (104) consisted of four

electrically propelled rapid transit cars. Both train consists were made up of 2601-3200

series rapid transit cars manufactured by the Budd Company between 1981 and 1987. The

48-foot-long cars pick up electrical power from a third rail by means of collector shoes.

Sets of two cars (married pairs) are permanently coupled together.

Four traction motors, one on each axle, power CTA rail cars. High-speed braking

is accomplished through electrical motor resistance (dynamic braking), while disc friction

brakes automatically cut in at lower speeds. Each car is also equipped with four electromagnetic track brakes, which can be activated separately via a push button or in

conjunction with electrical resistance/friction braking by moving the control handle to the

emergency, or B-4, position. When activated, the track brakes adhere magnetically to the

rail and act as a skid to slow the cars.

A handle at the operatorís control stand activates acceleration and braking.

Pushing the handle forward from a neutral position accelerates the train; pulling the

handle backward beyond the neutral position initiates braking. There are four braking

positions. Braking positions 1 through 3 are routinely used for service braking. Braking

position 4 is designated the emergency brake and activates the maximum brake rate as

well as the track brakes. Two brake pull cords in each car may also be used to initiate

braking. One pull cord is in the operatorís cab, and another is in the passenger

compartment of each car. Pulling the cord activates brake position 3 dynamic braking with

tailored friction braking.9

 It does not activate the track brakes.

Postaccident Tests and Inspections

Mechanical. The brake system of train 104 was tested and found to function

normally. A braking demonstration using similar 2601-3200 series cars indicated that with

full emergency braking, an empty train traveling 10 mph is capable of stopping within 10

to 15 feet on dry, level track. When the brake cord is used, the stopping distance at 10 mph

is between 15 and 20 feet. The CTA maintenance, inspection, and testing records of the

accident consist indicated that the equipment was in satisfactory condition and listed no

exceptions that would have prevented proper operation. The previous operator of train

104, who had the same control cab, and the pilot stated that the brakes functioned

9 ìTailored friction brakingî is defined as a variable level of friction braking added to the dynamic

braking effort such that total braking does not exceed the coefficient of friction between wheels and rail.
Factual Information 7 Special Investigation Report

normally. The accident operator also noted that the brakes functioned normally before the

collision.

Signal System. Routine signal function tests were performed by the CTA, and no

exceptions were noted. The CTAís signal maintenance, inspection, and testing records

indicated that the equipment at the accident location was in satisfactory condition and

listed no exceptions that would have prevented proper operation. It was noted that when a

train exited the single-track detour, the cab signal system would not cut back in unless the

two track circuits immediately ahead of a train entering the northbound track were

unoccupied. The cab signal system is designed such that the absence of any speed signal is

interpreted as a stop signal, providing a trainís cab signal equipment is activated. To be

activated when trains enter cab signal territory at Western or at the end of the single-track

detour, the train cab signal equipment must receive a speed signal. With regard to cab

signal activation when the incident train entered cab signal territory at Western Station, the

CTAís manager of signal maintenance told Safety Board investigators that around the time

of the accident, contractors were working at Western Station as part of the CTAís station

renewal program and were involved in a major rehabilitation of the station. He said the

CTA had had recurring problems with contractors damaging the train control equipment,

which resulted in cab signals not activating on some trains.

Sight Distance Test. For sight distance tests, an orange cone was placed at the

point of collision. Investigators then departed the Belmont Station northbound going

toward the cone at about 10 mph. Investigators could see the cone as the train exited the

subway portal and came out of a sweeping right-hand curve. They could see the cone from

about 800 feet away (see figure 3). 

Event Recorders. CTA cars do not have event recorders. While some CTA cars

have maintenance data loggers that capture some operating data, the cars of train 104 did

not.

Meteorological Information

The National Atmospheric and Oceanic Administration reported that at the time of

the accident, the weather at OíHare Airport was dry with high broken clouds and a

temperature of about 83° F.

Toxicological Information

In accordance with Federal Transit Administration (FTA) regulations found at 49

Code of Federal Regulations (CFR) 653 and 654, the operator of train 104 was required to

submit breath and urine specimens for postaccident toxicological testing. The specimen

collection was completed at 2:41 p.m. No drugs or alcohol were detected in the specimens.
Factual Information 8 Special Investigation Report

August 3 Accident10

Accident Narrative

At 8:15 a.m. on Friday, August 3, 2001, a CTA operator reported for duty at the

CTAís Kimball Station. His schedule called for him to make five round trips between

Kimball and downtown Chicago. (See figure 4.)

For his first trip, he departed Kimball on time, at 8:25 a.m., operating train 416. He

stated that although he was not exceeding the allowable speed, he experienced several cab

signal overspeed indications shortly after departing Kimball, which resulted in an

undesired brake application and stop.11 He indicated that the overspeed alarms occurred

while the train was operating at a low speed, as if the train wheels were slipping and

Figure 3. Operatorís view as train approaches 

June 17 accident location.

10 See appendix B for an accident brief on this accident.
Factual Information 9 Special Investigation Report

causing a false speedometer reading. He said he also experienced two ìblue lightî

alarms.12 The first blue light alarm activated as the train departed Addison Station. He

reported that he was able to reset this first alarm from the cab when he stopped at Paulina,

the next station along the line.

A second blue light alarm sounded after the train left Sedgwick Station. The

operator said he had intended to continue to Chicago Station, where he would troubleshoot

the problem.

In CTA cab signal territory when a trainís cab signal equipment is activated, a stop

signal displays a red aspect inside the train cab. If the operator does not stop the train, the

system will bring the train to a stop automatically. Such stops, whether automatic or in

response to operator input, are commonly referred to as ìR6.4î stops, after the CTA rule

number that addresses them. To proceed after an R6.4 stop, the operator must depress a

button in the control cab. While the train is operating in the R6.4 stop mode, the signaling

system physically limits the trainís speed to 15 mph. CTA rules stipulate that if the stop

11 As noted earlier, the cab signal system displays an authorized speed to the operator and results in an

automatic stop if that speed is exceeded.

12 A blue light alarm indicates that one of the cars in the train has a propulsion or auxiliary power

problem. In the event of a blue light alarm, a trouble light illuminates on the operatorís console, and an alarm

bell sounds in the cab. A trouble light also illuminates on both sides of the affected car.

Figure 4. Location of August 3 accident.

DOWNTOWN

LOOP

MERCHANDISE HANDISE

MART

CHICAGO

SEDGWICK

ARMITAGE

TO KIMBALL & LINDEN

LAKE

MICHIGAN

ACCIDENT

LOCATION

HA

A

T

N
Factual Information 10 Special Investigation Report

signal is caused by a train that is known to be close ahead, the operator is to wait for the

signal to clear before proceeding. If the reason for the stop is not known, the operator is to

call the operations control center for authorization before he depresses the pushbutton and

proceeds.

The operator said that he had experienced several R6.4 stops during the early part

of his run, which, he said, was not unusual during rush hour because of the close spacing

of trains. He stated that once he entered the combined Brown/Purple Line tracks at Clark

Junction, he proceeded after R6.4 stops without waiting for the train ahead to clear and

without contacting the operations control center. He stated that it was common practice for

operators to proceed on an R6.4 without waiting or calling.

He stated that he left Armitage Station after an R6.4 stop knowing that he was

following a Purple Line train close ahead and that he was leaving Sedgwick the last time

he saw the taillights of the Purple Line train. After leaving Sedgwick and passing Division

Avenue, he entered Church Curve, where visibility was limited by the church building. At

the south13 end of the curve, he said that he observed the taillights of a train (train 505)

stopped about 100 feet ahead. He stated that when he saw the stopped train, he moved the

control handle first to brake position 3 and then to the emergency position, but the train

did not stop. He estimated his sight distance at 100 feet and the impact speed at 10 mph. In

postaccident interviews, he said that just before the collision, he was facing forward.

Several witness on the train stated that they did not feel the brakes engage before impact.

Also, several witnesses on and outside the train stated that the operator had his head out

the side window just before the collision. In a second, later, interview, the operator said

that he might have been distracted by the blue light alarm.

Train 505, the standing train, originated at Linden, the Purple Line terminal, at

8:11 a.m. and was en route to the downtown Loop. The operator said that as he

approached Chicago Station, he received an R6.4 stop through the cab signaling

equipment and brought the train to a normal stop. He said that he knew that there was a

train ahead, so he waited for the cab signal to clear. He said that the cab signal did not

clear after a few minutes and that just as he was preparing to contact the operations control

center, he felt an impact from the rear and was thrown forward into the console.

Injuries

Chicago Police Department logs indicate that 118 people were transported to area

hospitals, all with minor injuries. (See table 3.) One pregnant woman who was treated and

released was re-admitted to the hospital with complications believed to be related to the

accident and, consequently, is listed in this report as having sustained a serious injury.

Emergency medical personnel assessed the injured at the accident scene. About 12 people

were removed from the elevated structure, using aerial lift equipment, and transported to

local hospitals. Any other injured people were evaluated on site and removed from the

train after it was moved to Chicago Station (see figure 5).

13 The accident trains were proceeding railroad south, toward the Loop.
Factual Information 11 Special Investigation Report

Damage

Equipment damage consisted of damaged couplers, anti-climbers, and electronics,

as well as buckled flooring and broken windows. Buckled flooring on train 505 prevented

car-end doors from opening or closing properly throughout the train consist. All end doors

on train 416 functioned. The CTA estimated the cost of damage repair at $136,138.

Table 3. Table 3. Injuries resulting from August 3 accident.

Injury Scalea Employees Passengers Others Total

Fatal 0 0 0 0

Serious 0 1 0 1

Minor 2 115 0 117

Total 2 116 0 118

a

49 Code of Federal Regulations 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

Figure 5. Emergency response personnel at accident scene.
Factual Information 12 Special Investigation Report

Personnel Information

The train 416 operator stated that he was first employed with the CTA as a student

intern in 1988 and had worked intermittently during summer vacations until 1993, when

he was hired as a permanent part-time employee. His personnel record indicates that he

qualified as an operator on March 20, 1997. He had been most recently recertified as an

operator on April 26, 2001.

His record indicates that while working as a switchman, he was referred for

remedial training for a rules violation that occurred on August 2, 2000. The violation

involved improper uncoupling procedures that resulted in damage to car side barriers. He

was referred for remedial training after passing a stop signal on October 23, 1998, in

violation of CTA operating rules. Table 4 shows his training and operating history.

Table 4. August 3 accident operatorís training and operating history.

After the June 17, 2001, rear-end collision on the CTA Blue Line, the CTA, in

response to an issue identified by the Safety Boardís investigation, began delivering a

mandatory 4-hour refresher course on cab signal rules, operation on sight, and emergency

braking to its employees. CTA officials stated that they intended to train all rail operating

Date Event

10/1/93 Hired as permanent part-time employee

5/22/95 Qualified as conductor

3/24/96 Became full-time employee

4/12/96 Qualified as flagman

3/20/97 Certified as train operator

8/22/97 Qualified as customer assistant

10/25/97 Qualified for one-man operation*

9/22/98 Qualified as switchman

10/23/98 Rules violation: passing stop signal

3/24/99 Passed train operator recertification

8/2/00 Safety violation: uncoupling procedure, individual re-training

4/26/01 Passed train operator recertification

8/3/01 Rear-end collision occurs

*For operations without a conductor.
Factual Information 13 Special Investigation Report

personnel. The train 416 operator had not yet had the training; he had been scheduled to

take it on the Monday following the accident.

The train 416 operator had been off duty about 9 hours and 45 minutes before

reporting to work on the day of the accident. He had been on duty approximately 50

minutes when the accident occurred. He reported that he had gone to bed at midnight on

the night before the accident and had arisen at 6:00 a.m. On April 2, the day before the

accident, he worked a double shift, working from 8:15 a.m. to 5:42 p.m. as an operator and

then from 6:00 p.m. to 10:30 p.m. as a customer assistant. He worked a single shift on all

other workdays during the 3 weeks preceding the accident. (No State or Federal regulation

limits a CTA rail transit operatorís hours of service.) He stated that his rest was adequate,

that he was in good health, that he was not taking any medications, and that he was not

having any medical problems that would interfere with his ability to perform his job.

Train Information

Train 416, the striking train, consisted of six electrically propelled rapid transit

cars manufactured by the Morrison Knudsen Company in 1993. The 48-foot-long cars

pick up electrical power from a third rail by means of collector shoes. Sets of two cars

(married pairs) are permanently coupled together. A handle at the operatorís control stand

activates acceleration and braking. Rotating the handle clockwise from a neutral position

accelerates the train; rotating the handle counterclockwise initiates braking. There are four

braking positions: braking positions 1 through 3 are routinely used for service braking;

braking position 4 is designated the emergency brake and activates the maximum brake

rate, as well as the track brakes.

Train 505, the struck train, consisted of six rapid transit cars manufactured by the

Boeing Vertol Company between 1976 and 1978. The cars were generally similar in

design to the cars on train 416.

Postaccident Tests and Inspections

Braking Tests. The brake system of train 416 was tested and functioned normally.

A braking test using the accident train demonstrated that on dry, level track, the train could

be brought from 10 mph to a stop within 28 feet if full emergency braking was used. A

second test was conducted at the accident location using a six-car Brown Line revenue

train with a standing load of passengers. The test train was operated at 10 mph. At the

point where standing train 505 would have been visible to the train 416 operator, the

brakes were applied. Using service brake position 3 (a lesser brake rate than emergency),

the train stopped in 31 feet. The CTA maintenance, inspection, and testing records on the

accident train consist indicated that the equipment was in satisfactory condition and listed

no exceptions that would have prevented the trainís stopping short of another train. Car

3455 had had a propulsion ventilation failure before the accident.14 The failure would have

resulted in a blue light alarm with the propulsion and dynamic braking no longer being

operative on this car. CTA cars are designed such that when dynamic braking does not

14 See discussion of data logger information under ìEvent Recordersî below.
Factual Information 14 Special Investigation Report

engage, friction braking will compensate. The accident operator stated that the train

brakes functioned normally before the collision. 

Signals. The signal system (both wayside and car-mounted equipment) was tested

and was found by the CTA to meet all test criteria. 

Sight Distance. Investigators determined that the side of a train standing at the

point of impact could first be glimpsed by a following train from a distance of about 373

feet as the following train exited Church Curve. The view of the rear of the train was

unobstructed from about 345 feet (see figure 6). 

Event Recorders. The cars making up train 416 had maintenance data loggers

that, in this case, provided information relevant to the accident. The collision impact

knocked electrical propulsion circuit breakers on two cars of the striking train out of

position. This event registered as a fault on the maintenance data loggers on those cars and

caused the logging of 5 seconds of data (approximately 3 seconds before and 2 seconds

after the breaker position change). The data indicated that the second car was moving 13

mph about 1 1/2 seconds before impact, when the car went from propulsion power to

emergency braking. The data indicated that the speed was reduced to approximately 11

mph at impact. The fifth car (3455) was not in power because of a previous propulsion

system failure and blue light alarm. Data logged on the fifth car was consistent with data

from the second car in terms of speed and friction braking. The data record for the fifth car

Figure 6. Operatorís view as train rounds Church Curve.
Factual Information 15 Special Investigation Report

indicated that the propulsion ventilation had failed, which would have caused a blue light

alarm in the cab.

Meteorological Information

The National Atmospheric and Oceanic Administration reported that the weather

at OíHare Airport at the time of the accident was clear and dry with a temperature of about

77° F.

Toxicological Information

Pursuant to requirements at 49 CFR 654.33 and 653.45,15 the operators of trains

416 and 505 were required to submit breath and urine specimens for postaccident

toxicological testing. The specimen collection was completed at 2:30 p.m. for the operator

of the standing train and at 3:15 p.m. for the operator of the striking train. CTA contractors

also collected breath and urine specimens from the accident train controller and the

operator of the northbound train, who witnessed the accident. No drugs or alcohol were

detected in any of the specimens.

Background Information Related to Both Accidents

CTA Operations

General. The CTA operates rail and bus transit service in the city of Chicago and

surrounding areas. It is the second largest transit system in the United States. The CTA

operates seven rail lines, each designated by a color. In 2000, CTA trains carried more

than 147 million passengers and operated trains over 222 miles of track.

Traffic Control/Signal System. The CTA OíHare Branch of the Blue Line uses a

cab signal system between OíHare and Western Stations. From Western Station south, the

signaling system comprises automatic block signals with mechanical trip stop arms. On

both sections, signaling is designed to maintain one unoccupied track circuit between any

two trains. A cab signal system is installed on the entire Brown Line.

The cab signal system picks up speed codes from the track circuits through an

antenna and displays them to the operator on an aspect display unit in the cab (see figure

7). An operator may operate up to the indicated speed. If the indicated speed is exceeded,

an alarm sounds, and the train must be put into braking position 2 or 3 and slowed to the

proper speed. If the operatorís response to an alarm is not timely, train braking will initiate

automatically after 1 1/2 seconds, and the train will be brought to a complete stop. The

system is designed such that, provided cab signaling is cut in, the absence of a speed code

in the track circuit is interpreted as a stop signal, which is covered by rule R6.4 (discussed

below). 

15 As a result of an October 2001 revision, these requirements are now found at 49 CFR 655.
Factual Information 16 Special Investigation Report

At the transition from cab signal territory to block signal territory on the Blue Line,

the cab signal system must be cut out; otherwise, trains will be brought to a stop because

of the absence of the required speed code. The system is cut out through use of a signal

card in the wayside equipment. At the transition back to cab signal territory from block

signal territory, the cab signal system is designed to cut back in as soon as any speed code

is detected. If a train does not detect a speed code, the cab signal system will not cut in. As

Figure 7. Cab signal aspect display unit.
Factual Information 17 Special Investigation Report

noted earlier, this same feature prevents the system from cutting back in if one or both of

the two track circuits ahead are occupied.

Operating Rules. The operating rulebook current at the time of the two accidents

was the Rail System Rule Book, dated June 1, 1995. Rule R6.4 states:

When a train receives a red or flashing aspect of a cab or wayside signal, the train

must be stopped and must NOT proceed until the motorman has been instructed to

do so by the controller.

If the reason for the stop is a train ahead which can be expected to proceed shortly,

the motorman must wait for the signal aspect to change to a proceed indication. 

If the reason for the stop is not evident, or if the signal does not clear within 30

seconds, the motorman must call the controller for instructions. If communication

with the controller cannot be established and it is safe to proceed:

IN CAB SIGNAL TERRITORY, proceed at not to exceed 15 mph expecting to

encounter a switch not properly lined or a broken rail-to next signal bond or

telephone and call controller again for instructions.

The purpose of requiring an operator to obtain authorization from the operations

control center before proceeding after an R6.4 stop is to allow the train controllers (1) to

check that a train is not close ahead (in which case, authorization can be withheld unless

closing in is desired for operational reasons) and (2) to note possible signal system

maintenance problems at specific locations. When the authorization to proceed is given, it

carries with it the requirement that trains ìkeep at a safe distance andÖoperate at a speed

which will enable a safe stop should a train ahead make a sudden stop.î16 Rule R6.5.2

states:

Should the ATC [automatic train control] or STEM [side trip emergency17]

equipment of a train already in service become less than fully operational,

motormen must stop and obtain authorization from the controller before

proceeding. The controller will provide specific instructions, may authorize

bypass of the automatic train stop (STEM, ATC or both) and may dispatch a

supervisor to intercept the train.

The CTA refers to its cab signal system as ìautomatic train control.î When active,

the system enforces compliance with stop signal indications automatically. Once a train is

stopped, the system allows an operator to proceed with a speed limited to 15 mph,

providing a button is depressed as in the August 3 accident. If the system is disengaged, as

in the June 17 accident, the operator may proceed without cab signals. 

Both accident operators indicated that they had observed violations of rule R6.4 or

R6.5.2 by other employees or managers. Shortly after the first accident, a Safety Board

16 CTA Rail System Rule Book, rule number R8.10.2.

17 ATC, or ìautomatic train control,î is the term the CTA uses to refer to its cab signal system. STEM,

or ìside trip emergency,î refers to an emergency circuit that bypasses the side trips, which are used in block

signal territory to provide a physical enforcement for stop signals.
Factual Information 18 Special Investigation Report

investigator who was riding in the cab of a CTA train observed a CTA manager proceed

without cab signals cutting in from Western Station into cab signal territory without

obtaining authorization from the operations control center, violating the same operating

rule as that involved in the June 17 accident. 

Regarding blue light alarms, CTA operating rule R8.35 states ìdefects in

equipment or any dangerous or unusual condition must be reported immediately to the

controller.î As part of the investigation of the second accident, Safety Board investigators

conducted field interviews of 22 CTA operating employees about procedures involved in

R6.4 stops and blue light alarms. These employees included 10 operators, 8 controllers,

and 4 training instructors. Of the 10 operators, 3 said they sometimes proceeded after an

R6.4 stop without waiting for the signal to clear and without contacting the operations

control center. Three of the eight controllers said they would not check for trains close

ahead before authorizing further movement after an operator reported an R6.4 stop. Six of

the operators said they would not report a blue light alarm until they had tried to reset it

and were ready to cut out a car. Seven controllers said they expected operators to call in

blue light alarms before attempting a reset.

CTA Operator Training and Performance Evaluation

Training. At the time of these accidents, the CTAís operator training consisted of

21 days of classroom and hands-on instruction. Employees who did not pass the program

were allowed to take additional training on their own time. The CTAís manager of rail

instruction stated that students were generally allowed three attempts to qualify as

operators before being dropped from the program. 

Evaluation. At the time of these accidents, the CTA monitored operator

performance and rules compliance through a program of observations and ride checks.

The CTAís system safety program plan (described in more detail below) describes the

program as a process in which:

Operating Rules and Procedures are constantly monitored on the Rail Lines by

Rail Supervisors, Line Managers, Performance Control Specialists, Control

Center Management Personnel, System Safety Inspectors and Rail Instructors

riding the trainsÖ.

The system safety program plan goes on to describe how rapid transit operators are

ìchecked by a Rail Instructor during actual job performance at regular six (6) month

intervals for the rest of their careerÖ.î

Rail operations department supervisors or managers perform ìpoint checksî and

ìride checksî on operators. Point checks are observations performed at a station; ride

checks involve riding with the operator. Observations and ride checks are documented on

a paper form. 

According to the CTAís manager of rail instruction, the schedule for twice yearly

ride checks by CTA training instructors was not being met at the time of the accidents.

There was no record of safety department operating rules compliance monitoring of either
Factual Information 19 Special Investigation Report

operator. The CTA did not employ unannounced efficiency tests designed to monitor and

evaluate operatorsí application and understanding of or compliance with the rules, nor

were such tests required by regulation.

During the investigation of the June 17 accident, the CTA produced records

indicating that the accident operator was the subject of 20 point checks and 6 ride checks

between April 1, 2001, and the accident on June 17. Blue Line supervisors or managers

performed these checks, and none reported any exception to the operatorís performance. 

The CTA did not produce any records of point checks or ride checks on the August

3 accident operator for the 60 days preceding the accident date or any records of training

department checks on the operator during the 12 months before the accident. The operator

said that the last time a training instructor had ridden with him was during his

recertification training in April 2001. Under the category of coordination and operation,

the recertification report was marked ìI,î which, according to the legend on the form,

indicates an insufficient basis for rating. CTA officials told the Safety Board that

ìInsufficientî is checked when the instructor does not have the opportunity to evaluate

these aspects of the operatorís performance. The recertification training report was

marked satisfactory for cooperation, initiative, and appearance. 

The system safety program plan indicates that the CTAís safety department also

conducts ride checks to monitor operator rules compliance. At the time of the accidents,

there was no numerical goal for safety department ride checks, and there was no record of

safety department ride checks having been performed with the June 17 operator within the

60 days preceding the accident or with the August 3 operator during the 2001 calendar

year. The CTA system safety program plan indicates that performance control specialists

(who work in the CTAís security department) also perform rules compliance monitoring

while they are on the line. There was no record of performance control specialists

monitoring the August 3 operator during the 60 days preceding the accident.

When the CTAís process of rules compliance monitoring determines that a

violation of rules has occurred, the operator is typically referred to the training department

for remedial instruction. During the 12 months preceding the accident, two operators were

referred for remedial instruction as a result of violating rule R6.4.

CTA Oversight

In its 1991 safety study18 on the oversight of rail rapid transit safety, the Safety

Board concluded that the primary responsibility for oversight of rail rapid transit safety

properly resides with the State and local governments of the localities in which the

systems operate. The Board also concluded, however, that the Urban Mass Transportation

Administration (UMTA), the predecessor of the FTA, had a legitimate role in ensuring

safety on rail rapid transit systems and could do so by providing guidelines to States and

local authorities for their development of effective oversight programs.

18 National Transportation Safety Board, Oversight of Rail Rapid Transit Safety. Railroad Safety Study

NTSB/SS-91/02 (Washington, D.C.: NTSB, 1991).
Factual Information 20 Special Investigation Report

Consequently, on August 6, 1991, the Safety Board recommended to the 11 States

that had rail rapid transit systems and to the District of Columbia that they:

R-91-37

Develop or revise, as needed, existing programs to provide for continual and

effective oversight of rail rapid transit safety. The elements of the oversight

program should include reviews of maintenance and inspection records, accident

investigation activities, audits of system safety program plans, reviews of the

transit system safety department, reviews of training programs, monitoring of

accident data, and periodic inspections of equipment and infrastructure.

On the same date, the Safety Board also recommended that UMTA:

R-91-33

Document and evaluate the effectiveness of existing State oversight activities of

rail rapid transit safety and develop guidelines for use by state and local

governments that address the critical elements of an effective oversight program.

Safety Recommendation R-91-37 to California, Florida, New York, and

Pennsylvania has been classified ìClosedAcceptable Action.î The recommendation to

Illinois, Maryland, Massachusetts, New Jersey, Ohio, and Virginia remains classified

ìOpenAcceptable Response.î The recommendation to the District of Columbia and

Georgia remains classified ìOpenAwaiting Response.î 

In December 1991, Congress gave the U.S. Department of Transportation the

authority to establish requirements for State safety oversight of rail fixed guideway mass

transportation systems and to withhold funding for those that do not meet the

requirements. In 1995, in response to the congressional mandate and after a rulemaking

process, the FTA promulgated State safety oversight regulations at 49 CFR Part 659.

These regulations became effective in 1996. Based on this Federal action, Safety

Recommendation R-91-33 was classified ìClosedñAcceptable Actionî on April 16, 1996.

The FTA regulations require that:

ï Each State with a rail fixed guideway system designate an oversight agency,

ï Each oversight agency develop a system safety program standard that complies

with the American Public Transportation Association (APTA) manual,

ï The oversight agency require each rail fixed guideway system to submit a

system safety program plan for approval,

ï The oversight agency require each rail fixed guideway system to submit an

internal safety audit report for review annually, 

ï The oversight agency conduct its own on-site safety review of the transit

agencyís system safety program plan, and

ï The oversight agency establish accident investigation procedures.
Factual Information 21 Special Investigation Report

System Safety Program Plan. Incorporated within the regulations, at

49 CFR 659.31 and 659.33, are requirements that fixed guideway transit systems, such as

the CTAís rail transit system, develop and implement a system safety program plan that

complies with the guidelines provided in APTAís Manual for the Development of Rail Transit

System Safety Program Plans. According to the APTA document, a system safety program

plan ìestablishes the Safety philosophy of the whole organization and provides the means

of implementation.î APTA identifies the overall goal of system safety program plans for

fixed guideway transit systems as follows:

To identify, eliminate, minimize, and/or control safety hazards and their attendant

risks by establishing requirements, lines of authority, levels of responsibility, and

accountability, and methods of documentation for the organization.19

A system safety program plan is a formal written document that identifies all

safety-related responsibilities and assigns the fulfillment of those responsibilities to

appropriate areas within the organization. The plan also establishes the specific safety

objectives and procedures of the organization. Each transit system develops its own plan.

The CTA issued its current plan in February 1999. 

Internal Safety Audit Program. One element of the system safety program plan is

an internal safety audit program. Once the system safety program plan is in place, the

transit system maintains internal oversight of its own system safety program plan to

ensure that all responsibilities are being fulfilled and coordinated. The CTAís safety

programís effectiveness and integrity are monitored through an internal safety audit

program carried out by the system safety department. The State safety oversight

regulations (discussed in more detail later in this report) require that each transit system

submit a report on its audit to the oversight agency. The CTA had submitted its year 2000

report to the Regional Transportation Authority of Northeastern Illinois (RTA) as required.

The CTA provided the Safety Board with its year 2000 internal safety audit report,

which, in its audit of rules compliance, was limited to the Red Line. Audit checklist item 4

states, ìservice rail operation employees comply with safety rules and S.O.P.s [standard

operating procedures].î The report found that this aspect of transportation department

responsibilities met plan requirements. There was no information in the audit report about

how this conclusion was reached.

The internal safety audit also looked at the CTAís training and safety departments.

It did not include a checklist item specifically addressing the training departmentís

program of twice yearly check rides with operators or the safety department operating

rules compliance monitoring of operators.

State Oversight and Audits. The FTA regulations require each State to designate

a State agency to provide safety oversight. Illinois designated the RTA as the oversight

agency for the CTA in 1997. The RTA issued a system safety program standard as required

19 APTA, Manual for the Development of Rail Transit System Safety Program Plans (Washington, D.C.:

APTA, 1991), p. vi.
Factual Information 22 Special Investigation Report

by FTA regulations on October 30, 1997. The standard lays out the procedures to be

followed by the CTA and the RTA to address the requirements of FTA-mandated State

safety oversight. 

Among other things, FTA regulations require that the RTA approve the CTAís

system safety program plan, investigate accidents,20 review the CTAís annual internal

audit report, and perform a triennial safety review of the CTA. In fulfilling that

responsibility, the RTA has the authority to audit and observe all CTA operations. Two

RTA employees devote part of their time to the State safety oversight program. The

majority of RTA employees are involved in the financial and budget oversight of the CTA,

METRA, and Pace.21 The RTA reports to an appointed board of directors. 

The FTA has audited several State programs to determine whether they are

complying with the requirements of 49 CFR 659. Such an audit was conducted in Chicago

in July 2000. The audit found one deficiency and three areas of concern.22 The deficiency

involved the RTAís not ensuring that CTA accident notifications and progress reports were

submitted in a timely manner. The areas of concern involved updating and clarifying the

RTA system safety program standard oversight policy and procedures. The RTA revised

and reissued its system safety program standard on September 12, 2000, in response to

findings of the FTA audit. The FTA advised the RTA by a letter dated September 25, 2000,

that ìall audit findings have been successfully addressed.î

The manager of the RTAís oversight division stated that in past years, RTA

staffmembers have not accompanied CTA auditors during internal safety audits. She stated

that the RTA intended to participate as observers during the CTAís 2002 internal safety

audits.

The RTAís first triennial on-site safety review of the CTAís system safety program

plan was conducted during May and June 2001 by consultants.23 The regulations define a

safety review as: 

A formal, comprehensive, on-site examination by the oversight agency of a transit

agencyís safety practices to determine whether they comply with the policies and

procedures required under the transit agencyís system safety program plan.

The triennial on-site safety review found that CTA transportation units operate in

general compliance with established rules and procedures. The review did not specifically

look at the training departmentís program of twice-yearly check rides with operators or the

safety departmentís operating rules compliance monitoring. The review found the CTAís

training programs to be in general compliance with its established procedures.

20 The regulations allow the oversight agency to delegate such investigations to the transit agency, and

that is what the RTA has elected to do.

21 METRA operates commuter rail service, and Pace operates bus service.

22 The term ìdeficienciesî is defined as serious findings that could jeopardize FTA funding. ìAreas of

concernî is defined as weaknesses that should be addressed.

23 FTA regulations permit the designated State agency to use contractors to conduct safety reviews.
Factual Information 23 Special Investigation Report

APTA Audits. The CTA participates in the voluntary APTA audit program. The

audits are conducted independently of FTA State safety oversight regulations. The last

APTA audit before the accidents was in 1998, and a report was issued on December 20,

1999. The audit found no problems with how transportation line management oversaw

rules compliance by operators. APTAís audit did not include a checklist item specifically

addressing the CTA training departmentís program of twice-yearly check rides with

operators or the CTA safety departmentís ride checks.

Other Information

Postaccident CTA Actions

CTA officials told investigators that the operator in the June 17 accident had been

discharged. Also, in an August 29, 2001, letter to the Safety Board, CTA management said

the following steps were being implemented after the June 17 accident (the management

had taken the steps in response to issues identified by the Safety Board investigation): 

ï In July 2001, the CTA began holding mandatory rules refresher classes for all

transportation managers and operators. The classes cover signal rule

compliance, the operation of trains prepared to stop short, and the use of

emergency braking.

ï The CTA revised its single-track procedure to eliminate the cutting out of cab

signals.

ï The CTA began reviewing the records of operators to identify for contact and

follow up those operators with multiple rules violations.

ï The CTA revised its signal test to include the aspects on the cab signal aspect

display unit. All operators must pass the test with a score of 100 percent during

certification and recertification.

The CTA system safety and environmental affairs department, in its report on the

second accident, which was given to the Safety Board on January 3, 2002, made four

recommendations. The CTA informed the Safety Board in a January 29, 2002, letter that

the recommendations had been adopted and had resulted in the following actions:

ï The accident operator was discharged.

ï Transportation managers and rail supervisors had been directed to increase

their line ride checks to ensure that employees are following rules and

procedures.

ï Operating employees who had not operated a train within 60 consecutive days

were required to take refresher training.

In addition to these steps, the mandatory rules refresher classes implemented after

the first accident were expanded to include CTA train controllers. The classes were begun
Factual Information 24 Special Investigation Report

on July 23, 2001, and were completed on September 17, 2001. The CTA also placed a

decal in each train operating cab to remind operators of the requirements of rule R6.4.

APTAís Standards Task Force

APTA formed a Rail Transit Standards Task Force in 2000. The task force bylaws

describe its purpose as the development of standards and recommended practices by and

for the transit industry through a broad-based consensus process. The task force objectives

include development of industry standards and recommended practices that have a high

potential to lead to safety improvements.

The task force bylaws define ìstandardsî as covering areas that involve a safetycritical task, process, component, or system. The final adoption of a standard is through

approval by a policy committee composed of the general managers of transit systems

participating in the task force.

Five committees are currently working on standards and recommended practices.

They are as follows:

ï Vehicle inspection and maintenance;

ï Operating practices;

ï Fixed structure inspection and maintenance;

ï Grade crossings; and

ï Vehicle crashworthiness.

One of the standards in an early stage of development is entitled ìGeneral Rule

Standard for Rule Compliance and Implementation.î The standard is expected to be

completed and issued by mid-2003. Adherence to APTA standards is voluntary. However,

one of the task force objectives is to ìover time, have State oversight programs reflect the

work done by the task force.î
25 Special Investigation Report

Analysis

General

Both accidents occurred during daylight hours and under satisfactory visibility and

track conditions. During postaccident tests and inspections, investigators found nothing to

indicate that either train 104 or train 416 had any mechanical defects or deficiencies that

would have prevented either one from stopping short of another train. However, a

propulsion system ventilation failure resulted in a blue light alarm in the cab of the August

3 train, and the operator stated that the alarm may have distracted him. A postaccident

examination of the signal system did not disclose any defects at either accident location.

However, it was noted in the June 17 accident that the presence of a train one or two track

circuits ahead resulted in cab signals on a following train not engaging upon exiting the

single-track detour. All evidence indicated that the braking systems operated as designed

during both accidents. The postaccident toxicological testing did not indicate that drugs or

alcohol contributed to either accident. The Safety Board, therefore, concludes that there

was no evidence of alcohol or drug use in these accidents and that the following factors

were neither causal nor contributory to either accident: weather, signal system

malfunction, or the braking systems of the trains. 

June 17 Accident

The accident train (train 104) operator stated the cab signal system did not cut in at

Western Station (four stations before the accident location). Although, she said, she

understood that in such an event, CTA rules required her to obtain authorization from the

operations control center for further movement, she proceeded without seeking such

authorization.

Regardless of the cab signal activation status at Western Station, a temporary

signal card was installed to de-activate cab signals as the train left California Station and

entered the single-track detour. This was done to expedite the movement of trains through

the single-track detour. With cab signals cut in, each train entering the single track would

have been brought to a stop by the cab signaling equipment and been limited to a speed of

15 mph through the detour. The operating plan called for cab signals to cut back in at

Belmont Station after northbound trains had cleared the single-track detour between

California and Belmont Stations. Because of the close spacing of the trains, the cab signals

did not cut back in for train 104, which had been operating without cab signals since

Western Station. Again, the operator proceeded without seeking authorization from the

operations control center. The Safety Board concludes that the CTAís practice of cutting

out cab signaling and allowing trains to move through a single-track detour at close

spacing set the stage for train 104 to re-enter and proceed on cab signal track with inactive

cab signals, albeit in violation of the CTAís operating rules. 
Analysis 26 Special Investigation Report

As a result of this accident, the CTA has discontinued the practice of cutting out

cab signals when single-track detours are established.

The purpose of the CTAís requirement that an operator get authorization to proceed

in cab signal territory without cab signals is to allow the operations control center to

confirm that a section of track ahead of the train is clear of other trains. The controller

must determine the location of the nearest train ahead and authorize movement ìon

sightî24 to a specified point short of the last known position of the train ahead. When the

authorization is given, the controller must maintain a manual block control sheet. The

ìmanual blockî system provides a procedural safeguard against collisions while the

engineering safeguards provided by the signal system are unavailable. When the

safeguards are not in place, the safety of train movements must rest entirely on the

operatorís ability to control the trainís speed and to stop short of another train. The Safety

Board, therefore, concludes that had the operator in the June 17 accident stopped and

contacted the control center when the cab signals on her train did not activate and had the

control center then followed existing manual block procedures, the accident would have

been prevented. 

The train 104 operator stated that as she proceeded out of Belmont Station, she

knew that another train was close ahead and that she had previously been close enough to

see its taillights. As she rounded a sweeping right-hand curve, she stated, her speed was 10

mph, and she was fully alert when she saw the train stopped ahead and applied the brakes,

which, she said, did not work properly to stop the train.

The Safety Board does not find this part of her account credible. The Safety Board

identified no mechanical condition or malfunction that would have prevented the train

from stopping had the brakes been applied appropriately. Sight distance tests indicated

that the standing train was visible from 800 feet away. At a train speed of 10 mph, the

operator had more than 50 seconds to see the train ahead and bring her own train to a stop,

without the need to resort to emergency braking. The Safety Board concludes that the

operator in the June 17 accident had ample time to see the train ahead and bring her train

to a safe stop; however, for unexplained reasons, she failed to do so. 

A review of the train 104 operatorís training and operating history indicates that

she was trained and qualified in three safety-sensitive positions; operator, flagman, and

switchman. She had failed the operator and flagman training programs twice and had

qualified on the third try only after receiving remedial training. She had failed switchman

training once and qualified on the second try after receiving remedial training. The CTAís

manager of training stated that trainees are typically given three chances to qualify. 

The operatorís record indicates that she had violated several CTA safety rules

during her 12-month career as an operator, including failing to stop at stop signals. The

CTAís response was to refer her for additional training, which she was given multiple

opportunities to pass. The CTAís system safety program plan specifies that training

personnel will ìmake contactî with operators twice yearly to evaluate their performance.

24 ìOn sightî is defined in CTA rules as ìwithin the range of vision.î
Analysis 27 Special Investigation Report

This schedule was not being met at the time of the accident, and the accident operator had

not been contacted. 

The CTA disciplinary process resulted in a corrective case interview, after which

the operator was referred for 24 hours of additional training. She successfully completed

the additional training 1 month before the accident and returned to service. Despite

repeated instances of violating the CTAís operating rules, she was allowed to remain in

service. The Safety Board concludes that CTAís management process for identifying and

addressing operators who do not meet safety performance standards was not effective in

addressing the repeated problems that the operator was experiencing. In response to this

issue, which was identified by the Safety Boardís investigation, the CTA implemented a

program to review operatorsí records and follow up with those who have multiple rules

violations.

August 3 Accident

The operator of train 416 said that shortly after departing Kimball Station, he

experienced several cab signal stop indications (R6.4 stops). He stated that the stops were

not unusual during the rush hour because of the close spacing of trains. 

CTA operating rule R6.4 required that the operator wait for the signal to clear after

each stop, since he knew a train was close ahead. The purpose of the requirement is to

prevent trains closing on each other unnecessarily. The rule provides a procedural

safeguard by maintaining at least one track circuit separation between trains. But the

operator stated that once he entered the combined Brown/Purple Line tracks at Clark

Junction, he repeatedly proceeded after R6.4 stops without waiting for the train ahead to

clear and without contacting the operations control center. He said that he knew a Purple

Line train was close ahead and that it was common practice for operators to proceed from

an R6.4 stop without either waiting for a proceed signal or calling for authorization from

the operations control center.

Because the operator consciously violated the rule, the safety of further train

movement relied entirely on his alertness and his ability to stop short of another train from

a maximum speed of 15 mph. The Safety Board concludes that had the operator in the

August 3 accident complied with the CTAís operating rules and waited for his stop signal

to clear before proceeding, the accident would have been prevented. 

He stated that he was leaving Sedgwick (the last station before the accident site) on

an R6.4 stop indication when he last saw the taillights of the Purple Line train. He said he

also had a propulsion system blue light alarm at this time. (The alarm illuminates a trouble

light on the console, activates a continuously ringing bell in the cab, and illuminates a

trouble light on the side of the affected car.) After leaving Sedgwick and passing Division

Avenue, he entered Church Curve, where visibility was limited by a church. He stated that

as he exited the curve, he saw the taillights of a train stopped about 100 feet ahead. He said

that he was alert and facing forward when he first saw the train. He said he then moved the
Analysis 28 Special Investigation Report

control handle first to brake position 3 and then to the emergency position, but that the

train did not stop.

The Safety Board could not find any mechanical reasons why the operator failed to

stop train 416 short of the standing train. Sight distance tests indicated that the standing

train was visible from 373 feet away which, at 13 mph (the speed indicated on the accident

trainís maintenance data logger), would have given the operator 18 seconds or more to see

the standing train and activate braking to safely stop and avoid an accident. But according

to the maintenance logger data, the operator did not activate emergency braking until 1 1/2

seconds before impact. 

Although the operator told investigators during postaccident interviews that he

was facing forward as the train rounded Church Curve, several witnesses stated that he

had his head out the side window just before the collision. In a second interview, he

conceded that he might have been distracted by the propulsion system blue light alarm.

The Safety Board concludes that the operator had ample time to see the train ahead and

bring his train to a safe stop; however, for unexplained reasons, he failed to do so. 

Rules Knowledge Among CTA Operating Personnel

CTA rule R6.4 does allow trains to proceed on an R6.4 stop indication under

specified conditions. The rule states that after waiting at least 30 seconds, the operator

must request authorization from the controller to proceed. The purpose is to allow the

controllers (1) to check that a train is not close ahead and (2) to note possible signal

system maintenance problems. When the authorization to proceed is given, it carries with

it the requirement that the train be operated at a speed and in a manner that will allow the

operator to stop short of another train, a misaligned switch, or a broken rail.

Had the operator asked for authorization to proceed, it is uncertain whether the

controller would have checked for trains close ahead and withheld authorization to

proceed. Three of eight interviewed controllers stated that if an operator reported an R6.4

stop, they (the controllers) would not check for trains close ahead before authorizing

further movement. In other words, had the operator in the August 3 accident called the

operations control center about the stop signal, he may have been given authority to

proceed without waiting for the signal to clear, and the accident may still have occurred. 

Some CTA employees were also confused about the proper procedures to follow

after an operator received a blue light alarm. Although CTA rule 8.35 states that ìdefects

in equipment or any dangerous or unusual condition must be reported immediately to the

controller,î 6 of the 10 interviewed operators said they would not report a blue light alarm

to the operations control center until they had tried to reset it and were ready to cut out a

car. Seven of the eight interviewed controllers said that they expected operators to call in

blue light alarms immediately. The Safety Board concludes that controllers and operators

were inconsistent in their application and understanding of the rules governing stop

signals and blue light alarms. 
Analysis 29 Special Investigation Report

After reviewing the results of the Safety Boardís field interviews of the staff, CTA

management included the controllers in a mandatory refresher course on signal rules

compliance that initially had been targeted at operators and supervisors.

Enforcement of Operating Rules on the CTA

In both the June 17 and August 3 accidents, operators knowingly violated

operating rules. Both accident operators indicated that they had observed similar rule

violations by other employees or managers; and, in fact, Safety Board investigators

observed a CTA manager violating a CTA operating rule. Limited field interviews with

CTA operating personnel indicated such rules violations were more widespread than the

occurrence of two accidents might suggest. 

The CTAís system safety program plan not inappropriately assigns primary

responsibility for operations rules compliance to the operations department. During the

course of the investigation, the Safety Board found that the actual implementation of the

CTAís rules compliance program did not match the description in the plan. For example,

the primary ways management was supposed to monitor operatorsí rules compliance was

by having rail supervisors and line managers do ride checks and point checks. But the

twice yearly monitoring of operators by training instructors described in the plan was not

being done. Also, the CTA safety department checks were not being made, at least in the

cases of the two accident operators. 

But even if the point checks and ride checks had been performed in accordance

with the established schedule, the Safety Board is not convinced that they would have

been effective in ensuring that operators strictly and consistently adhered to operating

rules. For example, point checks are performed at a station and, thus, do not permit an

evaluation of most operating rules. Ride checks are performed inside the operating cab,

and the operator is aware of the evaluatorís presence. Operators may be expected to follow

the rules to the letter during such evaluations, but management has no assurance that the

operator will exercise the same diligence when he or she is not being observed. The Safety

Board concludes that the CTAís program for the enforcement of operating rules was

inadequate in design and execution and that, consequently, rules violations, such as those

related to these two accidents, were not uncommon. 

The CTA does not have unannounced efficiency tests or tests for rules compliance

in which the operator is not aware that a test is in progress, nor does the FTA require such

tests. In contrast, the Federal Railroad Administration (FRA) regulations (49 CFR 217.9)

specifically address a program of operational tests, inspections, and record keeping on

railroads subject to FRA jurisdiction. Such rules compliance programs typically include

check rides and efficiency tests.25 Most railroads also periodically review event recorder

data to confirm that engineers are following the rules. 

25 Efficiency tests involve setting up a scenario, such as a stop signal, and documenting the operating

crewís actions to verify that applicable rules are complied with.
Analysis 30 Special Investigation Report

In the view of the Safety Board, rules compliance enforcement programs can be as

effective in preventing accidents in the transit industry as they are in the railroad industry.

Consequently, the Safety Board has previously urged transit agencies to strengthen their

rules compliance enforcement programs. For example, as a result of its investigation of a

collision involving two Greater Cleveland Regional Transit Authority (GCRTA) trains

near 98th Street Station in Cleveland, Ohio, on July 10, 1985,26 the Safety Board issued the

following safety recommendation to the GCRTA.

R-87-8

Perform and document frequent supervisory checks using a systematic procedure

to determine if train operators are complying with the operating rules, including

speed restrictions and signal rules.

In a March 4, 1988, letter, the GCRTA informed the Safety Board that ìrail

supervisors now perform a minimum of two ride checks per dayî and that: 

a field test is also conducted with automatic signals. Rail supervisorsÖset the

signal red or dark and monitor passing trains from a concealed vantage point to

observe proper adherence to operating rules.

Accordingly, Safety Recommendation R-87-8 was classified ìClosedó

Acceptable Action.î

As a result of its investigation of another collision involving two GCRTA trains

near 98th Street Station in Cleveland, Ohio, on July 2, 1991,27 the Safety Board issued the

following safety recommendation to the GCRTA:

R-93-1

Implement a management oversight program that effectively supervises train

operations and enforces the operating rules.

In a July 18, 1994, letter, the GCRTA informed the Safety Board that it had created

a rail oversight committee that had: 

put in place the formal structure to support an ongoing process to improve the

safety of the GCRTA. The structure includes regularly scheduled meetings, a

resolution tracking system and monthly safety audit summary reviews.

Accordingly, Safety Recommendation R-93-1 was classified ìClosedóAcceptable

Action.î

26 National Transportation Safety Board, Rear-End Collision of Two Greater Cleveland Regional

Transit Authority Red Line Rapid Transit Trains Near the 98th Street Station, Cleveland, Ohio, July 10,

1985, Railroad Accident Report NTSB/RAR-87/01 (Washington, D.C.: NTSB, 1987).

27 National Transportation Safety Board, Rear-End Collision Involving Two Greater Cleveland

Regional Transit Authority Trains Near the West 98th Street Station, Cleveland, Ohio, July 2, 1991, Railroad

Accident Report NTSB/RAR-93/01/SUM (Washington, D.C.: NTSB, 1993).
Analysis 31 Special Investigation Report

As a result of its investigation of a collision involving two Metropolitan

Transportation Authority/New York City Transit (NYCT) trains near 9th Avenue Station in

Brooklyn, New York, on February 9, 1995,28 the Safety Board issued the following safety

recommendation to the NYCT.

R-96-10

Revise the operating employee evaluation checklist to effectively determine

compliance with operation rules and instructions and include, at a minimum,

unannounced speed and signal tests and radio communications procedures.

In a May 22, 1996, letter, the NYCT informed the Safety Board that the checklist

had been revised to include ìconducting random unannounced radar checks of train

speeds.î In addition, the NYCT informed the Board that it had implemented an efficiency

test program. Accordingly, Safety Recommendation R-96-10 was classified ìClosedó

Acceptable Action.î

As shown by the June 17 and August 3 accidents, the CTA would benefit from a

comprehensive program of evaluations and efficiency tests similar to those in the railroad

industry and in other transit agencies. The Safety Board, therefore, believes that the CTA

should develop and implement systematic procedures for performing and documenting

frequent management checks to ensure all operating personnel are complying with CTA

operating rules, including speed restrictions and signal rules.

Such a rules compliance program might include procedures for supervisors to

follow in making unannounced observations, field audits at stop signals and of speed

restrictions, and periodic reviews of event recorder data.

Convening an independent panel of experts from other railroads and transit

agencies is one of the methods used in the transit industry when an agency, such as the

CTA, needs advice on program improvements or has had a significant series of accidents.

Such a ìpeer reviewî or ìblue ribbon panelî29 is a cost-effective way to allow an agency to

tap industry experts who have experience with the best industry practices in other

organizations. The Safety Board hopes that the CTA will obtain the best advice possible in

strengthening its operating rules compliance programs.

Another potential resource for transit agencies in establishing and maintaining a

safe transit system is APTAís standards and best practices that are currently in

development. The Safety Board believes that APTA should include specific guidance for

transit operators on performing unannounced rules compliance observations and

efficiency tests as the General Rule Standard for Rule Compliance and Implementation is

developed. 

28 National Transportation Safety Board, Collision and Derailment of Two Subway Trains Metropolitan

Transportation Authority New York City Transit in Brooklyn, New York, February 9, 1995, Railroad

Accident Report NTSB/RAR-96/01 (Washington, D.C.: NTSB, 1996).

29 APTA has a program to organize peer reviews at the request of transit agencies, although some

agencies organize such reviews on their own or through consultants.
Analysis 32 Special Investigation Report

CTA System Safety Plan

The CTA uses a system safety program plan as the basis for its overall safety

policy. In a recent Safety Board special investigation report,30 the Safety Board noted that

the appropriate use of such plans by rail transit systems provides a reliable means of

establishing and maintaining safe operations. Such plans, when fully implemented, set a

standard for safe procedures in all operational departments. The plans require periodic

audits to confirm that the safety standards are being satisfied. Audits are conducted by the

organization itself, by the State regulatory agency, and (upon request) by APTA. A welldrafted and fully implemented plan helps ensure that the organizationís approach to safety

concerns is systematic, consistent, and verifiable.

The CTAís system safety program plan assigns primary responsibility for internal

safety audits to the system safety and environmental affairs department. As noted earlier,

the CTAís system safety program was not effective in the area of rules compliance, yet the

agencyís year 2000 internal safety audit found that ìservice rail operation employees

[were complying] with safety rules and S.O.P.s.î The internal safety audit did not

specifically address the training departmentís program of twice-yearly check rides with

operators or the safety departmentís monitoring of operatorsí compliance with operating

rules, indicating that the CTAís internal audits may not have been sufficiently thorough.

The Safety Board, therefore, concludes that the CTAís internal safety audit was not

effective in identifying the inadequacies in the rules compliance program. 

APTA Guidance and Audits

In addition to its own internal safety audit program, the CTA has also engaged

APTA to conduct periodic safety audits. The last APTA safety audit before the accident,

which was conducted in 1998, took no exception to how transportation line management

oversaw operatorsí rules compliance. APTAís audit did not include a checklist item

specifically addressing the training departmentís program of twice-yearly check rides with

operators or the safety departmentís monitoring of operating rules compliance. The APTA

audit process creates a unique checklist for every transit system it audits. The checklist is

based on the transit systemís system safety program plan. 

Item 12 on the APTA System Safety Checklist in the Manual for the Development

of Rail Transit System Safety Program Plans addresses rules/procedure reviews. The

manual indicates that records reviews and supplemental spot checks are the methods to

use in determining whether rules are being followed. There is little specific guidance on

what rules compliance programs should entail or how they should be efficiently

implemented. 

30 National Transportation Safety Board, Maryland Transit Administration Light Rail Vehicle Accidents

at the Baltimore-Washington International Airport Transit Station near Baltimore, Maryland, February 13

and August 15, 2000, Railroad Special Investigation Report NTSB/SIR-01/02 (Washington, D.C.; NTSB,

2001).
Analysis 33 Special Investigation Report

The Safety Board concludes that the APTA Manual for the Development of Rail

Transit System Safety Program Plans, published on August 20, 1991, does not contain the

necessary specific guidance for assessing the effectiveness of rules compliance programs;

as a result, the guidelines are not effective tools for regulatory authorities or transit

agencies with regard to rules compliance programs. 

The Safety Board, therefore, believes that APTA should modify the Manual for the

Development of Rail Transit System Safety Program Plans to provide specific guidance

for transit agencies to use in auditing the effectiveness of their operating rules compliance

programs by referencing the APTA standard covering transit rules compliance and

efficiency test programs as audit criteria. 

Because the FTA requires that fixed guideway transit systems, such as the CTAís

rail transit system, develop and implement a system safety program plan that complies

with the guidelines in the 1991 APTA manual, the Safety Board believes that the FTA

should adopt the APTA manual that contains updated language on auditing the

effectiveness of operating rules compliance programs. Further, the Safety Board believes

that the FTA should simultaneously modify 49 CFR Part 659 so that the Part always

references the current APTA manual.

State Safety Oversight of Rail Rapid Transit Systems

As a result of its 1991 safety study on the oversight of rail rapid transit safety, the

Safety Board issued Safety Recommendation R-91-37 to the 11 States that then had rail

rapid transit systems and the District of Columbia, asking that they ìdevelop or revise, as

needed, existing programs to provide for continual and effective oversight of rail rapid

transit safety.î The recommendation to California, Florida, New York, and Pennsylvania

was classified ìClosedAcceptable Action.î The recommendation to Georgia, Illinois,

Maryland, Massachusetts, New Jersey, Ohio, Virginia, and the District of Columbia

remains in an ìOpenî status. In the same safety study, the Safety Board issued Safety

Recommendation R-91-33 to UMTA, predecessor of the FTA, asking, in part, that the

agency evaluate the effectiveness of existing State oversight of rail rapid transit safety and

ìdevelop guidelines for use by State and local governments that address the critical

elements of an effective oversight program.î 

In December 1991, Congress gave the U.S. Department of Transportation the

authority to establish requirements for State safety oversight of rail fixed guideway mass

transportation systems. Safety Recommendation R-91-33 was classified

ìClosedAcceptable Actionî on April 16, 1996, after the FTA had addressed the main

objectives of the recommendation by instituting rulemaking to require States with rail

fixed guideway systems to designate a State oversight agency and to establish a safety

oversight program.

Even though the Safety Board notes the FTAís increased role in State safety

oversight, deficiencies remain. Some of the inadequacies in State safety oversight, such as
Analysis 34 Special Investigation Report

those noted in this accident investigation, can probably be attributed to the fact that State

oversight agencies lack experience in overseeing their rail rapid transit systems. The role

of safety regulation is still relatively new to States such as Illinois, which had no rail

transit State safety oversight programs before Federal regulations were promulgated in

1996. As the States gain more experience and familiarity with the unique requirements of

rail rapid transit safety, they are likely to exercise more effective safety oversight of their

transit properties. 

In light of the progress that has been made in formalizing State safety oversight

programs for rail rapid transit, the Safety Board has reconsidered the status of Safety

Recommendation R-91-37. Because the 1991 congressional mandate to the U.S.

Department of Transportation, as well as the regulatory activities of the FTA, has largely

met the intent of the recommendation, the Safety Board reclassifies Safety

Recommendation R-91-37 to 11 States and the District of Columbia ìClosedNo Longer

Applicable.î 

State Oversight of the CTA

Illinois designated the RTA as the oversight agency for the CTA in 1997. State

safety oversight regulations give the RTA a fair degree of flexibility in how active it will

be in its oversight. For example, the FTA allows State agencies to delegate accident

investigation to the transit agency and to review the transit agencyís reports. State

agencies can also have contractors perform some of their oversight functions. 

In the case of the CTA, the RTA relied heavily on the CTAís internal safety audits

to verify that the CTAís rules compliance program was effective. But, as noted above, the

CTAís internal safety audits were not sufficiently rigorous to identify problems in rules

compliance. The Safety Board, therefore, concludes that the Illinois State safety oversight

program was hindered in monitoring rules compliance by its reliance on ineffective CTA

internal management and safety audit programs. The Safety Board is encouraged that the

RTA plans to play a more active role in carrying out its safety oversight responsibilities by

participating in the CTAís internal safety audits.

Event Recorders

The investigation of the second CTA accident showed that some CTA rail transit

cars contain a system for preserving a limited amount of train performance data when an

accident involves a specific triggering event (in this case, propulsion breakers on two rail

cars were knocked out of position by the collision impact). The data loggers record only a

limited amount of data and will record over existing data if new triggering events occur.

(Event recorders collect a much greater variety of data and record for a much longer

period of time.) It was happenstance that the accident involved a triggering event and,

thus, that data was available to investigators. Had the triggering event not occurred, as was
Analysis 35 Special Investigation Report

the case on the remainder of the cars in the train, no train performance data would have

been captured. The Safety Board, therefore, concludes that, because the transit cars

involved in these accidents either did not have event recorders or had event recorders with

only limited data-recording capability, insufficient information was available to provide

the basis for a thorough analysis of the actions of the operators and the performance of the

trains before the collisions. 

Previous Safety Board Event Recorder Recommendations 

On November 14, 1996, as a result of the Safety Boardís investigation of an

accident on the Washington Metrorail system,31 the Safety Board issued Safety

Recommendation R-96-46 to the FTA, which called for the FTA to:

R-96-46

Develop, with the assistance of the American Public Transit [Transportation]

Association, guidelines for the monitoring/recording devices that capture critical

performance and event data for rapid rail transit cars and urge transit agencies to

install these devices on new and rehabilitated cars.

The FTA, with APTA, prepared a report, dated June 1998, entitled Event Recorders

for Rail Rapid Transit Systems. In a September 4, 1998, letter, the FTA provided the

Safety Board with a copy of the report and indicated that the report would be distributed to

transit agencies developing specifications for rehabilitated and new rapid transit vehicles

and that the FTA would urge the installation of the devices. The report explored the

effectiveness and efficiency of using event recorders on rapid rail cars. It presented and

analyzed data; defined various aspects of using accident/accident event recorders;

included a cost, feasibility, and benefit analysis; and identified the technical requirements

for these devices in rapid rail transit. Based on this response, the Safety Board classified

Safety Recommendation R-96-46 ìClosedóAcceptable Actionî on January 6, 1999.

When, on November 14, 1996, the Safety Board issued Safety Recommendation

R-96-46 to the FTA, it also issued Safety Recommendation R-96-47 to APTA. The

recommendation asked APTA to:

R-96-47

Develop, with the assistance of the Federal Transit Administration, guidelines for

the monitoring/recording devices that capture critical performance and event data

for rapid rail transit cars and urge transit agencies to install these devices on new

and rehabilitated cars.

In addition to working with the FTA to develop the 1998 Event Recorders for Rail

Rapid Transit Systems report, APTA has, through various APTA-sponsored conferences

31 National Transportation Safety Board, Collision of Washington Metropolitan Area Transit Authority

Train T-111 with Standing Train at Shady Grove Passenger Station, Gaithersburg, Maryland, January 6,

1996, Railroad Accident Report NTSB/RAR-96/04 (Washington, D.C: 1996).
Analysis 36 Special Investigation Report

and symposia, urged transit agencies to install these devices on new and rehabilitated cars.

Based on this information, Safety Recommendation R-96-47 has been classified

ìClosedóAcceptable Action.î

Event Recorder Regulations

The FTA has issued no regulations that apply to event recorders on rail transit

vehicles. The FRA regulations concerning the requirements for event recorders on railroad

locomotives are at 49 CFR 229.135. These regulations do not apply to event recorders on

rail transit vehicles. According to the railroad locomotive safety standard definitions

provided at 49 CFR 229.5(g):

(g) Event recorder means a device, designed to resist tampering, that monitors and

records data on train speed, direction of motion, time, distance, throttle position,

brake applications and operations (including train brake, independent brake, and,

if so equipped, dynamic brake applications and operations) and, where the

locomotive is so equipped, cab signal aspect(s), over the most recent 48 hours of

operation of the electrical system of the locomotive on which it is installed. A

device, designed to resist tampering, that monitors and records the specified data

only when the locomotive is in motion shall be deemed to meet this definition

provided the device was installed prior to [insert the effective date of the rule]

[sic]and records the specified data for the last eight hours the locomotive was in

motion.

APTA Event Recorder Working Group

APTA is sponsoring a working group, the APTA Rail Transit Standards

Development Vehicle Inspection and Maintenance Committee, that is addressing event

recorders on rail transit vehicles, as well as a variety of other maintenance issues. The

committee consists of representatives from APTA, various transit properties, consultants,

and government entities. The committee is addressing inspection and maintenance

standards and recommended practices for rail transit event recorders. The committeeís

recorder standard is expected to detail maintenance intervals and techniques for data,

voice, and image recording systems (where available) on transit vehicles. The group

defers to the Institute of Electrical and Electronics Engineers (IEEE) Standard (1482.1) for

any recommended operational and crashworthiness standards. The committee expects to

have a final draft standard for rail transit event recording systems by the end of 2002.

In response to Safety Board recommendations to the transit industry through

APTA, the CTA has developed a draft specification and intends to equip its new rail transit

cars with event recorders meeting the IEEE 1482.1 standard. While the Safety Board is

encouraged by the CTAís plans to equip its future rail rapid transit cars with event

recorders, the Board is concerned that other transit agencies may not share the

commitment. To help expedite expanded employment of event recorders in rail transit

vehicles, the Safety Board believes that the FTA should require that new or rehabilitated

vehicles funded by FTA grants be equipped with event recorders meeting IEEE standard

1482.1 for rail transit vehicle event recorders. 
Analysis 37 Special Investigation Report

Positive Train Control

The Safety Board is concerned about the safety of rail passenger service when

backup systems are not available to intervene if an operator operates his train improperly

or fails to comply with wayside signals. The Safety Board has long maintained that the

most effective way to avoid train-to-train collisions is through the use of positive train

control (PTC) systems. Such systems prevent train collisions by automatically assuming

some control of the train when the operator does not comply with the signal indication. 

In both of these accident locations, cab signal systems with automatic train stop

features were installed. While this system is not a full PTC system, it does have several

attributes that the Safety Board has long proposed as part of a PTC system. The CTAís cab

signal system enforces restrictive signals by stopping a train if the operator does not

comply with the requirements of the signal; however, the operator can proceed after such a

penalty stop if a button is pressed, but the trainís speed is limited to 15 mph. The CTAís

operating rules add further restrictions.

In the case of the June 17 accident, to allow track maintenance, trains were routed

against the normal current of traffic where wayside cab signal equipment was not

installed. A temporary signal card was installed in wayside equipment to disengage the

cab signal system on northbound trains entering the single-track detour. The cab signal

system did not reactivate on the incident train when it returned to the normal track because

it was closely following a train ahead. The operator proceeded without any cab signal

protection, thus ignoring the CTAís operating rules. After the accident, the CTA

discontinued the practice of disengaging the cab signal system. As a result, a train that

enters a single-track detour where cab signals are not in force is limited to a speed of 15

mph or less until it returns to the normal track where higher cab signal codes are present. 

In the August 3 accident, the cab signal system was functioning as designed, and

the train was stopped by the system. However, as noted above, the equipment design

allowed the operator to proceed, not exceeding 15 mph. Again, this was not in compliance

with operating rules.

Train operations in manual or bypass mode, although undesirable, are required

with any train control system, including PTC systems, in case of equipment malfunction

or maintenance activities. For example, fully automated systems that are considered to

have PTC, such as the San Francisco BART and the Washington, D.C., Metro, may be

operated in a reduced-speed manual mode that overrides restrictions imposed by the PTC

system. Operating rules restricting and controlling such manual or bypass operations are

required on such systems. Violation of such rules on a PTC system still creates a risk of

collision just as it did on the CTAís cab signal system. However, PTC systems and cab

signaling systems with reduced speed functions for manual operations lessen the severity

of a collision, as the reduced speed function did in the August 3 accident. While PTC

remains a highly desirable safety improvement on any rail system, the circumstances of

these two accidents demonstrate the need for stringent enforcement of operating rules,

even in environments with PTC or cab signal systems.
38 Special Investigation Report

Conclusions

Findings

1. There was no evidence of alcohol or drug use in these accidents, and the following

factors were neither causal nor contributory to either accident: weather, signal system

malfunction, or the braking systems of the trains. 

2. The Chicago Transit Authorityís practice of cutting out cab signaling and allowing

trains to move through a single-track detour at close spacing set the stage for train 104

to re-enter and proceed on cab signal track with inactive cab signals, albeit in

violation of the Chicago Transit Authorityís operating rules. 

3. Had the operator in the June 17 accident stopped and contacted the control center

when the cab signals on her train did not activate and had the control center then

followed existing manual block procedures, the accident would have been prevented.

4. The operator in the June 17 accident had ample time to see the train ahead and bring

her train to a safe stop; however, for unexplained reasons, she failed to do so. 

5. The Chicago Transit Authorityís management process for identifying and addressing

operators who do not meet safety performance standards was not effective in

addressing the repeated problems that the operator in the June 17 accident was

experiencing.

6. Had the operator in the August 3 accident complied with the Chicago Transit

Authorityís operating rules and waited for his stop signal to clear before proceeding,

the accident would have been prevented. 

7. The operator in the August 3 accident had ample time to see the train ahead and bring

his train to a safe stop; however, for unexplained reasons, he failed to do so. 

8. Controllers and operators were inconsistent in their application and understanding of

the rules governing stop signals and blue light alarms. 

9. The Chicago Transit Authorityís program for the enforcement of operating rules was

inadequate in design and execution; and, consequently, rules violations, such as those

related to these two accidents, were not uncommon. 

10. The Chicago Transit Authorityís internal safety audit was not effective in identifying

the inadequacies in the rules compliance program.
Conclusions 39 Special Investigation Report

11. The American Public Transportation Association Manual for the Development of Rail

Transit System Safety Program Plans, published on August 20, 1991, does not contain

the necessary specific guidance for assessing the effectiveness of rules compliance

programs; as a result, the guidelines are not effective tools for regulatory authorities

or transit agencies with regard to rules compliance programs. 

12. The Illinois State safety oversight program was hindered in monitoring rules

compliance by its reliance on ineffective Chicago Transit Authority internal

management and safety audit programs.

13. Because the transit cars involved in these accidents either did not have event

recorders or had event recorders with only limited data-recording capability,

insufficient information was available to provide the basis for a thorough analysis of

the actions of the operators or the performance of the trains before the collisions.
40 Special Investigation Report

Recommendations

As a result of its investigation of the two Chicago Transit Authority accidents

discussed in this report, the National Transportation Safety Board makes the following

safety recommendations:

New Recommendations

To the Federal Transit Administration:

Adopt the American Public Transportation Association manual that

contains updated language on auditing the effectiveness of operating rules

compliance programs, and simultaneously modify 49 Code of Federal

Regulations Part 659 so that the Part always references the current

American Public Transportation Association manual. (R-02-18)

Require that new or rehabilitated vehicles funded by Federal Transit

Administration grants be equipped with event recorders meeting Institute

of Electrical and Electronics Engineers Standard 1482.1 for rail transit

vehicle event recorders. (R-02-19) 

To the American Public Transportation Association:

Include specific guidance for transit operators on performing unannounced

rules compliance observations and efficiency tests as the General Rule

Standard for Rule Compliance and Implementation is developed. (R-02-

20)

Modify the Manual for the Development of Rail Transit System Safety

Program Plans to provide specific guidance for transit agencies to use in

auditing the effectiveness of their operating rules compliance programs by

referencing the American Public Transportation Association standard

covering transit rules compliance and efficiency test programs as audit

criteria. (R-02-21)

To the Chicago Transit Authority:

Develop and implement systematic procedures for performing and

documenting frequent management checks to ensure all operating

personnel are complying with Chicago Transit Authority operating rules,

including speed restrictions and signal rules. (R-02-22)
41 Special Investigation Report

Recommendation Reclassified in this Report

To the Governors of the States of Georgia, Illinois, Maryland, Massachusetts, New 

Jersey, Ohio, and Virginia and the Mayor of the District of Columbia:

R-91-37

Develop or revise, as needed, existing programs to provide for continual and

effective oversight of rail rapid transit safety. The elements of the oversight

program should include reviews of maintenance and inspection records, accident

investigation activities, audits of system safety program plans, reviews of the

transit system safety department, reviews of training programs, monitoring of

accident data, and periodic inspections of equipment and infrastructure.

Safety Recommendation R-91-37, previously classified ìOpenAcceptable

Responseî (Illinois, Maryland, Massachusetts, New Jersey, Ohio, and Virginia) and

ìOpenAwaiting Responseî (Georgia and the District of Columbia) is reclassified

ìClosedNo Longer Applicableî in the ìState Safety Oversight of Rail Rapid Transit

Systemsî section of this report. 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

CAROL J. CARMODY

Acting Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: September 5, 2002

Recommendations

43 Special Investigation Report

 Appendix A

Brief: June 17, 2001, Chicago Transit Authority Accident

Railroad Accident Number: DCA-01-FR-005

Rail System: Chicago Transit Authority

Train: Blue Line trains 104 and 207

Accident Type: Rear-end collision

Location: Near Addison Station, Chicago, Illinois

Date and Time: June 17, 2001, 11:40 a.m.

Fatalities/Injuries: No fatalities; 22 injuries (none serious)

Accident Synopsis

On Sunday, June 17, 2001, at approximately 11:40 a.m., central daylight time,

Chicago Transit Authority (CTA) northbound train 104 collided with the rear end of

standing CTA train 207, about 1,200 feet south of the Addison Street Station. It was

estimated that train 104 had been traveling between 10 and 15 mph.

Each train consisted of four passenger cars. Train 104 had approximately 75

passengers, and train 207 had approximately 40. Eighteen passengers, an off-duty CTA

employee, and both train operators reported non-life threatening injuries. The collision did

not result in a derailment or fire. Damage was estimated at $30,000.

Investigation

The operator of the striking train reported for duty at 5:40 a.m. on Sunday, June

17, at OíHare Station. Her schedule called for two trips from OíHare to Forest Park and

back.

The northbound Blue Line track between California and Belmont Stations was out

of service for scheduled maintenance on the morning of the accident. Trains going in

either direction had to operate on the same single track between a left-hand crossover (to

National Transportation Safety Board

Washington, D.C. 20594

Railroad Accident Brief
44 Special Investigation Report

the southbound track) at California (the southernmost station) and a diamond crossover at

Belmont (the northernmost station). The detour was within cab signal1

 territory. Because

the cab signal system was designed to function only for traffic proceeding in the normal

direction of travel (in this case, southbound), cab signals had been temporarily cut out for

the detour area. Cab signals for the detoured trains were expected to cut back in when the

trains reached Belmont Station and returned to the northbound track. 

Just before the accident, three trains (210, 207, and 104) had proceeded

northbound through the single-track area. Train 210, the first of the three, made its

scheduled station stop at Belmont after leaving the single track. It then proceeded north

toward Addison and on to OíHare without incident.

The operator of train 207, the second of the three, also made a station stop at

Belmont. The operator stated that the cab signal system cut back in and functioned

normally as he neared the north end of the Belmont platform. As the train proceeded north

from Belmont, the operator stated, he received a stop signal on the cab signal system as he

approached Addison Station because train 210 was stopped in the station ahead. The

operator of train 207 stopped his train about 200 feet behind train 210. Shortly after

stopping, he said, he felt an impact and was thrown forward into the control stand.

The operator of the striking train (104) entered cab signal territory at Western,

where, she stated, the cab signaling did not cut in. She proceeded from Western toward the

single-track detour at 20 mph. At California, a pilot2

 operated her train through the detour.

Once back on the northbound track, she took control of her train from the pilot at the south

end of Belmont platform. She then operated to the north end of Belmont and stopped to

board and offload passengers. She stated that the cab signal system did not cut in. She

stated that she knew trains were ahead of her and consequently operated her train at about

15 mph out of Belmont without cab signal protection. CTA cab signal territory rules allow

a train operator to proceed when the cab signal system is inoperative only when he or she

had received authorization from CTAís operations control center. The operator stated that

she did not contact the operations control center when she was at Western or at Belmont,

even though she knew the operating rules required that she do so.

She stated that as she left the subway portal and exited a right-hand curve, she

observed a train stopped about 100 feet ahead. She stated that she moved the control

handle to brake 3 position and then pulled the brake cord, but the train did not stop. She

then mistakenly hit a sander button while trying to depress the track brake button. She

stated that when she did depress the track brake button, it was too late to be effective. She

estimated her sight distance as 100 feet and the impact speed as 10 mph.

1 A train with cab signals displays the governing signal aspect inside its cab as long as the train is

operating in territory equipped with a working cab signal system. The system is designed to cut out when a

train leaves cab signal territory and to cut back in when a train enters cab signal territory.

2 The CTA uses a pilot to control conflicting train movements over a temporary single-track detour.

No train can proceed through the detour without obtaining specific authorization from the pilot or without

having the pilot on board the train.

Appendix A
45 Special Investigation Report

The sight distance was determined to be an unobstructed 800 feet to the point of

impact. Tests indicate that CTA cars going 10 mph are capable of stopping within 10 to 15

feet. Consequently, the Safety Board determined that the operator of train 104 had

adequate time and distance to stop her train short of the rear of train 207 but that for

unknown reasons, she failed to do so. 

The train braking and signal systems were tested and found to function as

designed. However, it was noted that a trainís cab signals would not cut in after the train

left the single-track area if another train occupied one of the two blocks immediately

ahead.

The CTAís system safety program indicated that several departments constantly

monitored operating rules compliance. The Safety Boardís investigation found that this

was not the case. For example, the agencyís year 2000 internal safety audit found that

ìservice rail operation employees [were complying] with safety rules and S.O.P.s.î Yet,

the internal safety audit did not specifically address a training department program of

twice-yearly check rides with train operators that was not being done. The audit also did

not address the safety departmentís monitoring of train operatorsí compliance with

operating rules, which also appears to have not been done. The CTAís internal audits may

not have been sufficiently thorough and were not effective in identifying these

inadequacies in the rules compliance program.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the accident was the failure of the operator of train 104 to comply with operating rules.

Contributing to the accident was the failure of the Chicago Transit Authorityís

management to exercise adequate operational safety oversight.

Appendix A
46 Special Investigation Report

Appendix B

Brief: August 3, 2001, Chicago Transit Authority Accident

Railroad Accident Number: DCA-01-FR-007

Rail System: Chicago Transit Authority

Train: Brown and Purple Line trains 416 and 505

Accident Type: Rear-end collision

Location: Near Chicago Station, Chicago, Illinois

Date and Time: August 3, 2001, 9:04 a.m.

Fatalities/Injuries: No fatalities; 118 injuries (one serious)

Accident Synopsis

On Friday, August 3, 2001, at approximately 9:04 a.m., central daylight time,

Chicago Transit Authority (CTA) Brown Line train 416 collided with the rear end of

standing CTA Purple Line train 505 on elevated tracks near Hill Street in Chicago,

Illinois. Both trains were southbound. It was estimated that train 416 had been traveling 11

mph. Each train consisted of six passenger cars. The accident occurred during the morning

rush hour, and both trains had standing loads estimated at 90 passengers per car. Chicago

Police Department logs indicate that 118 people were transported to area hospitals, all

with minor injuries. One injury was later upgraded to serious.

Investigation

The operator of the striking train reported for duty at 8:15 a.m. on August 3 at

Kimball Station. His schedule called for five trips from Kimball to downtown Chicago,

around the Loop, and back to Kimball.

He departed Kimball on time for his first trip, at 8:25 a.m. He stated that he

experienced several cab signal overspeed malfunctions when he first operated the train out

National Transportation Safety Board

Washington, D.C. 20594

Railroad Accident Brief
47 Special Investigation Report

of Kimball. He also experienced two propulsion system blue light3 alarms. The first alarm

sounded in the cab as the train departed Addison Station. The operator stated he was able

to reset the first alarm from the cab when he stopped at the next station, which was

Paulina. A second alarm sounded after the train left Sedgwick Station. The operator stated

that he had intended to continue to Chicago Station, where he planned to troubleshoot the

problem.

He said that he had had several cab signal system stops before the collision and

remarked that the number of stops was not unusual during the rush hour due to the close

spacing of trains.4 According to the CTAís operating rules, when a train operator has a

stop signal, he should wait for the signal to indicate proceed when another train is known

to be ahead. If the train operator does not know why he received a stop, he must contact

the operations control center for authorization to move. The operator stated that once he

entered the combined Brown/Purple Line tracks at Clark Junction, he proceeded after

receiving stop signals without waiting for the train ahead to clear and without contacting

the operations control center. He stated that it was not uncommon for operators to proceed

without waiting or calling.

He stated that he left Armitage Station with his cab signal displaying a stop

indication, knowing that he was following a Purple Line train close ahead. He stated that

he was leaving Sedgwick the last time he saw the taillights of the Purple Line train. After

leaving Sedgwick and passing Division Avenue, he entered Church Curve, where

visibility was limited by a church. At the south end of the curve, he stated, he observed the

taillights of a train stopped about 100 feet ahead. He said that when he saw the train, he

moved the control handle first to brake position 3 and then to the emergency position, but

the train did not stop. He estimated his sight distance at 100 feet and the impact speed as

10 mph. He told investigators that he might have been distracted by a blue light propulsion

alarm.

The train braking and signal systems were tested and found to function normally.

A braking test at the accident location with a train of similar weight indicated that the

stopping distance was 31 feet. Sight distance tests determined that the side of a train

standing at the point of impact could first be glimpsed by a following train from a distance

of about 373 feet as the following train exited Church Curve. The view of the rear of the

train was unobstructed from about 345 feet.

Several witnesses told investigators that they observed the train operator with his

head out the side window of the train just before the collision. Data from a propulsion

event logger on the train indicated that the brakes were not applied until about 1.5 seconds

before impact.

3 A blue light alarm indicates that one of the cars in the train has a propulsion or auxiliary power

problem. In the event of a blue light alarm, a trouble light illuminates on the operatorís console, and an

alarm bell sounds in the cab. A trouble light also illuminates on both sides of the affected car.

4 A train with cab signals displays the governing signal aspect inside its cab as long as the train is

operating in territory equipped with a working cab signal system. A stop indication is displayed when

another train is occupying the block ahead.

Appendix B
48 Special Investigation Report

The CTAís system safety program indicated that several departments constantly

monitored operating rules compliance. The Safety Boardís investigation found that this

was not the case. For example, the agencyís year 2000 internal safety audit found that

ìservice rail operation employees [were complying] with safety rules and S.O.P.s.î Yet,

the internal safety audit did not specifically address a training department program of

twice-yearly check rides with train operators that was not being done. The audit also did

not address the safety departmentís monitoring of train operatorsí compliance with

operating rules, which also appears to have not been done. The CTAís internal audits may

not have been sufficiently thorough and were not effective in identifying these

inadequacies in the rules compliance program.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the accident was the failure of the operator of train 416 to comply with operating rules.

Contributing to the accident was the failure of the Chicago Transit Authorityís

management to exercise adequate operational safety oversight.

Appendix B
49 Special Investigation Report

Appendix C 

CTA Brown and Blue Lines